Review of High-Dollar Payments for Medicare Part B Claims Processed by Triple-S, Inc., for the Period January 1, 2003, Through December 31, 2005

摘要

Pursuant to Title XVIII of the Social Security Act, the Medicare program provides health insurance for persons 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. Triple-S, Inc. (Triple-S) is the Medicare Part B carrier for about 8,200 providers in Puerto Rico and the U.S. Virgin Islands. During calendar years (CY) 2003-2005, Triple-S processed more than 24 million Part B claims, 13 of which resulted in payments of $10,000 or more (high-dollar payments). Our objective was to determine whether Triple-Ss high-dollar Medicare payments to Part B providers were appropriate.