U.S. OFFICE OF PERSONNEL MANAGEMENT 

OFFICE OF THE INSPECTOR GENERAL 

OFFICE OF AUDITS 

Final Audit Report 

Subject: 

AUDIT OF CAREFIRST BLUECROSS BLUESHIELD
 

OWINGS MILLS, MARYLAND
 

Report No. lA-10-85-09-023 

Date: May 21, 2010 

':-CAUTION-­

This audit report has been distributed to federal officials wbo are responsible for the administration of lhe audited program. This audit 

report nlaY (ontain proprietary data which is pr'oteeted by Federal law (/8 U.S.C. 19115). ,Therefore, while thisandil report is available 

'under the Freedom of Information Act a.id made available to'jhe public on tile OIG wcbpage,: caution needs to be exercised before 

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UNITED STATES OFFICE OF PERSONNEL MANAGEMENT
 

Washington, DC 20415
 

Office of the 

Inspector General 

AUDIT REPORT
 

Federal Employees Health Benefits Program
 

Service Benefit Plan Contract CS 1039
 

BlueCross BlueShield Association
 

Plan Code 10
 

CareFirst BlueCross BlueShield
 

Washington, D.C. and Maryland Service Areas and Overseas Claims
 

Plan Codes 080108110821190/580/582/690
 

Owings Mills, Maryland
 

REPORT NO. IA-1O-85-09-023 DATE: May 21, 2010 

~~
 Assistant lnspector General 

for Audits 

www.usajobs.gov 
UNITED STATES OFFICE OF PERSONNEL MANAGEMENT
 

Washington, DC 20415
 

Office of the 

Inspector General 

EXECUTIVE SUMMARY
 

Federal Employees Health Benefits Program
 

Service Benefit Plan Contract CS 1039
 

BlueCross BIueShield Association
 

Plan Code 10
 

CareFirst BIueCross BlueShield
 

Washington, D.C. and Maryland Service Areas and Overseas Claims
 

Plan Codes 080/081/082119015801582/690
 

Owings Mills, Maryland
 

REPORT NO. lA-1O-85-09-023 DATE: May 21, 2010 

This final audit report on the Federal Employees Health Benefits Program (FEHBP) operations at 

CareFirst BlueCross BlueShield (Plan), which specifically included the Washington, D.C. and 

Maryland Service Areas and Overseas claims, questions $1,304,034 in health benefit charges and 

$60,561 in administrative expenses. The BlueCross BlueShield Association (Association) andlor 

Plan agreed (A) with $1,333,921 and disagreed (D) with $30,674 ofthe questioned charges. Lost 

investment income (LII) on the questioned charges amounts to $1,554. 

Our audit was conducted in accordance with Government Auditing Standards. The audit covered 

claim payments from January I, 2006 through October 31, 2008, as well as miscellaneous 

payments and credits and administrative expenses from 2004 through 2008 as reported in the 

Annual Accounting Statements. In addition, we reviewed the Plan's cash management practices 

related to FEHBP funds for contract years 2004 through 2008. Due to certain errors identified 

during our review of claim payments, we expanded our audit scope to also include additional 

claims potentially paid incorrectly during various periods from January 1, 2006 through 

September 30,2009. 

Questioned items are summarized as follows: 

www.opm.gDv www.usajobs.gov 
HEALTH BENEFIT CHARGES
 

Claim Payments 

• Amounts Paid Greater than Covered Charges fA) $684,657 

During our review of claims where the amounts paid were greater than the covered charges, 

we determined that the Plan incorrectly paid 164 claims, resulting in overcharges of $684,657 

to the FEHBP. 

• Inpatient Facility Claims - Duplicate or Overlapping Dates of Service $297,735 

The Plan incorrectly paid 124 inpatient facility claims, resulting in net overcharges of 

$297,735 to the FEHBP. Specifically, the Plan overpaid 120 claims by $298,204 and 

underpaid 4 claims by $469. The Association agreed with $267,061 (A) and disagreed with 

$30,674 (D) of the questioned charges. 

• Omnibus Budget Reconciliation Act of 1990 Review fA) $169,397 

The Plan incorrectly paid 12 claims that were priced or potentially should have been priced 

under the Omnibus Budget Reconciliation Act of 1990 pricing guidelines, resulting in net 

overcharges of$169,397 to the FEHBP. Specifically, the Plan overpaid 10 claims by 

$220,139 and underpaid 2 claims by $50,742. 

• Assistant Surgeon Review fA) $116,348 . 

The Plan incorrectly paid 146 assistant surgeon claims, resulting in net overcharges of 

$1l6,348 to the FEHBP. Specifically, the Plan overpaid 133 claims by $127,100 and 

underpaid 13 claims by $10,752. 

• Debarred Provider Payments (A) $15,564 

The Plan made 205 claim payments, totaling $15,564, to 3 debarred providers. 

• System Review fA) 

Based on our review ofjudgmental samples of 301 claims, we determined that the Plan 

incorrectly paid 5 claims, resulting in net undercharges of$52 to the FEHBP. Specifically, the 

Plan overpaid four claims by $1,948 and underpaid one claim by $2,000. 

11 
Miscellaneous Payments and Credits 

•	 Provider Audit Vendor Fees (A) $15,249 

The Plan paid commission fees to a vendor for Federal Employee Program (FEP) recoveries 

that were not realized, resulting in overcharges of $15,249 to the FEHBP. 

•	 Fraud Recovery Returned Untimely (A) $5,136 

In one instance, the Plan did not timely return a fraud recovery to the FEHBP. As a result of 

this finding, the Plan credited the FEHBP $5,136 for LIl on this recovery.
 

ADMINISTRATIVE EXPENSES
 

•	 BluesNet Charges Cf4) $60,561 

The Plan charged the FEHBP for BluesNet expenses that had already been charged to the 

FEHBP by the FEP Operations Center. As a result, the FEHBP is due $60,561, consisting of 

$56,846 for duplicate BluesNet charges and $3,715 for LIl on these charges. 

CASH MANAGEMENT 

Overall, we concluded that the Plan handled FEHBP funds in accordance with Contract CS 1039 

and applicable laws and regulations, except for the findings pertaining to cash management noted 

in the "Miscellaneous Payments and Credits" section. 

