Department of Health and Human Services

Office of Inspector General -- AUDIT

"Review of Medicare Payments For Beneficiaries With Institutional Status - PacifiCare of California, Santa Ana, California," (A-05-97-00013)

April 27, 1998


Complete Text of Report is available in PDF format (291 kb). Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.


EXECUTIVE SUMMARY:

The objective of this audit was to determine if capitation payments to PacifiCare of California were appropriate for beneficiaries reported as institutionalized.  We determined PacifiCare received Medicare overpayments totaling $9,700 for 14 beneficiaries incorrectly classified as institutionalized.  The 14 beneficiaries were part of a statistical sample of 100 Medicare beneficiaries reported as institutionalized during the period October 1, 1994 through September 30, 1996.  Based on our sample results, we estimate that PacifiCare received Medicare overpayments of at least $398,084 for beneficiaries incorrectly classified as institutionalized during the audit period.