Review of Medicare Claims Submitted by Inpatient Psychiatric Facilities During the Transition to The Prospective Payment System in 2005

摘要

As mandated by the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999, together with the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the Centers for Medicare & Medicaid Services (CMS) developed and implemented a prospective payment system for inpatient psychiatric facilities (IPF). The IPF prospective payment system was effective for cost-reporting periods beginning on or after January 1, 2005. Before that date, Medicare paid IPFs for services provided to beneficiaries pursuant to section 101(a) of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA). Specifically, Medicare based payments to IPFs on a reasonable cost per discharge, as determined by IPFs Medicare cost reports, subject to the limits imposed by the TEFRA. The IPF prospective payment system, in contrast, provides a standardized Federal per diem payment per discharge. CMS contracts with fiscal intermediaries to process and pay Medicare Part A claims submitted by institutional providers, including IPFs. Under the prospective payment system, IPFs must submit to the fiscal intermediaries a single discharge bill for an entire inpatient stay. CMS instructions state that if the beneficiarys stay begins before and ends on or after the date on which the IPF becomes subject to the prospective payment system (a transition stay), the fiscal intermediary must base its payments to the facility on prospective payment rates and rules. The instructions also state that IPFs that split the stay and submit two separate claims must cancel the split bills and then rebill the fiscal intermediary after the cancellation has been accepted. Our three prior reviews to determine whether IPFs had properly billed for transition stays during 2005 identified overpayments totaling $3.9 million for split bills paid by three fiscal intermediaries. This review covered the remaining 2,215 transition stays that IPFs nationwide split-billed to Medicare in 2005.