Review of Medicare Payments Exceeding Charges for Outpatient Services Processed by Wisconsin Physicians Service Insurance Corporation But Transitioned to TrailBlazer Health Enterprises, LLC, in Jurisdiction 4 for the Period January 1, 2006, Through June 30, 2009

摘要

During our audit period (January 2006 through June 2009), Wisconsin Physicians Service Insurance Corporation (WPS) processed approximately 55.6 million line items for outpatient services in Jurisdiction 4, of which 408 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. Effective October 2010, the claims that were originally processed by WPS in Jurisdiction 4 were transitioned to TrailBlazer Health Enterprises, LLC (TrailBlazer). Thus, the 408 line items will be adjudicated by TrailBlazer, and we are issuing our report to TrailBlazer. (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.) Our objective was to determine whether certain Medicare payments in excess of charges that WPS made to providers for outpatient services were correct.