Department of Health and Human Services

Office of Inspector General -- AUDIT

"Review of Claims for Multiple Procedures Performed in the Same Operative Session in Ambulatory Surgical Centers," (A-07-03-02660)

January 8, 2003


Complete Text of Report is available in PDF format (503 KB). Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.


EXECUTIVE SUMMARY:

The objective of this analysis was to evaluate the effectiveness of carriers’ claims processing systems in identifying payment reductions for multiple ambulatory surgical center procedures for calendar years 1997 through 2001.  Regulations require that when multiple services are provided in the same operative session, the highest paying procedure is reimbursable at the full payment rate while the other procedures are reimbursable at one-half the normal payment rate.  Our analysis showed that National Heritage Insurance Company of California’s systems failed to identify such instances, which resulted in provider overpayments for calendar years 1997 through 2001 of approximately $49,543, $146,922, $170,412, $184,980 and  $224,414 ($776,271), respectively.  Included in the identified overpayments is approximately $157,998 in beneficiary overpayments for coinsurance.  Most of the overpayments occurred because the carrier’s processing system did not identify multiple procedures performed during the same session when submitted on separate claims.