Medicare Compliance Review of Rush University Medical Center

Rush University Medical Center (the Hospital) complied with Medicare billing requirements for 63 of the 120 inpatient and outpatient claims we reviewed. However, the Hospital did not fully comply with Medicare billing requirements for the remaining 57 claims, resulting in overpayments of $814,150 for calendar years 2014 and 2015. Specifically, 51 inpatient claims had billing errors, resulting in overpayments of $812,744, and 6 outpatient claims had billing errors, resulting in overpayments of $1,406. These errors occurred primarily because the Hospital did not have adequate controls to prevent the incorrect billing of Medicare claims within the selected risk areas that contained errors. On the basis of our sample results, we estimated that the Hospital received overpayments of approximately $10.2 million for our audit period.

We recommended that the Hospital refund to the Medicare contractor $10.2 million (of which $814,150 was overpayments identified in our sample) in estimated overpayments for the audit period for claims that it incorrectly billed; exercise reasonable diligence to identify and return any additional similar overpayments received outside of our audit period, in accordance with the 60-day rule, and identify any returned overpayments as having been made in accordance with this recommendation; and strengthen controls to ensure full compliance with Medicare requirements. In written comments on our draft report, the Hospital generally disagreed with our findings and recommendations.