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Department of Health and Human Services

Office of Inspector General -- AUDIT

"Review of World Gym Physical Therapy Center Outpatient Rehabilitation Facility Program," (A-04-98-01191)

January 5, 2000


Complete Text of Report is available in PDF format (204 kb). Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.

EXECUTIVE SUMMARY:

This final report provides you with the results of our review of World Gym Physical Therapy Center's (the Provider) Outpatient Rehabilitation Facility Program.

The objective of our review was to determine whether the Outpatient Rehabilitation services claimed by the provider during the Fiscal Year (FY) ended December 31, 1997 met the Medicare eligibility and reimbursement criteria.

We reviewed a statistical sample of 100 claims containing 2,075 units of service that were provided to 82 Medicare beneficiaries during FY 1997. Ninety-two claims representing 1,966 units of service did not meet the Medicare eligibility and reimbursement requirements:

The Provider claimed gross charges totaling $873,763. Based on the results of our review, we estimate that $518,479 did not meet the Medicare eligibility and reimbursement requirements and, therefore, constituted an overpayment.

This overpayment occurred because the provider did not conduct monitoring activities to ensure that the beneficiaries admitted to the program met the eligibility criteria. In addition, the provider did not implement controls to ensure that the services were properly authorized by a physician and documented in the beneficiaries' folders.

We are recommending the Health Care Financing Administration (HCFA) direct the FI to: