Review of Separately Billed Composite Rate Laboratory Services Under the Medicare End Stage Renal Disease Program at Caritas St. Elizabeth's Medical Center

Our objective was to determine whether Caritas St. Elizabeth's Medical Center (the Hospital) billed Medicare in accordance with Medicare requirements for laboratory tests provided to end stage renal disease (ESRD) beneficiaries during calendar years (CY) 2004 and 2005. We found that he Hospital did not always bill Medicare in accordance with Medicare requirements for laboratory tests provided to ESRD beneficiaries.  Specifically, the Hospital incorrectly billed for (1) hematology laboratory services included in the composite rate, (2) automated multi-channel chemistry tests that did not meet specific reimbursement requirements, and (3) ferritin tests performed beyond the allowable frequency without medical justification.  Based on the results of a statistical sample, we estimated that Medicare overpaid the Hospital $61,628 for laboratory services provided to ESRD beneficiaries during CYs 2004 and 2005.

We recommended that the Hospital refund the Medicare Program $61,628 in overpayments for CYs 2004 and 2005, identify and refund any Medicare payments for ESRD-related laboratory services received after our audit period that did not meet Medicare requirements and strengthen its policies and procedures to ensure compliance with Medicare requirements.  The Hospital agreed with our findings and recommendations.