type: other

jurisdiction: US

text: b' DEPARTMENT OF HEALTH & HUMAN SERVICES Office of Inspector General\n\n Washington, D.C. 20201\n\n\n\n\nJanuary 30, 2012\n\nTO: Peter Budetti\n Deputy Administrator and Director\n Center for Program Integrity\n Centers for Medicare & Medicaid Services\n\n Deborah Taylor\n Director and Chief Financial Officer\n Office of Financial Management\n Centers for Medicare & Medicaid Services\n\nFROM: /Brian P. Ritchie/\n Assistant Inspector General for the\n Centers for Medicare & Medicaid Audits\n\nSUBJECT: Medicare Compliance Review of Kendall Regional Medical Center for Calendar\n Years 2009 and 2010 (A-04-11-07022) and Medicare Compliance Review of\n Springhill Medical Center for Calendar Years 2008 and 2009 (A-04-11-03067)\n\n\nAttached, for your information, are advance copies of our final reports for two of our hospital\ncompliance reviews. We will issue these reports to Kendall Regional Medical Center and\nSpringhill Medical Center within 5 business days.\n\nThese reports are part of a series of the Office of Inspector General\xe2\x80\x99s hospital compliance\ninitiative, designed to review multiple issues concurrently at individual hospitals. These reviews\nof Medicare payments to hospitals examine selected claims for inpatient and outpatient services.\n\nIf you have any questions or comments about these reports, please do not hesitate to contact me\nat (410) 786-7104 or through email at Brian.Ritchie@oig.hhs.gov or your staff may contact\nLori S. Pilcher, Regional Inspector General for Audit Services, Region IV, at (404) 562-7750, or\nthrough email at Lori.Pilcher@oig.hhs.gov.\n\nAttachment\n\ncc:\nJacquelyn White, Director\nOffice of Strategic Operations and Regulatory Affairs\nCenters for Medicare & Medicaid Services\n\x0c DEPARTMENT OF HEALTH & HUMAN SERVICES OFFICE OF INSPECTOR GENERAL\n\n\n Office of Audit Services, Region IV\n 61 Forsyth Street, SW, Suite 3T41\n Atlanta, GA 30303\nFebruary 1, 2012\n\nReport Number: A-04-11-07022\n\nMr. Ricardo Pavon\nChief Financial Officer\nKendall Regional Medical Center\n11750 Bird Road\nMiami, FL 33175\n\nDear Mr. Pavon:\n\nEnclosed is the U.S. Department of Health and Human Services, Office of Inspector General\n(OIG), final report entitled Medicare Compliance Review of Kendall Regional Medical Center\nfor Calendar Years 2009 and 2010. We will forward a copy of this report to the HHS action\nofficial noted on the following page for review and any action deemed necessary.\n\nThe HHS action official will make final determination as to actions taken on all matters reported.\nWe request that you respond to this official within 30 days from the date of this letter. Your\nresponse should present any comments or additional information that you believe may have a\nbearing on the final determination.\n\nSection 8L of the Inspector General Act, 5 U.S.C. App., requires that OIG post its publicly\navailable reports on the OIG Web site. Accordingly, this report will be posted at\nhttp://oig.hhs.gov.\n\nIf you have any questions or comments about this report, please do not hesitate to call me, or\ncontact Denise R. Novak, Audit Manager, at (305) 536-5309, extension 10, or through email at\nDenise.Novak@oig.hhs.gov. Please refer to report number A-04-11-07022 in all\ncorrespondence.\n\n Sincerely,\n\n\n\n /Lori S. Pilcher/\n Regional Inspector General\n for Audit Services\n\n\nEnclosure\n\x0cPage 2 \xe2\x80\x93 Mr. Ricardo Pavon\n\nDirect Reply to HHS Action Official:\n\nMs. Nanette Foster Reilly\nConsortium Administrator\nConsortium for Financial Management & Fee for Service Operations\nCenters for Medicare & Medicaid Services\n601 East 12th Street, Room 235\nKansas City, MO 64106\n\x0c Department of Health and Human Services\n OFFICE OF\n INSPECTOR GENERAL\n\n\n\n\n MEDICARE COMPLIANCE REVIEW OF\nKENDALL REGIONAL MEDICAL CENTER\nFOR CALENDAR YEARS 2009 AND 2010\n\n\n\n\n Daniel R. Levinson\n Inspector General\n\n February 2012\n A-04-11-07022\n\x0c Office of Inspector General\n http://oig.hhs.gov\n\n\n\nThe mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, is\nto protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the\nhealth and welfare of beneficiaries served by those programs. This statutory mission is carried out\nthrough a nationwide network of audits, investigations, and inspections conducted by the following\noperating components:\n\nOffice of Audit Services\n\nThe Office of Audit Services (OAS) provides auditing services for HHS, either by conducting audits with\nits own audit resources or by overseeing audit work done by others. Audits examine the performance of\nHHS programs and/or its grantees and contractors in carrying out their respective responsibilities and are\nintended to provide independent assessments of HHS programs and operations. These assessments help\nreduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS.\n\nOffice of Evaluation and Inspections\nThe Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress,\nand the public with timely, useful, and reliable information on significant issues. These evaluations focus\non preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness of\ndepartmental programs. To promote impact, OEI reports also present practical recommendations for\nimproving program operations.