Review Of Medicare Outlier Payments Made To Virginia Mason Medical Center For the Period August 1, 2000 Through December 31, 2001

EXECUTIVE SUMMARY:

The objective of this review was to determine whether Virginia Mason Medical Center's (the Medical Center) outpatient claims with outlier payments were billed to Medicare in accordance with applicable laws and regulations.  Our review of 34 outpatient prospective payment system (OPPS) claims found that the Medical Center incorrectly billed Medicare on 30 claims.  The billing errors included both overpayments and underpayments.  Twenty-six claims were overpaid by $55,143 and four claims were underpaid by $10,512, resulting in a net overpayment of $44,631.  The billing errors occurred because the Medical Center did not correctly implement the OPPS requirements when billing Medicare for outpatient services.  We recommended that the Medical Center (1) strengthen its billing procedures, (2) resubmit the claims found to be in error to the fiscal intermediary (FI) for adjustments, and (3) perform an internal review of OPPS outlier claims for services rendered during the period August 1, 2000 through March 31, 2002 and resubmit the claims to the FI for adjustments, as applicable.  The Medical Center generally concurred with our findings and recommendations.