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Federal audit shows Yale's Medicare billing practices in good health

Yale Medicine Magazine, 1998 - Winter/Spring


The Office of Inspector General of the U.S. Department of Health and Human Services (HHS) has given the School of Medicine a clean bill of health regarding its Medicare billing practices at Yale-New Haven Hospital. The School of Medicine was one of 49 institutions nationwide notified that they would be audited under the HHS Physicians at Teaching Hospitals (PATH) audit program.

Under Medicare rules, teaching physicians are permitted to bill for care they directly provide to patients. In addition, if the care is provided by a resident, the teaching physician supervising the resident can bill for those services only if he or she is sufficiently involved in the care, and if that involvement is appropriately documented. How much involvement was sufficient and what kind of documentation was required were matters of debate and confusion until HHS adopted new regulations in 1996 that attempted to clarify these issues.

The HHS PATH audit program has focused on Medicare payments to teaching physicians in academic medical centers for care provided before the new regulations were issued. Many academic medical centers have complained that the PATH audits are unfairly applying the new rules retroactively, finding innocent errors caused by confusion and unfairly calling them fraud.

The audit at Yale began in August 1996, and auditors reviewed a sample of Medicare payments to Yale School of Medicine for patients seen by Yale faculty physicians in 1994. The HHS auditors' conclusion: Yale is in compliance. "The results of this audit show Yale's commitment to compliance," said Dean David A. Kessler, M.D. "Compliance is difficult at times because the rules and regulations are complex and sometimes unclear. For Yale to have come through this audit so well is a tribute to the doctors and administrators at the School of Medicine."