Federal Reports

Northside Medical Center (The Hospital), in Youngstown, Ohio complied with Medicare billing requirements for diagnosis codes 261 and 262 for 2 of the 100 claims that we reviewed. However, the Hospital did not comply with Medicare billing requirements for the remaining 98 claims. For two of these claims, the medical record documentation supported a secondary diagnosis code other than 261 or 262, but the error resulted in no change to the diagnosis-related group or payment. For the remaining 96 claims, the billing errors resulted in overpayments of $464,000. These errors occurred because the Hospital used diagnosis code 261 or 262 when it should have used codes for other forms of malnutrition or no malnutrition diagnosis code at all. On the basis of our sample results, we estimated that the Hospital received overpayments of at least $1.28 million over 2 and a half years.

For the period January 1 through December 31, 2013, the Delaware Department of Health and Social Services, Division of Medicaid and Medical Assistance (State agency) did not fully comply with Federal Medicaid requirements for billing manufacturers for some rebates for physician-administered drugs dispensed to enrollees of managed-care organizations (MCOs). The State agency properly billed for most rebates for MCO drug utilization in our judgmental sample. However, the State agency did not have valid National Drug Codes (NDCs) for other drug utilization data submitted by MCOs for physician-administered drugs, and the State agency did not bill manufacturers for rebates for these drugs. We estimate that the State agency did not bill manufacturers for rebates totaling $230,000 ($127,000 Federal share). We did not have enough information to determine an estimate for some of the utilization.