Medical Review of Quitman Clinic's Partial Hospitalization Services for the Period August 1, 2000, Through December 31, 2002

EXECUTIVE SUMMARY:

The objective of this audit was to determine if Medicare claims submitted by Quitman Clinic for partial hospitalization program (PHP) services met Medicare reimbursement requirements.  Medical reviewers determined that none of the services on 100 sampled claims met Medicare reimbursement requirements.  Because none of the sampled claims were eligible for Medicare reimbursement, the entire universe of 1,714 claims for the period August 1, 2000, through December 31, 2002, totaling $12,491,797 in payments, should not have been billed to Medicare.  We recommended that Quitman Clinic refund to the Medicare program $12,491,797 in unallowable payments and strengthen its procedures to ensure that PHP claims meet Medicare reimbursement requirements.  While Quitman Clinic disagreed with the recommendation to repay the $12,491,797, it agreed to strengthen its procedures.