Review of Medicare Payments for Beneficiaries with Institutional Status - Kaiser Foundation Health Plan, Inc., Oakland, California

EXECUTIVE SUMMARY:

This final report points out that the Kaiser Foundation Health Plan, Inc., received Medicare overpayments totaling $229,656 for 315 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 315 beneficiaries included 266 that had admittance or discharge dates during the 30-day residency period.  The remainder consisted of: 16 beneficiaries residing in facilities not certified for Medicare or Medicaid; 28 beneficiaries for whom institutional residency could not be documented; and 5 beneficiaries with hospitals stays greater than 15 days.