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Medicare Payments for Inpatient Claims With Mechanical Ventilation

Announced on  | Last Modified on  | Project Number: A-09-22-03002
Status
Completed
Agency
Centers for Medicare and Medicaid Services

OBJECTIVE

We will review Medicare payments for inpatient hospital claims with certain Medicare Severity Diagnosis Related Group (MS-DRG) assignments that require mechanical ventilation to determine whether hospitals' DRG assignments and resultant Medicare payments were appropriate. Mechanical ventilation is the use of a ventilator to take over active breathing for a patient. For certain MS-DRGs to qualify for Medicare coverage, a beneficiary must have received more than 96 hours of mechanical ventilation. Our review will include claims for beneficiaries who received more than 96 hours of mechanical ventilation. Previous OIG reviews identified improper payments made because hospitals inappropriately billed for beneficiaries who did not receive at least 96 hours of mechanical ventilation.

TIMELINE

REPORT PUBLISHED

Medicare Improperly Paid Hospitals an Estimated $79 Million for Enrollees Who Had Received Mechanical Ventilation (A-09-22-03002)

24-A-09-094.01 to CMS - Open Unimplemented
Update expected on 08/24/2025
We recommend that the Centers for Medicare & Medicaid Services direct the MACs to recover from hospitals the portion of the $382,032 in identified overpayments for the sampled claims during our audit period that are within the 4-year reopening period in accordance with CMS's policies and procedures.

24-A-09-094.02 to CMS - Closed Implemented
Closed on 03/20/2025
We recommend that the Centers for Medicare & Medicaid Services educate hospitals on correctly counting the hours of mechanical ventilation and submitting claims with correct procedure and diagnosis codes, which could have saved an estimated $79,354,175 for our audit period.

View in Recommendation Tracker
Work Plan Type
Office of Audit Services
HHS Agencies
Centers for Medicare and Medicaid Services
Issue Areas
Financial Stewardship Hospitals
Target Groups
-
Financial Groups
Medicare A