Review of Outpatient Clinic Services Provided by The University of Massachusetts Memorial Medical Center for Fiscal Year 1999

EXECUTIVE SUMMARY:

The objective of this review was to determine whether outpatient clinic services were billed for and reimbursed in accordance with Medicare regulations.  Our review covered the period October 1, 1998 to September 30, 1999 (FY1999).  We reviewed the billing and medical records for a random sample of 100 clinical claims.  Our analysis disclosed that 17 of these claims did not meet the Medicare criteria for reimbursement.  Based on a statistical sample, we estimate that the Hospital had overstated its Medicare clinic service charges by $181,118.  We recommended that the Hospital strengthen its procedures to ensure that only charges for covered outpatient clinic services are billed to Medicare.  Further, the Hospital should follow proper procedures in ensuring clinic visits submitted for reimbursement are allowed and documented in accordance with Medicare regulations.  We will provide the results of our review to the fiscal intermediary, Associated Hospital Services, so that it can apply the appropriate adjustment of $181,118 to the Hospital's FY 1999 Medicare cost report.

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