Department of Health and Human Services

Office of Inspector General -- AUDIT

"Review of Outlier Payments Made to Mercy Hospital Under the Outpatient Prospective Payment System for the Period August 1, 2000 Through June 30, 2001," (A-01-02-00518)

April 17, 2003

Complete Text of Report is available in PDF format (580 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 35 claims with outlier payments of $133,798.  We found overpayments of $50, 280 were made for 33 of the selected claims because Mercy Hospital did not properly : (1) calculate the billable units for drugs in relation to the amount of the drug administered; and (2) identify multiple surgical procedures with specific HCFA Common Procedure Coding System codes.  For these 33 claims, the reduction to the outlier payment received exceeded the increased reimbursement Mercy Hospital would have received had it billed properly.  Mercy Hospital concurred with our findings and recommendations.