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

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Date Issued

Thursday, April 9, 2020

Submitting OIG

Department of Health & Human Services OIG

Other Participating OIGs

Department of Health & Human Services OIG

Agencies Reviewed/Investigated

Department of Health & Human Services

Report Number

A-01-16-00508

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.

Report Type

Audit

Agency Wide

Yes

Number of Recommendations

Questioned Costs

Funds for Better Use

Additional Details

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

Open Recommendations

This report has 6 open recommendations.

Recommendation Number	Significant Recommendation	Recommended Questioned Costs	Recommended Funds for Better Use
268603	No	$0	$0
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.
268608	No	$0	$0
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.
268606	No	$0	$0
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.
268604	No	$0	$0
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	No	$0	$0
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.
268609	No	$0	$0
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.