Review of Excessive Payments for Outpatient Services Processed by Chisholm Administrative Services in 2005

EXECUTIVE SUMMARY:

Our objective was to determine whether the high-dollar Medicare payment that Chisholm Administrative Services (Chisholm) made to a provider for an outpatient service was appropriate.  The high-dollar Medicare outpatient payment was not appropriate.  For calendar year 2005, Chisholm made one payment of $50,000 or more for outpatient services.  Our analysis indicated that, at the start of our fieldwork in February 2007, the payment was incorrect, and the provider had not refunded the $57,700 overpayment.  We notified the provider and requested that the claim be reviewed.  After reviewing the claim, the provider submitted an adjusted claim and refunded the overpayment.  The Chisholm medical review team reviewed and approved the revised amount.  We recommended that Chisholm review the provider's payment history for claims under $50,000 that bill code C9205 and correct any claims found in error and use the results of this audit in its provider education activities.  Chisholm agreed with our recommendations.