Review of High-Dollar Inpatient Claims Processed by Cahaba Government Benefit Administrators, LLC (Contractor No. 00010), for Calendar Years 2004 through 2006

摘要

Pursuant to Title XVIII of the Social Security Act (the Act), the Medicare program provides health insurance for people aged 65 and over and those who are disabled or have permanent kidney disease. The Centers for Medicare & Medicaid Services (CMS), which administers the program, contracts with fiscal intermediaries to process and pay Medicare Part A claims submitted by hospitals. The intermediaries use the Fiscal Intermediary Standard System and CMSs Common Working File (CWF) to process claims. The CWF can detect certain improper payments during prepayment validation. Section 1886(d) of the Act established the prospective payment system for inpatient hospital services. Under the prospective payment system, CMS pays hospital costs at predetermined rates for patient discharges based on the diagnosis-related group to which a beneficiarys stay is assigned. The Medicare Claims Processing Manual, Pub. No. 100-04, chapter 3, section 10.1, requires that hospitals submit claims on the appropriate forms for all provider billings, and chapter 1, section 80.3.2.2, requires that claims be completed accurately to be processed correctly and promptly. The diagnosis-related group payment is, with certain exceptions, payment in full to the hospital for all inpatient services. Section 1886(d)(5)(A)(ii) of the Act provides for an additional payment, known as an outlier payment, to hospitals for cases incurring extraordinarily high costs. Also, section 6011 of the Omnibus Budget Reconciliation Act of 1989 (P.L. No. 101-239) provides for an additional payment, known as an add-on payment, for blood clotting factor administered to hemophilia inpatients. During calendar years 2004 through 2006, Cahaba Government Benefit Administrators, LLC (Cahaba), was the fiscal intermediary for Alabama as contractor No. 00010. Cahaba processed approximately 1 million inpatient claims during this period, 97 of which resulted in payments of $200,000 or more (high-dollar payments). Our objective was to determine whether high-dollar Medicare payments that Cahaba made to Alabama hospitals for inpatient services were appropriate.