\n\nOffice of Investigations\nThe Office of Investigations (OI) conducts criminal, civil, and administrative investigations of fraud and\nmisconduct related to HHS programs, operations, and beneficiaries. With investigators working in all 50\nStates and the District of Columbia, OI utilizes its resources by actively coordinating with the Department\nof Justice and other Federal, State, and local law enforcement authorities. The investigative efforts of OI\noften lead to criminal convictions, administrative sanctions, and/or civil monetary penalties.\n\nOffice of Counsel to the Inspector General\nThe Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering\nadvice and opinions on HHS programs and operations and providing all legal support for OIG\xe2\x80\x99s internal\noperations. OCIG represents OIG in all civil and administrative fraud and abuse cases involving HHS\nprograms, including False Claims Act, program exclusion, and civil monetary penalty cases. In\nconnection with these cases, OCIG also negotiates and monitors corporate integrity agreements. OCIG\nrenders advisory opinions, issues compliance program guidance, publishes fraud alerts, and provides\nother guidance to the health care industry concerning the anti-kickback statute and other OIG enforcement\nauthorities.\n\x0c Notices\n\n\n THIS REPORT IS AVAILABLE TO THE PUBLIC\n at http://oig.hhs.gov\n\n Section 8L of the Inspector General Act, 5 U.S.C. App., requires\n that OIG post its publicly available reports on the OIG Web site.\n\nOFFICE OF AUDIT SERVICES FINDINGS AND OPINIONS\n\n The designation of financial or management practices as\n questionable, a recommendation for the disallowance of costs\n incurred or claimed, and any other conclusions and\n recommendations in this report represent the findings and\n opinions of OAS. Authorized officials of the HHS operating\n divisions will make final determination on these matters.\n\x0c EXECUTIVE SUMMARY\n\nBACKGROUND\n\nTitle XVIII of the Social Security Act (the Act) established the Medicare program, which\nprovides health insurance coverage to people aged 65 and over, people with disabilities, and\npeople with end-stage renal disease. The Centers for Medicare & Medicaid Services (CMS)\nadministers the Medicare program.\n\nSection 1886(d) of the Act established the inpatient prospective payment system (IPPS) for\nhospital inpatient services. Under the IPPS, CMS pays hospital costs at predetermined rates for\npatient discharges. The rates vary according to the diagnosis-related group (DRG) to which a\nbeneficiary\xe2\x80\x99s stay is assigned. The DRG payment is, with certain exceptions, payment in full to\nthe hospital for all inpatient costs associated with the beneficiary\xe2\x80\x99s stay.\n\nCMS implemented an outpatient prospective payment system (OPPS) for hospital outpatient\nservices, as mandated by the Balanced Budget Act of 1997, P.L. No. 105-33, and the Medicare,\nMedicaid, and SCHIP (State Children\xe2\x80\x99s Health Insurance Program) Balanced Budget Refinement\nAct of 1999, P.L. No. 106-113. Under the OPPS, Medicare pays for hospital outpatient services\non a rate-per-service basis that varies according to the assigned ambulatory payment\nclassification.\n\nPrior Office of Inspector General (OIG) audits, investigations, and inspections identified certain\npayments to hospitals that are at risk for noncompliance with Medicare billing requirements.\nOIG identified these types of payments to hospitals using computer matching, data mining, and\nanalysis techniques. This review is part of a series of OIG reviews of Medicare payments to\nhospitals for selected claims for inpatient and outpatient services.\n\nKendall Regional Medical Center (the Hospital) is a 412-bed acute care hospital located in\nMiami, Florida. Medicare paid the Hospital approximately $89 million for 17,220 inpatient and\n18,992 outpatient claims for services provided to beneficiaries during calendar years (CY) 2009\nand 2010 based on CMS\xe2\x80\x99s National Claims History data.\n\nOur audit covered $2,233,628 in Medicare payments to the Hospital for 108 claims that we\nselected as potentially at risk for billing errors. These claims had dates of service in CYs 2009\nand 2010 and consisted of 65 inpatient and 43 outpatient claims.\n\nOBJECTIVE\n\nOur objective was to determine whether the Hospital complied with Medicare requirements for\nbilling inpatient and outpatient services on selected claims.\n\nSUMMARY OF FINDINGS\n\nThe Hospital complied with Medicare billing requirements for 84 of the 108 claims we reviewed.\nHowever, the Hospital did not fully comply with Medicare billing requirements for selected\n\n\n\n i\n\x0cinpatient and outpatient claims. Specifically, of 108 sampled claims, 24 claims had billing\nerrors, resulting in overpayments totaling $90,222 for CYs 2009 and 2010. Overpayments\noccurred primarily because the Hospital did not have adequate controls to prevent incorrect\nbilling of Medicare claims.\n\nRECOMMENDATIONS\n\nWe recommend that the Hospital:\n\n \xe2\x80\xa2 refund to the Medicare contractor $90,222 in overpayments and\n\n \xe2\x80\xa2 strengthen controls to ensure full compliance with Medicare billing requirements.\n\nKENDALL REGIONAL MEDICAL CENTER COMMENTS\n\nIn written comments on our draft report, the Hospital concurred with most of our findings.\nRegarding our recommendations, the Hospital stated that it would refund the full amount of the\noverpayments and provided information on actions that it had taken to strengthen controls to\nensure full compliance with Medicare billing requirements.