Review of Claims for Multiple Procedures Performed in the Same Operative Session in Ambulatory Surgical Centers

EXECUTIVE SUMMARY:

The objective of our analysis was to evaluate the effectiveness of TrailBlazer Health Enterprises' claims processing system in identifying payment reductions for multiple ambulatory surgical center procedures for calendar years 1999 through 2001.  Regulations require that when multiple services are provided in the same operative session, the highest paying procedure is reimbursable at the full payment rate while the other procedures are reimbursable at one-half the normal payment rate.  Our analysis showed that TrailBlazer Health Enterprises' systems failed to identify such instances, which resulted in provider overpayments for calendar years 1999 through 2001of approximately $79,164, $51,665 and  $45,215 ($176,044), respectively.  Included in the identified overpayments is approximately $35,842 in beneficiary overpayments for coinsurance.  Most of the overpayments occurred because the carrier's processing system did not identify multiple procedures performed during the same session when submitted on separate claims.