OIG Recommends Closer Review of Skilled Nursing Facility Medicare Claims

November 21, 2012 | Aging Services Risk, Quality, & Safety Guidance

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​One quarter of all Medicare claims filed by skilled nursing facilities in 2009 contained errors that resulted in a combined $1.5 billion in overpayments by the Centers for Medicare and Medicaid Services (CMS), according to a November 13, 2012, report from the U.S. Department of Health and Human Services' Office of Inspector General (OIG). In most cases, the errors represented upcoding, often for unwarranted claims of ultrahigh therapy. Nearly half of the reviewed claims (47%) had errors in how they captured data on the Minimum Data Set (MDS), most frequently for services such as physical, occupational, or speech therapy; OIG notes that this is significant because the therapy data largely determines how claims are assigned to a Resource Utilization Group (RUG) and its corresponding payment rate.

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