\u2022Case 3: Claims Processing
BACKGROUND
The Centers for Medicare and Medicaid Services (CMS) administer the Medicare
program. CMS employs Medicare contractors, including Wisconsin Physicians Service
(WPS), to process and pay hospital outpatient claims using the Fiscal Intermediary
Shared System (FISS).
CMS implemented an outpatient prospective payment system (OPPS) for
hospital outpatient services. Under the OPPS, Medicare pays for hospital outpatient
services on a rate-per-service basis that varies according to the assigned ambulatory
payment classification group. Under the OPPS, outlier payments are available when
exceptionally costly services exceed established thresholds.
Common medical devices implanted during outpatient procedures include
cardiac devices, joint replacement devices, and infusion pumps. Generally, a provider
implants only one cardiac device during an outpatient surgical procedure. Under the
OPPS, payments to hospitals for medical devices are \u201cpackaged\u201d into the payments for
the procedures to insert devices. Hospitals are required to report accurately the number
of device units and related charges on their claims. The failure to report accurately the
device units and related charges could result in incorrect outlier payments.
Our audit covered $32,860 in Medicare outlier payments to hospitals for 14
claims for outpatient procedures that included the insertion of more than one of the
same type of medical device. The 14 claims had dates of service during calendar years
(CY) 2008 and 2009.
OBJECTIVE
\u00a9 2018 Laureate Education, Inc. Page 2 of 2
Our objective was to determine whether Medicare paid hospitals correctly for
outpatient claims processed by WPS that included procedures for the insertion of
multiple units of the same type of medical device.
SUMMARY OF FINDINGS
Of the 14 claims that we reviewed, Medicare correctly paid eight outpatient
claims processed by WPS that included procedures for the insertion of multiple units of
the same type of medical device. However, for the remaining six claims, Medicare did
not pay hospitals correctly. These incorrect payments were due to hospitals overstating
the number of units and related charges, resulting in excessive or unwarranted outlier
payments.
For the six claims, WPS made overpayments to hospitals totaling $17,996.
Incorrect payments occurred because hospitals had inadequate controls to ensure that
they billed accurately for claims that included the insertion of medical devices. In
addition, Medicare payment controls in the FISS were not always adequate to prevent
or
detect incorrect payments. Propose a plan of action to the Board of
Directors outlining a response to the Office of the Inspector General
(OIG).
\u2022 Recommend at least one suggestion for how the process
between WPS and CMS (Centers for Medicare and Medicaid Services) could
be improved<\/p>\n","protected":false},"excerpt":{"rendered":"
\u2022Case 3: Claims Processing BACKGROUND The Centers for Medicare and Medicaid Services (CMS) administer the Medicare program. CMS employs Medicare contractors, including Wisconsin Physicians Service (WPS), to process and pay hospital outpatient claims using the Fiscal Intermediary Shared System (FISS). CMS implemented an outpatient prospective payment system (OPPS) for hospital outpatient services. Under the OPPS, […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[12],"class_list":["post-28761","post","type-post","status-publish","format-standard","hentry","category-research-paper-writing","tag-religion-and-theology"],"_links":{"self":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/posts\/28761","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/comments?post=28761"}],"version-history":[{"count":0,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/posts\/28761\/revisions"}],"wp:attachment":[{"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/media?parent=28761"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/categories?post=28761"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/papersspot.com\/blog\/wp-json\/wp\/v2\/tags?post=28761"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}