Review of Medicare Payments Exceeding Charges for Outpatient Services Processed by National Government Services in Jurisdiction 15 for the Period January 1, 2006, Through June 30, 2009

Our audit found that 969 of 1290 selected line items for which National Government Services made Medicare payments to providers for outpatient services during the period January 2006 through June 2009 were incorrect. The line items included items totaling approximately $5.0 million, which the providers had not refunded by the beginning of our audit. Providers refunded overpayments on 201 line items totaling $700,000 before our fieldwork. The remaining 120 line items were correct.

Medicare uses an outpatient prospective payment system to pay certain outpatient providers. In this method of reimbursement, the Medicare payment is not based on the amount that the provider charges. Billed charges generally exceed the amount that Medicare pays the provider. Therefore, a Medicare payment that significantly exceeds the billed charges is likely to be an overpayment.

The deficiencies in the 969 incorrect line items included (1) incorrect units of service, (2) Healthcare Common Procedure Coding System (HCPCS) codes that did not reflect the procedure performed, (3) a combination of incorrect units of service and incorrect HCPCS coding, (4) unallowable services, and (5) a lack of supporting documents.

We recommended that National Government Services (1) recover the $5.0 million, (2) implement system edits that identify line item payments that exceed billed charges by a prescribed amount, and (3) use the results of this audit in its provider education activities. In its comments, National Government Services said that it would review each case and work to recover the amounts due to the program.