Healthcare Compliance Perspective – Medicaid Claims:
The Compliance Officer will involve the Risk Manager and work with appropriate Administrative Personnel to review the nursing home’s policies and procedures regarding billing and claims submission to insure they are appropriate, in place and being used. Staff will receive education/training on Medicaid’s allowed expenditures and the importance of accurate tracking of the various levels of patient care days. An audit will be developed and implemented on a regular basis to make sure that no nonallowable expenses are being submitted for payment and that all credit balances are refunded appropriately either back to Medicaid or to the former resident.
Findings in an audit of a nursing home by Tennessee State Auditors involved-nonallowable expenses, inaccurately reporting the number of residents’ days and failure to refund credit balances to former residents.
The audit found the nursing home had illegitimately filed claims and had been reimbursed for almost $50,000. These claims included disallowed expenses, misreporting of patient care days at Level 1 and Level 2.
The auditors also found that the nursing home had failed to refund credit balances totaling $32,000 to 68 residents who had been at the nursing home previously. Of this amount the audit said that $32,204.59 is owed to Medicaid and $885.70 is owed to two former Medicaid residents or their legal representatives.
The nursing home’s management made formal comments to address the audit’s findings and what was being done to address and correct them. The nursing homes officials reported that they “reviewed and modified their preparation process and educated their staff to ensure they correctly offset applicable marketing personnel.” They also said, all of the credit balances that were reviewed as part of this audit have been refunded to the appropriate payer(s).”
The auditors will be following up on these audit findings in June.
