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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
Federal Reports
Report Date
Agency Reviewed / Investigated
Report Title
Type
Location
Department of Health & Human Services
A South Texas Physical Therapist Claimed Unallowable Medicare Part B Reimbursement for Outpatient Physical Therapy Services
A physical therapist in South Texas claimed Medicare reimbursement for outpatient physical therapy services that did not meet Medicare reimbursement requirements in calendar years 2012 and 2013. Specifically, of the 100 beneficiary claim days in our random sample, the therapist properly claimed Medicare reimbursement on 81 beneficiary claim days, but improperly claimed Medicare reimbursement on the remaining 19 beneficiary claim days.
West Carroll Care Center Did Not Always Follow Care Plans for Residents Who Were Later Hospitalized With Potentially Avoidable Urinary Tract Infections
The West Carroll Care Center (the Nursing Home) (operating in Oak Grove, Louisiana) did not always provide service to its residents in accordance with their care plans, as required by Federal regulations, before the residents were hospitalized with urinary tract infections. Specifically, the Nursing Home did not monitor and document residents' hydration status, monitor and document the residents' conditions, and document residents' urine appearances as their care plans required.
For inpatient claims with certain Medicare Severity Diagnosis-Related Groups (MS-DRGs), Medicare requires that beneficiaries have received 96 or more hours of mechanical ventilation. For 137 of the 200 claims we reviewed, Medicare payments to hospitals complied with Medicare requirements; the beneficiaries had received 96 or more consecutive hours of mechanical ventilation. However, for the 63 remaining claims, Medicare payments to hospitals did not comply with requirements. Consequently, the claims were assigned incorrectly to MS DRGs 207 and 870, resulting in $1.5 million of overpayments. The hospitals confirmed that these claims were improperly billed and generally attributed the errors to incorrectly counting the number of hours that beneficiaries had received mechanical ventilation or to clerical errors in selecting the appropriate procedure code.
