Department of Health and Human Services

"Review of Outlier Payments Made to Eastern Maine Medical Center Under the Outpatient Prospective Payment System for the Period August 1, 2000 Through June 30, 2001," (A-01-02-00507)

January 15, 2003

Complete Text of Report is available in PDF format (446 kb). Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.


The objective of this review was to determine whether outpatient claims with outlier payments were billed in accordance with Medicare laws and regulations. We judgmentally selected 33 claims with outlier payments of $208,250. We found overpayments of $59,470 were made for 28 of the selected claims because Eastern Maine Medical Center (EMMC) did not bill for the correct number of units of drugs and biologicals. We found that a conversion error in EMMC's billing system when outpatient prospective payment system was implemented resulted in unwarranted or excessive outlier payments. Specifically, a programming change designed to convert operating room units from multiple units to one unit was inadvertently applied to all line items reducing the line item reimbursement. This reduction in line item reimbursement, combined with charges being recorded in full, generated outlier reimbursement in excess of the appropriate reimbursement amount.  The EMMC concurred with our findings and recommendations.