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Department of Health and Human Services

Office of Inspector General -- AUDIT

"Review of Claims for Care Plan Oversight Services Paid More Than $150 by National Heritage Insurance Company for Calendar Years 2001 through 2003," (A-09-04-00056)

January 14, 2005


Complete Text of Report is available in PDF format (536 kb). Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.


EXECUTIVE SUMMARY:

Our audit objective was to determine whether care plan oversight (CPO) claims for which National Heritage Insurance Company (NHIC) paid more than $150 were billed and paid in accordance with Medicare requirements.  For calendar years 2001 through 2003, CPO claims for which NHIC paid more than $150 were not billed or paid in accordance with Medicare requirements.  As a result, 14 California physicians were overpaid $14,800.  These overpayments occurred because physicians or physician billing contractors misunderstood the Medicare billing requirements for CPO services or incorrectly billed due to computer software and clerical errors, and NHIC did not have controls to detect CPO claims billed with more than 1 unit of service.  We recommended that NHIC recover the $14,800 in overpayments for CPO services, identify and recover Medicare overpayments for CPO claims billed with more than 1 unit of service provided subsequent to our audit period, remind physicians of the Medicare billing requirements for CPO services, and implement controls to detect CPO claims billed with more than 1 unit of service.  NHIC concurred with our findings and recommendations.