Medicare Paid Millions More for Physician Services at Higher Nonfacility Rates Rather Than at Lower Facility Rates While Enrollees Were Inpatients of Facilities

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Date Issued

Tuesday, May 30, 2023

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

Components

Centers for Medicare and Medicaid Services

Report Number

A-04-21-04084

Report Type

Audit

Number of Recommendations

Questioned Costs

$22,463,193

Funds for Better Use

Open Recommendations

This report has 6 open recommendations.

Recommendation Number	Significant Recommendation	Recommended Questioned Costs	Recommended Funds for Better Use
23-A-04-080.01	No	$22,463,193	$0
We recommend that the Centers for Medicare & Medicaid Services direct its Medicare contractors to reprocess the physician service claim lines during our audit period for which enrollees were Part A SNF inpatients but the services were incorrectly coded with the nonfacility place-of-services 32 (NF or SNF with no part A coverage) to recover $22,463,193.
23-A-04-080.02	No	$0	$0
We recommend that the Centers for Medicare & Medicaid Services notify appropriate practitioners (i.e., those for whom CMS determines this audit constitutes credible information of potential overpayments) so that they 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.
23-A-04-080.03	No	$0	$0
We recommend that the Centers for Medicare & Medicaid Services establish CWF system edits to detect instances in which practitioners incorrectly use the nonfacility place-of-service code 32 (NF or SNF with no Part A coverage) while an enrollee is a Part A SNF inpatient and the nonfacility place-of-service-code causes a higher payment rate, and direct its Medicare contractors to apply these recommended CWF system edits retroactively or otherwise reprocess the claim lines for similarly coded physician services furnished after our audit period and before CMS establishes these edits.
23-A-04-080.04	No	$0	$0
We recommend that the Centers for Medicare & Medicaid Services take the necessary steps, including seeking legislative authority, if necessary, to revise its regulations to ensure that Medicare pays the facility rate for physician services furnished while enrollees are Part A SNF or hospital inpatients irrespective of where the services are actually furnished or otherwise ensure that Medicare does not pay twice for any of the practice expenses incurred for physician services furnished while enrollees were Part A SNF or hospital inpatients, which could have resulted in the Medicare program paying up to $22,142,489 less and enrollees paying up to $5,609,125 less in cost-sharing during our 2-year audit period.
23-A-04-080.05	No	$0	$0
We recommend that the Centers for Medicare & Medicaid Services consider developing a mechanism for SNFs and hospitals to indicate on the claim when a Part A inpatient leaves the facility and returns on the same day to help ensure that Medicare does not pay twice for any of the practice expenses incurred for physician services furnished while enrollees were Part A SNF or hospital inpatients.
23-A-04-080.06	No	$0	$0
We recommend that the Centers for Medicare & Medicaid Services provide additional education to practitioners on the appropriate use of place-of-service codes while an enrollee is a Part A inpatient.