Medicare Paid Millions More for Physician Services at Higher Nonfacility Rates Rather Than at Lower Facility Rates While Enrollees Were Inpatients of Facilities

Submitting OIG:

Department of Health & Human Services OIG

Date Issued:

Tuesday, May 30, 2023

Agency Reviewed / Investigated:

Department of Health & Human Services

Submitting OIG-Specific Report Number:

A-04-21-04084

Component, if applicable:

Centers for Medicare & Medicaid Services

Centers for Medicare and Medicaid Services

Location(s):

United States

Type of Report:

Audit

Questioned Costs:

$22,463,193

Funds for Better Use:

Number of Recommendations:

Report updated under NDAA 5274:

View Document:

Attachment	Size
42104084.pdf	2.58 MB

Recommendation Number	Recommendation Status	Significant Recommendation
23-A-04-080.01	Open	No
We recommend that the Centers for Medicare & Medicaid Services direct its Medicare contractors to reprocess the physician service claim lines during our audit period for which enrollees were Part A SNF inpatients but the services were incorrectly coded with the nonfacility place-of-services 32 (NF or SNF with no part A coverage) to recover $22,463,193.
23-A-04-080.02	Open	No
We recommend that the Centers for Medicare & Medicaid Services notify appropriate practitioners (i.e., those for whom CMS determines this audit constitutes credible information of potential overpayments) so that they can exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.
23-A-04-080.03	Open	No
We recommend that the Centers for Medicare & Medicaid Services establish CWF system edits to detect instances in which practitioners incorrectly use the nonfacility place-of-service code 32 (NF or SNF with no Part A coverage) while an enrollee is a Part A SNF inpatient and the nonfacility place-of-service-code causes a higher payment rate, and direct its Medicare contractors to apply these recommended CWF system edits retroactively or otherwise reprocess the claim lines for similarly coded physician services furnished after our audit period and before CMS establishes these edits.
23-A-04-080.04	Open	No
We recommend that the Centers for Medicare & Medicaid Services take the necessary steps, including seeking legislative authority, if necessary, to revise its regulations to ensure that Medicare pays the facility rate for physician services furnished while enrollees are Part A SNF or hospital inpatients irrespective of where the services are actually furnished or otherwise ensure that Medicare does not pay twice for any of the practice expenses incurred for physician services furnished while enrollees were Part A SNF or hospital inpatients, which could have resulted in the Medicare program paying up to $22,142,489 less and enrollees paying up to $5,609,125 less in cost-sharing during our 2-year audit period.
23-A-04-080.05	Open	No
We recommend that the Centers for Medicare & Medicaid Services consider developing a mechanism for SNFs and hospitals to indicate on the claim when a Part A inpatient leaves the facility and returns on the same day to help ensure that Medicare does not pay twice for any of the practice expenses incurred for physician services furnished while enrollees were Part A SNF or hospital inpatients.
23-A-04-080.06	Open	No
We recommend that the Centers for Medicare & Medicaid Services provide additional education to practitioners on the appropriate use of place-of-service codes while an enrollee is a Part A inpatient.

Recommendation Number

Recommendation Status

Significant Recommendation

Additional Details

23-A-04-080.01

Open

We recommend that the Centers for Medicare & Medicaid Services direct its Medicare contractors to reprocess the physician service claim lines during our audit period for which enrollees were Part A SNF inpatients but the services were incorrectly coded with the nonfacility place-of-services 32 (NF or SNF with no part A coverage) to recover $22,463,193.

23-A-04-080.02

Open

We recommend that the Centers for Medicare & Medicaid Services notify appropriate practitioners (i.e., those for whom CMS determines this audit constitutes credible information of potential overpayments) so that they can exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.

23-A-04-080.03

Open