Review of Medicare Payments Exceeding Charges for Outpatient Services Processed by Wisconsin Physicians Service Insurance Corporation in Jurisdiction 5 for the Period January 1, 2006 Through June 30, 2009.

摘要

For this audit, we reviewed outpatient claims from both the Legacy and Jurisdiction 5 Workloads. (For purposes of this report, we refer to claims from the Legacy and Jurisdiction 5 Workloads as Jurisdiction 5.) During our audit period (January 2006 through June 2009), WPS processed approximately 322.2 million line items for outpatient services in Jurisdiction 5, of which 2,200 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 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 2,197 of the 2,200 line items because 2 providers associated with 3 line items were either no longer in business or in bankruptcy. Our objective was to determine whether certain Medicare payments in excess of charges that WPS made to providers for outpatient services were correct.