Review of Excessive Payments for Outpatient Claims Processed by National Government Services for Calendar Years 2003 Through 2005: California Providers

Our objective was to determine whether Medicare payments of $50,000 or more (high-dollar payments) that National Government Services made to hospitals for outpatient services were appropriate.  Of the 59 high-dollar payments that National Government Services made for outpatient services for calendar years 2003 through 2005, 18 were appropriate.  The remaining 41 payments included overpayments totaling $3,463,740.  For all 41 claims, the hospitals inappropriately overstated the units of service, occasionally in combination with incorrect procedure codes.  The hospitals have already refunded the overpayments; comments we received from some hospitals indicated that they were analyzing their billing systems and procedures and would provide training and make system enhancements as appropriate.

Because National Government Services has already recovered the overpayments from the hospitals and implemented a Fiscal Intermediary Standard System edit to suspend high-dollar outpatient claims for prepayment review, we have not included any recommendations in this report.  National Government Services officials agreed with the results of our audit.