LOST INVESTMENT INCOME ON AUDIT FINDINGS 

As a result of our audit findings presented in this audit report, the FEHBP is due LIl of 

$1,~, calculated through December 31, 2009. 

J1] 
CONTENTS
 

PAGE 

EXECUTIVE SUMMARY	 i
 

I. INTRODUCTION AND BACKGROUND	 I
 

II. OBJECTIVES, SCOPE, AND METHODOLOGY	 3
 

III. AUDIT FINDINGS AND RECOMMENDATIONS	 6
 

A. HEALTH BENEFIT CHARGES	 6
 

I. Claim Payments	 ' 6
 

a. Amounts Paid Greater than Covered Charges	 6
 

b. Inpatient Facility Claims - Duplicate or Overlapping Dates of Service 11
 

c. Omnibus Budget Reconciliation Act of 1990 Review	 15
 

d. Assistant Surgeon Review	 17
 

e. Debarred Provider Payments	 21
 

f. System Review	 23
 

2. Miscellaneous Payments and Credits	 25
 

a. Provider Audit Vendor Fees	 25
 

b. Fraud Recovery Returned Untimely	 26
 

B. ADMINISTRATIVE EXPENSES	 27
 

1. BluesNet Charges	 27
 

C. CASH MANAGEMENT	 28
 

D. LOST INVESTMENT INCOME ON AUDIT FINDINGS	 28
 

IV. MAJOR CONTRIBUTORS TO THIS REPORT.	 30
 

V. SCHEDULES 

A. CONTRACT CHARGES 

B. QUESTIONED CHARGES 

C. LOST INVESTMENT INCOME CALCULAnON 

APPENDIX	 (BlueCross BlueShield Association response, dated February 19,2010, 

to the draft audit report) 
I. INTRODUCTION AND BACKGROUND
 

INTRODUCTION
 

This final audit report details the findings, conclusions, and recommendations resulting from our 

audit of the Federal Employees Health Benefits Program (FEHBP) operations at CareFirst 

BlueCross BlueShield (Plan), pertaining to the Washington, D.C. (DC) and Maryland Service 

Areas and Overseas claims. The Plan is located in Owings MiJJs, Maryland. 

The audit was perfonned by the Office ofPersonnel Management's (OPM) Office ofthe 

Inspector General (DIG), as established by the Inspector General Act of 1978, as amended. 

BACKGROUND 

The FEHBP was established by the Federal Employees Health Benefits (FEHB) Act (Public Law 

86-382), enacted on September 28, 1959. The FEHBP was created to provide health insurance 

benefits for federal employees, annuitants, and dependents. OPM's Retirement and Benefits 

Office has overall responsibility for administration ofthe FEHBP. The provisions ofthe FEHB 

Act are implemented by OPM through regulations, which are codified in Title 5, Chapter 1, Part 

890 ofthe Code ofFederal Regulations (CFR). Health insurance coverage is made available 

through contracts with various health insurance carriers. 

The BlueCross BlueShield Association (Association), on behalf of participating BlueCross and 

BlueShield plans, has entered into a Government-wide Service Benefit Plan contract (CS 1039) 

with OPM to provide a health benefit plan authorized by the FEHB Act. The Association 

delegates authority to participating local BlueCross and BlueShield plans throughout the United 

States to process the health benefit claims of its federal subscribers. The Plan is one of 

approximately 63 local BlueCross and BJueShield (BCBS) plans participating in the FEHBP. 

The Association has established a Federal Employee Program (FEP') Director's Office in 

Washington, D.C. to provide centralized management for the Service Benefit Plan. The FEP 

Director's Office coordinates the administration of the contract with the Association, member 

BCBS plans, and OPM. 

The Association has also established an FEP Operations Center. The activities ofthe FEP 

Operations Center are perfonned by CareFirst BlueCross BlueShield, located in Washington, 

D.C. These activities include acting as fiscal intennediary between the Association and member 

plans, verifYing subscriber eligibility, approving or disapproving the reimbursement ofloeal plan 

payments ofFEHBP claims (using computerized system edits), maintaining a history file of all 

FEHBP claims, and maintaining an accounting of all program funds. 

I Throughout this report, when we refer to "FEP" we are referring to the Service Benefit Plan lines of business at the 

Plan. When we refer to the "FEHBP" we are referring to the program that provides health benefits to federal employees. 
Compliance with laws and regulations applicable to the FEHBP is the responsibility of the 

Association and Plan management. Also, management of the Plan is responsible for establishing 

and maintaining asystem ofinternal controls. 

All findings from our previous audits of the Plan, pertaining to the DC and Maryland Service 

Areas and Overseas claims (Report No. lA-10-85-03-103, dated August 19,2005, and Report 

No. lA-10-06-03-033, dated December 1,2004), for contract years 1999 through 2002 have 

been satisfactorily resolved. 

The results ofthis audit were provided to the Plan in written audit inquiries; were discussed with 

Plan and/or Association officials throughout the audit and at an exit conference; and were 

presented in detail in a draft report, dated December 3, 2009. The Association's comments 

offered in response to the draft report were considered in preparing our final report and are 

included as an Appendix to this report. Also, additional documentation provided by the 

Association and Plan on various dates through March 9, 2010, was considered in preparing our 

final report. 

2
 
II. OBJECTIVES, SCOPE, AND METHODOLOGY
 

OBJECTIVES
 

The objectives of our audit were to detennine whether the Plan charged costs to the FEHBP and 

provided services to FEHBP members in accordance with the tenns ofthe contract. Specifically, 

our objectives were as follows: 

Health Benefit Charges 

•	 To detennine whether the Plan complied with contract provisions relative to benefit 

payments. 

•	 To detennine whether miscellaneous payments charged to the FEHBP were in 

compliance with the terms ofthe contract. 

•	 To determine whether credits and miscellaneous income relating to FEHBP benefit 

payments were returned promptly to the FEHBP. 

Administrative Expenses 

•	 To detennine whether administrative expenses charged to the contract were actual, 

allowable, necessary, and reasonable expenses incurred in accordance with the tenus 

of the contract and applicable regulations. 

