Review of High-Dollar Payments for Oklahoma Medicare Part B Claims Processed by Pinnacle Business Solutions, Inc., for the Period January 1, 2003, Through December 31, 2003

The objective of this review was to determine whether Pinnacle Business Solutions, Inc.'s (Pinnacle) high-dollar Medicare payments to Oklahoma Part B providers were appropriate.  Of the 160 high-dollar payments that Pinnacle made to providers, 149 were appropriate.  However, Pinnacle overpaid providers $104,608 for the remaining 11 claims.  One provider refunded an overpayment, totaling $17,042, prior to our fieldwork.  Another provider refunded an overpayment, totaling $34,938, during our fieldwork.  Nine overpayments, totaling $53,723, and one underpayment, totaling $1,094, remained outstanding.  We recommended that Pinnacle recover the $53,723 in overpayments, refund the $1,094 underpayment, review all 2003 claims with Healthcare Common Procedure Coding System code Q0187 to determine whether the correct drug price was used to calculate the reimbursement, review for accuracy claims that had a charged amount equal to the allowed amount, and consider using the results of this audit in its provider education activities.  Pinnacle agreed with the findings and recommendations.