Review of Medicare Payments Exceeding Charges for Outpatient Services Processed by Pinnacle in Jurisdiction 7 for the Period January 1, 2006 Through June 30, 2009

摘要

During our audit period (January 2006 through June 2009), Pinnacle Business Solutions, Inc. (Pinnacle), processed approximately 32 million line items for outpatient services in Arkansas, of which 596 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. On claims from the same providers that submitted the 596 line items, we identified an additional 274 line items that had (1) a Medicare line payment amount that exceeded the line billed charge amount by at least $500 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 generally are 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 Pinnacle made to providers for outpatient services were correct.