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EXECUTIVE SUMMARY:
The objective of this review was to determine whether Medicare properly reimbursed Redding Medical Center (the hospital) for outpatient cardiac rehabilitation services. We determined that the hospital met the Medicare cardiac rehabilitation coverage requirements for direct physician supervision although a written policy describing the physician’s roles and responsibilities was not established. Further, we found that the hospital’s policies and procedures did not fully meet the Medicare requirement that outpatient cardiac rehabilitation services should be provided “incident to” a physician’s professional services. In addition, from our specific claims review for a sample of 30 beneficiaries who received 726 outpatient cardiac rehabilitation services during calendar year 2001, we determined that the hospital received Medicare reimbursement for outpatient cardiac rehabilitation services, amounting to about $1,239, for which the diagnosis used to establish the patient’s eligibility for outpatient cardiac rehabilitation services may not have been supported by medical record documentation, or which were otherwise unallowable.