Review of TrailBlazer Health Enterprises Outlier Payments to Clinic Resources Management, Inc., for Partial Hospitalization Services for the Period August 1, 2000, Through December 31, 2003

EXECUTIVE SUMMARY:

Our objective was to determine whether the fiscal intermediary, TrailBlazer Health Enterprises (TrailBlazer), calculated Medicare outlier payments to Clinic Resources Management, Inc. (Quitman Clinic) in accordance with Medicare reimbursement requirements.  TrailBlazer correctly calculated Medicare outlier payments to Quitman Clinic during the period May 1 through December 31, 2003; however, for the period August 1, 2000, to May 1, 2003, TrailBlazer did not calculate outlier payments in accordance with Medicare reimbursement requirements.  As a result, TrailBlazer overpaid Quitman Clinic $8,802,649.