Over $400K in Medicare Reimbursed
Boone Hospital did not fully comply with Medicare billing requirements, resulting in overpayments of $407,495.
- The Department of Health and Human Service (HHS) Office of Inspector General (OIG) released the results of its audit on Boone Hospital (the Hospital) to determine if Medicare payments to the Hospital for 307 claims complied with Medicare requirements for billing outpatient and inpatient services during calendar year (CY) 2012. During this audit it was discovered that the Hospital did not fully comply with Medicare billing requirements, resulting in overpayments of $407,495.
The Centers for Medicare & Medicaid Services (CMS) pays for hospital outpatient services on a rate-per-service basis that varies according to the ambulatory payment classification. CMS also pays inpatient hospital costs at predetermined rates for patient discharges. The rates vary according to the diagnosis-related group (DRG) to which a beneficiary’s stay is assigned and the severity level of the patient’s diagnosis is assessed. OIG is responsible for providing continual and adequate oversight of Medicare payments to hospitals.
The Hospital, located in Columbia, Missouri, filed 17,565 inpatient and 93,826 outpatient claims for services provided to beneficiaries during CYs 2010 and 2011. Medicare paid the Hospital approximately $193 million for these claims.
However, it was discovered that the Hospital did not fully comply with Medicare billing requirements for 105 out of 307 claims, resulting in overpaymentsof $407,495 for CYs 2010 and 2011 and CYS 2009 and 2012. Sixty seven inpatient claims had billing errors, resulting in overpayments of $306,094, and 38 outpatient claims had billing errors, resulting in net overpayments of $101,401.
“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,” the report reads.
OIG recommended that the Hospital refund the Medicare contractor $407,495, consisting of $306,094 in overpayments for 67 incorrectly billed inpatient claims and $101,401 in overpayments for 37 incorrectly billed outpatient claims. OIG also recommended that the Hospital determine the amount of overpayment for the one outpatient claim that had not been reprocessed and refund that amount to Medicare, and that the Hospital strengthen its controls to ensure full compliance with Medicare requirements.
In written comments the Hospital agreed with the OIG’s findings and recommendations.
“In response to the audit we want to assure you that Boone Hospital Center is committed to ensuring appropriate operational procedures and controls are in place to minimize the risk of billing errors.” The Hospital wrote in response. The hospital then indicated that it had fully reimbursed the overpayment as the audit had indicated and were implementing new procedures to ensure future compliance with Medicare requirements. Some of the changes the Hospital intends to make are developing and instating a new front end process, and continuing feedback and education to staff to reduce the possibility of human error.