\n\nThe Hospital\xe2\x80\x99s comments are included in their entirety as the Appendix.\n\nOFFICE OF THE INSPECTOR GENERAL RESPONSE\n\nThe Hospital did not provide any additional information that would cause us to modify the\nfinding related to inpatient transfers. The Hospital provided reasons for the errors but is\nultimately responsible for coding the bill based on its discharge plan for the patient, or if it finds\nout subsequently that hospital or postacute care occurred, it is responsible for either coding the\noriginal bill as a transfer or submitting an adjustment bill. We strongly encourage the Hospital to\nstrengthen its controls in this area.\n\n\n\n\n ii\n\x0c TABLE OF CONTENTS\n\n Page\n\nINTRODUCTION........................................................................................................................1\n\n BACKGROUND ...................................................................................................................1\n Hospital Inpatient Prospective Payment System ..........................................................1\n Hospital Outpatient Prospective Payment System .........................................................1\n Hospital Payments at Risk for Incorrect Billing ............................................................2\n Medicare Requirements for Hospital Claims and Payments .........................................2\n Kendall Regional Medical Center ..................................................................................3\n\n OBJECTIVE, SCOPE, AND METHODOLOGY .................................................................3\n Objective ........................................................................................................................3\n Scope ..............................................................................................................................3\n Methodology ..................................................................................................................3\n\nFINDINGS AND RECOMMENDATIONS ..............................................................................4\n\n BILLING ERRORS ASSOCIATED WITH INPATIENT CLAIMS ....................................5\n Inpatient Transfers .........................................................................................................5\n Inpatient Claims Paid in Excess of Charges ..................................................................6\n\n BILLING ERRORS ASSOCIATED WITH OUTPATIENT CLAIMS ................................6\n Outpatient Claims With Payments Greater Than $25,000.............................................6\n Outpatient Claims Billed With Modifier 59 ..................................................................6\n Outpatient Claims Paid in Excess of Charges................................................................7\n\n RECOMMENDATIONS ......................................................................................................7\n\n KENDALL REGIONAL MEDICAL CENTER COMMENTS ............................................7\n\n OFFICE OF INPECTOR GENERAL RESPONSE ..............................................................7\n\nAPPENDIX\n\n KENDALL REGIONAL MEDICAL CENTER COMMENTS\n\n\n\n\n iii\n\x0c INTRODUCTION\n\nBACKGROUND\n\nTitle XVIII of the Social Security Act (the Act) established the Medicare program, which\nprovides health insurance coverage to people aged 65 and over, people with disabilities, and\npeople with end-stage renal disease. The Centers for Medicare & Medicaid Services (CMS)\nadministers the Medicare program. Medicare Part A provides inpatient hospital insurance\nbenefits and coverage of extended care services for patients after hospital discharge. Medicare\nPart B provides supplementary medical insurance for medical and other health services,\nincluding coverage of hospital outpatient services.\n\nCMS contracts with Medicare contractors 1 to, among other things, process and pay claims\nsubmitted by hospitals.\n\nHospital Inpatient Prospective Payment System\n\nSection 1886(d) of the Act established the inpatient prospective payment system (IPPS) for\nhospital inpatient services. Under the IPPS, CMS pays hospital costs at predetermined rates for\npatient discharges. The rates vary according to the diagnosis-related group (DRG) to which a\nbeneficiary\xe2\x80\x99s stay is assigned and the severity level of the patient\xe2\x80\x99s diagnosis. The DRG\npayment is, with certain exceptions, payment in full to the hospital for all inpatient costs\nassociated with the beneficiary\xe2\x80\x99s stay.\n\nHospital Outpatient Prospective Payment System\n\nCMS implemented an outpatient prospective payment system (OPPS) for hospital outpatient\nservices, as mandated by the Balanced Budget Act of 1997, P.L. No. 105-33, and the Medicare,\nMedicaid, and SCHIP (State Children\xe2\x80\x99s Health Insurance Program) Balanced Budget Refinement\nAct of 1999, P.L. No. 106-113. 2 The OPPS was effective for services furnished on or after\nAugust 1, 2000. Under the OPPS, Medicare pays for hospital outpatient services on a rate-per-\nservice basis that varies according to the assigned ambulatory payment classification (APC).