Cash Management 

•	 To determine whether the Plan handled FEHBP funds in accordance with applicable 

laws and regulations concerning cash management in the FEHBP. 

SCOPE 

We conducted our perfonnance audit in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perfonn the audit to obtain sufficient and 

appropriate evidence to provide a reasonable basis for our findings and conclusions based on our 

audit objectives. We believe that the evidence obtained provides a reasonable basis for our 

findings and conclusions based on our audit objectives. 

We reviewed the BlueCross and BlueShield FEHBP Annual Accounting Statements as they 

pertain to Plan codes 080, 081, 082, 190,580,582, and 690 for contract years 2004 through 

2008. During this period, the Plan paid approximately $6.8 billion in health benefit charges and 

$412 million in administrative expenses for the DC and Maryland Service Areas and Overseas 

claims (See Figure 1 and Schedule A). 

3
 
Specifically, we reviewed approximately $54 million in claim payments made from January], 

2006 through October 31, 2008 for proper adjudication, and from various periods from January 1, 

2006 through September 30, 2009 for our expanded reviews of certain claim payment errors. In 

addition, we reviewed miscellaneous payments and credits, such as refunds and subrogation 

recoveries, administrative expenses, and cash management for 2004 through 2008. 

In planning and conducting our audit, we 

obtained an understanding of the Plan's 

internal control structure to help detennine 

the nature, timing, and extent of our 

auditing procedures. This was detennined 

to be the most effective approach to select 

areas of audit. For those areas selected, we 

primarily relied on substantive tests of 

transactions and not tests of controls. 

Based on our testing, we did not identify 

any significant matters involving the Plan's 

internal control structure and its operation. 

However, since our audit would not 

necessarily disclose all significant matters 

in the internal control structure, we do not 

express an opinion on the Plan's system of 

internal controls taken as a whole. 

CareFirst BlueCross B1ueShield 

Contract Charges $2.0
 

$1.5
 III 

c 

.Q 

iii $1.0 M 

$0.5 

$0.0 

2005 2006 2007 2008 

Contract Years 

2004 

r;I Health Benefit Payrrents _ Admnistralive Expenses 

Figure 1 - Contract Charges 

We also conducted tests to detennine whether the Plan had complied with the contract, the 

applicable procurement regulations (i.e., Federal Acquisition Regulations (FAR) and Federal 

Employees Health Benefits Acquisition Regulations (FEHBAR), as appropriate), and the laws 

and regulations governing the FEHBP. The results of our tests indicate that, with respect to the 

item~-tested, the Plan did not comply with all provisions of the contract and federal procurement 

regulations. Exceptions noted in the areas reviewed are set forth in detail in the "Audit Findings 

and Recommendations" section of this audit report. With respect to the items not tested, nothing 

came to our attention that caused us to believe that the Plan had not complied, in all material 

respects, with those provisions. 

In conducting our audit, we relied to varying degrees on computer-generated data provided by the 

FEP Director's Office, the FEP Operations Center, the Plan, and the Centers for Medicare and 

Medicaid Services. Due to time constraints, we did not verify the reliability of the data generated 

by the various infonnation systems involved. However, while utilizing the computer-generated 

data during our audit testing, nothing came to our attention to cause us to doubt its reliability. 

We believe that the data was sufficient to achieve our audit objectives. 

The audit was perfonned at the Plan's office in Owings Mills, Maryland on various dates from 

May 4,2009 through August 7, 2009. Audit fieldwork was also perfonned at our offices in 

Washington, D.C.; Cranberry Township, Pennsylvania; and Jacksonville, Florida. 

4
 
METHODOLOGY 

We obtained an understanding of the internal controls over the Plan's claims processing, 

financial, and cost accounting systems by inquiry of Plan officials. 

To test the Plan's compliance with the FEHBP health benefit provisions, we selected and 

reviewed samples of 2,287 claims? These claim samples include our expanded reviews of 

certain errors identified during our evaluation of claim payments. We used the FEHBP contract, 

the Service Benefit Plan brochure, the Plan's provider agreements, and the Association's FEP 

administrative manual to determine the allowability of benefit payments. The results ofthese 

samples were not projected to the universe of claims. 

We interviewed Plan personnel and reviewed the Plan's policies, procedures, and accounting 

records during our audit of miscellaneous payments and credits. We also judgmentally selected 

and reviewed 133 health benefit refunds, totaling $10,602,342 (from a universe of73,223 

refunds, totaling $42,448,024); 97 subrogation recoveries, totaling $5,789,590 (from a universe 

of 5,636 subrogation recoveries, totaling $13,939,217); 69 provider audit recoveries, totaling 

$3,426,753 (from a universe of 1,751 provider audit recoveries, totaling $10,445,902); 102 

special plan invoices, totaling $7,518,783 in net payments (from a universe of 2,212 special plan 

invoices, totaling $65,126,329 in net payments); 80 provider advance adjustments and balances, 

totaling $202,855,400 (from a universe of 614 provider advance adjustments and balances, 

totaling $444,578,300); and 30 fraud recoveries, totaling $3,060,473 (from a universe of 534 

fraud recoveries, totaling $4,555,776), to determine if refunds and recoveries were promptly 

returned to the FEHBP and ifmiscellaneous payments were properly charged to the FEHBP. The 

results ofthese samples were not projected to the universe of miscellaneous payments and 

credits. 

We judgmentally reviewed administrative expenses charged to the FEHBP for contract years 

2004 through 2008. Specifically, we reviewed administrative expenses relating to cost centers, 

natural accounts, out-of-system adjustments, prior period adjustments, pension, post-retirement, 

employee health benefits, executive compensation, Association dues, lobbying, return on 

investment, subcontracts, and Health Insurance Portability and Accountability Act of 1996 

compliance. We used the FEHBP contract, the FAR, and the FEHBAR to determine the 

allowability, allocability, and reasonableness of charges. The results of the testing were not 

projected to the universe of administrative expenses. 

We also reviewed the Plan's cash management to detennine whether the Plan handled FEHBP 

funds in accordance with Contract CS 1039 and applicable laws and regulations. 

