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首页> 美国政府科技报告 >Review of High-Dollar Payments for Inpatient Services Processed by Wisconsin Physicians Service for Calendar Years 2004 through 2005 Hospitals with Five or more High-Dollar Payments
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Review of High-Dollar Payments for Inpatient Services Processed by Wisconsin Physicians Service for Calendar Years 2004 through 2005 Hospitals with Five or more High-Dollar Payments

机译：2004年至2005年威斯康星医师服务处理的住院服务高额美元支付回顾五年或五年以上高额医疗费用的医院

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Pursuant to Title XVIII of the Social Security Act (the Act), the Medicare program provides health insurance for people age 65 and over and those who are disabled or have permanent kidney disease. The Centers for Medicare & Medicaid Services (CMS), which administers the program, contracts with fiscal intermediaries to process and pay Medicare Part A claims submitted by hospitals. The intermediaries use the Fiscal Intermediary Standard System and CMSs Common Working File to process claims. The Common Working File can detect certain improper payments during prepayment validation. Section 1886(d) of the Act established the prospective payment system for inpatient hospital services. Under the prospective payment system, CMS pays hospital costs at predetermined rates for patient discharges based on the diagnosis-related group to which a beneficiarys stay is assigned. The Medicare Claims Processing Manual, Pub. No. 100-04, chapter 3, section 10.1, requires that hospitals submit claims on the appropriate forms for all provider billings, and chapter 1, section 80.3.2.2, requires that claims be completed accurately to be processed correctly and promptly. The diagnosis-related group payment is, with certain exceptions, payment in full to the hospital for all inpatient services. Section 6011 of the Omnibus Budget Reconciliation Act of 1989 (P.L. No. 101-239) provides that prospective payment system hospitals receive payment, in addition to the basic diagnosis-related group payment, for blood clotting factor administered to hemophilia inpatients. Also, section 1886(d)(5)(A)(ii) of the Act provides for an additional payment, known as an outlier payment, to hospitals for cases incurring extraordinarily high costs. During calendar years 2004 through 2006, Mutual of Omaha Insurance Company was a fiscal intermediary for providers in all States except New York. Mutual of Omaha Insurance Company processed approximately 6.9 million inpatient claims during this period, 520 of which resulted in payments of $200,000 or more (high-dollar payments) to hospitals that each received 5 or more such payments. In November 2007, Wisconsin Physicians Service assumed the fiscal intermediary operations of Mutual of Omaha Insurance Company. Our objective was to determine whether selected high-dollar Medicare payments that Wisconsin Physicians Service made to hospitals for inpatient services were appropriate.

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