Assist Audit of HCFA's Fiscal Year 1998 Financial Statements at Palmetto Government Benefits Administrators (PGBA)

EXECUTIVE SUMMARY:

Palmetto Government Benefits Administrators (PGBA) serves as both the Medicare fiscal intermediary and carrier for the State of South Carolina as well as the durable medical equipment regional carrier and regional home health intermediary for several States. We determined whether Medicare claims paid by PGBA were reimbursed in accordance with Medicare laws and regulations. With the assistance of PGBA and peer review organization medical review personnel, we identified overpayments totaling $34,852 and underpayments totaling $1,239 for these claims during the first quarter of Fiscal Year 1998--our audit period. The overpayments and underpayments occurred for various reasons, including insufficient documentation, incorrect coding of procedures, and lack of medical necessity. We also identified two durable medical equipment payment errors which may indicate the need for PGBA to improve its claims processing edits. Officials of PGBA generally concurred with our recommendations for financial adjustments and procedural improvements.