2 See the audit findings for "Amounts Paid Greater than Covered Charges" (A l.a), "Inpatient Facility Claims ­

Duplicate or Overlapping Dates of Service" (A1.b), "Omnibus Budget Reconciliation Act of 1990 Review" (A I.e), 

"Assistant Surgeon Review" (AI.d), "Debarred Provider Payments" (A I.e), and "System Review" (Al.f) on pages 6 

through 24 for specific details of our sample selection methodologies. 

5 
III. AUDIT FINDINGS AND RECOMMENDATIONS
 

A.	 HEALTH BENEFIT CHARGES 

1.	 Claim Payments 

a.	 Amounts Paid Greater than Covered Charges $684,657 

The Plan incorrectly paid 164 claims, resulting in overcharges of $684,657 to the 

FEHBP. 

Contract CS 1039, Part III, section 3.2 (b)(l) states, "The Carrier may charge a cost to 

the contract for a contract term if the cost is actual, allowable, allocable, and 

reasonable." Part II, section 2.3(g) states, "Ifthe Carrier or OPM determines that a 

Member's claim has been paid in error for any reason ... the Carrier shall make a 

prompt and diligent effort to recover the erroneous payment ...." 

Contract CS 1039, Part II, section 2.6 states, "(a) The Carrier shall coordinate the 

payment of benefits under this contract with the payment of benefits under Medicare 

... (b) The Carrier shall not pay benefits under this contract until it has determined 

whether it is the primary carrier ...." 

Contract CS 1039, Part III, section 3.8 states, "the Carrier will retain and make 

available all records applicable to a contract term ...." 

The following summarizes our review of claims whe.re amounts paid were greater 

than covered charges. 

DC Service Area 

For the period January 1, 2006 through October 31,2008, we identified 14,163 claims 

where the amounts paid were greater than the covered charges by a total of 

$18,524,241. From this universe, we selected and reviewed a judgmental sample of 

192 claims with a total variance of $6,419,838, and determined ifthe Plan paid these 

claims properly. Our sample included all claims where the amounts paid exceeded 

covered charges by $15,000 or more. Based on our review, we determined that four 

ofthese claims were paid incorrectly, resulting in overcharges of $596,153 to the 

FEHBP. 

The claim payment errors resulted from the following reasons: 

•	 In one instance, a claims processor entered incorrect pricing information when 

resolving a deferred claim, resulting in an overcharge of $512,739 to the FEHEP. 

6
 
e	 In one instance, a claims processor did not enter a year-end split claim override 

code, resulting in an overcharge of$83,075 to the FEHBP. 

•	 The Plan did not reject two claims with inaccurate information, resulting in 

overcharges of $339 to the FEHBP. In each instance, the claim contained a claim 

line with revenue code 360 representing "operating room services" and procedure 

code 95991 representing "other procedures administered by a physician." Since 

procedure 95991 is not an operating room service, these claims should have been 

rejected by the claims processors. 

When we initially identified this error, we concluded that the error could have 

impacted more claims resulting in significant overcharges to the FEHBP. 

Therefore, we requested the Plan to identifY all claims paid from January 1, 2006 

through June 30, 2009 that were potentially processed with this type of error, and 

determine if the claims were paid correctly. The Plan identified 97 claims, 

totaling $17,693 in payments, that were potentially processed with this type of 

error. We reviewed these claims and determined that 77 additional claims were 

paid incorrectly, resulting in overcharges of $10,052 to the FEHBP. 

Maryland Service Area 

For the period January 1,2006 through October 31,2008, we identified 252 claims 

where the amounts paid were greater than the covered charges by a total of $53,520. 

From this universe, we selected and reviewed a judgmental sample of 34 claims with 

a total variance of $41,533, and determined if the Plan paid these claims properly. 

Our sample included all claims where the amounts paid exceeded covered charges by 

$250 or more. Based on our review, we determined that 15 of these claims were paid 

incorrectly, resulting in overcharges of $25,841 to the FEHBP. 

The claim payment errors resulted from the foHowing reasons: 

•	 The Plan incorrectly paid five claims, resulting in overcharges of$11,350 to the 

FEHBP. These errors occurred due to claims processors entering incorrect units 

or not correctly processing claims with occupational therapy services that were 

billed by a home health agency. 

•	 In two instances, the Plan's claims processing system did not deduct the Medicare 

payments, resulting in overcharges of$6,665 to the FEHBP. 

Because this is a claims system error, we requested the Plan to identifY all claims 

paid from January 1,2006 through June 30,2009 that were potentially processed 

with this type of error and detennine if these claims were paid correctly. The Plan 

identified 126 claims, totaling $97,491 in payments, that were potentially 

processed with this type of error. We reviewed these claims and detennined that 

21 additional claims were paid incorrectly, resulting in overcharges of $1 0,342 to 

7
 
the FEHBP. As of October 9, 2009, the Plan is working to correct this system 

error. 

•	 The Plan did not properly coordinate five claims with Medicare, resulting in 

overcharges of$5,362 to the FEHBP. 

•	 The Plan paid three claims using the 2006 non-participating (par) surgery 

allowances even though the billed charges were less, resulting in overcharges of 

$2,464 to the FEHBP. These errors occurred because the FEP national claims 

system was programmed to pay the 2006 non-par surgery allowance rather than the 

lesser of the non-par surgery allowance or billed charges. 

Since this system error potentially also affected the DC Service Area and Overseas 

claims, we expanded our review ofthis error to include the DC and Maryland 

Service Areas and Overseas claims (See "Expanded Review ofthe 2006 Non-Par 

Surgery Allowance" below). According to the FEP Director's Office, this non-par 

system error has been corrected. 

Overseas Claims 

For the period January 1, 2006 through October 31,2008, we identified 30 claims 

where the amounts paid were greater than the covered charges by a total of $39,704. 

From this universe, we selected and reviewed a judgmental sample of eight claims 

with a total variance of $32,599, and determined if the Plan paid these claims 

properly. Our sample included aU claims where the amounts paid exceeded covered 

charges by $1,000 or more. Based on our review, we determined that four of these 

claims were paid incorrectly, resulting in overcharges of$II,881 to the FEHBP. 

