News: OIG sites New York-Presbyterian Hospital, targets medical necessity

$14.2 million. That’s what Medicare paid New York-Presbyterian Hospital in overpayments for 123 claims because the hospital did not have “adequate controls to prevent the incorrect billing of Medicare claims,” according to the Office of the Inspector General (OIG).

For 46 of the selected inpatient claims, the hospital incorrectly billed Medicare Part A for beneficiary stays that it should have billed as outpatient or outpatient with observation services. Medicare payments may not be made for items or services that “are not reasonable and necessary for the diagnosis or treatment of illness or injury,” says the OIG. Documentation must reflect why inpatient care is medically necessary, and include conditions and procedures deemed appropriate for the level of care.

Additionally, for four of the selected outpatient claims, the hospital incorrectly billed Medicare for HCPCS procedure codes that were medically unnecessary. The medical record must contain why procedures and tests are necessary for the condition(s) patients present with.

The OIG recommended the facility strengthen their efforts to ensure compliance with Medicare documentation and billing requirements.