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Series: Selected Inpatient and Outpatient Billing Requirements
Announced on | Last Modified on | Series Number: SRS-A-25-012
Status
Active
Agency
Centers for Medicare and Medicaid Services
OBJECTIVE
This review is part of a series of hospital compliance reviews that focus on hospitals with claims that may be at risk for overpayments. Prior OIG reviews and investigations have identified areas at risk for noncompliance with Medicare billing requirements. We will review Medicare payments to acute care hospitals to determine hospitals' compliance with selected billing requirements and recommend recovery of overpayments. Our review will focus on those hospitals with claims that may be at risk for overpayments.
There are 30 projects in this series.
Project titles will remain unpublished until projects are complete and reports are posted.
ACTIVE PROJECTS IN THIS SERIES (12)
Project A-07-21-05134
•
Announced on Sep 14, 2021
Project A-07-21-05133
•
Announced on Nov 18, 2021
Project A-04-22-07101
•
Announced on Aug 3, 2022
Project A-02-22-01022
•
Announced on Aug 16, 2022
Project A-04-23-08095
•
Announced on Oct 11, 2022
Project A-09-23-03001
•
Announced on Oct 26, 2022
Project A-05-23-00004
•
Announced on Nov 2, 2022
Project A-04-23-07104
•
Announced on Dec 1, 2022
Project A-03-23-00001
•
Announced on Jan 5, 2023
Project A-07-24-05147
•
Announced on Jan 26, 2024
Project A-07-24-05148
•
Announced on Jan 26, 2024
Project OAS-25-04-089
•
Announced on Jun 12, 2025
COMPLETED PROJECTS IN THIS SERIES (18)
Sarasota Memorial Hospital
Project A-04-23-08098 • Completed on February 25, 2026
St. Joseph's Hospital Health Center
Project A-02-20-01004 • Completed on December 16, 2021
Jewish Hospital
Project A-04-19-08077 • Completed on August 18, 2021
Lake Hospital System
Project A-05-19-00024 • Completed on June 30, 2021
Staten Island University Hospital
Project A-02-18-01025 • Completed on June 24, 2021
Virtua Our Lady of Lourdes Hospital
Project A-02-18-01018 • Completed on May 4, 2021
Sunrise Hospital & Medical Center
Project A-04-19-08075 • Completed on March 31, 2021
Providence Medical Center
Project A-07-18-05113 • Completed on December 16, 2020
Edward W. Sparrow Hospital
Project A-05-18-00045 • Completed on November 12, 2020
St. Francis Hospital
Project A-05-18-00048 • Completed on October 21, 2020
Alta Bates Summit Medical Center
Project A-04-19-08071 • Completed on September 30, 2020
Flagstaff Medical Center
Project A-07-18-05112 • Completed on September 1, 2020
The Ohio State University Hospital
Project A-05-18-00042 • Completed on May 22, 2020
Forbes Hospital
Project A-03-18-00005 • Completed on March 27, 2020
Texas Health Presbyterian Hospital Dallas
Project A-04-18-08068 • Completed on December 10, 2019
St. Vincent Hospital
Project A-05-18-00040 • Completed on November 27, 2019
Northwest Medical Center
Project A-04-18-08064 • Completed on November 26, 2019
Carolinas Hospital
Project A-04-18-08063 • Completed on November 26, 2019
TIMELINE
February 1, 2018
Project Announced
Carolinas Hospital - A-04-18-08063
March 7, 2018
Project Announced
Northwest Medical Center - A-04-18-08064
April 2, 2018
Project Announced
Forbes Hospital - A-03-18-00005
April 6, 2018
Project Announced
Providence Medical Center - A-07-18-05113
April 16, 2018
Project Announced
Flagstaff Medical Center - A-07-18-05112
April 20, 2018
Project Announced
Virtua Our Lady of Lourdes Hospital - A-02-18-01018
May 15, 2018
Project Announced
Edward W. Sparrow Hospital - A-05-18-00045
May 30, 2018
Project Announced
The Ohio State University Hospital - A-05-18-00042
June 27, 2018
Project Announced
Staten Island University Hospital - A-02-18-01025
August 1, 2018
Projects Announced
Texas Health Presbyterian Hospital Dallas - A-04-18-08068
St. Vincent Hospital - A-05-18-00040
August 6, 2018
Project Announced
St. Francis Hospital - A-05-18-00048
January 22, 2019
Project Announced
Alta Bates Summit Medical Center - A-04-19-08071