The claim payment errors resulted from the following reasons: 

•	 The Plan processed three claims using the incorrect number of days, resulting in 

overcharges of $7,501 to the FEHBP. 

•	 The Plan paid one claim at the incorrect per diem rate, resulting in an overcharge 

of$4,380 to the FEHBP. 

Expanded Review of the 2006 Non-Par Surgery AUowance 

Since additional claims may have been affected by the 2006 non-par surgery allowance 

error noted under the "Maryland Service Area", we identified all claims for the DC and 

Maryland Service Areas and Overseas claims with dates of service from January 1, 

2006 tluough December 31, 2006 that were subject to the 2006 non-par surgery 

pricing. We identified 153 claims, totaling $520,920 in payments, that were 

potentially processed incorrectly. We requested the Plan to review these claims and 

dctennine ifthey were paid correctly. After reviewing the Plan's response, we 

8
 
determined that 43 additional claims were paid incorrectly, resulting in overcharges of 

$30,388 to the FEHBP. 

The following summarizes the overcharges: 

•	 For the DC Service Area, the Plan incorrectly paid 12 claims, resulting in 

overcharges of $2,772 to the FEHBP. The claim payment errors resulted from the 

following reasons: 

:>	 The Plan paid eight claims using the 2006 non-par surgery allowances even 

though the billed charges were less, resulting in overcharges of$1,624 to the 

FEHBP. 

:>	 The Plan incorrectly priced four claims due to claims processor errors, resulting 

in overcharges of$I,148 to the FEHBP. 

•	 For the Maryland Service Area, the Plan incorrectly paid seven claims, resulting 

in overcharges of $7,314 to the FEHBP. The claim payment errors resulted from 

the folJowing reasons: 

:>	 The Plan paid five claims using the 2006 non-par surgery allowances even 

though the billed charges were less, resulting in overcharges of $3,090 to the 

FEHBP. 

:>	 The Plan incorrectly priced two claims due to claims processor errors, resulting 

in overcharges of $4,224 to the FEHBP. 

•	 For the Overseas claims, the Plan incorrectly paid 24 claims, resulting in 

overcharges of $20,302 to the FEHBP. The claim payment errors resulted from 

the following reasons: 

:>	 The Plan did not provide a response or supporting documentation for five 

claims, resulting in unsupported charges of $11,149 to the FEHBP. 

:>	 The FEP national claims system did not calculate the appropriate co-insurance 

for 18 claims, resulting in overcharges of $6,604 to the FEHBP. We expanded 

our review of this potential system error under the "System Review" (Al.f) 

audit finding. 

:>	 The Plan incorrectly priced one claim due to a claims processor error, resulting 

in an overcharge of $2,549 to the FEHBP. 

9
 
Association's Response: 

In response to the amount questioned in the draft report, the Association agrees with 

$680,153 ($605,925 + $25,841 + $10,342 + $11,881 + $2,772 + $3,090 + $20,302) 

and disagrees with $105,127 ($71,321 + $2,492 + $31,314). 

The Association states that the Plan has initiated recovery efforts for the confinned 

overpayments and has returned various amounts recovered to the FEHBP. To the 

extent that errors did occur, the Association also states that these payments were good 

faith erroneous benefit payments and fall within the context ofCS 1039, Part II, 

section 2.3(g). Any payments the Plan is unable to recover are allowable charges to 

the FEHBP. As good faith erroneous payments, lost investment income (LII) does not 

apply to the claim payment errors identified in this finding. 

In reference to the overpayments caused by claims processor errors, the Association 

states, "The overpayments were the results of Claims Examiner errors and were used 

as training tools in the recent re-fresher training session. In addition, the Plan has a 

quality review area that reviews claims and identifies payment errors. The identified 

payment errors are then discussed with the management in the Operations Areas. The 

objective is to determine whether individual examiners may need further training or if 

there is a pattern of inconsistency in the adjudication process for multiple Claims 

Examiners. The identified errors are used to determine the focus ofthe training for the 

group." 

As part of its FEP overpayment recovery action plan, the Association states that "the 

FEP Director's Office sends the System-wide Claims Review Listing to the Plan 

which also includes an AmoWlt Paid Greater Than Covered Charges Listing. The
 

. Plan ... reviews and returns the results of its review to the FEP Director's Office as
 

required. Where appropriate, refunds are initiated. However, there appears to be a
 

difference in the claim selection criteria used to select these claims for aPM and the 

selection criteria used to generate the FEP Director's Office System-wide Claims 

Review Listing. We will re-evaluate our selection criteria to determine if any changes 

are required to bring it more in line with the aPM claim selection criteria." 

OIG Comments: 

Based on our review of the Association's response and additional documentation 

provided by the Plan, we revised the amount questioned from the draft report to 

$684,657. Subsequent to receiving the Association's response, the Plan provided 

additional documentation supporting concurrence with the revised questioned 

amount. 

10
 
Recommendation 1 

We recommend that the contracting officer disallow $684,657 for claim overcharges 

and verify that the Plan returns all amounts recovered to the FEHBP. 

b.	 Inpatient Facility Claims - Duplicate or Overlapping Dates of Service $297,735 

The Plan incorrectly paid 124 inpatient facility claims, resulting in net overcharges of 

$297,735 to the FEHBP. Specifically, the Plan overpaid 120 claims by $298,204 and 

underpaid 4 claims by $469. 

As prevtously cited from CS 1039, costs charged to the FEHBP must be actual, 

allowable, allocable, and reasonable. If errors are identified, the Plan is required to 

make a diligent effort to recover the overpayments. The Carrier shall retain and make 

available all records applicable to a contract term. Also, the Plan must coordinate the 

payment of benefits with Medicare. 

The following summarizes our review of inpatient facility claims with duplicate or 

overlapping dates of service. 

Overseas Claims 

We performed a computer search for potential duplicate payments on inpatient facility 

claims paid during the period January 1,2006 through August 31, 2009. We 

identified 44 groups of claims with duplicate or overlapping dates of service. These 

44groups included 89 claims with total amounts paid of$616,079. Based on our 

review, we determined that 29 of these claims were paid incorrectly, resulting in 

overcharges of $166,965 to the FEHBP. 

