Inadequate training, staff errors lead to Medicare overpayments at Jefferson, other hospitals

Hospitals are chalking up Medicare overpayments to inadequate training and inadvertent errors in three recent audits by the Office of the Inspector General, released last month.

For example, Thomas Jefferson University Hospitals in Philadelphia received $43,000 in overpayments because it incorrectly billed for inpatient same-day readmissions. In four of the 133 same-day readmissions that OIG looked at, Jefferson inappropriately billed the second admission as a separate inpatient stay instead of a continuous stay.

Jefferson's case management personnel misinterpreted the readmissions and determined they weren't related to the first admission, but OIG in its report said the readmissions were, in fact, related to the prior stays and should have been billed as such. OIG also determined Jefferson did not have adequate training to review same-day readmissions.

In a letter to the OIG, Jefferson CEO and President Thomas Lewis said it has implemented a same-day admission and repeat policy to identify and notify providers of the federal regulations and expanded its Medicare continuous stay policy. Jefferson also provided additional training.

Jefferson isn't alone in misinterpreting federal requirements. Similarly, St. Vincent's Medical Center in Bridgeport, Conn., didn't fully understand Medicare billing requirements for 41 inpatient and outpatient claims out of the 198 reviewed claims, the OIG found. The errors resulted in more than a quarter of a million dollars ($284,773) in overpayments in 2009 and 2010.

Although another hospital, Carolinas Medical Center in North Carolina, received nearly $6,000 in overpayments, the health system said the reason was inadvertent keying errors by new coding staff and not a lack of training. The OIG found that the Carolinas Medical Center had errors in eight of the 73 brachytherapy (Iridium-192) Medicare claims the agency reviewed.

In efforts to curb overall spending, the administration has voiced aggressive campaigns to curb overpayments due to fraud or errors. The Centers for Medicare & Medicaid Services, for example, will begin to conduct Recovery Audit Prepayment reviews June 1.

RACs identified and collected $397.8 million in overpayments during the first quarter of fiscal 2012 (October through December 2011)--the largest amount of improper payments recovered during one quarter since the RAC program began.

For more information:
- see the Thomas Jefferson University Hospitals audit report (.pdf)
- read the St. Vincent's Medical Center audit report (.pdf)
- here's the Carolinas Medical Center audit report (.pdf)
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