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

EXECUTIVE SUMMARY:

Our objective was to determine whether the claims that Green Cross, Inc. submitted for partial hospitalization program (PHP) services met Medicare reimbursement requirements.  Green Cross submitted claims for PHP services that did not meet Medicare reimbursement requirements.  Medical reviewers determined that 95 of the 100 sampled PHP claims did not meet Medicare reimbursement requirements relating to initial certification/evaluation, recertification, and/or beneficiary eligibility.  We recommended that CMS determine the allowability of the claims that resulted in our $4,762,036 statistical estimate of unallowable payments.  In its comments on our draft report, Green Cross strongly disagreed with the findings and took issue with many aspects of the review, including the audit process and the medical determinations.