Deeper Than the Headlines: OIG’s Medicare Compliance Review of Mobile Infirmary Medical Center

The OIG’s most recent Medicare Compliance Review of a hospital was posted on their website on Oct. 24, 2018. The hospital that underwent the review was the Mobile Infirmary Medical Center.

OIG found the hospital complied with Medicare billing requirements for 87 of the 100 inpatient claims they reviewed. However, the hospital did not fully comply with Medicare billing requirements for the remaining 13 claims according to the OIG. This resulted in net overpayments of $163,104 in calendar years 2015 and 2016.

Specifically, eight claims either did not meet Medicare criteria for acute inpatient rehabilitation or did not comply with Medicare documentation requirements, resulting in overpayments of $162,448.  In four of the eight claims, the hospital incorrectly billed Medicare Part A for beneficiary stays that did not meet Medicare criteria for acute inpatient rehabilitation. Additionally, for four of the eight claims, the hospital incorrectly billed IRF claims that did not comply with Medicare documentation requirements.

The eight errors consisted of the following:

• for four claims, there was not a reasonable expectation at the time of admission that the patient required the intensive rehabilitation therapy services that are provided in an IRF
• for two claims, the documentation did not support that a rehabilitation physician developed and documented an individualized overall plan of care
• for two claims, the documentation did not show that all required team members were present at the interdisciplinary team conferences.

In addition, five claims had incorrectly billed outlier payments, resulting in net overpayments of $656. Based on OIG’s sample results, they estimated that the hospital received overpayments of at least $340,125 for the audit period.  The OIG recommended the hospital refund to the Medicare contractor $340,125 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 rule; and strengthen controls to ensure full compliance with Medicare requirements.

Of course, there are at least two sides to every story.  In this review, the hospital did not agree with all the OIG’s findings and recommendations. Specifically, the hospital disagreed that it incorrectly billed inpatient rehabilitation claims. In addition, the hospital disagreed with OIG’s recommendation to identify and return any additional similar overpayments received outside of the audit period.

The OIG’s response stated they obtained independent medical review for all IRF claims in their sample. They provided the independent medical reviewers with all documentation necessary to sufficiently determine medical necessity and documentation requirements for the IRF claims, and their report reflects the results of that review. Based on the hospital’s rebuttal and OIG’s internal review, the OIG reduced the overpayment amount and associated recommendation in their report from the initial recommended recovery amount in their draft report.

As always, reviewing these full OIG reports can provide insight into their methods as well as specific areas and types of services they feel are vulnerable to non-compliance.  This insight can guide your internal compliance efforts as well.