Review of Medicare Outlier Payments at Rhode Island Hospital for Fiscal Year 1999

EXECUTIVE SUMMARY:

The objective of this review was to determine whether Fiscal Year 1999 Medicare outlier payments to Rhode Island Hospital (RIH) were reimbursed in accordance with Medicare laws and regulations.  Our review determined that RIH received $105,686 in overpayments relating to services that were not ordered by a physician, were not properly documented, or resulted from a clerical billing error.  We recommended that RIH: (1) review documentation requirements with hospital staff to ensure that all services provided are appropriately documented in the medical record in accordance with standards of practice and Medicare laws and regulations, emphasizing the need to document physician orders; (2) improve its controls over the billing process to ensure that only services that are ordered by a physician and are supported by appropriate documentation are billed; (3) strengthen its controls related to the detection and prevention of improper charges for 'open' service codes; and (4) return to the appropriate fiscal intermediary, the overpayments associated with services identified as not properly documented or not ordered by a physician.  The hospital has issued an adjustment to reimburse Medicare for the overpayment related to a clerical error.  The RIH generally concurred with our findings and identified steps they have taken, and plan to take to address our recommendations.

---