Department of Health and Human Services

Office of Inspector General -- AUDIT

"Review of High-Dollar Payments for Medicare Part B Claims Processed by Triple-S, Inc., for the Period January 1, 2003, Through December 31, 2005," (A-02-07-01041)

February 21, 2008


PDF File Complete Text of Report is available in PDF format (472 kb). Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.


EXECUTIVE SUMMARY:

Our objective was to determine whether Triple-S, Inc.s high-dollar (Triple-S) Medicare payments to Part B providers were appropriate.  During calendar years 20032005, Triple-S processed 13 Part B payments of $10,000 or more.  Of the 13 high-dollar payments that Triple-S made to providers, 3 were appropriate.  However, for the 10 remaining payments, Triple-S overpaid providers $45,426 for 4 payments and CMSs Program Safeguard Contractor was reviewing 6 payments.  Providers refunded two of the four overpayments, totaling $32,445, prior to our fieldwork.  Two overpayments, totaling $12,981, remained outstanding.

We recommended that Triple-S (1) recover the $12,981 overpayment and (2) consider identifying and recovering any additional overpayments made for high-dollar Part B claims paid after calendar year 2005.  Triple-S agreed with our first recommendation.  Regarding our second recommendation, Triple-S stated that it implemented a computer edit on May 16, 2007, to identify and help recover potential high-dollar overpayments.  However, Triple-Ss action did not address any potential high-dollar overpayments made between January 1, 2006, and May 15, 2007.