Review of High-Dollar Payments for Medicare Part B Claims Processed by Triple-S, Inc., for the Period January 1, 2003, Through December 31, 2005

Our objective was to determine whether Triple-S, Inc.'s high-dollar (Triple-S) Medicare payments to Part B providers were appropriate.  During calendar years 2003'2005, Triple-S processed 13 Part B payments of $10,000 or more.  Of the 13 high-dollar payments that Triple-S made to providers, 3 were appropriate.  However, for the 10 remaining payments, Triple-S overpaid providers $45,426 for 4 payments and CMS's Program Safeguard Contractor was reviewing 6 payments. Providers refunded two of the four overpayments, totaling $32,445, prior to our fieldwork.  Two overpayments, totaling $12,981, remained outstanding.

We recommended that Triple-S (1) recover the $12,981 overpayment and (2) consider identifying and recovering any additional overpayments made for high-dollar Part B claims paid after calendar year 2005. Triple-S agreed with our first recommendation. Regarding our second recommendation, Triple-S stated that it implemented a computer edit on May 16, 2007, to identify and help recover potential high-dollar overpayments. However, Triple-S's action did not address any potential high-dollar overpayments made between January 1, 2006, and May 15, 2007.