Review of Yale New Haven Hospital's Claims for Outpatient Procedures that Included the Replacement of Medical Devices for Calendar Years 2007 and 2008

摘要

The Centers for Medicare & Medicaid Services (CMS), which administers the Medicare program, pays for hospital outpatient services under a prospective payment system. Medical Device Replacement Common medical devices implanted during outpatient procedures include pacemakers, cardioverter defibrillators, and neurostimulators. Occasionally, devices need to be replaced. Providers may receive full or partial credit from manufacturers for devices that are covered under warranty or replaced because of recalls. To offset these credits, Medicare reduces the payment for the replacement of a device if (1) the device is replaced without cost to the provider, (2) the provider receives full credit for the cost of the replaced device, or (3) the provider receives partial credit equal to or greater than 50 percent of the cost of the replacement device. For services furnished on or after January 1, 2007, CMS established reporting requirements for a provider that incurs no cost or that receives full credit for a replaced device. In such circumstances, CMS requires the provider to report the modifier FB and to report reduced charges on a claim that includes a procedure code for the insertion of a replacement device. For services furnished on or after January 1, 2008, CMS also requires the provider to report the modifier FC on a claim that includes a procedure code for the insertion of a replacement device if the provider receives a credit from the manufacturer of 50 percent or more of the cost of the replacement device. Yale-New Haven Hospital Yale New-Haven Hospital (the Hospital) is a 667-bed acute-care hospital located in New Haven, Connecticut. National Government Services (NGS) processes and pays the Hospitals Medicare claims for outpatient services. NGS paid the Hospital a total of $2.3 million for 160 claims for outpatient procedures that included the replacement of medical devices during calendar years 2007 and 2008. Our objective was to determine whether the Hospital complied with Medicare requirements for obtaining credits available from manufacturers for replaced medical devices and for reporting the appropriate modifier and charges to reflect the credits received.