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Dialysis Services Provided by Atlantis Health Care Group of Puerto Rico, Inc., Did Not Comply With Medicare Requirements Intended To Ensure the Quality of Care Provided to Medicare Beneficiaries

Atlantis Health Care Group of Puerto Rico, Inc., claimed dialysis services that did not comply with Medicare requirements during all 100 beneficiary-months that we sampled. (A beneficiary-month was defined as all dialysis services provided to a Medicare beneficiary during 1 calendar month.) For example, Atlantis claimed reimbursement for dialysis services for which (1) beneficiaries' medical information was not adequately supported, (2) plans of care or comprehensive assessments did not comply with Medicare requirements, and (3) physicians' orders did not meet Medicare requirements.

These errors occurred because Atlantis' electronic health records system and related procedures were not adequate to ensure that certain end-stage renal disease measurements and comorbidities documented in beneficiaries' medical records were correctly reported on their associated Medicare claims. Additionally, while Atlantis had policies and procedures in place to ensure that dialysis services were properly ordered and adequately documented, and that plans of care and comprehensive assessments contained all required elements, these policies and procedures were not effective, not followed, or did not meet Medicare requirements.

We estimated that Atlantis received unallowable Medicare payments of at least $403,000 for dialysis services that did not comply with Medicare requirements. Many of the deficiencies we identified did not affect Atlantis' Medicare reimbursement for the services since they were reimbursed on a bundled per treatment basis or related to Medicare conditions for coverage. However, the deficiencies could have a significant impact on the quality of care provided to Medicare beneficiaries and could result in the provision of inappropriate or unnecessary dialysis services.

We recommended that Atlantis refund an estimated $403,000 to the Medicare program. We also made a series of recommendations to strengthen Atlantis' policies and procedures for ensuring that dialysis services comply with Medicare requirements. Atlantis concurred with our findings and recommendations and described actions it has taken or planned to take to address them.