A new government report claims that Medicare overpaid Rush University Medical Center by $10.2 million, and the agency wants the money back. But the Chicago academic medical center disagrees with the findings.
The Department of Health and Human Services Office of Inspector General said it conducted the investigation as part of a series of hospital compliance reviews to determine whether organizations were at risk for noncompliance with Medicare billing requirements, particularly for medical necessity and coding requirements.
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The audit (PDF) revealed that the organization complied with 63 of the 120 inpatient and outpatient claims reviewed for the 2014 and 2015 audit period. However, the OIG found billing errors in the remaining 57 claims, resulting in overpayments of $814,000 for those calendar years. The inpatient billing errors including billing inpatient rehabilitation facility services as inpatient services and incorrectly billing diagnosis-related group codes. Outpatient billing errors including insufficient documentation in the medical record and incorrectly billing outpatient services with modifier -59.
Based on the sample results, the OIG said it estimated the hospital received overpayments of approximately $10.2 million for the audit period.
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Although it’s unclear whether the hospital will appeal the findings, it does dispute many of the OIG’s findings and recommendations. In a letter to the OIG dated Oct. 5, which was included in the report, Janis Anfossi, associate compliance officer at Rush, said the organization disagrees with the conclusions for more than half of the inpatient rehabilitation cases reviewed and it doesn’t know enough about the OIG’s methodology to confirm the amount the agency extrapolated from the sample is correct.
“That said, we are committed to making prompt repayment of any overpayments we have identified, and we will continue to work with you and other appropriate government representatives regarding a process for quantifying any overpayment and potential refund amounts,” she wrote.
Furthermore, Anfossi said, the hospital’s compliance program conducted a six-year look-back audit for inpatient rehabilitation to assess or than what the OIG examined. The financial error rate across that period was substantially less than what the OIG identified in its sample, she said.
The OIG, however, maintains its findings and recommendations are valid. The claims were subject to a focused medical review to determine whether the services met medically necessity and coding requirements, it said. Each denied case was reviewed by two clinicians, including a physician. “We stand by those determinations,” the OIG report concluded.