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EXECUTIVE SUMMARY:
This report provides the results of the OIG’s review of amounts paid to two Texas physicians, who were reimbursed more than $150 per claim for care plan oversight (CPO) services provided during the 2-year period ended December 31, 2002. Our audit objective was to determine if the amounts paid for CPO services met Medicare reimbursement requirements. Two Texas physicians billed and were improperly paid $15,897 for 236 CPO services on 9 CPO claims. None of the 236 services met Medicare reimbursement requirements because the physicians (1) did not provide 230 of the services and (2) did not have supporting documentation for the remaining 6 services. In addition, when TrailBlazer, the Medicare carrier for the State of Texas, paid these CPO claims, it did not have claim-processing system edits in place to ensure that only one service was billed on each claim. Since then, TrailBlazer has implemented such edits to reduce two or more billed CPO services to one service on each claim. After these edits were in place, we did not identify any additional overpayments for excessive CPO services during our audit period.
We recommended that TrailBlazer (1) recover the $15,897 of overpayments made to the two physicians for physician CPO services improperly billed to Medicare; (2) review physician CPO service claims paid after our audit period to ensure that its claim-processing system edits have continued to prevent improper payments for excessive CPO services; and (3) continue its efforts to provide physicians with education covering Medicare’s requirements for billing and documenting CPO services. TrailBlazer agreed with our findings and recommendations.