Review of Outpatient Psychiatric Services Provided by Coral Gables Hospital for Calendar Year Ending December 31, 1997

EXECUTIVE SUMMARY:

This report points out that Coral Gables Hospital (Hospital) did not have adequate controls in place to ensure that the beneficiaries enrolled in the Hospital's partial hospitalization program (PHP) met Medicare eligibility criteria and that the services billed met the reimbursement requirements. As a result, based on a statistical projection at the 90 percent confidence level, we estimate that the hospital overstated its Fiscal Year (FY) 1997 Medicare outpatient psychiatric charges by $1,031,497. Further, our review showed that the PHP costs in the Hospital's FY 1997 cost report were overstated because the Hospital inappropriately included $1,648,063 in costs that were not related to the PHP operation. We recommended that the Hospital 1) strengthen its procedures to ensure that charges for outpatient psychiatric services are covered and properly documented in accordance with Medicare requirements and 2) develop procedures to properly exclude costs related to noncovered services from its Medicare cost reports. We will also provide the results of our review to the Fiscal Intermediary, so that it can apply the appropriate adjustments to the Hospital's FY 1997 Medicare cost report.