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Audit (A-04-10-06128)

11-22-2011
Review of Medicare Payments Exceeding Charges for Outpatient Services Processed by First Coast Service Options, Inc., in Jurisdiction 9 for the Period January 1, 2008, Through June 30, 2009

Executive Summary

Our audit found that 113 of the 295 selected line items for which First Coast made Medicare payments to providers for outpatient services during the period January 2008 through June 2009 were incorrect. The line items included items totaling approximately $847,000, which the providers had not refunded by the beginning of our audit. Providers refunded overpayments on three line items totaling $544,000 before our fieldwork. The remaining 179 line items were correct.

Medicare uses an outpatient prospective payment system to pay certain outpatient providers. In this method of reimbursement, the Medicare payment is not based on the amount that the provider charges. Billed charges generally exceed the amount that Medicare pays the provider. Therefore, a Medicare payment that significantly exceeds the billed charges is likely to be an overpayment.

The deficiencies in the 113 incorrect line items included (1) incorrect units of service, (2) a combination of incorrect units of service claimed and incorrect Healthcare Common Procedure Coding System (HCPCS) codes, (3) HCPCS codes that did not reflect the procedures performed, and (4) a lack of supporting documentation.

We recommended that First Coast (1) recover the $847,000 in identified overpayments, (2) implement system edits that identify line item payments that exceed billed charges by a prescribed amount, and (3) use the results of this audit in its provider education activities. First Coast generally agreed with our recommendations.

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