Department of Health & Human Services OIG

Facet-joint injections of an anesthetic with or without a steroid are used to diagnose or treat chronic neck and back pain. To address inappropriate billing for pain management tied to overuse of spinal facet-joint injections, the Medicare Administrative Contractors (MACs) developed a limitation of...

The Hospital is a 599-bed short-term, acute care, for profit hospital, located in Las Vegas, Nevada. According to CMS’s National Claims History (NCH) data, Medicare paid the Hospital approximately $245 million for 15,000 inpatient and 25,308 outpatient claims from January 1, 2017, through December...

This audit is part of a series of hospital compliance audits. Using computer matching, data mining, and other data analysis techniques, we identified hospital claims that were at risk for noncompliance with Medicare billing requirements. For calendar year (CY) 2017, Medicare paid hospitals $206...

Our previous work at other hospitals identified these types of hospital claims, among others, that were at risk for noncompliance:• inpatient claims billed with elective surgical procedures,• inpatient claims billed with high-risk DRG codes, • inpatient claims billed with high-severity-level DRG...

Medicare payments may not be made for items or services that “are not reasonable andnecessary for the diagnosis or treatment of illness or injury or to improve the functioning of amalformed body member” (Social Security Act (the Act) § 1862(a)(1)(A)). In addition, the Actprecludes payment to any...

This audit is part of a series of hospital compliance audits. Using computer matching, data mining, and other data analysis techniques, we identified hospital claims that were at risk for noncompliance with Medicare billing requirements. For calendar year (CY) 2017, Medicare paid hospitals $206...

The Hospital complied with Medicare billing requirements for 54 of the 100 inpatient and outpatient claims we reviewed. However, the Hospital did not fully comply with Medicare billing requirements for the remaining 46 claims, resulting in overpayments of $1.6 million for the audit period...

The Medicare hospice benefit allows providers to claim Medicare reimbursement for hospice services provided to individuals with a life expectancy of 6 months or less and who have elected hospice care. Previous OIG reviews found that Medicare inappropriately paid for hospice services that did not...