Review Of Fiscal Year 2000 Medicare Error Rate At Seguros De Servicios De Salud De Puerto Rico

EXECUTIVE SUMMARY:

The objective of  the review was to assess claims processing operations at Seguros de Servicios de Salud de Puerto Rico that contributed to the preparation of the fiscal year (FY) 2000 combined financial statements for the Centers for Medicare and Medicaid Services (CMS).  The review identified areas with respect to claims processing where corrective actions are needed to comply with applicable laws and regulations and prevent material misstatement of the CMS financial statements.  Specifically, our sample of 680 claims identified 68 claims that did not comply with Medicare laws and regulations.  These errors were detected through medical review of supporting documentation and detailed testing by OIG auditors.  Contributing significantly to the errors noted during the course of the review was the fact that provider records did not completely and accurately support amounts reimbursed by Medicare.