Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Policy & Regulation News

Nebraska Receives $268K in Excess Federal Reimbursement

By Ryan Mcaskill

Between computer and human error, Nebraska received excess payments for Federal Medicaid reimbursement.

- The Department of Health and Human Service (HHS) Office of Inspector General (OIG) has released the results of its audit of the Nebraska Medicaid program from April 1, 2011 through December 31, 2013. It was discovered that during the audit period, Nebraska claimed $268,000 in excess Federal reimbursement for Medicaid family planning inpatient claims with sterilization and delivery procedures.

Federal law and regulations authorize Federal Medicaid reimbursement to States for family planning services which includes inpatient sterilization procedures, prevent or delay pregnancy or otherwise control family size. It is handled at an enhanced Federal medical assistance percentage (FMAP) of 90 percent. Previous reports have found that some States improperly claim reimbursement at the enhanced rate that were only eligible for regular rates or were ineligible altogether.

In Nebraska, Federal reimbursement is available at the 90-percent rate for inpatient sterilization services. When these services are delivered during a single hospital stay, the Centers for Medicare and Medicaid Services (CMS) requires the State agency’s claim for Federal reimbursement distinguish between those costs attributed to family planning that are eligible for the 90-percent rate and those costs attributed to other covered services.

During the audit period, the State agency reported costs of $2,020,973 for 324 inpatient claims with sterilization and delivery procedures for which the State agency claimed Federal reimbursement of $1,549,241 at either the 90-percent rate of the FMAP.

However, it was discovered that the State agency did not correctly claim costs for inpatient claims with sterilization and delivery procedures for the audit period. For the 11 quarters of the audit, the State agency incorrectly claimed the costs associated with 804 sterilization procedures instead of claiming the costs for the 324 procedures that were actually performed. In addition, one quarter also saw the State agency inadvertently based its claims on the wrong amount. As a result of the errors, the State agency received $268,285 of unallowable Federal reimbursement.

“These errors occurred because the State agency did not follow its policies and procedures,” the report reads. “The State agency had policies and procedures to identify and claim the costs attributable to inpatient sterilization procedures. However, a computer-programming error caused the State agency’s sterilization report to show an incorrect number of sterilization procedures than the number actually performed. In addition, a human error caused the State agency to base its claim for one quarter on an incorrect amount.”

The OIG recommended that the State agency refund the $268,285 to the Federal Government and strengthen its policies and procedures to ensure that costs for inpatient claims. In written comments responding to the report, the State agency agreed to refund the incorrectly claimed costs to the Federal government and described corrective actions that it had taken to strengthen its controls.



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