Audit of Medicare Payments for Emergency Department Services Provided in Nonemergency Department Sites of Service

CMS did not ensure compliance with Medicare requirements for claims that were billed using emergency department procedure codes, but the place of service code (for physician claims) or revenue center code (for hospital claims) was billed as a nonemergency. Medicare improperly paid physicians for 9,749 procedures totaling $922,524 that physicians improperly billed for emergency department procedures with nonemergency place of service codes. Medicare also made $14.2 million in potentially improper payments to hospitals for claims billed with emergency department procedure codes and nonemergency revenue center codes. In addition, enrollees may have been held responsible for Part B deductibles that the hospitals potentially should not have charged.

CMS did not ensure that Medicare contractors had adequate claims processing controls in place—specifically system edits—to identify and prevent the improper payments. Additionally, CMS did not provide adequate guidance to ensure that hospitals complied with Medicare requirements when billing for these services.