Review of High-Dollar Outpaient Claims Processed by CAHABA Government Benefit Administrators Fiscal Intermediary No. 00010 for the Period January 1, 2004, Through December 31, 2006

摘要

The objective of the report was to determine whether Cahaba GBAs high-dollar outpatient payments to Alabama providers were appropriate. 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.