Medicare Made $11.7 Million in Overpayments for Nonphysician Outpatient Services Provided Shortly Before or During Inpatient Stays

Submitting OIG:

Department of Health & Human Services OIG

Report Description:

Prior OIG audits identified significant overpayments to hospital outpatient providers for nonphysician services furnished shortly before or during inpatient stays. In those audits, we recommended that the Centers for Medicare & Medicaid Services (CMS) recover overpayments, ensure that edits to prevent such overpayments were in place and working properly, and educate providers on the proper billing of nonphysician outpatient services. CMS generally concurred with our recommendations and implemented them. However, our analysis of recent claim data indicated that overpayments for nonphysician outpatient services might still be occurring. We performed this audit as a followup to our previous work.

Date Issued:

Friday, May 1, 2020

Agency Reviewed / Investigated:

Department of Health & Human Services

Submitting OIG-Specific Report Number:

A-01-17-00508

Component, if applicable:

Centers for Medicare & Medicaid Services

Location(s):

Agency-Wide

Type of Report:

Audit

Questioned Costs:

$11,707,874

Funds for Better Use:

Number of Recommendations:

View Document:

Attachment	Size
11700508.pdf	2.66 MB

Additional Details Link:

https://oig.hhs.gov/oas/reports/region1/11700508.asp

Recommendation Number	Recommendation Status	Significant Recommendation
268843	Open	No
We recommended that CMS ensure that all necessary information is included in the CWF edits to accurately identify and prevent incorrect payments for nonphysician outpatient services provided within 3 days before the date of admission, on the date of admission, or during IPPS stay.
268844	Open	No
We recommended that CMS direct the Medicare contractors to recover the portion of $11.7 million in identified overpayments (for claims within the 4-year reopening period) resulting from the 40,984 incorrectly billed services and instruct the outpatient providers to refund the portion of the $2,785,607 in deductible and coinsurance amounts (for claims within the 4-year reopening period) that may have been incorrectly collected from beneficiaries or from someone on their behalf.
268864	Open	No
We recommended that CMS direct the MACs to based upon the results of this audit, notify the appropriate providers so that the providers 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
268865	Open	No
We recommended that CMS direct the MACs to educate outpatient providers on how to correctly bill nonphysician outpatient services provided within 3 days before the date of admission, on the date of admission, or during IPPS stays.

Recommendation Number

Recommendation Status

Significant Recommendation

Additional Details

268843

Open

We recommended that CMS ensure that all necessary information is included in the CWF edits to accurately identify and prevent incorrect payments for nonphysician outpatient services provided within 3 days before the date of admission, on the date of admission, or during IPPS stay.

268844

Open

We recommended that CMS direct the Medicare contractors to recover the portion of $11.7 million in identified overpayments (for claims within the 4-year reopening period) resulting from the 40,984 incorrectly billed services and instruct the outpatient providers to refund the portion of the $2,785,607 in deductible and coinsurance amounts (for claims within the 4-year reopening period) that may have been incorrectly collected from beneficiaries or from someone on their behalf.

268864

Open