June 3, 2019
Project Announced
Sunrise Hospital & Medical Center - A-04-19-08075
June 12, 2019
Project Announced
Lake Hospital System - A-05-19-00024
August 12, 2019
Project Announced
Jewish Hospital - A-04-19-08077
November 7, 2019
Project Announced
St. Joseph's Hospital Health Center - A-02-20-01004
The Hospital complied with Medicare billing requirements for 74 of the 100 inpatient and outpatient claims we reviewed. However, the Hospital did not fully comply with Medicare billing requirements for the remaining 26 claims, resulting in net overpayments of $272,364 from January 1, 2020, through December 31, 2021 (audit period).
On the basis of our sample results, we estimated that the Hospital received net overpayments of at least $12.1 million for the audit period.
These errors occurred primarily because the Hospital did not always follow its written policies and procedures to prevent the incorrect billing of Medicare claims within the selected risk areas that contained errors.
26-A-04-049.01 to CMS - Open Unimplemented
Update expected on
08/24/2026
We recommend that the Hospital refund to the Federal government the estimated $12,199,717 in net overpayments for incorrectly billed claims, excluding amounts presumed to be unrecoverable under the Section 1870 waiver of liability provision.
26-A-04-049.02 to CMS - Open Unimplemented
Update expected on
08/24/2026
We recommend that the Hospital consider conducting one or more internal audits or investigations for claims beyond our audit period, based on the risks identified by this audit, to identify any similar overpayments and return any identified overpayments to the Medicare program.
26-A-04-049.03 to CMS - Open Unimplemented
Update expected on
08/24/2026
We recommend that the Hospital provide additional training to clinical and billing personnel on its policies and procedures related to the following: The Two-Midnight Rule; The medical necessity of inpatient and outpatient services; IRF admissions; The billing of services provided; Inpatient and outpatient coding.
The Hospital complied with Medicare billing requirements for 60 of the 100 inpatient and outpatient claims we audited. However, the Hospital did not fully comply with Medicare billing requirements for the remaining 40 claims, resulting in overpayments of $666,021 for the audit period. Specifically, 37 inpatient claims and 3 outpatient claims had billing errors.
On the basis of our sample results, we estimated that the Hospital received overpayments of approximately $4.8 million for the audit period. As of the publication of this report, this amount included claims outside of the Medicare 4-year claim-reopening period.
21-A-02-085.01 to CMS - Closed Implemented
Closed on
12/29/2022
We recommend that Virtua Our Lady of Lourdes Hospital refund to the Medicare contractor the portion of the $4,765,305 in estimated overpayments for the audit period for claims that it incorrectly billed that are within the 4-year reopening period.
21-A-02-085.02 to CMS - Closed Unimplemented
Closed on
07/27/2023
We recommend that Virtua Our Lady of Lourdes Hospital based on the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.
21-A-02-085.03 to CMS - Closed Implemented
Closed on
12/29/2022
We recommend that Virtua Our Lady of Lourdes Hospital strengthen controls to ensure that all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation and all required documentation is included in the medical records; all inpatient beneficiaries meet Medicare requirements for inpatient hospital services; procedure, diagnosis, and HCPCS codes are supported in the medical records and staff are properly trained; and the use of bypass modifiers is supported in the medical records.
We recommend that Staten Island University Hospital refund to the Medicare contractor the portion of the $11,761,274 in estimated overpayments for the audit period for claims that it incorrectly billed that are within the 4-year reopening period.
