Medicare Improperly Paid Hospitals for Beneficiaries Who Had Not Received 96 or More Consecutive Hours of Mechanical Ventilation 

For inpatient claims with certain Medicare Severity Diagnosis-Related Groups (MS-DRGs), Medicare requires that beneficiaries have received 96 or more hours of mechanical ventilation. For 137 of the 200 claims we reviewed, Medicare payments to hospitals complied with Medicare requirements; the beneficiaries had received 96 or more consecutive hours of mechanical ventilation. However, for the 63 remaining claims, Medicare payments to hospitals did not comply with requirements. Consequently, the claims were assigned incorrectly to MS DRGs 207 and 870, resulting in $1.5 million of overpayments. The hospitals confirmed that these claims were improperly billed and generally attributed the errors to incorrectly counting the number of hours that beneficiaries had received mechanical ventilation or to clerical errors in selecting the appropriate procedure code.