Review of Medicare Outlier Payments at Brigham and Women's Hospital for Fiscal Year 1999

EXECUTIVE SUMMARY:

This review determined that Brigham and Women's Hospital (BWH) received $295,671 in overpayments relating to services that were not ordered by a physician, represented an inappropriate admission, were not provided/not ordered by a physician, were duplicate billings, erroneous pharmacy charges, or incorrectly billed lung acquisition charges.  In addition, the hospital performed a self-review of Fiscal Year 2000 lung acquisition charges and initiated adjustments for incorrectly billed claims that returned an additional $61,902 in overpayments to Medicare.  We recommended that BWH:  (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 actually performed are billed and only inpatient admissions that are medically necessary and appropriate are billed; (3) strengthen its controls related to the detection and prevention of erroneous charges from the pharmacy department; (4) establish procedures in the billing department for the recognition of credits to Medicare billing and the processing of appropriate adjustments; and (5) establish controls to ensure that lung acquisition charges, paid for on a reasonable cost basis, are billed under the appropriate revenue center code on the Medicare claim form.  The BWH concurred with our findings and identified steps they have taken, and plan to take to address our recommendations.

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