Review of Medicare Payments for Beneficiaries with Institutional Status - Inter Valley Health Plan, Pomona, California

EXECUTIVE SUMMARY:

The objective of this review was to determine if payments to Inter Valley Health Plan (Contract H0545) were appropriate for beneficiaries reported as institutionalized.  The final report points out that Inter Valley received Medicare overpayments totaling $319,355 for 27 beneficiaries incorrectly reported as institutionalized during the period January 1, 1998 through December 31, 2000.  Twenty-six of the identified beneficiaries were residents of domiciliary facilities that did not qualify a beneficiary for institutional status.  Inter Valley should not have received payment at the enhanced institutional rate.