Department of Health and Human Services

"Review of Medicare Payments for Beneficiaries with Institutional Status, Aetna U.S. Healthcare, King of Prussia, Pennsylvania," (A-05-01-00090)

July 23, 2002

Complete Text of Report is available in PDF format (345 kb). 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 Aetna (Contract H3951) were appropriate for beneficiaries reported as institutionalized.  We determined that Aetna received Medicare overpayments totaling $87,516 for 90 beneficiaries incorrectly reported as institutionalized during the period January 1, 1998 through December 31, 2000.  Institutional status requirements specify that a beneficiary must be a resident of a qualifying facility for a minimum of 30 consecutive days immediately prior to the first day of the current reporting month.  The 90 beneficiaries included 48 that had admittance or discharge dates during the 30-day residency period and 42 beneficiaries residing in facilities not certified for Medicare or Medicaid.