OIG Report: Medicare / Nursing Home Payments that Exceed National Norms Raise Fraud Concerns

From the Office of Inspector General:

Payments for Medicare Part B Services During Non-Part A Nursing Home Stays in 2008

Summary

We found that Medicare paid $4.9 billion in 2008 for Part B services during nursing home stays not paid for by Part A (hereinafter referred to as non-Part A stays). Three service categories, therapy services, evaluation and management, and major and minor medical procedures, made up 58 percent of the total payment. On average, Medicare paid $16.75 per day per beneficiary for Part B services across all service categories and beneficiaries. However, the average varied widely across service categories and States in which the services occurred; the highest average daily payments were for dialysis services and services in Louisiana. Examining average daily payments across nursing homes, we found that payments to some nursing homes exceeded three times the national average daily payment within certain service categories, most prominently drugs and biologicals and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS).

The variation and unusual patterns found in this review raise concerns of potential fraud, waste, and abuse. Therefore, items and services billed under Part B for nursing home residents during non-Part A stays continue to warrant specialized monitoring. To facilitate such monitoring, we plan to undertake additional reviews and in-depth analyses focusing on specific service types.

This study is part of OIG's activities to monitor Part B payments for items and services furnished to nursing home residents during non-Part A stays. We used resident assessment data from the Minimum Data Set to identify nursing home stays nationwide during 2008 and reviewed Part B claims that occurred during non-Part A stays. This report provides insights into payment and utilization patterns for Part B services, as well as geographic differences, that will guide further review and identification of providers of Part B services warranting scrutiny by OIG and CMS.

Read the complete report.

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