Review of Outpatient Psychiatric Services Provided by John Hopkins Bayview Medical Center During Fiscal Year 1997

EXECUTIVE SUMMARY:

The objective of this review was to determine whether psychiatric services rendered on an outpatient basis were billed for and reimbursed to Johns Hopkins Bayview Medical Center (JHBMC) in accordance with Medicare requirements.  During Fiscal Year (FY) 1997, JHBMC was reimbursed $1,139,893 for 2,935 Medicare claims submitted to the Medicare fiscal intermediary (FI).  Our audit determined that many of the outpatient psychiatric services claimed by JHBMC did not meet the Medicare criteria for reimbursement.  Specifically, a team of medical experts determined that 59 of the 100 sampled paid claims included unallowable services.  The 100 sampled claims contained 570 units of service of which 443 units were denied by medical reviewers.  Based on our statistical sample, we estimate that JHBMC overstated its FY 1997 Medicare outpatient psychiatric charges by at least $957,458.  We recommended that JHBMC strengthen procedures to ensure that charges for outpatient psychiatric services are for covered services and are properly documented in accordance with Medicare requirements.  We are providing the results of our audit to CareFirst, the FI, so that they can recover the estimated overpayment and also ensure that the FY 1997 Medicare cost report is updated to accurately reflect allowable Medicare charges for outpatient psychiatric services rendered.