EXECUTIVE SUMMARY:

This final report concludes that Group Health Cooperative of Puget Sound had adequate controls to ensure that higher (enhanced) Medicare payments, made in behalf of institutionalized patients, were discontinued when the patients were no longer institutionalized and the entitlement to the higher payments ended. However, from a random sample of 100 monthly payments, 4 beneficiaries were found to have been inappropriately classified as institutionalized, resulting in Medicare overpayments totaling $9,769. We reported a need to reemphasize to Group Health staff the importance of promptly reporting changes in beneficiary status, and to establish procedures for making retroactive adjustments when such errors were identified by Group Health. We also recommended a refund of the $9,769.