'Review of Excessive Payments for Carrier Services Processed by TrailBlazer Health Enterprises for the Period January 1, 2003, Through December 31, 2003

Of the 382 payments of $10,000 or more (high-dollar payments) that TrailBlazer Health Enterprises (TrailBlazer) made to providers in 2003, 270 were appropriate. TrailBlazer was the Medicare Part B carrier for about 65,000 providers in Texas, Delaware, the District of Columbia, Maryland, and parts of Virginia. TrailBlazer incorrectly paid providers for 103 of the remaining claims, which resulted in net overpayments totaling $236,523. Also, providers were unable to locate any records for the beneficiaries on three claims totaling $46,903. We were unable to determine whether five claims were paid correctly based on available information and did not review one claim because the provider had filed for bankruptcy.

We recommended that TrailBlazer (1)ensure that identified net overpayments totaling $236,523have been recovered (2) recover $46,903 for the three unsupported claims (3) identify and recover any overpayments related to system pricing errors (4) review internal controls related to updating system pricing for procedure codes (5) review internal controls related to manual processing and claim adjustment and (6) use the results of this audit in its provider education activities.

TrailBlazer agreed with the majority of our findings. For one finding, TrailBlazer agreed that the error had occurred but disagreed that it had affected all of the claims processed. TrailBlazer also disagreed with some of our calculations of overpayment amounts.