Department of Health

Monitoring of Medicaid Payments for Nursing Home Bed Reserve Days

If a Medicaid-eligible nursing home patient needs to be temporarily hospitalized, Medicaid will often pay the nursing home to reserve a bed for a limited number of days pending the patientís return. Our audit determined whether nursing home claims submitted to Medicaid for bed reserve days were appropriate, and if not, to what extent did nursing home claims exceed the bed reserve day limits and if Medicaid overpayments were made. We audited the claims filed by two nursing homes which accounted for over 60 percent ($17.6 million) of these payments. We found the claims for both exceeded the number of days allowed and both had been systematically miscoding claims for days that should have been billed as standard care because the patients were no longer hospitalized. Because the reimbursement rates were the same for standard and reserve care during our audit period, we determined that no significant overpayments occurred.

However, the law was amended in June 2010 to reduce the number of days for bed reserve claims for each patient and the rate paid for these days. Therefore, it is likely that, if the billing errors we identified continue, overpayments will be made in the future. We concluded the Department needs to take proactive steps to remind nursing homes of the proper methods for coding bed reserve claims and needs to improve its monitoring and oversight of these claims.

For a complete copy of Report 2010-S-21 click here.