\nCMS uses Healthcare Common Procedure Coding System (HCPCS) codes 3 and descriptors to\nidentify and group the services within each APC group. All services and items within an APC\ngroup are comparable clinically and require comparable resources.\n\n\n1\n Section 911 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, P.L. No. 108-173,\nrequired CMS to transfer the functions of fiscal intermediaries and carriers to Medicare administrative contractors\n(MAC) between October 2005 and October 2011. At the time of our fieldwork, most, but not all, of the MACs were\nfully operational; for jurisdictions where the MACs were not fully operational, the fiscal intermediaries and carriers\ncontinued to process claims. For purposes of this report, the term \xe2\x80\x9cMedicare contractor\xe2\x80\x9d means the fiscal\nintermediary, carrier, or MAC, whichever was applicable.\n2\n In 2009 SCHIP was formally redesignated as the Children\xe2\x80\x99s Health Insurance Program.\n3\n HCPCS codes are used throughout the health care industry to standardize coding for medical procedures, services,\nproducts, and supplies.\n\n\n 1\n\x0cHospital Payments at Risk for Incorrect Billing\n\nPrior Office of Inspector General (OIG) audits, investigations, and inspections identified certain\npayments to hospitals that are at risk for noncompliance with Medicare billing requirements.\nOIG identified these types of payments to hospitals using computer matching, data mining, and\nanalysis techniques. The types of payments to hospitals reviewed by this and related audits\nincluded payments for claims billed for:\n\n \xe2\x80\xa2 inpatient transfers,\n\n \xe2\x80\xa2 outpatient claims with payments greater than $25,000,\n\n \xe2\x80\xa2 outpatient claims billed with Modifier 59,\n\n \xe2\x80\xa2 inpatient and outpatient claims paid in excess of charges,\n\n \xe2\x80\xa2 inpatient claims with payments greater than $150,000,\n\n \xe2\x80\xa2 inpatient and outpatient manufacturer credits for replaced medical devices,\n\n \xe2\x80\xa2 inpatient claims for blood clotting factor drugs, and\n\n \xe2\x80\xa2 inpatient hospital-acquired conditions and \xe2\x80\x9cpresent on admission\xe2\x80\x9d 4 indicator reporting.\n\nFor purposes of this report, we refer to these areas at risk for incorrect billing as \xe2\x80\x9crisk areas.\xe2\x80\x9d\n\nThis review is part of a series of OIG reviews of Medicare payments to hospitals for selected\nclaims for inpatient and outpatient services.\n\nMedicare Requirements for Hospital Claims and Payments\n\nSection 1862(a)(1)(A) of the Act states that Medicare payments may not be made for items and\nservices that \xe2\x80\x9care not reasonable and necessary for the diagnosis or treatment of illness or injury\nor to improve the functioning of a malformed body member.\xe2\x80\x9d In addition, section 1833(e) of the\nAct precludes payment to any provider of services or other person without information necessary\nto determine the amount due the provider.\n\nFederal regulations (42 CFR \xc2\xa7 424.5(a)(6)) state that the provider must furnish to the Medicare\ncontractor sufficient information to determine whether payment is due and the amount of\npayment.\n\n\n\n4\n \xe2\x80\x9cPresent on admission\xe2\x80\x9d refers to diagnoses that are present at the time the order for inpatient admission occurs.\nConditions that develop during an outpatient encounter, including emergency department, observation, or outpatient\nsurgery, are also considered present on admission. Acute care hospitals are required to complete the present on\nadmission indicator field on the Medicare inpatient claim for every diagnosis billed.\n\n\n 2\n\x0cThe Medicare Claims Processing Manual (the Manual), Pub. No. 100-04, chapter 1, section\n80.3.2.2, requires providers to complete claims accurately so that Medicare contractors may\nprocess them correctly and promptly. Chapter 23, section 20.3, of the Manual states that\nproviders must use HCPCS codes for most outpatient services.\n\nKendall Regional Medical Center\n\nKendall Regional Medical Center (the Hospital) is a 412-bed acute care hospital located in\nMiami, Florida. Medicare paid the Hospital approximately $89 million for 17,220 inpatient and\n18,992 outpatient claims for services provided to beneficiaries during calendar years (CY) 2009\nand 2010 based on CMS\xe2\x80\x99s National Claims History data.\n\nOBJECTIVE, SCOPE, AND METHODOLOGY\n\nObjective\n\nOur objective was to determine whether the Hospital complied with Medicare requirements for\nbilling inpatient and outpatient services on selected claims.\n\nScope\n\nOur audit covered $2,233,628 in Medicare payments to the Hospital for 108 claims that we\njudgmentally selected as potentially at risk for billing errors. These claims had dates of service\nin CYs 2009 and 2010 and consisted of 65 inpatient and 43 outpatient claims.\n\nWe focused our review on the risk areas that we had identified during and as a result of prior\nOIG reviews at other hospitals. We evaluated compliance with selected billing requirements but\ndid not use medical review to determine whether the services were medically necessary.\n\nWe limited our review of the Hospital\xe2\x80\x99s internal controls to those applicable to the inpatient and\noutpatient areas of review because our objective did not require an understanding of all internal\ncontrols over the submission and processing of claims. Our review allowed us to establish\nreasonable assurance of the authenticity and accuracy of the data obtained from the National\nClaims History file, but we did not assess the completeness of the file.