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EXECUTIVE SUMMARY:
The objective of this review was to determine whether Pinnacle Business Solutions, Inc.’s (Pinnacle) high-dollar Medicare payments to Missouri Part B providers were appropriate. Of the 59 high-dollar payments that Pinnacle made to providers, 46 were appropriate. However, Pinnacle overpaid providers $65,506 for the remaining 13 payments. Providers stated that they had refunded two of the overpayments, totaling $17,643, prior to our fieldwork; however, Pinnacle had not received the refund for one claim with an overpayment totaling $14,440. Eleven overpayments, totaling $47,863, remained outstanding. We recommended that Pinnacle recover the $47,863 in overpayments identified during our audit, process the corrected claim and recover the $14,440 overpayment that the provider stated that it had corrected prior to our audit but Pinnacle had not received, review for accuracy claims that had a charged amount equal to the allowed amount, and consider using the results of this audit in its provider education activities. Pinnacle agreed with the findings and recommendations.