Medical Review of Synergy Behavioral Health'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 Synergy Rehab Services Inc. (Synergy) submitted for partial hospitalization program (PHP) services met Medicare reimbursement requirements.  For 51 of 100 sampled claims, medical reviewers determined that Medicare reimbursement requirements were not met, primarily for two reasons:  (1) the patient did not need, or was unable to benefit from, the services; and (2) the patient's medical records lacked the required documentation.  We recommended that CMS determine the allowability of the claims that resulted in our $3,098,296 statistical estimate of unallowable payments.  Synergy strongly disagreed with the findings and took issue with many aspects of the review, including the audit review process and the medical determinations.  We have issued the final report directly to CMS for resolution.