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Audit (A-02-07-01039)

Review of High-Dollar Payments for Medicare Part B Outpatient Claims Processed by National Government Services for the Period January 1, 2003, Through December 31, 2005

Executive Summary

Of the 166 high-dollar payments ($50,000 or more) for Medicare Part B outpatient claims that we reviewed, 128 payments were appropriate. However, National Government Services overpaid hospitals $14.6 million for 38 claims. Hospitals refunded $13.5 million for 17 of the 38 overpayments prior to our fieldwork. At the start of our fieldwork, 21 overpayments totaling $1.1 million remained outstanding.

National Government Services made the overpayments because hospitals claimed incorrect units of service, billed incorrect charge amounts, used an incorrect Healthcare Common Procedure Coding System code, and did not have documentation supporting services billed. In addition, the Medicare claim processing systems did not have sufficient edits in place during calendar years 2003-2005 to detect and prevent payments for these types of erroneous claims.

We recommended that National Government Services inform us of the status of the recovery of the $1.1 million in overpayments that our audit identified and use the results of this audit in its provider education activities. National Government Services agreed with our recommendations.

Complete Report

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Office of Inspector General, U.S. Department of Health and Human Services | 330 Independence Avenue, SW, Washington, DC 20201