Review of High-Dollar Payments for Missouri Medicare Part B Claims Processed by Pinnacle Business Solutions, Inc., for the Period January 1, 2003, Through December 31, 2003

The objective of this review was to determine whether Pinnacle Business Solutions, Inc.'s (Pinnacle) high-dollar Medicare payments to Missouri Part B providers were appropriate.  Of the 59 high-dollar payments that Pinnacle made to providers, 46 were appropriate. However, Pinnacle overpaid providers $65,506 for the remaining 13 payments.  Providers stated that they had refunded two of the overpayments, totaling $17,643, prior to our fieldwork; however, Pinnacle had not received the refund for one claim with an overpayment totaling $14,440.  Eleven overpayments, totaling $47,863, remained outstanding.  We recommended that Pinnacle recover the $47,863 in overpayments identified during our audit, process the corrected claim and recover the $14,440 overpayment that the provider stated that it had corrected prior to our audit but Pinnacle had not received, review for accuracy claims that had a charged amount equal to the allowed amount, and consider using the results of this audit in its provider education activities.  Pinnacle agreed with the findings and recommendations.