21-A-02-113.02 to CMS - Closed Unimplemented
Closed on
11/08/2021
We recommend that Staten Island University Hospital based on the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.
21-A-02-113.03 to CMS - Closed Unimplemented
Closed on
10/25/2021
We recommend that Staten Island University Hospital strengthen controls to ensure that all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation, all inpatient beneficiaries meet Medicare requirements for inpatient hospital services, the use of bypass modifiers is supported in the medical records, and staff are properly trained.
We recommend that Forbes Hospital refund to the Medicare contractor $3,343,748 ($590,646 in net overpayments identified in our sample) in estimated overpayments for incorrectly billed claims that are within the reopening period.
20-A-03-081.02 to CMS - Closed Implemented
Closed on
03/16/2021
Based upon the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any returned overpayments as having been made in accordance with this recommendation.
20-A-03-081.03 to CMS - Closed Implemented
Closed on
08/03/2020
Strengthen controls to ensure full compliance with Medicare requirements by ensuring that all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation; ensuring that all inpatient beneficiaries meet Medicare criteria for inpatient hospital services; ensuring that the procedure and diagnosis codes used are supported by the medical records; and ensuring that the codes used for distinct procedural services are supported by the medical records.
We recommend that the Hospital refund to the Medicare contractor $3,461,279 ($3,461,376 less $97 that has already been repaid) in estimated overpayments for the audit period for claims that it incorrectly billed.
20-A-04-034.02 to CMS - Closed Implemented
Closed on
05/21/2025
We recommend that the Hospital 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.
20-A-04-034.03 to CMS - Closed Implemented
Closed on
03/10/2020
We recommend that the Hospital strengthen controls to ensure full compliance with Medicare requirements, specifically ensure all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation; ensure documentation supporting the medical necessity for inpatient hospital services is contained in the medical records; ensure procedure and diagnosis codes are supported in the medical records and staff are properly trained; ensure procedures are in place to properly bill claims subject to SNF consolidated billing requirements; and ensure medical records accurately document distinct procedural services and staff are properly.
We recommend that Northwest Medical Center refund to the Medicare contractor $1,203,705 ($1,207,729 less $4,024 that has already been repaid) in estimated overpayments for the audit period for claims that it incorrectly billed.
20-A-04-035.02 to CMS - Closed Implemented
Closed on
03/25/2020
We recommend that Northwest Medical Center 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.
20-A-04-035.03 to CMS - Closed Implemented
Closed on
03/25/2020
We recommend that Northwest Medical Center strengthen controls to ensure full compliance with Medicare requirements, to ensure that all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation; documentation supporting the medical necessity for inpatient hospital services is contained in the medical records; diagnosis codes are supported in the medical records and staff are properly trained; and medical records accurately document distinct procedural services and staff are properly trained.
We recommend that the Texas Health Presbyterian Hospital Dallas refund to the Medicare contractor $10,597,133 ($10,711,548 less $114,415 that the Hospital has already repaid) in estimated overpayments for the audit period for claims that it incorrectly billed.
20-A-04-039.02 to CMS - Closed Implemented
Closed on
10/29/2021
We recommend that the Texas Health Presbyterian Hospital Dallas 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.
20-A-04-039.03 to CMS - Closed Implemented
Closed on
12/31/2020
We recommend that the Texas Health Presbyterian Hospital Dallas ensure all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation and all required documentation is included in the medical record; ensure all inpatient beneficiaries meet Medicare criteria for inpatient hospital services; ensure procedure and diagnosis codes are supported in the medical records and staff are properly trained; and ensure HCPCS codes are supported in the medical records and staff are properly trained.
We recommend that St. Vincent Hospital refund to the Medicare contractor $2,111,647 (of which $293,404 was net overpayments identified in our sample) in estimated overpayments for incorrectly billed services.
