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Department of Health and Human Services

Office of Inspector General -- AUDIT

"Review of Medicare Payments Made to PacifiCare of Texas Incorporated, a Health Maintenance Organization in San Antonio, Texas," (A-06-94-00028)

June 8, 1995


Complete Text of Report is available in PDF format (736 kb). Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.

EXECUTIVE SUMMARY:

This audit is one of a series of reviews the Office of Inspector General is conducting under our "Strategic Plan for the Oversight of Managed Care". The final report points out that PacifiCare (a risk-based health maintenance organization) received overpayments totaling $617,577 on behalf of Medicare beneficiaries who were erroneously classified as; (1) eligible for Medicaid (dual eligible), (2) an end-stage renal disease (ESRD) beneficiary, or who no longer resided in PacifiCare's service area (out-of-area). In addition to a financial adjustment, we recommended actions PacifiCare can take to preclude erroneous classification of Medicare beneficiaries in the above categories. Officials of PacifiCare concurred in all our findings and recommendations.