Audit of Outlier Payments Made to Massachusetts General Hospital Under the Outpatient Prospective Payment System for the Period August 1, 2000 Through June 30, 2001

EXECUTIVE SUMMARY:

The objective of this review was to determine whether outpatient claims with outlier payments were billed in accordance with Medicare laws and regulations.  Based on our review of 30 judgmentally selected outpatient hospital claims with outlier payments totaling $95,464, we found that for 14 of the 30 claims Massachusetts General Hospital (MGH) received overpayments totaling $9,803 because the hospital billed the incorrect number of units for the drug intravenous immune globulin (IVIG).  MGH attributes problems converting clinical units of IVIG to billable units to complexities and inconsistencies in the billing guidelines during the outpatient prospective payment system implementation periods.  MGH performed an internal review of all outpatient claims with the drug IVIG for the period August 1, 2000 through December 31, 2001 and identified additional overpayments of $156,023.  We commend the hospital for its efforts to identify additional overpayments and strengthen controls for billing IVIG.

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