EXECUTIVE SUMMARY:
The primary objective of the audit was to evaluate the medical necessity of the care and services provided and the reasonableness of the charges and reimbursements made during the period from January 1995 through March 31, 1996.
The Operation Restore Trust team questioned $148,955 of the $1,305,163 in Medicare charges reported for the 40 sample beneficiaries in our audit. This amount is comprised of $60,908 of charges for which the skilled nursing facility (SNF) could not produce adequate supporting documentation, $55,533 for services which were not reasonable or necessary, and $32,514 of services which are specifically unallowable.
We are recommending an adjustment of the above charges. In addition, we request that a focused review of all rehab therapies and the physician orders for these therapies be conducted the by the fiscal intermediary in order to recoup overpayments made to this SNF and to implement corrective action by the facility.