Skip to main content
Report File
Date Issued
Submitting OIG
Department of Health & Human Services OIG
Other Participating OIGs
Department of Health & Human Services OIG
Agencies Reviewed/Investigated
Department of Health & Human Services
Report Number
A-04-18-04067
Report Description

Prior OIG audits identified Medicare overpayments to hospitals that did not comply with Medicare's post-acute-care transfer policy (transfer policy). CMS generally concurred with our recommendations, but subsequent analysis that we conducted indicated that CMS's system edits were still not properly designed and that hospitals may be using condition codes to bypass CMS's system edits to receive higher reimbursements for inpatients transferred to home health services.

Report Type
Audit
Agency Wide
Yes
Number of Recommendations
9
Questioned Costs
$722,288
Funds for Better Use
$266,356,313
Additional Details
https://oig.hhs.gov/oas/reports/region4/41804067.asp

Open Recommendations

This report has 6 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
269164 No $0 $218,538,919

We recommended that CMS direct its Medicare contractors to reprocess the remaining inpatient claims identified in our sample frame with an incorrect patient discharge status code when beneficiaries resumed home health services within 3 days of discharge and recover the portion of the estimated $218,538,919 in overpayments that are within the 4-year reopening period along with similarly coded inpatient claims after our audit period.

269170 No $0 $0

We recommended that CMS use data analytics to identify hospitals that disproportionately use condition code 42 when the diagnosis codes on the inpatient claim and the respective home health claim appear related.

269166 No $0 $40,610,333

We recommended that CMS direct its Medicare contractors to analyze the remaining inpatient claims in our sample frame with a condition code 42, determine which claims were overpaid, and recover the portion of the estimated $40,610,333 in potential overpayments that are within the 4-year reopening period along with similarly coded inpatient claims paid after our audit period.

269171 No $0 $0

We recommended that CMS consider reducing the need for clinical judgment when processing claims under the post-acute-care transfer policy by taking the necessary actions, including seeking legislative authority if necessary, to deem any home health service within 3 days of discharge to be “related” (which would have saved an estimated $46.6 million during our 2-year audit period).

269168 No $0 $0

We recommended that CMS create CWF edits to prevent the use of condition code 43 from allowing the hospital to receive the full MS-DRG payment when the beneficiary receives home health services within 3 days of discharge.

269167 No $0 $0

We recommended that CMS correct its CWF edits to ensure that the edits use the home health services on each line within a home health claim rather than only the first line, which will allow the edits to capture home health claims that overlap a hospital stay.

Department of Health & Human Services OIG

United States