Summary of Findings

Of the 14 claims that we reviewed, Medicare paid eight correctly for outpatient claims processed by WPS that included procedures for the insertion of multiple units of the same type of medical device. However, for the remaining six claims, Medicare did not pay hospitals correctly. These incorrect payments were due to hospitals overstating the number of units and related charges, resulting in excessive or unwarranted outlier payments.

For the six claims, WPS made overpayments to hospitals totaling $17,996. Incorrect payments occurred because hospitals had inadequate controls to ensure that they billed accurately for claims that included the insertion of medical devices. In addition,Medicare payment controls in the FISS were not always adequate to prevent or detect incorrect payments.

Source: United States Department of Health and Human Services. (2012). Review of outpatient claims processed by Wisconsin Physicians Service that included procedures for the insertion of multiple units of the same type of medical device in calendar years 2008 and 2009. Retrieved https://oig.hhs.gov/oas/reports/region1/11100532.pdf

1. As an executive for the Wisconsin Physicians Service (WPS) Insurance Corporation, after reviewing the case, what recommendations would you propose to the Board of Directors that they should prepare for as a response from the OIG?
2. What should WPS do with CMS to improve the process