Review of Medicare Payments for Beneficiaries with Institutional Status, Aetna U.S. Healthcare, King of Prussia, Pennsylvania

The objective of this review was to determine if payments to Aetna (Contract H3951) were appropriate for beneficiaries reported as institutionalized.  We determined that Aetna received Medicare overpayments totaling $87,516 for 90 beneficiaries incorrectly reported as institutionalized during the period January 1, 1998 through December 31, 2000.  Institutional status requirements specify that a beneficiary must be a resident of a qualifying facility for a minimum of 30 consecutive days immediately prior to the first day of the current reporting month.  The 90 beneficiaries included 48 that had admittance or discharge dates during the 30-day residency period and 42 beneficiaries residing in facilities not certified for Medicare or Medicaid.