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Series: Medicare Part B Services Provided to Patients Residing in Nursing Homes

Announced on  | Last Modified on  | Series Number: SRS-A-26-011
Status
Completed
Agency
Centers for Medicare and Medicaid Services

OBJECTIVE

Medicare pays physicians, non-physician practitioners, and other providers for services rendered to Medicare beneficiaries, including those residing in nursing homes (NHs). Most of these Part B services are not subject to consolidated billing; therefore, each provider submits a claim to Medicare. Since the 1990s, OIG has identified problems with Part B payments for services provided to NH residents. An opportunity for fraudulent, excessive, or unnecessary Part B billing exists because NHs may not be aware of the services that the providers bill directly to Medicare, and because NHs provide access to many beneficiaries and their records. We will determine whether Part B payments to Medicare beneficiaries in NHs are appropriate and whether NHs have effective compliance programs and adequate controls over the care provided to their residents.

There is 1 project in this series.

COMPLETED PROJECTS IN THIS SERIES (1)

Audit of Medicare Part B Services Provided to Patients Residing in Nursing Homes

Project A-06-21-04002 • Completed on July 15, 2026

TIMELINE

  • January 19, 2021
    Project Announced

    Audit of Medicare Part B Services Provided to Patients Residing in Nursing Homes - A-06-21-04002

  • February 5, 2026
    Series Number SRS-A-26-011 Assigned
  • July 15, 2026
    Project Complete - A-06-21-04002

    Audit of Medicare Part B Services Provided to Patients Residing in Nursing Homes complete. This audit resulted in 2 recommendations.

  • July 15, 2026
    Series Complete

    Medicare Part B Services Provided to Patients Residing in Nursing Homes complete.

1 REPORT PUBLISHED

Novitas Solutions, Inc., Improperly Paid Approximately $19.5 Million for Selected Medicare Part B Services Provided to Patients Residing in Nursing Homes (A-06-21-04002)
  • Of the 150 sample items, 91 did not meet Medicare requirements and guidance for evaluation and management, psychotherapy, or podiatry services provided to patients residing in nursing homes.
  • During our audit period, Novitas’s oversight of provider billing and provider education was not sufficient to ensure that the providers fully understood Medicare coding and documentation requirements for the selected services.
  • On the basis of our sample results, we estimated that Novitas improperly paid approximately$19.5 million for the selected services that did not meet Medicare requirements and guidance.

26-A-06-080.01 to CMS - Open Unimplemented
Update expected on 01/14/2027
We recommend that Novitas implement additional oversight (e.g., documentation and billing guidance, medical reviews, and/or provider internal audits) to prevent improper payments associated with provider billing of E/M, psychotherapy, and podiatry services, which could have saved an estimated $19,480,109 for our audit period.

26-A-06-080.02 to CMS - Open Unimplemented
Update expected on 01/14/2027
We recommend that Novitas provide annual education to providers and their billing staff specific to the Medicare requirements and guidance for billing E/M, psychotherapy, and podiatry services.

View in Recommendation Tracker
Work Plan Type
Office of Audit Services
HHS Agencies
Centers for Medicare and Medicaid Services
Issue Areas
Financial Stewardship
Target Groups
-
Financial Groups
Medicare B