These claim payment errors resulted from the following: 

•	 The Plan paid 21 duplicate claims, resulting in overcharges of $98,238 to the 

FEHBP. These claims did not defer on the claims system as potential duplicates 

for review by the processors. 

•	 The Plan reprocessed six claims with revised charges but did not adjust or void 

the previous claim payments, resulting in overcharges of $33,497 to the FEHBP. 

•	 In one instance, the Plan did not provide a complete response and/or 

documentation to support a claim payment of $30,674. SpeCifically, the Plan 

could not locate the wire transfer documentation supporting the actual amount 

paid to the provider. 

•	 In one instance, a claims processor keying error caused a duplicate claim not to 

defer on the claims system, resulting in an overcharge of $4,556 to the FEHBP. 

11 
Due to the munber of claim payment errors identified from this review of Overseas 

claims, we expanded our review to also include the DC and Maryland Service Areas. 

We also expanded our audit scope for these service areas to cover inpatient facility . 

claims paid through September 30, 2009. 

DC Service Area 

We perfonned a computer search for potential duplicate payments on inpatient facility 

claims paid during the period January 1,2006 through September 30, 2009. We 

identified 138 groups of claims with duplicate or overlapping dates of service. The 

138 groups included 285 claims with total amounts paid of$I,968,743. From this 

universe, we selected and reviewed a judgmental sample of 128 groups (representing 

263 claims), totaling $1,964,223 in payments, to detennine if the Plan paid these 

claims properly. Our sample included all groups with potential duplicate claim 

payments of $100 or more. 

Based on our review, we detennined that 61 of these claims were paid incorrectly, 

resulting in net overcharges of $82,023 to the FEHBP. Specifically, the Plan overpaid 

58 claims by $82,323 and underpaid 3 claims by $300. These claim payment errors 

resulted from the following: 

•	 The Plan paid 16 duplicate claims, resulting in overcharges of $35,729 to the 

FEHBP. Since the Plan processed these claims under different or incorrect 

provider identification numbers, the claims did not defer on the claims system as 

potential duplicates for review by the processors. 

•	 The Plan processed 17 claims with unauthorized days of service, resulting in 

overcharges of$18,031 to the FEHBP (non-duplicate errors). 

•	 The Plan reprocessed eight claims with revised charges but did not adjust or void 

the previous claim payments, resulting in overcharges of$13,285 to the FEHBP. 

•	 The Plan paid eight duplicate claims, resulting in overcharges of$7,039 to the 

FEHBP. Due to various claims processor keying errors, these claims did not defer 

on the claims system as potential duplicates for review by the processors. 

•	 The Plan incorrectly paid six claims due to providers submitting claims with 

incorrect dates of service, resulting in overcharges of$5,137 to the FEHBP (nonduplicate errors). 

•	 The Plan paid three duplicate claims, resulting in overcharges of $3, I 02 to the 

FEHBP. Since these claims were processed on the same day as the original 

claims, the claim system did not defer these claims as potential duplicates for 

review by the processors. 

12
 
o	 The Plan paid three claims that contained other Plan payment errors, resulting in 

undercharges of$300 to the FEHBP (non-duplicate errors). 

Maryland Service Area 

We performed a computer search for potential duplicate payments on inpatient facility 

claims paid during the period January 1, 2006 through September 30, 2009. We 

identified 61 groups with duplicate or overlapping dates of service. The 61 groups 

included 129 claims with total amounts paid of $459,560. From this universe, we 

selected and reviewed a judgmental sample of 57 (representing 121 claims), totaling 

$456,979 in payments, to determine if the Plan paid these claims properly. Our 

sample included all groups with potential duplicate claim payments of $1 00 or more. 

Based on our review, we determined that 34 of these claims were paid incorrectly, 

resulting in net overcharges of $48,747 to the FEHBP. Specifically, the Plan overpaid 

33 claims by $48,916, and underpaid 1 claim by $169. These claim payment errors 

resulted from the following: 

•	 The Plan reprocessed nine claims with revised charges but did not adjust or void 

the previous claim payments, resulting in overcharges of $20,000 to the FEHBP. 

•	 The Plan paid 11 duplicate claims, resulting in overcharges of$14,737 to the 

FEHBP. Since the Plan processed these claims under different or incorrect 

provider identification numbers, the claims did not defer on the claims system as 

potential duplicates for review by the processors. 

•	 In six instances, the Plan reimbursed the State of Maryland (Medicaid program) 

for claims where Medicaid paid as the primary insurer when the FEHBP was the 

primary insurer. The Plan also paid the providers for these claims, resulting in 

duplicate charges of $5,887 to the FEHBP. 

•	 The Plan paid five duplicate claims, resulting in overcharges of $5,220 to the 

FEHBP. Since these claims were processed on the same day as the original claims, 

the claim system did not defer these claims as potential duplicates for review by 

the processors. 

•	 In one instance, the Plan incorrectly processed a case management claim, resulting 

in duplicate charges of $1,020 to the FEHBP. 

•	 The Plan did not properly coordinate two claims with Medicare, resulting in net 

overcharges of $1,883 to the FEHBP (non-duplicate errors). Specifically, the Plan 

overpaid one claim by $2,052 and underpaid one claim by $169. 

13
 
Association's Response: 

In response to the amount questioned in the draft report, the Association agrees with 

$250,299 ($136,291 + $82,023 + $31,985), is reviewing $11,541, and disagrees with 

the remaining questioned amount. 

The Association states that the Plan has initiated recovery efforts for the confinued 

overpayments and has returned various amounts recovered to the FEHBP. To the 

extent that errors did occur, the Association also states that these payments were good 

faith erroneous benefit payments and fall within the context ofCS 1039, Part II, 

section 2.3(g). Any payments the Plan is unable to recover are allowable charges to 

the FEHBP. As good faith erroneous payments, LII does not apply to the claim 

payment errors identified in this finding. 

The Association also states, "The FEP Claims System includes an edit that is 

designed to defer inpatient claims with overlapping dates of services. However, a 

review ofthis issue indicates that this edit only generates a deferral ifthe claims are 

from the same provider. As a result of this finding, the FEP Director's Office is 

modifying this edit to defer all inpatient claims with overlapping dates of service 

regardless ofwhether the Provider is the same or not. We expect this system 

enhancement to be implemented later in 2010. 