20-A-05-036.02 to CMS - Closed Implemented
Closed on
12/22/2022
We recommend that St. Vincent Hospital exercise reasonable diligence to identify and return any additional similar overpayments received outside of our audit period, in accordance with the 60-day rule, and identify any returned overpayments as having been made in accordance with this recommendation.
20-A-05-036.03 to CMS - Closed Implemented
Closed on
12/22/2022
We recommend that St. Vincent Hospital strengthen controls to ensure full compliance with Medicare requirements; specifically, ensure that all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation, all inpatient beneficiaries meet Medicare criteria for inpatient hospital services, diagnosis, discharge status, and admission source codes are supported in the medical records and staff are properly trained, and medical records accurately document the appropriate number of units and distinct procedural services and that staff are properly trained.
We recommend that The Ohio State University Hospital refund to the Medicare contractor $3,736,490 (of which $335,832 was net overpayments identified in our sample) in estimated overpayments for incorrectly billed services that are within the 4-year claim reopening period.
20-A-05-107.02 to CMS - Closed Implemented
Closed on
06/10/2021
We recommend that The Ohio State University Hospital based on the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.
20-A-05-107.03 to CMS - Closed Implemented
Closed on
02/13/2021
We recommend that The Ohio State University Hospital strengthen controls to ensure full compliance with Medicare requirements; specifically, ensure that all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation; all inpatient beneficiaries meet Medicare criteria for inpatient hospital services; diagnosis and discharge status codes are supported in the medical records and staff are properly trained, and medical records accurately document the appropriate number of units and distinct procedural services and that staff are properly trained.
We recommend that Edward W. Sparrow Hospital based on the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.
21-A-05-019.02 to CMS - Closed Implemented
Closed on
03/01/2021
We recommend that Edward W. Sparrow Hospital strengthen controls to ensure full compliance with Medicare requirements; specifically, ensure that all inpatient beneficiaries meet Medicare requirements for inpatient hospital services and evaluation and management services are supported in the medical records.
We recommend that St. Francis Hospital refund to the Medicare contractor the portion of the $1,620,452 in estimated overpayments for the audit period for claims that it incorrectly billed that are within the 4-year reopening period.
21-A-05-009.02 to CMS - Closed Unimplemented
Closed on
03/16/2023
We recommend that St. Francis Hospital, based on the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.
21-A-05-009.03 to CMS - Closed Implemented
Closed on
02/08/2022
We recommend that St. Francis Hospital strengthen controls to ensure full compliance with Medicare requirements; specifically, ensure that all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation; all inpatient beneficiaries meet Medicare requirements for inpatient hospital services; procedure and diagnosis codes are supported in the medical records and staff are properly trained; and medical records accurately document distinct procedural services and staff are properly trained.
We recommend that Flagstaff Medical Center refund to the Medicare contractor $79,216 in estimated overpayments for the audit period for claims that it incorrectly billed.
20-A-07-149.02 to CMS - Closed Implemented
Closed on
01/05/2021
We recommend that Flagstaff Medical Center based on the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule,8 and identify any of those returned overpayments as having been made in accordance with this recommendation.
20-A-07-149.03 to CMS - Closed Implemented
Closed on
01/05/2021
We recommend that CMS strengthen controls to ensure full compliance with Medicare requirements.
We recommend that Sunrise Hospital & Medical Center refund to the Medicare contractor $23,606,895 ($23,615,809 less $8,914 that the Hospital has already repaid) in net estimated overpayments for the audit period for claims that it incorrectly billed that are within the 4-year reopening period.
21-A-04-075.02 to CMS - Closed Implemented
Closed on
12/22/2022
We recommend that Sunrise Hospital & Medical Center based on the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.
