Review of High-Dollar Payments for Louisiana Medicare Part B Claims Processed by Pinnacle Business Solutions, Inc., for the Period January 1 Through December 31, 2006

摘要

Pursuant to Title XVIII of the Social Security Act, the Medicare program provides health insurance for people age 65 and over and those who are disabled or have permanent kidney disease. The Centers for Medicare & Medicaid Services (CMS), which administers the program, contracts with carriers to process and pay Medicare Part B claims submitted by physicians and medical suppliers (providers). CMS guidance requires providers to bill accurately and to report units of service as the number of times that a service or procedure was performed. Carriers currently use the Medicare Multi-Carrier Claims System and CMSs Common Working File to process Part B claims. These systems can detect certain improper payments during prepayment validation. During calendar year (CY) 2006, Arkansas Blue Cross and Blue Shield, now doing business as Pinnacle Business Solutions, Inc. (Pinnacle), was the Medicare Part B carrier for providers in several States, including about 16,800 providers in Louisiana. Pinnacle processed more than 11.4 million Louisiana Part B claims, 57 of which resulted in payments of $10,000 or more (high-dollar payments). Our objective was to determine whether Pinnacles high-dollar Medicare payments to Louisiana Part B providers in 2006 were appropriate.