\n\nThis report focuses on selected risk areas and does not represent an overall assessment of all\nclaims submitted by the Hospital for Medicare reimbursement.\n\nWe conducted our fieldwork at the Hospital during April of 2011.\n\nMethodology\n\nTo accomplish our objective, we:\n\n \xe2\x80\xa2 reviewed applicable Federal laws, regulations, and guidance;\n\n\n\n 3\n\x0c \xe2\x80\xa2 extracted the Hospital\xe2\x80\x99s inpatient and outpatient paid claims data from CMS\xe2\x80\x99s National\n Claims History file for CYs 2009 and 2010;\n\n \xe2\x80\xa2 used computer matching, data mining, and analysis techniques to identify claims\n potentially at risk for noncompliance with selected Medicare billing requirements;\n\n \xe2\x80\xa2 selected a judgmental sample of 108 claims (65 inpatient and 43 outpatient) for detailed\n review;\n\n \xe2\x80\xa2 reviewed available data from CMS\xe2\x80\x99s Common Working File for the sampled claims to\n determine whether the claims had been cancelled or adjusted;\n\n \xe2\x80\xa2 reviewed the itemized bills and medical record documentation the Hospital provided to\n support the sampled claims;\n\n \xe2\x80\xa2 requested that the Hospital conduct its own review of the selected sampled claims to\n determine whether the services were billed correctly;\n\n \xe2\x80\xa2 reviewed the Hospital\xe2\x80\x99s procedures for assigning HCPCS codes and submitting Medicare\n claims;\n\n \xe2\x80\xa2 discussed the incorrectly billed claims with Hospital personnel to determine the\n underlying causes of noncompliance with Medicare requirements;\n\n \xe2\x80\xa2 calculated the correct payments for those claims requiring adjustment; and\n\n \xe2\x80\xa2 discussed the results of our review with Hospital officials.\n\nWe conducted this performance audit in accordance with generally accepted government\nauditing standards. Those standards require that we plan and perform the audit to obtain\nsufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions\nbased on our audit objectives. We believe that the evidence obtained provides a reasonable basis\nfor our findings and conclusions based on our audit objective.\n\n FINDINGS AND RECOMMENDATIONS\n\nThe Hospital complied with Medicare billing requirements for 84 of the 108 claims we reviewed.\nHowever, the Hospital did not fully comply with Medicare billing requirements for selected\ninpatient and outpatient claims. Specifically, of 108 sampled claims, 24 inpatient and outpatient\nclaims had billing errors, resulting in overpayments totaling $90,222 for CYs 2009 and 2010.\nOverpayments occurred primarily because the Hospital did not have adequate controls to prevent\nincorrect billing of Medicare claims.\n\nOf the 65 sampled inpatient claims, 14 claims had billing errors resulting in overpayments\ntotaling $78,815:\n\n\n\n 4\n\x0c \xe2\x80\xa2 For inpatient transfers, the Hospital incorrectly billed Medicare for patient discharges that\n should have been billed as transfers (10 errors totaling $39,605 in overpayments).\n\n \xe2\x80\xa2 For inpatient claims paid in excess of charges, the Hospital billed Medicare with incorrect\n DRG codes (four errors totaling $39,210 in overpayments).\n\nOf the 43 sampled outpatient claims, 10 claims had billing errors resulting in overpayments\ntotaling $11,407:\n\n \xe2\x80\xa2 For outpatient claims with payments greater than $25,000, the Hospital billed Medicare\n with incorrect HCPCS codes (one error totaling $7,045 in overpayments).\n\n \xe2\x80\xa2 For outpatient claims billed with modifier 59, the Hospital incorrectly billed for HCPCS\n codes that did not require modifier 59 (six errors totaling $3,403 in overpayments).\n\n \xe2\x80\xa2 For outpatient claims paid in excess of charges, the Hospital submitted claims to\n Medicare with incorrect HCPCS codes (three errors totaling $959 in overpayments).\n\nBILLING ERRORS ASSOCIATED WITH INPATIENT CLAIMS\n\nThe Hospital incorrectly billed Medicare for 14 of 65 sampled inpatient claims. These errors\nresulted in overpayments totaling $78,815.\n\nInpatient Transfers\n\nFederal regulations (42 CFR \xc2\xa7 412.4(b)) state that a discharge of a hospital inpatient is\nconsidered to be a transfer if the patient is readmitted the same day to another hospital unless the\nreadmission is unrelated to the initial discharge. A discharge of a hospital inpatient is also\nconsidered to be a transfer when the patient\xe2\x80\x99s discharge is assigned to one of the qualifying\nDRGs and the discharge is to home under a written plan of care for the provision of home health\nservices from a home health agency and those services begin within 3 days after the date of\ndischarge (42 CFR \xc2\xa7 412.4(c)). A hospital that transfers an inpatient under the above\ncircumstances is paid a graduated per diem rate for each day of the patient\xe2\x80\x99s stay in that hospital,\nnot to exceed the full DRG payment that would have been paid if the patient had been discharged\nto another setting (42 CFR \xc2\xa7 412.4(f)).