tci Medicare Compliance & Reimbursement - 2003 Issue 19

Managed Care: THE DEVIL IS IN THE DETAILS WITH INSTITUTIONALIZED STATUS

Keeping up with the institutionalized status of Medicare beneficiaries enrolled in Medicare+ Choice plans has long been a compliance headache for managed care organizations - and persistent HHS Office of Inspector General scrutiny combined with nebulous requirements have only exacerbated the problem. Medicare pays a higher monthly rate to MCOs for beneficiaries who are institutionalized, and the OIG has undertaken a series of audits to make sure plans aren't collecting excess reimbursement by misclassifying the institutionalized status of their members. In its latest review of the issue - focusing on a Kansas City, MO plan - the watchdog agency...

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