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EXECUTIVE SUMMARY:
The objective of this review was to determine whether claims for care plan oversight (CPO) services rendered by physicians in Puerto Rico were paid in accordance with Medicare requirements. We found that physicians billed for CPO services but were not adhering to the Medicare requirements that govern such services. In all 30 claims tested, physicians did not maintain required supporting documentation in their medical records to establish that reimbursable CPO services had actually been provided and that their billings to Medicare were proper and justified. Physicians interviewed were not aware of the requirements to bill Medicare for CPO services, some indicated that they did not understand the concept of reimbursement for CPO and many believed they were entitled to bill Medicare just for signing the plan of care. Although Triple S had provided some educational outreach, it is apparent that a much greater effort is needed. Because we found all 30 claims in our random sample were in error, there is a significant risk that $2,159,018 for 37,020 claims was improperly reimbursed by the Medicare carrier to physicians for CPO services rendered during the period January 1, 1999 through December 31, 2000. We believe the degree of noncompliance we encountered in our review and the unfamiliarity of physicians with Medicare billing requirements necessitates immediate action by Triple S. We are recommending that Triple S (1) develop an action plan targeted towards providing educational outreach to promote full awareness of the CPO billing requirements among the physician community, (2) perform periodic post payment review of CPO claims submitted by physicians to ascertain that physicians are adhering to Medicare billing requirements, and (3) conduct additional reviews of claims by physicians with significant CPO billings to recover inappropriate payments that have been made. Triple S agreed to immediately address our recommendations.