Review of Select Medicare Payments Exceeding Charges for Outpatient Services Processed by National Government Services in Jurisdiction 13 for the Period January 1, 2006, Through June 30, 2009

摘要

In March 2008, National Government Services (NGS) was awarded the Medicare administrative contractor contract for Jurisdiction 13, which includes the States of Connecticut and New York. During our audit period (January 2006 through June 2009), approximately 197 million line items for outpatient services were processed in Jurisdiction 13, of which 1,903 line items had (1) a Medicare line payment amount that exceeded the line billed charge amount by at least $1,000 and (2) 3 or more units of service. (A single Medicare claim from a provider typically includes more than one line item. In this audit, we did not review entire claims; rather, we reviewed specific line items within the claims that met these two criteria. Because the terms payments and charges are generally applied to claims, we will use line payment amounts and line billed charges.) We reviewed only 1,841 of these line items because 8 providers associated with 62 line items were no longer in business or were in bankruptcy. Our objective was to determine whether certain Medicare payments in excess of charges that NGS made to providers for outpatient services were correct.