Federal Reports

The Vanderbilt University Medical Center (the Hospital), located in Nashville, Tennessee, complied with Medicare billing requirements for 172 of the 245 inpatient and outpatient claims we reviewed. However, the Hospital did not fully comply with Medicare billing requirements for the remaining 73 claims, resulting in net overpayments of $305,000. Specifically, 34 inpatient claims had billing errors resulting in net overpayments of $221,000, and 39 outpatient claims had billing errors resulting in overpayments of $84,000. These errors occurred primarily because the Hospital did not have adequate controls to prevent the incorrect billing of Medicare claims within the selected risk areas that contained errors. On the basis of our sample results, we estimated that the Hospital received overpayments of at least $1.14 million for the audit period. During the course of our audit, the Hospital reprocessed 30 claims with overpayments of $134,000 that we verified as correctly reprocessed. Accordingly, we have reduced the recommended refund by this amount.

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.

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.