In addition, the Plan has included the claims that were incorrectly coded as part of the 

training program for the Claims Examiners. Lastly, the Plan will provide additional 

training to all Claims Examiners by the second quarter of201 0 with an emphasis on 

the importance of coding claims correctly. The FEP Director's Office will also add 

these claim types to its System-wide claims listings that are sent to all Plans." 

.Regarding the contested overpayments, the Association states that the services were for 

different patients or coded incorrectly, or the dates of services were coded incorrectly. 

DIG Comments: 

Based on our review of the Association's response and additional documentation 

provided by the Plan, we revised the amount questioned from the draft report to 

$297,735. Subsequent to receiving the Association's response, the Plan provided 

additional documentation supporting agreement with $267,061 and disagreement with 

$30,674 ofthe revised questioned amount. The contested amount pertains to an 

overseas claim where the Plan could not locate the wire transfer documentation 

supporting the actual amount paid to the provider. We will continue to question this 

claim until the Association or Plan provides adequate documentation supporting the 

amount paid to the provider. 

14
 
Recommendation 2 

We recommend that the contracting officer disallow $298,204 for claim overcharges 

and verify that the Plan returns aU amounts recovered to the FEHBP. 

Recommendation 3 

We recommend that the contracting officer allow the Plan to charge the FEHBP $469 

if additional payments are made to the providers to correct the underpayment errors. 

Recommendation 4 

We recommend that the contracting officer ensure that the Association and Plan have 

implemented corrective procedures to prevent these types of errors in the future. 

c. Omnibus Budget Reconciliation Act of 1990 Review $169,397 

The Plan incorrectly paid 12 claims that were priced or potentially should have been 

priced under the Omnibus Budget Reconciliation Act of 1990 (OBRA 90) pricing 

guidelines, resulting in net overcharges of $169,397 to the FEHBP. SpecificaUy, the 

Plan overpaid 10 claims by $220,139 and underpaid 2 claims by $50,742. 

As previously cited from CS 1039, costs charged to the FEHBP must be actual, 

allowable, allocable, and reasonable. If errors are identified, the Plan is required to 

make a diligent effort to recover the overpayments. Also, the Plan must coordinate 

the payment of benefits with Medicare. 

OBRA 90 limits the benefit payments for certain inpatient hospital services provided 

to annuitants age 65 or older who are not covered under Medicare Part A. The 

FEHBP fee-for-service plans are required to limit the claim payment to the amount 

equivalent to the Medicare Part A payment. However, the claims for the Maryland 

Service Area and Overseas are not subject to OBRA 90 pricing. 

Using a program developed by the Centers for Medicare and Medicaid Services to price 

OBRA 90 claims, we recalculated the claim payment amounts for the claims in our 

samples that were subject to and/or processed as OBRA 90. 

The following summarizes our OBRA 90 review for the DC Service Area. 

OBRA 90 Claim Pricing Errors 

For the period January 1, 2006 through October 31, 2008, we identified 3,657 claims, 

totaling $42,169,361 in payments, that were subject to OBRA 90 pricing guidelines. 

From this universe, we selected and reviewed a judgmental sample of 95 claims, 

totaling $8,482,494 in payments, to determine if these claims were correctly priced by 

15
 
the FEP Operations Center and paid by the Plan. Our sample included all OBRA 90 

claims with amounts paid of $40,000 or more. 

Based on our review, we determined that eight of these claims were paid incorrectly, 

resulting in net overcharges of$150,325 to the FEHBP. Specifically, the Plan 

overpaid seven claims by $161,342 and underpaid one claim by $11,017. 

These claim payment errors resulted from the following: 

•	 In two instances, the claims processors incorrectly priced split claims, resulting in 

net overcharges of$80,818 to the FEHBP. Specifically, the Plan overpaid one 

claim by $91,835 and underpaid one claim by $11,017. 

•	 The Plan did not properly coordinate six claims with Medicare, resulting in
 

overcharges 0[$69,507 to the FEHBP.
 

Claims Not Priced Under OBRA 90 (Possible OBRA 90 Claims) 

For the period January 1, 2006 through October 31, 2008, we identified 7,414 claims, 

totaling $27,093,377 in payments, that were potentially subject to OBRA 90 pricing 

guidelines but appeared to be paid under the Plan's standard pricing procedures. From 

this universe, we selected and reviewed a judgmental sample of 175 claims, totaling 

$8,268,888 in payments, to determine if the Plan paid these claims properly. Our 

sample included all possible OBRA 90 claims with amounts paid of$25,000 or more. 

Based on our review, we determined that four of these claims were paid incorrectly, 

resulting in net overcharges of $19,072 to the FEHBP. Specifically, the Plan overpaid 

. three claims by $58,797 and underpaid one claim by $39,725. 

These claim payment errors resulted from the following: 

•	 In one instance, a claims processor inadvertently made an unnecessary claim
 

adjustment, resulting in an overcharge of $23,294 to the FEHBP.
 

•	 The Plan did not properly coordinate three claims with Medicare, resulting in net 

undercharges of$4,222 to the FEHBP. Specifically, the Plan overpaid two claims 

by $35,503 and underpaid one claim by $39,725. 

Association's Response: 

The Association agrees with the finding. The Association states that the Plan has 

initiated recovery efforts for the confirmed overpayments, and as ofFebruary 1,2010, 

the Plan had recovered and returned $86,617 to the FEHBP. The Association also 

states that these payments were good faith erroneous benefit payments and fall within 

the context of CS 1039, Part II, section 2.3(g). Any payments the Plan is unable to 

16
 
re,cover are allowable charges to the FEHBP. As good faith erroneous payments, LII 

does not apply to the claim payment errors identified in this finding. 

The Association states, "When the claims were originalJy submitted to the Operations 

Center, there were coding discrepancies. These payment differences occurred because 

the examiners did not submit the correct infonnation when the claims were initially 

manually processed. The claims were paid in error because Claims Examiners 

entered incorrect fields for Medicare Part B payment infonnation; incorrectly coded 

split admission between two claims and adjusted an original OBRA 90 priced claim 

incorrectly. To reduce these types of pricing errors in the future, the Plan has 

implemented and updated its Policy & Procedure for OBRA '90 claim processing.... 

