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CMS Improperly Paid $38M for ED Outpatient Imaging, OIG Says

John Commins, for HealthLeaders Media, April 20, 2011

The Centers for Medicare & Medicaid Services' "inconsistent payment guidance" erroneously allowed about $38 million for improperly documented imaging claims in hospital outpatient emergency departments in 2008, a Department of Health and Human Services Office of Inspector General audit has determined.

A breakdown of the erroneous payments included 19% of claims -- with a value of $29 million -- for interpretation and reports for computed tomography and magnetic resonance imaging and 14% of claims -- valued at $9 million -- for interpretation and reports for X?rays, the OIG audit found.

Of the allowed Medicare claims for CTs and MRIs in hospital outpatient EDs in 2008, the OIG audit found that:

  • 12% ($18 million) did not have physicians' orders as part of the medical record
  • 12% ($19 million) did not have documentation to support that interpretation had been performed
  • 5% ($7.3 million) had overlapping errors

Of the allowed Medicare claims for X-rays in hospital outpatient EDs in 2008, the OIG audit found that

  • 8.6% ($5.5 million) did not have physicians' orders as part of the medical record
  • 8.2% ($5.4 million) did not have documentation to support that interpretation had been performed
  • 3% ($1.9 million) of claims had overlapping errors

The audit also found that 12% ($19 million) of CT and MRI claims and 16% ($10 million) of X-ray claims were for interpretation and reports that, while not erroneous, were performed after beneficiaries left EDs, OIG said. 

OIG blamed the overpayments on what it said was CMS' "inconsistent payment guidance on the timing for interpretation. In 2008, 71% of interpretation and reports for X?rays and 69% of interpretation and reports for CTs and MRIs did not follow one or more of the American College of Radiology-suggested documentation guidelines." 

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1 comments on "CMS Improperly Paid $38M for ED Outpatient Imaging, OIG Says"


Mike domer (4/20/2011 at 9:39 AM)
Notice - no discussion of whether the exams were medically necessary for the patients care. That is not questioned in any way. No doubt there was a patient with a medical need in the ED that was addressed by the Medical Staff. So, one can assume the care was necessary and now Medicare doesn't want to pay because an i wasn't dotted or a t wasn't crossed - ie bureaucratic you know what. If the service was medically necessary pay the claim. If Medicare doesn't that cost is PASSED ON TO THE REST OF US THROUGH HIGHER CHARGES TO BLUE CROSS ET AL. It is a hidden tax on the consumer.