Medicare Compliance Review of WakeMed Raleigh Campus

WakeMed Raleigh Campus (the Hospital), located in Raleigh, NC, complied with Medicare billing requirements for 187 of the 263 inpatient claims that we reviewed. However, the Hospital did not fully comply with Medicare billing requirements for the remaining 76 claims, resulting in net overpayments of approximately $250,000 for the audit period. On the basis of our sample results, we estimated that the Hospital received overpayments of at least $697,000 for the audit period. These errors occurred primarily because the Hospital did not have adequate controls to prevent the incorrect billing of Medicare claims within the selected risk areas that contained errors.

We recommended that the Hospital refund to the Medicare program $697,608 in estimated overpayments for the audit period for claims that it incorrectly billed; exercise reasonable diligence to identify and return any additional similar overpayments received outside of our audit period, in accordance with the 60-day repayment rule, and identify any returned overpayments as having been made in accordance with this recommendation; and strengthen controls to ensure full compliance with Medicare requirements.

In written comments on our draft report, the Hospital disagreed with our findings on certain claims and contended that the extrapolation of our results was not justifiable or appropriate. The Hospital also disagreed with any suggestion that the audit results demonstrate deficiencies in its key controls for coding, billing, and documenting within the medical records. The Hospital stated that it would continue to assess its obligations under the 60-day rule and conduct any necessary expanded review within the time limits established under the program requirements.

After reviewing the Hospital's comments, we maintain that our findings and recommendations are valid. We used an independent medical reviewer to determine whether certain sampled claims were appropriately billed. Additionally, we used statistically valid sampling methodology in our sample selection and in determining the estimated Medicare overpayment.