Review of High-Dollar Payments for District of Columbia Medicare Part B Claims Processed by TrailBlazer Health Enterprises for the Period January 1, 2003, Through December 31, 2005

TrailBlazer Health Enterprises (TrailBlazer) overpaid providers $89,000 for 5 of the 36 high-dollar payments ($10,000 or more) for calendar years (CY) 2003-05. Twenty-nine payments were appropriate. TrailBlazer, the Medicare Part B carrier for the District of Columbia, processed 36 high-dollar payments during the audit period.  One provider refunded an overpayment totaling $36,000 prior to our fieldwork.  Four overpayments totaling $53,000 remain outstanding.  For two payments, the provider was no longer in business.

We recommended that TrailBlazer: (1) recover the $53,000 in overpayments and (2) consider identifying and recovering any additional overpayments made to providers for high-dollar Part B claims paid after CY 2005.  TrailBlazer stated that it had initiated the recovery of the outstanding overpayments identified by the audit and had implemented multiple internal controls since 2003, including in June 2005 the addition of an edit to review high-dollar Part B claim.  However, because it does not receive funding to do so, it would not identify and recover and additional overpayments for high-dollar Part B claims paid after CY 2005.