Policy & Regulation News

Mission Hospital Billing Errors Result in Overbilling of $443K

By Ryan Mcaskill

- The Department of Health and Human Services’ (HHS) Office of Inspector General (OIG) released the results of a compliance review of Mission Hospital in Asheville, North Carolina. The audit was conducted for the calendar years of 2011 and 2012 and it was discovered that Mission Hospital did not fully comply with Medicare requirements for billing inpatient and outpatient services, resulting in overpayments of at least $443,183 over that time frame.

Mission, a 795-bed hospital, is part of the Mission Health System. According to Centers for Medicare & Medicaid Services’ (CMS) National Claims History data, during 2011 and 2012 Medicare paid Mission approximately $697 million for 53,057 inpatient and 295,685 outpatient claims for services provided to beneficiaries.

The audit itself covered $18,584,513 in Medicare payments to Mission for 2,105 claims that were potentially at risk for billing errors. A random sample of 192 claims were selected that totaled $2,760,822. and consisted of 110 inpatient and 82 outpatient claims.

The review found Mission complied with Medicare billing requirements for 144 of the 192 inpatient and outpatient claims. However, the remaining 48 claims contained errors and did not comply with billing requirements, resulting in overpayments of $121,594 during the audit period. More specifically, 28 inpatient claims had errors resulting in $100,165 in overpayments and 20 outpatient claims had errors resulting in overpayments of $21,429.

  • Accountable Care Organizations Need Financial Accountability
  • Atrius Health Makes the Business Case for Risk-Based Payments
  • CPT Codes Created for Novavax COVID-19 Vaccine, Administration
  • The errors occurred mainly because Mission did not have adequate controls to prevent incorrect billing of Medicare claims within the selected risk areas. Based on the sample, OIG estimates that Mission received overpayments of $443,183.

    OIG recommends that Mission refund the Medicare program $443,183 in estimated overpayments and strengthen controls to ensure that full compliance with Medicare requirements.

    Mission responded to the audit results and partially disagrees with the findings. The Hospital agrees that 23 claims were billed incorrectly, but debates the validity of the remaining 25 claims and plans to appeal each of them. Mission also disagrees with the extrapolation citing (1) the audit report had insufficient information to determine validity of the sample and (2) it did not provide details of the statistical methodology.

    Additional challenges that Mission has brought up include:

    • The timing of the review and directive mean no action should be taken until the review is finalized as Mission should not have been able to bill Medicare Part B for any claim under the timely filing rules.
    • Four of the disputed claims have record requests and denials already in place.
    • One medical device claim did not obtain a manufacturer’s credit.

    OIG responded to each of Mission’s objections and stands by its recommendations of repaying the Medicare program $443,183 and improving the controls to ensure full compliance.