Excessive Payments for Outpatient Services Processed by Mutual of Omaha

EXECUTIVE SUMMARY:

Our objective was to determine whether high-dollar Medicare payments that Mutual of Omaha made to providers for outpatient services were appropriate.  Some of the high-dollar Medicare outpatient payments were not appropriate.  During calendar year 2003, Mutual of Omaha made 54 payments of $50,000 or more each for outpatient services. At the start of our fieldwork in April 2005: (a) 9 of the payments were correct; (b) 17 of the payments were incorrect, and the providers had refunded $5,466,816 in overpayments; and, (c) 28 of the payments were incorrect, and the providers had not refunded $2,808,384 in associated overpayments.  Contrary to Federal guidance, the providers in all 45 (17 plus 28) instances inappropriately overstated the units of service.

We recommended that Mutual of Omaha: (1) inform us of the status of the recovery of the $2,808,384 in overpayments that our audit identified, (2) identify and recover additional overpayments made on high-dollar outpatient claims paid after calendar year 2003, and (3) use the results of this audit in its provider education activities.  Mutual of Omaha agreed with our recommendations.

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