Review of Claims Processing for Ambulatory Surgical Services Performed in Hospital Outpatient Departments

EXECUTIVE SUMMARY:

This final audit report points out that claims for ambulatory surgical services (ASC) performed in hospital outpatient departments were potentially overstated because the hospitals submitted two or more claims for the same ASC surgical services. In the cost settlement process potential overpayments could total as much as $2 million relative to these claims. We are recommending that the Health Care Financing Administration implement a computer edit to ensure that such claims are detected, educate providers regarding the proper submission of ASC claims and instruct the fiscal intermediaries to utilize the data from our computer applications to determine if adjustments to providers' cost reports are needed.

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