Review of Medicaid Credit Balances at Northridge Healthcare and Rehabilitation as of June 30, 2009

摘要

Pursuant to Title XIX of the Social Security Act, the Medicaid program provides medical assistance to low-income individuals and individuals with disabilities. The Federal and State Governments jointly fund and administer the Medicaid program. At the Federal level, the Centers for Medicare & Medicaid Services (CMS) administers the program. Each State administers its Medicaid program in accordance with a CMS-approved State plan. Although the State has considerable flexibility in designing and operating its Medicaid program, it must comply with applicable Federal requirements. In Arkansas, the Department of Human Services (the State agency) administers the States Medicaid program. Credit balances may occur when the reimbursement that a provider receives for services provided to a Medicaid beneficiary exceeds the program payment ceiling or when the reimbursement is for unallowable costs, resulting in an overpayment. Credit balances also may occur when a provider receives payments for the same services from the Medicaid program and another third-party payer. In such cases, the provider should return the existing overpayment to the Medicaid program, which is the payer of last resort. Section 1903(d)(2)(C) of the Act, implemented at 42 CFR SC 433.300(b), states: when an overpayment is discovered ... the State shall have a period of 60 days in which to recover or attempt to recover such overpayment before adjustment is made in the Federal payment to such State on account of such overpayment. ... The adjustment in the Federal payment shall be made at the end of the 60 days, whether or not recovery was made. Although the State agency does not have any regulations requiring providers to refund Medicaid credit balances within a specific timeframe, the Manual of Cost Reimbursement Rules for Long Term Care Facilities contains instructions related to overpayments. Specifically, section 1-12 states that overpayments will be corrected when discovered. Northridge Healthcare and Rehabilitation is a 224-bed nursing home located in North Little Rock, Arkansas, that participates in the Medicaid program. It is a for-profit facility doing business as Convacare Management, Inc. Northridge provides nursing care, therapeutic services, and long-term care. Our objective was to determine whether the Medicaid credit balances recorded in Northridges accounting records for patient services constituted overpayments that should have been returned to the Medicaid program pursuant to Federal and State requirements.