CMS's System Edits Significantly Reduced Improper Payments to Acute-Care Hospitals After May 2019 for Outpatient Services Provided to Beneficiaries Who Were Inpatients of Other Facilities

Submitting OIG:

Date Issued:

Thursday, September 22, 2022

Agency Reviewed / Investigated:

Submitting OIG-Specific Report Number:

A-09-22-03007

Component, if applicable:

Centers for Medicare & Medicaid Services

Centers for Medicare and Medicaid Services

Location(s):

United States

Type of Report:

Audit

Questioned Costs:

$39,310,499

Funds for Better Use:

Number of Recommendations:

View Document:

Attachment	Size
92203007.pdf	1.31 MB

Recommendation Number	Recommendation Status	Significant Recommendation
22-A-09-102.01	Open	No
We recommend that the Centers for Medicare & Medicaid Services: direct the MACs to recover from acute-care hospitals the portion of the $39,310,499 in identified improper payments for our audit period that are within the 4-year reopening period in accordance with CMS's policies and procedures;
22-A-09-102.03	Open	No
based upon the results of this audit, notify appropriate providers (i.e., those for whom CMS determines this audit constitutes credible information of potential overpayments) 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;
22-A-09-102.04	Open	No
identify any outpatient claims after our audit period for services provided to beneficiaries who were inpatients of other facilities and direct the MACs to recover any improper payments;

Recommendation Number

Recommendation Status

Significant Recommendation

Additional Details

22-A-09-102.01

Open

22-A-09-102.03

Open

22-A-09-102.04

Open