Review of Medicare Outpatient Prospective Payment System Outlier Payments - Rush Presbyterian-St. Luke's Medical Center, Chicago, Illinois

EXECUTIVE SUMMARY:

The objective of this audit was to determine whether Rush-Presbyterian-St. Luke's Medical Center (Rush) was reimbursed properly for outlier payments made during the initial implementation of the Outpatient Prospective Payment System.  We determined Rush was reimbursed improperly on 38 of the 50 outpatient claims that were reviewed, which resulted in 35 overpayments and 3 underpayments.  The 35 overpayments were attributable to a problem within the Fiscal Intermediary's (FI) claims processing system and totaled $7,726.  The three underpayments of $7,752 pertained to improperly billing Medicare for implantable devices.  Rush should have billed these implantable devices using a specific HCPCS code, which would have resulted in a higher claim reimbursement with no outlier payment.  We recommended Rush refund the overstated outlier overpayments of $7,726 and resubmit the claims with the improperly billed implantable devices in order to recover the identified underpayments of $7,752.  Rush concurred with our findings and will work with their FI in addressing our recommendations.