EXECUTIVE SUMMARY:
The primary objective of the review 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 1996.
The Operation Restore Trust reviewers questioned $198,663 of the $1,006,495 in charges for 40 beneficiaries in our sample. This amount is comprised of $100,549 for unallowable services, $51,802 for services which were not reasonable or medically necessary and $46,312 for services for which the skilled nursing facility (SNF) could not produce adequate supporting documentation. Therefore, we are recommending an adjustment of the above charges. In addition, we request that a detailed review of all rehabilitative therapies and physician orders for these therapies be conducted by the fiscal intermediary and State agency in order to recoup overpayments made to the SNF and to implement corrective action by the facility.