\n\nFor 10 of the 17 sampled claims for inpatient transfers, the Hospital incorrectly billed Medicare\nfor patient discharges that should have been billed as transfers. For these claims, the Hospital\nshould have coded the discharge status either as a transfer to another hospital or to home under a\nwritten plan of care for the provision of home health services. However, the Hospital incorrectly\ncoded the discharge status as left against medical advice or discharged to home; thus the Hospital\nshould have received the per diem payment instead of the full DRG. The Hospital stated that\nthese errors occurred because the medical record documentation did not indicate that the\nbeneficiaries were going to be transferred to another hospital, a fact that remained unknown until\nsubsequent communications with the MAC, or that the beneficiaries were going to receive\n\n\n 5\n\x0cservices from home health agencies within 3 days of discharge. As a result, the Hospital\nreceived overpayments totaling $39,605.\n\nInpatient Claims Paid in Excess of Charges\n\nSection 1862(a)(1)(A) of the Act states that Medicare payments may not be made for items or\nservices that \xe2\x80\x9care not reasonable and necessary for the diagnosis or treatment of illness or injury\nor to improve the functioning of a malformed body member.\xe2\x80\x9d In addition, the Manual, chapter 1,\nsection 80.3.2.2, states, \xe2\x80\x9cIn order to be processed correctly and promptly, a bill must be\ncompleted accurately.\xe2\x80\x9d\n\nFor four of the eight sampled claims, the Hospital billed Medicare with incorrect DRG codes.\nThe Hospital stated that the incorrect coding occurred because of human error. As a result, the\nHospital received overpayments totaling $39,210.\n\nBILLING ERRORS ASSOCIATED WITH OUTPATIENT CLAIMS\n\nThe Hospital incorrectly billed Medicare for 10 of 43 sampled outpatient claims. These errors\nresulted in overpayments totaling $11,407.\n\nOutpatient Claims With Payments Greater Than $25,000\n\nSection 1833(e) of the Act precludes payment to any provider of services or other person without\ninformation necessary to determine the amount due the provider. Additionally, the Manual,\nchapter 1, section 80.3.2.2, \xe2\x80\x9cIn order to be processed correctly and promptly, a bill must be\ncompleted accurately.\xe2\x80\x9d\n\nFor one of the six sampled claims, the Hospital submitted a claim to Medicare with an incorrect\nHCPCS code. For this claim, the Hospital used the procedure code for initial insertion of a\ncardiac device rather than using the procedure code for replacement of a cardiac device, the\nprocedure actually performed. The Hospital stated that the incorrect claim occurred because of\nhuman error. As a result, the Hospital received an overpayment of $7,045.\n\nOutpatient Claims Billed With Modifier 59\n\nThe Manual, chapter 1, section 80.3.2.2, states: \xe2\x80\x9cIn order to be processed correctly and\npromptly, a bill must be completed accurately.\xe2\x80\x9d In addition, chapter 23, section 20.9.1.1, states:\n\xe2\x80\x9cThe \xe2\x80\x9859\xe2\x80\x99 modifier is used to indicate a distinct procedural service.... This may represent a\ndifferent session or patient encounter, different procedure or surgery, different site, or organ\nsystem, separate incision/excision, or separate injury (or area of injury in extensive injuries).\xe2\x80\x9d\n\nFor 6 of the 24 sampled claims, the Hospital incorrectly billed Medicare for HCPCS codes that\ndid not require modifier 59. These errors occurred because the staff misunderstood the billing\nrequirements for modifier 59. As a result, the Hospital received overpayments totaling $3,403.\n\n\n\n\n 6\n\x0cOutpatient Claims Paid in Excess of Charges\n\nSection 1833(e) of the Act precludes payment to any provider of services or other person without\ninformation necessary to determine the amount due the provider. Additionally, the Manual,\nchapter 1, section 80.3.2.2, requires providers to complete claims accurately so that Medicare\ncontractors may process them correctly and promptly.\n\nFor three of the five sampled claims, the Hospital submitted claims to Medicare with incorrect\nHCPCS codes. The Hospital stated that these errors occurred because of human error. As a\nresult, the Hospital received overpayments totaling $959.\n\nRECOMMENDATIONS\n\nWe recommend that the Hospital:\n\n \xe2\x80\xa2 refund to the Medicare contractor $90,222 in overpayments and\n\n \xe2\x80\xa2 strengthen controls to ensure full compliance with Medicare billing requirements.\n\nKENDALL REGIONAL MEDICAL CENTER COMMENTS\n\nIn written comments on our draft report, the Hospital concurred with most of our findings.\nRegarding our recommendations, the Hospital stated that it would refund the full amount of the\noverpayments and provided information on actions that it had taken to strengthen controls to\nensure full compliance with Medicare billing requirements.\n\nThe Hospital stated that it did not concur with some of our findings related to inpatient transfers.\nThe Hospital stated that these errors occurred because the medical record documentation did not\nindicate that the beneficiaries were going to be transferred to another hospital, which was\nunknown until subsequent communications with the MAC, or that the beneficiaries were going\nto receive home health services within 3 days of discharge.\n\nThe Hospital\xe2\x80\x99s comments are included in their entirety as the Appendix.