Department of Health and Human Services

Office of Inspector General -- AUDIT

"Review Of Medicare Reimbursement For Outpatient Cardiac Rehabilitation Services For Calendar Year 2001, MountainView Hospital, Las Vegas, Nevada," (A-09-03-00045)

November 7, 2003


Complete Text of Report is available in PDF format (1.34 mb). Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.


EXECUTIVE SUMMARY:

The objective of this review was to determine whether Medicare properly reimbursed MountainView Hospital (the Hospital) for outpatient cardiac rehabilitation services.  Our review found that even though physician supervision is generally assumed to be met in an outpatient hospital department, the Hospital did not designate a physician to directly supervise the services provided by its cardiac rehabilitation program staff.  Further, the Hospital did not provide the services “incident to” a physician’s professional services.  In addition, from our specific claims review for a non-statistical sample of 10 beneficiaries who received 129 outpatient cardiac rehabilitation services during Calendar Year 2001, we determined that the Hospital received Medicare reimbursement for the services, amounting to approximately $350, for which the diagnoses used to establish the patient’s eligibility for the services may not have been supported by medical record documentation, or which were otherwise unallowable.  We attributed these questionable services to weaknesses in the Hospital’s internal controls and oversight procedures.  We recommended that the Hospital (1) work with its fiscal intermediary regarding the direct physician supervision and “incident to” requirements; (2) work with its fiscal intermediary to establish the amount of repayment liability, estimated to be as much as $350; (3) bill for evaluation and orientation services only when performed by a physician; and (4) implement controls to ensure that documentation is maintained in the medical records to support outpatient cardiac rehabilitation services that are provided.  The Hospital agreed to take actions based on our recommendations, although it did not concur with our findings regarding direct physician supervision and “incident to” physician services.