The Missouri Department of Social Services (State agency) did not comply with Federal and State requirements prohibiting Medicaid payments for inpatient hospital services related to treating certain provider-preventable conditions (PPCs), which are certain reasonably preventable conditions caused by medical accidents or errors in a health care setting. The State agency did not follow the provision of its Centers for Medicare & Medicaid Services (CMS)-approved State plan directing it to perform a retrospective clinical review of the claims with diagnosis codes identified as PPCs. In addition, the State agency paid inpatient hospital claims in which the present-on-admission (POA) indicator data field had been left blank. We identified inpatient hospital claims totaling $2.7 million ($1.7 million Federal share) that contained a diagnosis code identified as a PPC and (1) a POA code indicating that the condition was not present on admission, (2) a POA code indicating that the documentation in the patient’s medical record was insufficient to determine whether the condition was present on admission, or (3) no POA code. Therefore, we are setting aside this amount for resolution by CMS and the State agency.
MO
United States
