Wisconsin Physicians Service Insurance Corporation Made Incorrect Medicare Payments to Providers for Outpatient Services

Report Materials

• Full Report (PDF, 1.8 MB)
• Report Highlights (PDF, 361.3 KB)

Why OIG Did This Audit

• A series of previous OIG audits of Medicare Part B services examined whether payments for outpatient services that Medicare administrative contractors made to providers in excess of the providers' billed charges were correct. Those audits found that some providers that billed charges in excess of the amounts that Medicare paid received incorrect payments.
• This audit, a followup to that previous series of OIG audits, assessed whether certain Medicare Part B payments that Wisconsin Physicians Service Insurance Corporation (WPS) made to providers that were in excess of billed charges were correct.

What OIG Found

• Of the 801 selected claim lines for which WPS paid providers during January 1, 2022, through December 31, 2023 (audit period), 138 claim lines were incorrect and resulted in overpayments totaling at least $140,182 that WPS made to providers.
• In addition, we identified 31 claim lines totaling $76,640 for which providers received Part B payments; however, there was no supporting documentation.
• Providers attributed the overpayments we identified to clerical errors and issues with their billing systems. In addition, WPS had system edits in place, but those edits, and WPS's review of payments flagged by those edits, did not always identify the claim lines that were in error, which resulted in the overpayments.

What OIG Recommends

We made five recommendations to WPS, including that it confirm the recovery of the $140,182 in

overpayments. We also made procedural recommendations regarding the need to locate additional medical record documentation related to claim lines totaling $76,640 and recover any identified overpayments, the enhancement of existing system edits, and the enhancement of WPS's provider education activities. The full recommendations are in the report.

WPS concurred with all of our recommendations and described steps it had taken and planned to take to address them.