Medicare Compliance Review of Vanderbilt University Medical Center for 2013 and 2014

The Vanderbilt University Medical Center (the Hospital), located in Nashville, Tennessee, complied with Medicare billing requirements for 172 of the 245 inpatient and outpatient claims we reviewed. However, the Hospital did not fully comply with Medicare billing requirements for the remaining 73 claims, resulting in net overpayments of $305,000. Specifically, 34 inpatient claims had billing errors resulting in net overpayments of $221,000, and 39 outpatient claims had billing errors resulting in overpayments of $84,000. These errors occurred primarily because the Hospital did not have adequate controls to prevent the incorrect billing of Medicare claims within the selected risk areas that contained errors. On the basis of our sample results, we estimated that the Hospital received overpayments of at least $1.14 million for the audit period. During the course of our audit, the Hospital reprocessed 30 claims with overpayments of $134,000 that we verified as correctly reprocessed. Accordingly, we have reduced the recommended refund by this amount.

We recommended that the Hospital (1) refund to the Medicare program $1.01 million ($1.14 million minus $134,000) in estimated overpayments on claims incorrectly billed for the audit period and (2) strengthen controls to ensure full compliance with Medicare requirements. The Hospital did not specifically address our recommendations. However, the Hospital agreed with the report findings for 68 of the 73 claim errors but disputed 3 inpatient and 2 outpatient claim errors.