Federal Reports

Promise Hospital of Ascension (The Hospital), in Gonzales, Louisiana, did not comply with Medicare requirements for billing Kwashiorkor on any of the 62 claims that we reviewed. The Hospital used diagnosis code 260 for Kwashiorkor but should have billed for other forms of malnutrition or no malnutrition at all. For four of the inpatient claims, substituting a more appropriate diagnosis code produced no change in the diagnosis-related group or payment amount. However, for the remaining 58 inpatient claims, the errors resulted in overpayments of $465,000. The Hospital believes that all claims that we identified were appropriately submitted for payment.

Medicare paid 10 of 143 selected inpatient claims for bone marrow and stem cell transplant procedures in accordance with Medicare requirements. However, 133 claims did not comply with those requirements. For 120 of these claims, the hospitals incorrectly billed Medicare Part A for beneficiary stays that should have been billed as outpatient or outpatient with observation services. These claims did not have clinical evidence supporting that an inpatient level of care was required before, during, or after the transplant procedures were performed. For the remaining 13 claims, the hospitals billed incorrect Medicare Severity Diagnosis-Related Groups (MS DRGs). As a result of the 133 errors, Medicare overpaid the hospitals by $6.3 million. Medicare overpaid the hospitals because existing controls were not effective in preventing the overpayments.