Corporate Compliance

Gov't audit insider 2/03/04: Review of the cardiac rehabilitation services at the Robert Wood Johnson University Hospital (Hamilton) in Hamilton, New Jersey.

Healthcare Auditing Weekly, February 3, 2004

The Office of Inspector General (OIG) continued its nationwide scrutiny of outpatient cardiac rehabilitation services with an audit of the Robert Wood Johnson University Hospital (Hamilton) in Hamilton, New Jersey. The OIG checked the hospital's "incident to" policies and procedures against Medicare requirements, and verified that Medicare payments for outpatient cardiac rehabilitation services met the requirements for covered diagnoses and adequate documentation.

To verify that services were properly reimbursed, auditors took the following actions:

  • Interviewed staff and evaluated Hamilton's policies and procedures to get a sense of the hospital's cardiac rehabilitation program management and its billing procedures

  • Searched for any discrepancies between the program's policies and procedures and national Medicare coverage requirements

  • Assessed the qualifications of the program's staff and documented direct physician supervision given for cardiac rehabilitation services.

  • Compared reimbursement data and lines of service to Hamilton's documentation and Medicare claims for 10 beneficiaries who received cardiac rehabilitation services at the hospital

  • Examined medical records for "incident to" services and used the records, physician referral and supporting records, and Hamilton's cardiac rehabilitation documentation to verify that the diagnoses identified on Medicare claims were appropriate

  • Verified that advanced cardiac life support equipment was available in the cardiac rehabilitation exercise area

    "Incident to" services and a couple cases of suspect billing and documentation were both sticking points for the auditors. The OIG said they were "unable to identify the physician professional services to which the cardiac rehabilitation services were provided incident to, and that some of the program's questionable services came from failings in Hamilton's internal controls and oversight procedures. Putting aside the OIG's complaints, Hamilton had only $548 in reimbursements-within the pool of 10 beneficiaries' claims the OIG reviewed-that did not meet Medicare criteria.

    Click here to read the audit report called "Review Of Outpatient Cardiac Rehabilitation Services at Robert Wood Johnson University Hospital Hamilton (A-02-03-01016)."

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