Federal Audit Shows Yale Medicare Billing Practices in Good Health

The Office of Inspector General of the U.S. Department of Health and Human Services – HHS – has given the Yale 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.

“The results of this audit show Yale’s commitment to compliance,” said David A. Kessler, dean of the School of Medicine. “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.”

Under Medicare rules, teaching physicians can be reimbursed for care they provide directly to patients. If the care is provided by a resident – a medical school graduate still undergoing training, the teaching physician supervising the resident can be reimbursed 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 1996, when HHS adopted new regulations that attempted to clarify these issues.

The HHS PATH audit program has focused on Medicare payments to 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.

Although HHS agreed not to pursue the PATH audits in certain states, including Massachusetts, the program has continued in other states, including Connecticut and New York. Last month, the American Medical Association and the Association of American Medical Colleges, together with six other health care associations and 13 academic medical centers, filed a lawsuit against the federal government challenging the legality of the PATH audit program.

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.

Medicare, the federal program that covers health-care costs for the elderly and disabled, reimburses hospitals for salaries and costs associated with training residents.