Report Materials
EXECUTIVE SUMMARY:
Aetna US Healthcare (AUSHC) contracts with the Federal Government to provide health benefits to Medicare beneficiaries. The Federal Government pays AUSHC a per-member-per-month rate for each enrolled Medicare beneficiary. AUSHC receives an enhanced rate for those beneficiaries who reside in facilities designated as institutions and who meet a qualifying 30-day residency period. Between January 1, 1996 and September 30, 1998, AUSHC incorrectly identified 12 beneficiaries in institutional status. Six did not meet the 30-day residency requirement, while six resided in facilities that were not defined as institutions. We recommended that AUHSC refund $113,993 in overpayments resulting from this misclassification. This included $5,338 that represented overpayments received after September 30, 1998 for two beneficiaries that continued to be erroneously identified as institutionalized. We also recommended that AUSHC strengthen their internal controls to prevent these errors from occurring.
Notice
This report may be subject to section 5274 of the National Defense Authorization Act Fiscal Year 2023, 117 Pub. L. 263.