Improper Hospital Charges for Priority Tests Claimed for Medicare Reimbursement

HRD-83-36: Published: Jan 13, 1983. Publicly Released: Jan 13, 1983.

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GAO is currently reviewing ancillary service utilization to assess the reasonableness and medical necessity of ancillary services claimed for Medicare reimbursement.

GAO found that many hospitals claim "stat" charges for Medicare reimbursement which is not allowed. These charges represent an extra charge for diagnostic tests performed on a priority basis. The Health Care Financing Administration (HCFA) Medicare Provider Reimbursement Manual is silent on the allowability of stat charges. However, the view that they are not allowable is contained in a letter to a consultant to the Blue Cross Association. A ruling on stat charges has been requested because Blue Cross plans were uncertain about how to treat such charges and some were reimbursing hospitals for the charges.

Recommendations for Executive Action

  1. Status: Closed - Not Implemented

    Comments: HCFA does not intend to act on the recommendation because of the Medicare prospective payment system. Although GAO does not agree with this reason, it will not pursue the recommendation because the amount involved is relatively small.

    Recommendation: The Secretary of HHS should direct the Administrator, HCFA, to specifically address the nonallowability of stat charges in the Medicare Provider Reimbursement Manual.

    Agency Affected: Department of Health and Human Services

  2. Status: Closed - Not Implemented

    Comments: HCFA does not intend to implement this recommendation. In addition, HCFA is not implementing the other recommendation which would be necessary to make this one work.

    Recommendation: The Secretary of HHS should direct the Administrator, HCFA, to require intermediary auditors to spot check for the inclusion of stat charges during their onsite audits of hospitals.

    Agency Affected: Department of Health and Human Services

 

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