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Department of Health and Human Services

Review of Medicare Payments for Beneficiaries with Institutional Status, BlueCross of Northeastern Pennsylvania, Wilkes-Barre, Pennsylvania

May 22, 2002

Complete Text of Report is available in PDF format (112kb). Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.


The objective of this review was to determine if payments to BlueCross (Contract H3953) were appropriate for beneficiaries reported as institutionalized.  The final report points out that BlueCross received Medicare overpayments totaling $62,432 for 99 beneficiaries incorrectly reported as institutionalized during the period January 1, 1998 through December 31, 2000.  Forty-four of the beneficiaries did not meet the 30-day residency requirement for the month claimed in an institution.  For 37 other beneficiaries, there was no evidence of institutional residency for the month(s) questioned.  The remaining 18 beneficiaries were residents of domiciliary facilities not certified for Medicare or Medicaid.