Review of Costs Claimed by Rocky Mountain Health Maintenance Organization for Calendar Year 1998

This report provides the results of our audit titled,. The objective of the review was to evaluate the Medicare cost report for allowability of costs, and the claims processing system for potential payment of duplicate claims.  Generally, we found that costs claimed on the 1998 cost report were allowable and that Rocky Mountain Health Maintenance Organization (Rocky) was aggressive at recovering duplicate payments.  We were able to determine that Rocky recovered $1,951,092 due to duplicate payments providers received from both Rocky and the carrier.   However, we were not able to trace the adjustment of the carrier's paid claim directly to claims paid by Rocky.   Without this capability, it is not possible to determine that all appropriate adjustments are being made.  We recommended that Rocky strengthen its current claims processing system to provide a more efficient and effective method in recording the adjustments for duplicate payments.