21-A-04-075.03 to CMS - Closed Implemented
Closed on
07/19/2021
We recommend that Sunrise Hospital & Medical Center strengthen controls to ensure that: (1) all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation and all required documentation is included in the medical records, (2) all inpatient beneficiaries meet Medicare requirements for inpatient hospital services, (3) outlier payments are calculated correctly by billing the correct units of service and charges on the claim and staff are properly trained, (4) the use of bypass modifiers is supported in the medical records and staff are properly trained, and (5) HCPCS codes are supported in the medical records and staff are properly trained.
We recommend that Providence Medical Center refund to the Medicare contractor the portion of the $325,241 in estimated overpayments for the audit period for claims that it incorrectly billed that are within the 4-year reopening period.
21-A-07-039.02 to CMS - Closed Implemented
Closed on
04/19/2021
We recommend that Providence Medical Center based on the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule, and identify any of those returned overpayments as having been made in accordance with this recommendation.
21-A-07-039.03 to CMS - Closed Implemented
Closed on
04/19/2021
We recommend that Providence Medical Center strengthen controls to ensure full compliance with Medicare requirements.
We recommend that Alta Bates Summit Medical Center refund to the Medicare contractor $16,346,371 ($16,395,489 less $49,118 that the Hospital has already repaid) in estimated overpayments for the audit period for claims that it incorrectly billed.
20-A-04-177.02 to CMS - Closed Implemented
Closed on
02/20/2024
We recommend that Alta Bates Summit Medical Center based on the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule, and identify any of those returned overpayments as having been made in accordance with this recommendation.
20-A-04-177.03 to CMS - Closed Implemented
Closed on
11/15/2023
We recommend that Alta Bates Summit Medical Center strengthen controls to ensure that all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation and all required documentation is included in the medical records, procedure and diagnosis codes are supported in the medical records and staff are properly trained, all inpatient beneficiaries meet Medicare requirements for inpatient hospital services, the use of bypass modifiers is supported in the medical records, and staff are properly trained.
We recommend that Jewish Hospital refund to the Medicare contractor $13,486,524 in estimated overpayments for the audit period for claims that it incorrectly billed that are within the 4-year claim reopening period.
21-A-04-143.02 to CMS - Closed Unimplemented
Closed on
12/26/2023
We recommend that Jewish Hospital based on the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.
21-A-04-143.03 to CMS - Closed Implemented
Closed on
11/08/2021
We recommend that Jewish Hospital strengthen internal controls by: strengthening procedures to verify that all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation, developing processes to ensure that procedure and diagnosis codes are supported in the medical records, providing additional training to inpatient and outpatient coding staff on the use of bypass modifiers, and developing procedures to verify that the use of bypass modifiers is supported in the medical records.
We recommend that Lake Hospital System refund to the Medicare contractor the portion of the $4,385,974 in estimated overpayments for the audit period for claims that it incorrectly billed that are within the 4-year reopening period.
21-A-05-116.02 to CMS - Closed Unimplemented
Closed on
06/25/2025
We recommend that Lake Hospital System based on the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule, and identify any of those returned overpayments as having been made in accordance with this recommendation (This recommendation does not apply to any overpayments that are both within our sampling frame (i.e., the population from which we selected our statistical sample) and refunded based on the extrapolated overpayment amount. Those overpayments are already covered in the previous recommendation.).
21-A-05-116.03 to CMS - Closed Implemented
Closed on
11/09/2021
We recommend that Lake Hospital System strengthen controls to ensure full compliance with Medicare requirements.
Refund to the Medicare contractor $389,973 in estimated overpayments for the audit period for claims that it incorrectly billed that are within the 4-year claim reopening period.
22-A-02-021.02 to CMS - Closed Implemented
Closed on
09/17/2024
Based on the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.
22-A-02-021.03 to CMS - Closed Implemented
Closed on
03/30/2022
Strengthen internal controls by: strengthening procedures to verify that all inpatient beneficiaries meet Medicare requirements for inpatient hospital services, strengthening processes to ensure that diagnosis codes and HCPCS codes are supported in the medical records, and providing additional training to coding staff on DRG and HCPCS code assignments.
