Review of High-Dollar Payments for Medicare Part B Claims Processed by National Government Services for New Jersey Providers for the Period January 1, 2003, Through December 31, 2005

摘要

Pursuant to Title xvm 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. In addition, pursuant to 42 U.S.C. SC 1395u(b)(6)(B) and (E), skilled nursing facilities are required to bill for all services provided to a facility resident. CMS guidance also requires carriers to pay for physician services based on a fee schedule. Carriers currently use the Medicare Multi-Carrier Claims System and CMS's Common Working File to process Part B claims. These systems can detect certain improper payments during prepayment validation. National Government Services (formerly Empire Medicare Services) is the Medicare Part B carrier for about 38,000 providers in New Jersey. During calendar years (CY) 2003-2005, National Government Services processed more than 94 million Part B claims, 1,265 of which resulted in payments of $10,000 or more (high-dollar payments). Our objective was to determine whether National Government Services' high-dollar Medicare payments to Part B providers in New Jersey were appropriate.