Review of Excessive Payments for Outpatient and Inpatient Services Processed by Blue Cross and Blue Shield of Georgia

Of the 94 high-dollar payments that Blue Cross and Blue Shield of Georgia, Inc. (BCBSG) made to Medicare Part A providers in calendar years 2004 and 2005, 12 totaling $264,000 were inappropriate.  Eight overpayments totaling $209,000 had been refunded before the start of our fieldwork and four overpayments totaling $54,000 remained outstanding.  BCBSG is a fiscal intermediary serving Medicare providers in Georgia.  It had edits in place for high-dollar charges during our audit period, which contributed to the high number of appropriate payments it processed.  However, BCBSG made some inappropriate payments because neither its system nor the common working file had sufficient edits in place during calendar years 2004 or 2005 to detect billing errors related to the Healthcare Common Procedure Coding System codes and units of service.

We recommended that BCBSG recover the $ 54,000 in identified overpayments.  BCBSG agreed with our findings.  BCBSG stated it had recovered $13,000 of the identified overpayments and was in the process of recovering the remaining $42,000.