OIG recommends consistency for Medicare's outlier payments policies
Healthcare Auditing Weekly, June 3, 2008
The Office of Inspector General (OIG) recommended in its Compendium of Unimplemented Office of Inspector General Recommendations the Centers for Medicare and Medicaid Services (CMS) require retroactive adjustments of outpatient outlier payments.
The OIG found significant outpatient outlier overpayments to community mental health centers due to clerical or mathematical errors. When the OIG recommended they pay CMS back, the fiscal intermediaries said CMS considered outpatient outlier payments to be final and not subject to retroactive adjustments.
Prior to 2003, this was CMS’s policy regarding both inpatient and outpatient PPS, but in 2003, the inpatient PPS policy was changed to require retroactive adjustments of outlier payments in certain circumstances. CMS did not, however, change its policy for outpatient PPS.
- Be consistent with outlier payments
- Require retroactive adjustment of outpatient outlier payments in certain circumstances
The current policy is not cost efficient and results in losses to the Medicare Trust Fund, creates payment inequities, and may punish providers that comply with Medicare requirements.
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