New York Hospital to Pay $7 Million in Civil Fraud Settlement

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Original story posted on: October 26, 2012

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Westchester Medical Center in Valhalla, N.Y., billed Medicaid for outpatient services at its mental health center that did have required documentation, according to the U.S. Attorney’s Office in southern New York.

From August 2001 to June 2010, the hospital’s mental health outpatient clinics did not have the core documentation, such as progress notes and treatment plans, that ensure billed services were provided, the U.S. Attorney’s Office stated.

The medical center management “knew for years that the outpatient mental health clinics were missing documentation,” the U.S. Attorney’s Office stated. Until June 2010, the medical center failed to take “any but the most insignificant steps” to address problems or to conduct audits of clinic records. It also did not return millions of dollars in Medicaid funds that it was overpaid for services without proper documentation.

The $7 million civil fraud settlement was announced Oct. 24.

RAC Issues

Region C recovery auditor (RAC) Connolly joined HealthDataInsights, the Region D RAC, in posting a pre-payment review issue as part of CMS’ demonstration. The issue is the same – reviewing MS-DRG 312 (synocope and collapse) – but affects Florida, Louisiana, North Carolina and Texas.

Connolly does not list a description of the issue on its website, but HealthDataInsights explains it this way: “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. DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 312, principal diagnosis, secondary diagnosis and procedures affecting or potentially affecting the DRGs.”

For more, check the RACs’ websites or CMS’ website for the RAC pre-payment review demonstration at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/CERT/RAC-Prepay-Review.html.

Inpatient hospital

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

CMS pre-pay demonstration: MS-DRG 312 (synocope and collapse)

8/27/12

Fla., La., N.C., Texas,

(None listed on Connolly website.)

CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapters 6, 13

About the Author

Karen Long is the editor of Physician Solutions for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

Contact the Author

KLong@decisionhealth.com

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Karen Long

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