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EXECUTIVE SUMMARY:
The objective of this review was to determine whether outpatient claims with outlier payments were billed in accordance with Medicare laws and regulations. We judgmentally selected 35 claims with outlier payments of $133,798. We found overpayments of $50, 280 were made for 33 of the selected claims because Mercy Hospital did not properly : (1) calculate the billable units for drugs in relation to the amount of the drug administered; and (2) identify multiple surgical procedures with specific HCFA Common Procedure Coding System codes. For these 33 claims, the reduction to the outlier payment received exceeded the increased reimbursement Mercy Hospital would have received had it billed properly. Mercy Hospital concurred with our findings and recommendations.