EXECUTIVE SUMMARY:
This report provides the results of our review of outpatient psychiatric services provided by the Newton-Wellesley Hospital (Hospital) during calendar year 1996. The objective of our review was to determine whether psychiatric services rendered on an outpatient basis were billed for and reimbursed in accordance with Medicare regulations.
Medicare regulations require that each medical record contain sufficient documentation to justify the treatment provided.
In CY 1996 the Hospital submitted for reimbursement about $367,000 in charges for outpatient psychiatric services. To determine whether controls were in place regarding outpatient charges, we reviewed the medical and billing records for five beneficiaries, selected judgmentally, whose outpatient psychiatric charges totaled $12,991. Our analysis showed that $1,120 or about 9 percent of these charges were either not covered by Medicare (7 percent) or not documented in the medical records (2 percent). Specifically, these charges were either for a smoking cessation class or there was no evidence that the beneficiary attended the number of therapy sessions that was indicated on the bill submitted to Medicare. As a result, charges on the Medicare cost report are overstated.
We recommend that the Hospital strengthen its procedures to ensure that outpatient psychiatric services are covered by Medicare, rendered and supported in the medical records.
In its response the Hospital concurred with our recommendation.