OHSU Received $2.4M in Medicare Overpayments
A new study finds human error caused Oregon Health and Science University to receive overpayments between 2010 and 2012.
- The Department of Health and Human Services (HHS) Office of Inspector General (OIG) released a Medicare compliance review of Oregon Health and Science University (OHSU) for a three year span from 2010 through 2012. During this time, it was discovered that the University did not fully comply with Medicare requirements for billing inpatient services, resulting in overpayments of approximately $2.4 million over the time of the audit.
This review is part of a larger series of hospital compliance reviews that used computer matching, data mining and data analysis techniques to identify hospital claims that were at risk for noncompliance with Medicare billing requirements. In the calendar year of 2012, Medicare paid hospitals $148 billing, which represents 43 percent of all fee-for-service payments. This makes proper oversight more critical.
The OHSU is a 572-bed acute-care hospital located in Portland, Oregon. During the audit period, Medicare paid OHSU approximately $504 million for 24,249 inpatient and 390,167 outpatient claims for services provided to beneficiaries. The audit itself covered $3,506,361 in Medicare payments to OHSU for 113 claims that were selected as potentially at risk for billing errors. They were spread out over the three years and consist of 102 inpatient and 11 outpatient claims.
It was discovered that OHSU complied with Medicare billing requirements for 45 of the 102 inpatient claims and all 11 of the outpatient claims. However, the remaining 57 inpatient claims resulted in overpayments of $2,419,351 during the audit.
These errors are the results of inadequate controls to prevent the incorrect billing of Medicare claims. Specifically, the incorrect billing of Medicare Part A for beneficiary stays that should have been billed as outpatient or outpatient with observation services. Under Medicare, payments may not be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness, injury or to improve the functioning of a malformed body member.
The errors were also contributed to the staff’s reliance on screening tools used during the audit period. The tools indicate that stem cell transplants are appropriate for inpatient admission, however, these tools did not make a distinction between a full and reduced-intensity transplant. Because of this, OHSU staff believed inpatient level of care was needed. This led to 36 claims being classified as inpatient that were actually outpatient and aspects of an inpatient claim like a case management review did not always occur.
The OIG recommended that OHSU refund the $2,419,351 in overpayments to the Medicare contractor for the 57 incorrectly billed inpatient claims and strengthen controls to ensure full compliance with Medicare requirements. OHSU agreed with the findings and the recommendations and provided information on actions that it has taken to address them.
