Department of Health and Human Services

Office of Inspector General -- AUDIT

Complete Text of Report is available in PDF format (2.1 mb). Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.

EXECUTIVE SUMMARY:

The objective of this review was to determine whether the services on rehabilitation claims paid to Avante At Leesburg (Avante) of Leesburg, Florida, were medically necessary, properly billed, and adequately supported by medical documentation.  A complete medical review of the 100 claims sampled showed that 20 included medically unnecessary or improperly billed skilled services.  As a result, we estimated that Medicare overpaid Avante at least $708,086 for services that did not meet Medicare requirements. 

We recommended that Avante (1) refund to the Medicare program $708,086 in overpayments, (2) ensure that future claims with skilled services comply with Medicare requirements on medical necessity, (3) establish adequate controls to ensure that the correct claims are adjusted, and (4) work with its fiscal intermediary to determine the amount of overpayments made subsequent to our audit period and refund the overpayments to the Medicare program.  Avante disagreed with the medical reviewers’ determination that 30 Resource Utlization Groups be denied or downcoded.  However, we relied on the knowledge and expertise of the medical reviewers; therefore, we stand by the findings and recommendations.