\n\nOFFICE OF THE INSPECTOR GENERAL RESPONSE\n\nThe Hospital did not provide any additional information that would cause us to modify the\nfinding related to inpatient transfers. The Hospital provided reasons for the errors but is\nultimately responsible for coding the bill based on its discharge plan for the patient, or if it finds\nout subsequently that hospital or postacute care occurred, it is responsible for either coding the\noriginal bill as a transfer or submitting an adjustment bill. 5 We strongly encourage the Hospital\nto strengthen its controls in this area.\n\n\n\n\n5\n 63 Fed. Reg. 40979, 40980 (July 31, 1998).\n\n\n 7\n\x0cAPPENDIX\n\x0c APPENDIX: KENDALL REGIONAL MEDICAL\n\n CENTER COMMENTS \n Page 1 of 4\n\n-- --.,,"<,-------------\n --KENDALL REGIONAL\n --rMedicol Center\n Quality Care. Done Right.\n\n\n\n\n December 7, 2011\n\n Lori S. Pilcher\n Regional Inspector General for Audit Services\n DHHS OIG\n Office of Audit Services, Region IV\n 61 Forsyth Street SW Suite 3T41\n Atlanta, GA 30303\n\n Re: Medicare Compliance Review of Kendal Regional Medical Center\n For Calendar Years 2009 and 2010\n\n Dear Ms. Pilcher:\n\n This letter is provided in response to your correspondence dated October 19, 2011, regarding the above\n referenced audit of selected Medicare inpatient and outpatient claims submitted by Kendall Regional\n Medical Center (the "Hospital").\n\n Per the instructions in your letter, provided below are the Hospital\'s statements of concurrence or non\xc2\xad\n concurrence, and corrective action taken or planned for the following five (5) areas cited in the audit\n report:\n \xe2\x80\xa2 Inpatient Transfers\n \xe2\x80\xa2 Inpatient Claims Paid in Excess of Charges\n \xe2\x80\xa2 Outpatient Claims with Payments Greater than $25,000\n \xe2\x80\xa2 Outpatient Claims Billed with Modifier 59\n \xe2\x80\xa2 Outpatient Claims Paid in Excess of Charges\n\n 1) INPA.TIENT TRANSFERS\n\n The Audit report concluded that the Hospital incorrectly billed Medicare on ten (10) claims for\n patient discharges that should have been billed as transfers and recommends that the Hospital refund\n overpayments related to these claims in the amount of $39,605.00.\n\n A. Statement of Non-Concurrence:\n The Hospital respectfully declines to concur with the finding of noncompliance related to 6 of the 10\n claims for the following reasons:\n\n These errors occurred because the medical record documentation at the time of discharge was\n based on the healthcare decisions of the physician, patient and/or family members. The\n medical record did not indicate that the beneficiaries were going to be transferred to another\n hospital, a fact that remained unknown until subsequent communications with the MAC, or that\n the beneficiaries were going to receive services from home health agencies within 3 days of\n discharge. As a result, $30,594.00 of the $39,605.00 was beyond the Hospital\'s control.\n\n\n\n\n Please visit U~ at: www.kendallmed.com\n\x0c Page 2 of 4\n\n\nOIG Audit Response\nPage 2\n\nB. Correction Action Taken or Planned:\n\n 1. \t As a quality improvement measure, the HIM Department established a pre-bill review of\n inpatient accounts. Discharge dispositions were included in quality reviews performed by\n External Vendor.\n 2. \t Coding staff continue to work with Case Management identifying discharge disposition\n discrepancies as well as continue to monitor internal web based tool.\n 3. \t Case management and coders were retrained on the need for accurate and timely\n documentation of the expected discharge disposition of the patient. They were reminded of the\n intent and importance of discharge disposition documentation.\n 4. \t Case management and coders were re-educated on HCA\'s Medicare Post Acute Transfer Rule\n manual and completed the assigned web-based training course entitled "Transfer Rule - HCA\xc2\xad\n CO-BIL-178-HP - The Medicare Post Acute Care Transfer Rule."\n\n2) \t INPATIENT CLAIMS PAID IN EXCESS OF CHARGES\n\n The audit report concluded that the Hospital billed Medicare with incorrect DRG codes on four\n(4) of the sampled claims, and recommends that the Hospital Refund overpayments related to these\nclaims in the amount of $39,210.00.\n\nA. State of Concurrence:\n\nThe Hospital concurs with the findings of the audit report for these claims and the recommended\nrefund.\n\nB. Correction Active Taken or Planned:\n\nThis incorrect coding occurred as a result of human error. The Hospital implemented a plan which\nincluded:\n\n 1. \t Coders were in-serviced regarding error and retraining was performed.\n 2. \t Coders received additional coding courses to enhance their coding knowledge.\n 3. \t External Vendor was contracted for quality review of inpatient accounts, focused on areas of\n opportunity. External Vendor review included coder education.\n\n3) OUTPATIENT CLAIMS WITH PAYMENTS GREATER THAN $25,000.00\n\n The audit report concluded that one of the sampled claims was submitted with an incorrect\nHCPCS code, and recommends that the Hospital refund an overpayment in the amount of $7,045.00.\n\n\nA. State of Concurrence:\n\nThe Hospital concurs with the findings of the audit report for these claims and the recommended\nrefund.\n\x0c Page 3 of 4\n\n\nDIG Audit Response\nPage 3\n\nB. Correction Active Taken or Planned:\n\nThis incorrect coding occurred as a result of human error. The Hospital implemented a plan which\nincluded:\n\n 1. \t Coders were in-serviced regarding error and retraining was performed.\n 2. \t Coders received additional coding courses to enhance their coding knowledge.