Review of Excessive Payments for Outpatient Services at Swedish Medical Center, First Hill, for Calender Years 2004 Through 2007

摘要

Pursuant to Title XVIII of the Social Security Act, the Medicare program provides health insurance for people aged 65 and over and those who are disabled or have permanent kidney disease. The Centers for Medicare & Medicaid Services, which administers the program, contracts with fiscal intermediaries to process and pay Medicare claims submitted by hospital outpatient departments. Medicare uses an outpatient prospective payment system to pay for hospital outpatient services. Medicare guidance requires providers to bill accurately using proper Healthcare Common Procedure Coding System codes and to report units of service as the number of times that a service or procedure was performed. Wisconsin Physicians Service Insurance Corporation (WPS) serves as a fiscal intermediary. WPS is the fiscal intermediary for Swedish Medical Center First Hill (First Hill), a hospital located in Seattle, Washington. We reviewed 53 Medicare outpatient payments to First Hill with paid amounts that exceeded charges by $500 or more for calendar years 2004 through 2007. Our objective was to determine whether selected Medicare outpatient claims from First Hill in which payments exceeded charges were appropriate.