An Estimated 87 Percent of Inpatient Psychiatric Facility Claims With Outlier Payments Did Not Meet Medicare's Medical Necessity or Documentation Requirements

Submitting OIG:

Department of Health & Human Services OIG

Report Description:

Under the inpatient psychiatric facility (IPF) prospective payment system (PPS), Medicare pays IPFs a standard per diem rate for inpatient services, modified for patient- and facility-level characteristics and length of stay. In addition, the IPF PPS includes an outlier payment policy that makes an additional payment in cases with unusually high costs to limit financial losses to IPFs.

Date Issued:

Thursday, April 9, 2020

Agency Reviewed / Investigated:

Department of Health & Human Services

Submitting OIG-Specific Report Number:

A-01-16-00508

Component, if applicable:

Centers for Medicare & Medicaid Services

Location(s):

Agency-Wide

Type of Report:

Audit

Questioned Costs:

Funds for Better Use:

Number of Recommendations:

View Document:

Attachment	Size
11600508.pdf	2.23 MB

Additional Details Link:

https://oig.hhs.gov/oas/reports/region1/11600508.asp

Recommendation Number	Recommendation Status	Significant Recommendation
268603	Open	No
We recommend that the Centers for Medicare & Medicaid Services increase the number of postpayment reviews of IPF claims to provide IPFs with more feedback on their compliance with Medicare requirements.
268604	Open	No
We recommend that the Centers for Medicare & Medicaid Services research whether the physician certification and recertification requirements are useful in preventing inappropriate payments and: - if they are useful, continue to enforce them but - if they are not useful, take the steps necessary to eliminate or amend those requirements.
268605	Open	No
We recommend that the Centers for Medicare & Medicaid Services, while the certification requirements remain in place, revise regulations or guidance to IPFs to require that physician certifications and recertifications be in a specific form, format, or language.
268606	Open	No
We recommend that the Centers for Medicare & Medicaid Services promulgate regulations to require that each IPF should have a policy compliant with State law to protect and promote the patient’s right to make informed decisions that includes standards for documenting the patient’s ability to make informed decisions.
268608	Open	No
We recommend that the Centers for Medicare & Medicaid Services reassess the current CMS reimbursement policy for administrative necessary days that meet inpatient coverage requirements because the beneficiary has not met his or her discharge requirements to determine payment accuracy and effects on beneficiaries.
268609	Open	No
We recommend that the Centers for Medicare & Medicaid Services determine whether patient in-hospital fall rates should be added to the IPFQR program and whether CMS should require present-on-admission indicators on claims as an aid to tracking in-hospital falls.

Recommendation Number

Recommendation Status

Significant Recommendation

Additional Details

268603

Open

We recommend that the Centers for Medicare & Medicaid Services increase the number of postpayment reviews of IPF claims to provide IPFs with more feedback on their compliance with Medicare requirements.

268604

Open

We recommend that the Centers for Medicare & Medicaid Services research whether the physician certification and recertification requirements are useful in preventing inappropriate payments and: - if they are useful, continue to enforce them but - if they are not useful, take the steps necessary to eliminate or amend those requirements.

268605

Open