Centers for Medicare and Medicaid Services Did Not Reconcile Medicare Outlier Payments in Accordance with Federal Regulations and Guidance.

摘要

The Centers for Medicare & Medicaid Services (CMS) uses a prospective payment system (PPS) to pay Medicare-participating hospitals (hospitals) for providing inpatient hospital services to Medicare beneficiaries. Under the PPS, CMS adjusts basic prospective payments for unusually high costs. These additional payments, known as outlier payments, are designed to protect hospitals from excessive losses due to unusually high-cost cases. CMS has historically projected outlier payments to be 5.1 percent of total basic prospective payments. To allow for these outlier payments, CMS reduced basic prospective payments by 5.1 percent. From Federal fiscal year (FY) 1998 through FY 2002, CMSs total outlier payments exceeded 5.1 percent. As a result, CMS paid hospitals approximately $9 billion more in outlier payments than the $17.6 billion that it had intended. CMS stated that some hospitals had taken advantage of vulnerabilities in the outlier payment methodology to maximize their outlier payments. These vulnerabilities allowed some cases to qualify as outliers when, in actuality, they were not unusually high-cost cases.