Department of Health and Human Services

Office of Inspector General -- AUDIT

"Audit of Medicare Payments to PacifiCare of California for Beneficiaries Classified as Institutionalized in January 1998," (A-09-01-00056)

September 21, 2001


Complete Text of Report is available in PDF format (777 KB). Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.


EXECUTIVE SUMMARY:

The objective of this review was to determine if enhanced Medicare payments made to PacifiCare of California (PacifiCare) were appropriate for beneficiaries classified as institutionalized in January 1998.  We estimate that PacifiCare received Medicare overpayments of at least $2,083,163 for beneficiaries incorrectly classified as institutionalized in January 1998.  We recommended that PacifiCare: (1) refund the specific overpayments of $66,658 identified in the sample; (2) coordinate with CMS to ensure that adjustments already submitted, totaling $8,756, are processed; and (3) review the balance of the institutionalized beneficiary universe to identify and refund additional overpayments (total overpayments are estimated to be $2,083,163).