\n 3. \t External Vendor was contracted to perform a quality review of 100 outpatient records with\n regard to areas of opportunity and any identified trends. External Vendor review included coder\n education.\n\n4. OUTPATIENT CLAIMS WITH MODIFIER 59\n\n The audit report concluded that the Hospital incorrectly billed Medicare for six (6) claims with\nHCPCS codes that did not require Modifier 59, and recommended that the Hospital refund\noverpayments related to these claims in the amount of $3,403.00.\n\nA. State of Concurrence:\n\nThe Hospital concurs with the findings of the audit report for these claims and the recommended\nrefund.\n\nB. Correction Active Taken or Planned:\n\nThe incorrect addition of Modifier 59 to the HCPCS codes on the subject claims was the result of the\ncoding staff misunderstanding when to appropriately assign modifier 59 to a HCPCS code. The Hospital\nimplemented a plan which included:\n\n 1. \t Coders were in-serviced regarding error and retraining was performed.\n 2. \t Coders received additional coding courses to enhance their coding knowledge and application of\n modifier 59.\n 3. \t External Vendor was contracted to perform a quality review of 100 outpatient records with\n regards to areas of opportunity and any identified trends. External Vendor review included\n coder education.\n\n5. OUTPATIENT CLAIMS PAID IN EXCESS OF CHARGES\n\n The audit report concluded that the Hospital billed Medicare with incomplete or inaccurate\ninformation on three claims with incorrect HCPCS codes, and recommends that the Hospital refund\noverpayments related to these claims in the amount of $959.00.\n\nA. State of Concurrence:\n\nThe Hospital concurs with the findings of the audit report for these claims and the recommended\nrefund.\n\x0c Page 4 of 4\n\n\nDIG Audit Response\nPage 4\n\n\n\nB. Correction Active Taken or Planned:\n\nThis incorrect coding occurred as a result of human error. The Hospital implemented a plan which\nincluded:\n\n 1. \t Coders were in-serviced regarding error and retraining was performed.\n 2. \t Coders received additional coding courses to enhance their coding knowledge.\n 3. \t External Vendor was contracted to perform a quality review of 100 outpatient records with\n regard to areas of opportunity and any identified trends. External Vendor review included coder\n education.\n\n\n\nCONCLUSION:\n\nKendall Regional Medical Center is committed to full compliance with all laws, Regulations, policies and\nprocedures required for its participation in the Medicare program. Accordingly, the Hospital will\ncomply with the Recommendations of the audit report by promptly submitting an overpayment refund\nin the amount of $90,222.24 and strengthening its controls in the area of Medicare billing compliance as\nspecified in this responsive letter.\n\nIf you rE\'quire further information, please do not hesitate to contact the undersigned at 305-227-5500.\n\n\n\nRespectfully Submitted,\n ,/I\n /\n /\n ~7\' ./\'\n ,/ ./\n /\t \'\n / i - ___\n\nRicard? P ~ \')\nChief iFtflancia\\ Qff~\n\nRP/MGN\n\x0c'


type: legislation

jurisdiction: EU

text:
 20.9.2013
 NL
 Publicatieblad van de Europese Unie
 L 250/26
 UITVOERINGSVERORDENING (EU) Nr. 898/2013 VAN DE COMMISSIE
 van 9 september 2013
 houdende inschrijving van een benaming in het register van beschermde oorsprongsbenamingen en beschermde geografische aanduidingen (Aceite de Navarra (BOB))
 DE EUROPESE COMMISSIE,
 Gezien het Verdrag betreffende de werking van de Europese Unie,
 Gezien Verordening (EU) nr. 1151/2012 van het Europees Parlement en de Raad van 21 november 2012 inzake kwaliteitsregelingen voor landbouwproducten en levensmiddelen (1), en met name artikel 52, lid 2,
 Overwegende hetgeen volgt:
 (1)
 Verordening (EG) nr. 510/2006 van de Raad van 20 maart 2006 inzake de bescherming van geografische aanduidingen en oorsprongsbenamingen van landbouwproducten en levensmiddelen (2) is bij Verordening (EU) nr. 1151/2012 ingetrokken en daardoor vervangen.
 (2)
 Overeenkomstig artikel 6, lid 2, van Verordening (EG) nr. 510/2006 is de door Spanje ingediende aanvraag tot registratie van de naam „Aceite de Navarra” bekendgemaakt in het Publicatieblad van de Europese Unie
 (3).
 (3)
 Aangezien bij de Commissie geen bezwaren zijn ingediend overeenkomstig artikel 7 van Verordening (EG) nr. 510/2006, moet de benaming „Aceite de Navarra” worden ingeschreven in het register van beschermde oorsprongsbenamingen en beschermde geografische aanduidingen,
 HEEFT DE VOLGENDE VERORDENING VASTGESTELD:
 Artikel 1
 De in de bijlage bij deze verordening vermelde benaming wordt ingeschreven in het register van beschermde oorsprongsbenamingen en beschermde geografische aanduidingen.
 Artikel 2
 Deze verordening treedt in werking op de twintigste dag na die van de bekendmaking ervan in het Publicatieblad van de Europese Unie.
 Deze verordening is verbindend in al haar onderdelen en is rechtstreeks toepasselijk in elke lidstaat.
 Gedaan te Brussel, 9 september 2013.
 Voor de Commissie, namens de voorzitter,
 Dacian CIOLOȘ
 Lid van de Commissie
 (1) PB L 343 van 14.12.2012, blz. 1.
 (2) PB L 93 van 31.3.2006, blz. 12.
 (3) PB C 322 van 24.10.2012, blz. 9.
 BIJLAGE
 In bijlage I bij het Verdrag genoemde landbouwproducten voor menselijke consumptie:
 Categorie 1.5. Oliën en vetten (boter, margarine, spijsolie, enz.)
 SPANJE
 Aceite de Navarra (BOB)