Report Materials
Why OIG Did This Audit
- A series of previous OIG audits of Medicare Part B services examined whether payments for outpatient services that Medicare administrative contractors made to providers in excess of the providers’ billed charges were correct. Those audits found that some providers that billed charges in excess of the amounts that Medicare paid received incorrect payments.
- This audit, a followup to that previous series of OIG audits, assessed whether certain Medicare Part B payments that Wisconsin Physicians Service Insurance Corporation (WPS) made to providers that were in excess of billed charges were correct.
What OIG Found
- Of the 801 selected claim lines for which WPS paid providers during January 1, 2022, through December 31, 2023 (audit period), 138 claim lines were incorrect and resulted in overpayments totaling at least $140,182 that WPS made to providers.
- In addition, we identified 31 claim lines totaling $76,640 for which providers received Part B payments; however, there was no supporting documentation.
- Providers attributed the overpayments we identified to clerical errors and issues with their billing systems. In addition, WPS had system edits in place, but those edits, and WPS’s review of payments flagged by those edits, did not always identify the claim lines that were in error, which resulted in the overpayments.
What OIG Recommends
We made five recommendations to WPS, including that it confirm the recovery of the $140,182 in
overpayments. We also made procedural recommendations regarding the need to locate additional medical record documentation related to claim lines totaling $76,640 and recover any identified overpayments, the enhancement of existing system edits, and the enhancement of WPS’s provider education activities. The full recommendations are in the report.
WPS concurred with all of our recommendations and described steps it had taken and planned to take to address them.
26-A-07-082.01 to CMS - Open Unimplemented
Update expected on
01/20/2027
We recommend that WPS confirm to OIG that the $140,182 in overpayments associated with the 123 incorrect claim lines—for which WPS has already processed a corrected claim—has been fully recovered.
26-A-07-082.02 to CMS - Open Unimplemented
Update expected on
01/20/2027
We recommend that WPS locate the medical record documentation associated with the 31 claim lines totaling $76,640 in which WPS paid the 2 providers that we were not able to contact, determine whether those claim lines were supported and correctly paid, and recover any identified overpayments.
26-A-07-082.03 to CMS - Open Unimplemented
Update expected on
01/20/2027
We recommend that WPS work with the providers associated with the 15 incorrect claim lines for which WPS had not processed the corrected claims as of the end of our audit work and recover any identified overpayments.
26-A-07-082.04 to CMS - Open Unimplemented
Update expected on
01/20/2027
We recommend that WPS work with CMS to enhance existing system edits that identify line-item payments that exceed billed charges and that WPS enhance its processes for review of payments flagged by the enhanced system edits.
26-A-07-082.05 to CMS - Open Unimplemented
Update expected on
01/20/2027
We recommend that WPS use the results of this audit to enhance its provider education activities.
View in Recommendation Tracker
Notice
This report may be subject to section 5274 of the National Defense Authorization Act Fiscal Year 2023, 117 Pub. L. 263.