tci Medicare Compliance & Reimbursement - 2019 Issue Q4

Industry Note: Faulty Reconciliation Policy Cost Feds Millions

Outlier behavior can prove problematic for providers, but also for the federal programs that govern them. Context: After uncovering issues with the Centers for Medicare & Medicaid Services’ (CMS) reconciliation policies for hospitals that received outlier claims payments, the HHS Office of Inspector General (OIG) conducted a study to pinpoint the problem. “Our objective was to determine whether CMS paid hospitals more for Medicare outlier payments than the hospitals would have been paid if their outlier payments had been reconciled,” notes the OIG brief. Findings: As a sampling, OIG pulled claims data for 60 hospitals for the...

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