Review of High-Dollar Payments for Outpatient Services Processed by First Coast Service Options, Inc., for the Period January 1, 2004, Through December 31, 2005

摘要

Our objective was to determine whether high-dollar Medicare payments that First Coast made to hospitals for outpatient services were appropriate. Of the 40 high-dollar payments that First Coast made for outpatient services for CYs 2004 and 2005, 23 were appropriate. The remaining 17 payments included overpayments totaling $1,498,529, which the hospitals had not refunded by the beginning of our audit. The hospitals received these overpayments by billing excessive units of service. First Coast made these incorrect payments because neither the Fiscal Intermediary Standard System nor the CWF had sufficient edits in place during CYs 2004 and 2005 to detect and prevent the overpayments.