Review of High-Dollar Payments for Maryland and District of Columbia Medicare Hospital Outpatient Claims Processed by Highmark Medicare Services for the Period October 1, Through December 31, 2005

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. 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. Fiscal intermediaries currently use the Fiscal Intermediary Standard System and CMSs Common Working File to process hospital outpatient claims. These systems can detect certain improper payments during prepayment validation. Prior to October 1, 2005, CareFirst of Maryland was the Medicare fiscal intermediary for Maryland and the District of Columbia. On October 1, 2005, Highmark Medicare Services (Highmark) assumed the fiscal intermediary operations for Maryland and the District of Columbia. During the period October 1 through December 31, 2005, Highmark processed over 600,000 outpatient claims, 5 of which resulted in payments of $50,000 or more (high-dollar payments). The objective was to determine whether high-dollar Medicare payments that Highmark made to hospitals for outpatient services as the fiscal intermediary for Maryland and the District of Columbia were appropriate.