Review of Outlier Payments Made to the Baystate Medical Center Under the Outpatient Prospective Payments System For The Period August 1, 2000 Through June 30, 2001

EXECUTIVE SUMMARY :

This report presents the results of our audit of outpatient claims with outlier payments submitted by the Baystate Medical Center (Hospital) under the Medicare outpatient prospective payment system (OPPS).  The objective of our audit was to determine whether outpatient claims with outlier payments were billed in accordance with Medicare laws and regulations.  For the period August 1, 2000 through June 30, 2001, we reviewed a sample of 38 such claims, totaling $145,736, and found that 37 claims were incorrectly billed.  Specifically, the billing errors primarily included claims with incorrect ambulatory payment classification codes, as well as claims with incorrect units and clerical errors.  As a result, we identified both overpayments and underpayments resulting in a net Medicare overpayment to the Hospital of $7,939.  We recommended that the Hospital strengthen its policies and procedures with regard to billing for outpatient services under OPPS and to initiate adjustments with the Medicare Fiscal Intermediary for the $7,939 in overpayments identified through this audit.  The Hospital agreed with our findings and recommendations.

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