“… Prior Office of Inspector General (OIG) reviews estimated that the Centers for Medicare & Medicaid Services (CMS) paid $169 million for SNF services in calendar years (CYs) 1996 through 2001 when the 3-day rule was not met. 1 Though the Medicare contractors generally agreed with our findings, CMS told them not to recover improper payments because CMS could not determine whether SNFs were “at fault” in not meeting the 3-day rule, which meant that the Medicare beneficiaries would have become responsible for the payment. 2 Rather than pursuing recoupment, CMS issued instructions to providers regarding the importance of complying with the applicable requirements…”
“OBJECTIVE
Our objective was to determine whether CMS paid SNF claims with dates of service during CYs 2013 through 2015 (the most recent available data at the start of our audit) when the 3-day rule was not met.”
“FINDINGS
CMS improperly paid 65 of the 99 SNF claims we sampled when the 3-day rule was not met.17 Improper payments associated with these 65 claims totaled $481,034. On the basis of our sample results, we estimated that CMS improperly paid $84,202,593 for SNF services that did not meet the 3-day rule during CYs 2013 through 2015. We attribute the improper payments to the absence of a coordinated notification mechanism among the hospitals, beneficiaries, and SNFs to ensure compliance with the 3-day rule. We noted that hospitals did not always provide correct inpatient stay information to SNFs, and SNFs knowingly or unknowingly reported erroneous hospital stay information on their Medicare claims to meet the 3-day rule. We determined that the SNFs used a combination of inpatient and non-inpatient hospital days to determine whether the 3-day rule was met.18 Because CMS allowed SNF claims to bypass the CWF qualifying stay edit during our audit period, these SNF claims were not matched with the associated hospital claims that reported inpatient stays of less than 3 days…” Read the full article here.
Source: CMS Improperly Paid Millions of Dollars for Skilled Nursing Facilities When the Medicare 3-Day Inpatient Hospital Stay Requirement was Not Met, February 2019. OIG.
