The Oklahoma State Department of Health (OSDH) contracted with PCG to perform an audit of the state’s Trauma Fund (“the Fund”). The Fund is a public health safety net which allows for the reimbursement of uncompensated care costs associated with trauma care provided by recognized trauma facilities, physicians, and emergency medical providers to the under and uninsured. PCG was selected by OSDH to conduct on-site medical and financial records reviews of 100 providers receiving payment from the Trauma Fund for services provided during calendar year 2009.
Based on claims data provided by OSDH, PCG selected a statistically valid sample of claims from each Fund-eligible provider type and coordinated on-site reviews with providers and their staffs. After interviewing appropriate Trauma Fund staff, PCG developed specific audit protocols for each provider type eligible for submitting claims to the Fund. Regulations and interviews with staff suggested that there were unique issues within each provider type that required thorough review. PCG conducted all 100 visits in approximately four months.
PCG performed reviews at 36 hospitals receiving reimbursement from the Fund for 2009 claims. PCG’s review included twenty 20 of the top 25 hospitals in terms of dollar value of claims and 16 additional hospitals chosen at random. PCG reviewed a total of 1,170 hospital claims, accounting for $17,613,642 in claimed uncompensated trauma care.
PCG performed reviews at 44 physician groups receiving reimbursement from the Trauma Fund for 2009 claims. PCG’s review included all of the top 10 physician groups in terms of dollar value of claims, a random selection of 10 physician groups ranked eleven 11 through 25, and a random selection of 24 additional physician groups ranked 26 or higher in the dollar value of claims submitted to the Trauma Fund. PCG reviewed 1,207 physician claims, accounting for $445,394 in claimed uncompensated trauma care.
PCG performed reviews at 20 EMS groups receiving reimbursement from the Trauma Fund for services rendered in calendar year 2009. PCG’s review included all of the top 10 EMS providers offering air services and all of the top 10 EMS providers offering ground services; each in terms of the dollar amount of Trauma Fund distribution. PCG reviewed 448 EMS claims accounting for $1,186,965 in claimed uncompensated trauma care.
In total, PCG found that 10 percent of reviewed 2009 uncompensated trauma care claims submitted by hospitals, physicians, and EMS providers failed to comply with the Trauma Fund’s eligibility criteria. PCG identified 283 claims which failed to meet the Trauma Fund’s eligibility criteria, representing $1,110,511 in incorrect Trauma Fund payments.