In a Medicare compliance audit of critical care services provided by Lahey Clinic in Burlington, Massachusetts, the HHS Office of Inspector General (OIG) found a high error rate.[1] But the overpayment amount was small and OIG didn’t extrapolate it.
Lahey Clinic is a multidisciplinary physician practice and teaching affiliate of Tufts University School of Medicine. OIG audited a stratified random sample of 100 inpatient admissions that included 1,410 critical services. Medical records for 10 of the admissions, with 92 critical care services, were reviewed by an independent medical reviewer.
The findings: Lahey didn’t comply with Medicare requirements for 56 critical care services and was overpaid $6,015 during the audit period of Jan. 1, 2017, to March 31, 2019. Lahey billed when the patients had conditions that didn’t indicate critical care services were medically necessary or “when the physician didn’t directly provide services at the level of care required for critical care services,” OIG contended. Forty-one services should have been billed with the CPT code for subsequent hospital care, and 13 services didn’t meet Medicare requirements for critical care or another E/M service. Lahey billed another two critical care services with CPT code 99291 (critical care, first 30 to 74 minutes) when it should have used 99292 (critical care, each additional 30 minutes).
“They did not extrapolate because they limited the audit to 10 admissions instead of the usual 100 due to the resource-intensive effort required to perform a medical review,” said Ronald Hirsch, M.D., vice president of R1 RCM. OIG recommended Lahey return the overpayments and identify and refund any potential additional overpayments in accordance with Medicare’s 60-day overpayment refund rule.
In a written response, Lori Dutcher, chief compliance officer for Beth Israel Lahey Health, said it agrees with 16 of OIG’s findings but not the other 40. For those, “our analysis of the medical records concluded that critical care services were appropriately provided and supported,” she wrote. Lahey is determining whether it owes money under the 60-day rule and will refund money if that’s the case.