EXECUTIVE SUMMARY:
This Operation Restore Trust report provides you with the results of our review of Medassist-OP, Incorporated, (Medassist) located in Palm Harbor, Florida. The primary objective of our review was to determine whether the orthotic "L" procedure code claims submitted by Medassist for beneficiaries residing in New York and New Jersey met Medicare reimbursement guidelines. As part of this objective, we focused on whether services were rendered for the procedure codes claimed and if the correct procedure codes were claimed.
We randomly selected 113 claims submitted by Medassist for Medicare reimbursement during the period January 1, 1994 though December 3 1, 1996. Our review disclosed that Medassist did in fact provide products and services for all the claims in our sample, but in 99 percent of the cases (112 of 113 claims), the billing did not meet Medicare reimbursement guidelines. We determined that Medassist improperly: submitted 79 claims whereby the product supplied did not meet the definition of the procedure code billed to Medicare. Medassist upcoded the claims; . misrepresented services on 27 claims when they billed one product under two separate procedure codes; submitted three claims for durable medical equipment (DME) for residents of nursing homes; and received reimbursement for three claims in excess of the least costly alternative pricing methodology.