Indiana Claimed Medicaid Reimbursement for High-Dollar Inpatient Services That Were Unallowable.

摘要

The Indiana Office of Medicaid Policy and Planning (State agency) uses a prospective payment system to claim Medicaid reimbursement for inpatient service costs based on the charges that a hospital submits to the State agency. When a hospitals charges exceed predetermined charge thresholds, the State agency makes what is known as an outlier payment. Outlier payments are intended to protect hospitals against large financial losses associated with high-cost cases. Because of these outlier payments, extraordinarily high-cost cases generally result in high-dollar Medicaid payments. Previous Office of Inspector General reviews found a high occurrence of erroneous Medicaid payments associated with high-dollar inpatient service claims reimbursed by the States. The objective of this review was to determine the allowability of certain high-dollar Medicaid payments that the State agency made to hospitals for inpatient services.