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OIG Semiannual Report Notes Potential Overpayments for Outpatient Services

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Provider errors, unallowable services and insufficient documentation caused Medicare to overpay for outpatient services, according to the Office of Inspector General’s Semiannual Report for April through September.

OIG recommended that contractors implement “system edits to identify line item payments that exceed billed charges” and to use audit results it notes in the report. The reports include six jurisdictions.

·Palmetto GBA (Jurisdiction 1) – Almost 70 percent of the 1,323 selected line items for outpatient services were incorrect and included overpayments of about $7.5 million that had not been returned, OIG stated.

·Noridian Administrative Services (Jurisdiction 2) – Almost 70 percent of the 1,340 selected line items for outpatient services were incorrect and included overpayments of about $6.2 million that had not been returned, OIG stated.

·Noridian Administrative Services (Jurisdiction 3) – Almost 85 percent of the 1,913 selected line items for outpatient services were incorrect and included overpayments of about $5.8 million that had not been returned, OIG stated.

·National Government Services (Jurisdiction 8) – About 68 percent of the 1,407 selected line items for outpatient services were incorrect and included overpayments of about $7 million that had not been returned, OIG stated.

·First Coast Service Options (Jurisdiction 9) – Almost 78 percent of the 326 selected line items for outpatient services were incorrect and included overpayments of about $1.7 million that had not been returned, OIG stated.

·Highmark Medicare Services (Jurisdiction 12) – Almost 57 percent of the 739 selected line items for outpatient services were incorrect and included overpayments of about $532,000 that had not been returned, OIG stated.

For more on the Semiannual Report, visit http://oig.hhs.gov/reports-and-publications/archives/semiannual/2011/fall/HHS-OIG-SAR-Fall2011.pdf.

3 RACs Post New Issues

Region A, B and D recovery auditors posted issues recently. See below for more information.

Inpatient hospital

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Medical necessity review – MS-DRG 483, major joint-limb reattachment procedures of upper extremity with CC/MCC

11/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 607, minor skin disorders without MCC

11/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

Medical necessity review – MS-DRG 337, peritoneal adhesiolysis without CC/MCC

11/22/11

Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt.

Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730

 

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