OIG audit finds IRF overpayments of more than $400,000 at Georgia hospital

March 7, 2018

Medicare Web

Incorrect inpatient rehabilitation facility (IRF) claims led to $444,458 in overpayments at Memorial University Medical Center, a Savannah, Georgia-based hospital, according to a recent Office of Inspector General (OIG) audit report. IRF billing compliance has been on the OIG’s radar for several years, and Medicare Administrative Contractors and supplemental medical review contractors have been placing these claims under increased scrutiny.

The IRF claims were only part of the OIG’s audit of Memorial University Medical Center. The OIG reviewed a sample of 131 of the hospital’s inpatient and outpatient claims from January 1, 2015, through December 31, 2016, including 30 IRF claims. Overall, Memorial University Medical Center hit the mark, and the OIG found that 92 of the 131 claims were correct. However, the remaining 39 claims were incorrect and resulted in $599,530 in overpayments. The incorrect IRF claims made up the majority of the overpayment. The OIG found errors on 23 of the 30 audited IRF claims. The hospital incorrectly billed Medicare Part A for beneficiary stays that did not meet Medicare’s criteria for acute inpatient rehabilitation, the OIG said in its report.

The patient’s medical record must include several specific pieces of documentation to ensure that IRF coverage requirements are met, the OIG report said. These include:

A comprehensive pre-admission screening
A post-admission rehabilitation physician evaluation
An individual overall plan of care developed by a rehabilitation physician

The medical record must also demonstrate that IRF care is reasonable and necessary and that the patient requires a more intensive level of rehabilitation services than is provided in a hospital inpatient setting. On several IRF claims specifically cited in the report, Memorial University Medical Center failed to document pre-admission screening, post-admission evaluation, or a plan of care.

Hospitals should review documentation for IRF claims to ensure that medical necessity and documentation requirements are met. For more on IRF audits, guidelines, and medical necessity criteria, see the March issue of Case Management Monthly, available to Revenue Cycle Advisor subscribers.