The OIG found that Sunrise Hospital & Medical Center in Winchester, Nevada complied with Medicare billing requirements for 46 of the 100 inpatient and outpatient claims reviewed.
A version of this article was first published April 12, 2021, by HCPro's Revenue Cycle Advisor, a sibling publication to HealthLeaders.
Sunrise Hospital & Medical Center in Winchester, Nevada, submitted Medicare claims for rehabilitative services that did not comply with Medicare billing requirements, resulting in an estimated $23.6 million in overpayments submitted over a two-year period, according to an April Office of Inspector General (OIG) report.
To determine whether the hospital complied with Medicare billing requirements for certain rehabilitative services, the OIG reviewed a stratified random sample of 85 inpatient and 15 outpatient claims billed by the hospital under Medicare Part A between January 1, 2017, through December 31, 2018. The audit included several claim types including but not limited to:
- Inpatient claims with comprehensive error rate testing DRG codes
- Inpatient rehabilitation facility claims
- Outpatient claims paid in excess of $25,000
- Outpatient skilled nursing facility consolidated billing
The OIG found that Sunrise Hospital & Medical Center complied with Medicare billing requirements for 46 of the 100 inpatient and outpatient claims reviewed. The hospital did not fully comply with Medicare billing requirements for the remaining 54 claims. Specifically, 50 inpatient claims and 4 outpatient claims had billing errors, resulting in overpayments of $1,002,049.
The identified billing errors included unreasonable and unnecessary inpatient services because beneficiaries did not require the active and ongoing therapeutic intervention of multiple therapy disciplines; did not require and could not be expected to actively participate in, and benefit from, intensive rehabilitation; were not sufficiently stable at the time of admission; or did not require supervision by a rehabilitation physician.
The remaining billing errors were linked to claims incorrectly billed as inpatient, incorrect outlier payments, incorrectly billed outpatient modifiers, and incorrectly billed HCPCS codes.
Based on these findings, the OIG recommends that Sunrise Hospital & Medical Center:
- Refund to the Medicare contractor $23,606,895 in net estimated overpayments for the audit period
- Identify, report, and return any additional overpayments in accordance with the 60-day rule
- Strengthen controls to ensure proper coding and billing for certain rehabilitative services
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