Review of Outpatient Claims Processed by Trailblazer Health Enterprises, LLC That Included Procedures for the Insertion of Multiple Units of the Same Type of Medical Device for Calendar Years 2008 and 2009

摘要

The Centers for Medicare & Medicaid Services (CMS) administers the Medicare program. CMS contracts with Medicare contractors, including TrailBlazer Health Enterprises (TrailBlazer), to process and pay hospital outpatient claims using the Fiscal Intermediary Shared System (FISS). CMS implemented an outpatient prospective payment system (OPPS) for hospital outpatient services. Under the OPPS, Medicare pays for hospital outpatient services on a rate-per-service basis that varies according to the ambulatory payment classification group to which the service is assigned. Under the OPPS, outlier payments are available when exceptionally costly services exceed established thresholds. Common medical devices implanted during outpatient procedures include cardiac devices, joint replacement devices, and prosthetics. Generally, a provider implants only one cardiac device during an outpatient surgical procedure. Under OPPS, payments to hospitals for medical devices are packaged into the payment for the procedure to insert the device. Hospitals are required to report the number of device units and related charges accurately on their claims.