Review of High-Dollar Payments for Arkansas Medicare Part B Medicare Outpatient Claims Processed by Trailblazer Health Enterprises 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 fiscal intermediaries to process and pay Medicare Part B claims submitted by hospital outpatient departments. The intermediaries use the Fiscal Intermediary Standard System and CMSs Common Working File to process claims. The Common Working File can detect certain improper payments during prepayment validation. Medicare guidance requires providers to bill accurately and to report units of service as the number of times that the service or procedure was performed. TrailBlazer Health Enterprises (TrailBlazer) is a Medicare fiscal intermediary serving more than 3,000 Medicare providers in Texas, New Mexico, and Colorado. For calendar year (CY) 2006, TrailBlazer processed approximately 8.8 million outpatient claims, 75 of which resulted in payments of $50,000 or more (high-dollar payments). Beginning January 3, 2006, CMS required intermediaries to implement a Fiscal Intermediary Standard System edit to suspend potentially excessive Medicare payments for prepayment review. The edit suspends high-dollar outpatient claims and requires intermediaries to determine the legitimacy of the claims. Our objective was to determine whether the high-dollar Medicare payments that TrailBlazer made to providers for outpatient services were appropriate.