Health Systems

Presbyterian Hospital Overcharges Medicare Over $10 Million, According to Audit

The U.S. Department of Health and Human Services Department estimates that Texas Health Presbyterian Hospital in Dallas incorrectly billed Medicare more than $10 million, based on an audit performed by the Office of the Inspector General.

The routine audit looked at 100 randomly selected claims from the hospital in 2016 and 2017, and found that only 59 of them complied with Medicare billing requirements. The other 41 claims were incorrectly billed and resulted in overpayment of $500,323 for the audit period. The audit said that errors included rehabilitation claims that did not meet coverage or documentation requirements, inpatient claims that should have been billed as outpatient, and incorrect codes.

“These errors occurred primarily because the Hospital did not have adequate controls to prevent the incorrect billing of Medicare claims within the selected risk areas that contained errors,” the audit reads.

The audit scaled their 100-claim sample to all of the Medicare claims processed by the facility, and is asking for the hospital to refund $10.6 million to Medicare. The errors would account for 4 percent of the $249 million that Medicare paid to the hospital for 13,574 inpatient and 52,075 outpatient claims for the audit period, January 1, 2016, to December 31, 2017.

The hospital disagreed with a majority of the findings in the audit, and said that only six of the 100 claims had errors. It said that the OIG’s medical reviewer “has a history of significant error rates in its claim denials,” in its work as the Hospital’s Qualified Independent Contractor, and says it will be a conflict of interest should this reviewer be used in the appeal process.

After the OIG makes a recommendation to CMS, it will send out letters about each claim. Texas Health Resources intends to appeal the claims on a case by case basis. Because the 100 claims were used to make an estimate for the entire hospital, one appealed claim could mean hundreds of thousands of dollars.

“While Texas Health disagrees with most of the OIG’s report, we do acknowledge that the OIG correctly identified some opportunities for improvement, especially around documentation and coding. But thanks to our active compliance department, we were already working on improving these processes before the OIG notified us that they were going to audit Texas Health Dallas,” said Stephen O’Brien, Director of Public Relations for Texas Health.

In 2017, Medicare paid hospitals $206 billion nationwide, representing more than half of all fee-for-service payments for that year.

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