Results of Review of America's Behavioral Health Center

EXECUTIVE SUMMARY:

This report provides the results of the Review of America's Behavioral Health Center's (ABHC) Partial Hospitalization Program (PHP).

The objective of this review was to determine whether the partial hospitalization services claimed by ABHC between January 1, 1998 and July 31, 1998 for 30 beneficiaries were in accordance with Medicare eligibility and reimbursement requirements.

Our review showed that:

• 26 of 30 beneficiaries did not meet the eligibility criteria for PHP services.
• 28 of 30 beneficiaries received services that were not reasonable or medically necessary for their conditions.
• ABHC was paid $452,928 for 93 claims that did not meet the Medicare eligibility and reimbursement requirements.

In our opinion, this occurred because the provider did not ensure that the beneficiaries admitted to the facility met the Medicare eligibility criteria for PHP services, or that the services billed met the Medicare reimbursement requirements. Based on the results of our review, we recommend that the Health Care Financing Administration (HCFA) direct the Fiscal Intermediary (FI) to:

• initiate recovery action against the provider for the $452,928 overpayment, and
• conduct additional claim reviews to identify other unallowable services.