Review of Medicare Payments for Beneficiaries with Institutional Status, Kaiser Foundation Health Plan, Portland, Oregon

EXECUTIVE SUMMARY:

This final report provides the results of our audit entitled, "Review of Medicare Payments for Beneficiaries with Institutional Status." Our objective was to determine if payments to Kaiser Foundation Health Plan, under Medicare risk contract H9003, were appropriate for beneficiaries reported as institutionalized.

We determined Kaiser received Medicare overpayments totaling $10,472 for 20 beneficiaries incorrectly classified as institutionalized. The 20 beneficiaries were part of a statistical sample of 100 Medicare beneficiaries reported as institutionalized during the period October 1, 1994 through September 30, 1996. Based on our sample results, we estimate that Kaiser received Medicare overpayments of at least $105,624 for beneficiaries incorrectly classified as institutionalized during the audit period.

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