The Office of the Inspector General for HHS found 121,454 emergency department procedures were possibly billed incorrectly in 2021 and 2022, leading to over $15.1 million in improper or potentially improper payments.
Medicare improperly paid physicians $922,524 and may have improperly paid hospitals $14.2 million. These claims used emergency department procedure codes alongside nonemergency place-of-service or revenue center codes. Medicare beneficiaries may also have paid Part B deductibles that could have been incorrectly charged by hospitals, which could have totaled up to $394,591.
Out of the nonemergency sites that could have been incorrectly billed, inpatient hospitals, on-campus-outpatient hospitals and independent clinics were billed most frequently.
“According to the federal requirements, emergency department procedure codes should be used only if the patient is seen in the emergency department,” the report said.
Of the $14.2 million routed to hospitals, OIG found Medicare paid $9,553,078 and $4,656,827 to noncritical and critical access hospitals, respectively.
“CMS did not provide adequate guidance to ensure that hospitals complied with Medicare requirements when billing for these services,” the report said.
CMS agreed to encourage Medicare contractors to recover payments from physicians, but the agency did not concur with OIG’s four other recommendations, which included evaluating the possibly improper hospital payments, guiding contractors to refine claims processing controls, specifying emergency revenue center code use and directing contractors to examine claims beyond the audit period.
