Audit of Medicare Claim Lines for Which Payments Exceeded Charges

OBJECTIVE

CMS contracts with Medicare Administrative Contractors to, among other things, process and pay claims for items and services covered under Medicare Part B, including, but not limited, to physicians’ services; outpatient hospital services; drugs and biologicals that are usually not self-administered; durable medical equipment; and outpatient physical therapy, occupational therapy, and speech-language pathology services. Generally, Medicare Part B payments are based on a fee schedule, prospective payments system, or some other method (e.g., a percentage of the average sales price for Part B drugs and biologicals), instead of a cost or charge basis. In most cases, a health care provider’s billed charges exceed the amount that Medicare pays for Part B items and services. Therefore, a Medicare payment that significantly exceeds the billed charges can be an overpayment. Previous OIG audits found that when a health care provider was paid more than it charged for a claim line, that claim line was often incorrect, which resulted in overpayment to the health care provider. Our objective will be to determine whether certain Medicare payments that exceeded charges for Medicare Part B items and services were correct.

TIMELINE

• August 15, 2024
  Announced
• July 21, 2026
  Complete

  Audit of Medicare Claim Lines for Which Payments Exceeded Charges complete. This audit resulted in 5 recommendations.

REPORT PUBLISHED

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