Audit of the Medicare Partial Hospitalization Program at the Program, Incorporated

EXECUTIVE SUMMARY:

The entire sampled amount of $1,683,560 charged for PHP services (for which The Program received interim payment of $1,009,493) did not meet Medicare requirements. We found, through medical review, that 100 percent of charges for the services included on 20 judgementally selected beneficiaries claims did not meet Medicare requirements for one or more reasons. The Program received interim payments of $2,688,297 on the submitted charges of $4,482,935 for all services claimed during the period of our audit. We did not project the results of our audit to the entire universe because our sample was judgementally selected.

We recommend that the fiscal intermediary, Mutual of Omaha (Mutual):

1. Ensure that any future charges submitted by The Program for Medicare reimbursements are appropriate and properly documented in accordance with Medicare requirements.
2. Recover the $1,009,493 paid to The Program during the period January 1, 1996 through September 30, 1998 for the 20 beneficiaries in our sample,
3. Perform a medical review of the 110 beneficiaries who were not included in our sample to determine whether the claims during the period January 1, 1996 through September 30, 1998 for these beneficiaries were allowable, and collect additional overpayments as appropriate.