Audit of Flagship Convalescent Center Skilled Nursing Facility, Newport Beach, California

EXECUTIVE SUMMARY:

The primary objective of the audit was to evaluate the medical necessity of the care and services provided and the reasonableness of the charges and reimbursements made during the period from January 1, 1995 through March 31, 1996.

The Operation Restore Trust team questioned $287,664 of the $1,474,634 in Medicare charges reported for the 40 sample beneficiaries in our audit. This amount consisted of $253,202 which was not reasonable or necessary, $30,713 of charges which were not properly documented, and $3,649 for services which were not covered. Therefore, we are recommending an adjustment of the above charges. In addition, we request that a focused review of all rehabilitative therapies and the physician orders for these therapies be conducted by the fiscal intermediary and the State agency in order to recoup overpayments made to this skilled nursing facility and to implement corrective action by the facility.