Review of Partial Hospitalization Services and Audit of Medicare Cost Report for Community Behavioral Services, a Florida Community Mental Health Center

(A- and A-04-96-02124)

EXECUTIVE SUMMARY:

CIN: A-

This final report points out that Community Behavioral Services (CBS) claimed Medicare reimbursement totaling $4.5 million representing 31,951 services to 305 Medicare beneficiaries in Fiscal Year (FY) 1995. Our review of services provided to 43 of these beneficiaries disclosed that: 7,868 (71 percent) of the services were provided to 31 beneficiaries who, in the opinion of medical experts, did not meet the Medicare eligibility criteria for receiving partial hospitalization program (PHP) services; and 286 (3 percent) of the services provided to 6 beneficiaries were considered unallowable by medical review personnel because they were either not documented, the services were not reasonable and necessary, the services were not ordered, or the supporting documentation was not dated, not signed, or duplicated. We recommended that the fiscal intermediary (FI) recover the amount overpaid to CBS and place the four providers owned by CBS under focused medical review with special emphasis on beneficiary eligibility.

CIN: A-04-96-02124

This final reports points out that CBS claimed costs totaling $2.3 million in FY 1994. Our review disclosed that the claimed costs included costs that were not allocable or reimbursable according to Medicare reimbursement requirements. The cost report included $1.4 million that was not related to patient care, not reasonable and necessary and costs that were not supported with sufficient documentation to determine whether the costs were incurred, reasonable and necessary, and related to patient care. The FI notified CBS of the unallowed costs and took recovery action. The Health Care Financing Administration took action to suspend payments to this provider until the overpayments are recovered. We recommended that the FI review subsequent cost reports for similar unallowable costs. The FI agreed with our recommendations.