TrailBlazer Health Enterprises, LLC: Audit of Medicare Claims by Podiatrists and Optometrists for Comprehensive Nursing Facility Assessments for Calendar Years 1995 through 1998

EXECUTIVE SUMMARY:

This final audit report presents the results of our audit of claims by podiatrists and optometrists for comprehensive nursing facility (CNF) assessments during Calendar Years 1995 through 1998. We found that Texas podiatrists and optometrists inappropriately billed Medicare for CNF assessment services totaling $3,939,316 and $2,191,830, respectively. TrailBlazer paid $2,166,213 and $1,316,246 for their claims. We recommended that TrailBlazer: (1) issue a reminder to podiatrists and optometrists not to bill for any service they are not licensed to perform, and (2) implement computer edits to prevent payment of CNF assessments claimed by podiatrists and optometrists. TrailBlazer agreed with our audit findings and recommendations, and have implemented the recommended corrective actions. We have requested that TrailBlazer not seek recovery of the overpayments at this time as we are still evaluating the issue.