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Report File
Date Issued
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-01-17-00508
Report Description

Prior OIG audits identified significant overpayments to hospital outpatient providers for nonphysician services furnished shortly before or during inpatient stays. In those audits, we recommended that the Centers for Medicare & Medicaid Services (CMS) recover overpayments, ensure that edits to prevent such overpayments were in place and working properly, and educate providers on the proper billing of nonphysician outpatient services. CMS generally concurred with our recommendations and implemented them. However, our analysis of recent claim data indicated that overpayments for nonphysician outpatient services might still be occurring. We performed this audit as a followup to our previous work.

Report Type
Audit
Agency Wide
Yes
Number of Recommendations
2
Questioned Costs
$11,707,874
Funds for Better Use
$0
Additional Details
https://oig.hhs.gov/oas/reports/region1/11700508.asp

Open Recommendations

This report has 4 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
268864 No $0 $0

We recommended that CMS direct the MACs to based upon the results of this audit, notify the appropriate providers 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

268865 No $0 $0

We recommended that CMS direct the MACs to educate outpatient providers on how to correctly bill nonphysician outpatient services provided within 3 days before the date of admission, on the date of admission, or during IPPS stays.

268843 No $0 $0

We recommended that CMS ensure that all necessary information is included in the CWF edits to accurately identify and prevent incorrect payments for nonphysician outpatient services provided within 3 days before the date of admission, on the date of admission, or during IPPS stay.

268844 No $11,707,874 $0

We recommended that CMS direct the Medicare contractors to recover the portion of $11.7 million in identified overpayments (for claims within the 4-year reopening period) resulting from the 40,984 incorrectly billed services and instruct the outpatient providers to refund the portion of the $2,785,607 in deductible and coinsurance amounts (for claims within the 4-year reopening period) that may have been incorrectly collected from beneficiaries or from someone on their behalf.

Department of Health & Human Services OIG

United States