Provider Notice issued 12/22/10

Inappropriate Outlier Payments to Hospitals

The Department of Health and Human Services, Office of Inspector General, recently conducted a federal audit of certain high-dollar claims paid by the Illinois Department of Healthcare and Family Services. The audit identified a significant number of inpatient claims with extraordinarily high charges that resulted in outlier payments. This has become an area of concern because there has been a steady increase of outlier reimbursements.  

The affected hospitals were contacted to determine if the claim charges were correct. In the majority of sample cases, the charges were incorrect. The hospitals attributed the elevated charges to two main causes:

• Data entry errors

• Lack of documentation to support the higher charges. 

Hospitals are reminded that they are responsible for submittal of accurate claim information. For paper UB-04 claims, the certification information on the reverse side of the form requires hospitals to attest to the accuracy of the claim information submitted. For claims submitted electronically, a post-payment certification, Form HFS 194-M-C, Billing Certification, accompanies each paper remittance advice that contains an electronically submitted paid service. It is the responsibility of the provider who submitted the claim for payment to review the Remittance Advice and sign the Billing Certification form attesting to the accuracy of the information therein. The signed Billing Certification form must be maintained in the hospital’s records for three years from the date of the Remittance Advice to which it relates, or for the time period required by applicable federal and state laws, whichever is longer.

Claims containing charges that are found to be erroneous will be recouped and other administrative actions may result. 

Any questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 1-877-782-5565.

Theresa A. Eagleson, Administrator

Division of Medical Programs