A federal audit has concluded that UPMC Presbyterian Shadyside overbilled Medicare $796,202 on claims filed from 2008 through 2011.
The overpayments in 113 claims, discovered in a review of 238 claims considered at high risk for error, were found during a Medicare compliance audit by the U.S. Department of Health and Human Services' Office of the Inspector General.
The report recommended that UPMC repay the overpaid amount. UPMC spokeswoman Gloria Kreps said on Tuesday, "We have reprocessed all claims identified by the audit for corrected reimbursement."
More than half the overpayment amount, $419,260, came in 39 of 156 inpatient claims that the inspector general said should have been billed as either outpatient or "observation" cases.
In recent years, Medicare has taken a more restrictive view of what qualifies as an inpatient admission, a classification that carries higher reimbursement payments for hospitals. Under the tighter rules, even an overnight stay does not necessarily meet inpatient stay requirements.
In this case, the report said, "Presbyterian Shadyside officials stated that case management staff either made inappropriate decisions when reviewing patient admission status or failed to review the status due to time constraints."
Another $171,146 in overpayments resulted from the hospital not adjusting its billing for replacing a medical device in cases where the manufacturer either replaced the device at no charge or provided a credit.
The report says UPMC officials acknowledged that the hospital "had inadequate controls to identify, obtain and properly report credits from medical device manufacturers."
Ms. Kreps added that UPMC "has made significant efforts to ensure our utilization review processes are compliant with established [Centers for Medicare & Medicaid Services] procedures and guidance regarding inpatient admission and billing. Control enhancement recommendations and training were provided in the areas identified."
She also noted that UPMC Presbyterian Shadyside received about $1.05 billion from Medicare for just over 460,000 claims during the 2008 to 2011 period.
The inspector general's office conducts periodic reviews of claims to ensure that the estimated $150 billion in yearly Medicare payments -- representing 45 percent of all fee-for-service payments, according to HHS -- are legitimate.
A copy of the UPMC report may be found at http://oig.hhs.gov/oas/reports/region3/31206105.pdf.
Steve Twedt: email@example.com or 412-263-1963. First Published October 15, 2013 8:00 PM