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 31, 2018 (audit period).Our audit covered about $41 million in Medicare payments to the Hospital for 2,117 claims that were potentially at risk for billing errors. We selected for review a stratified random sample of 100 claims (85 inpatient and 15 outpatient) with payments totaling $2.4 million. Medicare paid these 100 claims during our audit period.We focused our audit on the risk areas that we identified as a result of prior OIG audits at other hospitals. We evaluated compliance with selected billing requirements.
Open Recommendations
| Recommendation Number | Significant Recommendation | Recommended Questioned Costs | Recommended Funds for Better Use | Additional Details | |
|---|---|---|---|---|---|
| 270344 | No | $0 | $0 | ||
| 1. We recommend that Sunrise Hospital & Medical Center refund to the Medicare contractor $23,606,895 ($23,615,809 less $8,914 that the Hospital has already repaid) in net estimated overpayments for the audit period for claims that it incorrectly billed that are within the 4-year reopening period. | |||||
| 270346 | No | $0 | $0 | ||
| 3. We recommend that Sunrise Hospital & Medical Center strengthen controls to ensure that: (1) all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation and all required documentation is included in the medical records, (2) all inpatient beneficiaries meet Medicare requirements for inpatient hospital services, (3) outlier payments are calculated correctly by billing the correct units of service and charges on the claim and staff are properly trained, (4) the use of bypass modifiers is supported in the medical records and staff are properly trained, and (5) HCPCS codes are supported in the medical records and staff are properly trained. | |||||