Also, the FEP Director's Office includes potential OBRA '90 priced claims in its 

periodic System-wide Claims Review to facilitate early identification and recovery of 

OBRA '90 claim payment errors. Completion of these periodic reports assists in the 

timely identification and recovery of OBRA '90 claim payment errors." 

Recommendation 5 

We recommend that the contracting officer disallow $220,139 for claim overcharges 

and verifY that the Plan returns all amounts recovered to the FEHBP. 

Recommendation 6 

We recommend that the contracting officer allow the Plan to charge the FEHBP 

$50,742 if additional payments are made to the providers to correct the underpayment 

errors. 

d. Assistant Surgeon Review $116.348 

The Plan incorrectly paid 146 assistant surgeon claims, resulting in net overcharges of 

$116,348 to the FEHBP. Specifically, the Plan overpaid 133 claims by $127,100 and 

underpaid 13 claims by $10,752. 

As previously cited from CS 1039, costs charged to the FEHBP must be actual, 

allowable, allocable, and reasonable. Iferrors are identified, the Plan is required to 

make a diligent effort to recover the overpayments. Also, the Plan must coordinate 

the payment of benefits with Medicare. 

The following summarizes our review of potential assistant surgeon overpayments. 

DC Service Area 

For the period January 1,2006 through October 31, 2008, we identified 1,170 

assistant surgeon claim groups, totaling $235,547 in potential overpayments, that may 

nol have been paid in accordance with the Plan's assistant surgeon pricing procedures. 

17
 
From this universe, we selected and reviewed a judgmental sample of 84 assistant 

surgeon claim groups, totaling $77,781 in potential overpayments, to detennine if the 

Plan paid these claims properly. Our sample included all assistant surgeon claim 

groups with potential overpayments of $500 or more. The majority of these claim 

groups contained one primary surgeon and one assistant surgeon claim. 

Based on our review, we determined that 40 claims were paid incorrectly, resulting in 

net overcharges of $56,963 to the FEHBP. Specifically, the Plan overpaid 39 claims 

by $57,332 and underpaid 1 claim by $369. 

The claim payment errors resulted from the following: 

•	 The Plan incorrectly paid 29 claims that were subject to the Omnibus Budget 

Reconciliation Act of 1993 (OBRA 93) pricing guidelines, resulting in 

overcharges of $47,822. 

}- Seventeen of the claims were paid in error due to Palmetto (OBRA 93 pricing 

vendor) not recognizing the physician assistant pricing modifier "AS" and 

erroneously calculating the physician assistant fee. These physician assistant 

claims should have been priced according to the Medicare fee schedule (13.6 

percent ofthe primary surgeon fee). Consequently, the Plan overpaid these 

claims, resulting in overcharges of $30,602 to the FEHBP. 

);>	 Twelve of the claims were paid in error due to a Palmetto claims processing 

system error which caused an incorrect calculation of the assistant surgeon fee 

for claims containing assistant surgeon pricing modifiers 80, 81, or 82. These 

assistant surgeon claims should have been priced according to the Medicare fee 

schedule (16 percent of the primary surgeon fee). Consequently, the Plan 

overpaid these claims, resulting in overcharges of $17,220 to the FEHBP. 

•	 The Plan incorrectly paid five assistant surgeon claims, resulting in overcharges of 

$3,901 to the FEHBP. These overcharges were due to the claim system's incorrect 

calculation ofthe assistant surgeon or physician assistant fees, which should have 

been priced at 20 percent of the primary surgeon allowed amount. 

•	 In three instances, the claims processors entered incorrect pricing infonnation, 

resulting in overcharges of$3,787 to the FEHBP. 

•	 In three instances, the claims processors overrode system edits, resulting in net 

overcharges of $1 ,453 to the FEHBP. Specifically, the Plan overpaid two claims 

by $1,822 and underpaid one claim by $369. 

18
 
Maryland Service Area 

For the period January 1, 2006 through October 31, 2008, we identified 2,938 

assistant surgeon claim groups, totaling $300,036 in potential overpayments, that may 

not have been paid in accordance with the Plan's assistant surgeon pricing procedures. 

From this universe, we selected and reviewed a judgmental sample of 68 assistant 

surgeon claim groups, totaling $65,764 in potential overpayments, to determine if the 

Plan paid these claims properly. Our sample included all assistant surgeon claim 

groups with potential overpayments of $500 or more. The majority of these claim 

groups contained one primary surgeon and one assistant surgeon claim. 

Based on our review, we determined that 54 claims were paid incorrectly, resulting in 

net overcharges of $53,501 to the FEHBP. Specifically, the Plan overpaid 51 claims 

by $55,022 and underpaid 3 claims by $1,521. 

The claim payment errors resulted from the following: 

•	 The Plan incorrectly paid 34 assistant surgeon claims, resulting in overcharges of 

$38,068 to the FEHBP. These overcharges were due to the claim system's 

incorrect calculation of the assistant surgeon or physician assistant fees, which 

should have been priced at 20 percent of the primary surgeon allowed amount. 

•	 The Plan incorrectly paid 15 claims that were subject to OBRA 93 pricing 

guidelines, resulting in overcharges of $15,365. 

	 Twelve of the claims were paid in error due to Palmetto not recognizing the 

physician assistant pricing modifier "AS" and erroneously calculating the 

physician assistant fee. These physician assistant claims should have been 

priced according to the Medicare fee schedule (13.6 percent of the primary 

surgeon fee). Consequently, the Plan overpaid these claims, resulting in 

overcharges of $13,170 to the FEHBP. 

	 Three of the claims were paid in error due to a Palmetto claims processing 

system error which caused an incorrect calculation ofthe assistant surgeon fee 

for claims containing assistant surgeon pricing modifiers 80, 81, or 82. These 

assistant surgeon claims should have been priced according to the Medicare 

fee schedule (16 percent ofthe primary surgeon fee). Consequently, the Plan 

overpaid these claims, resulting in overcharges of $2,195 to the FEHBP. 

•	 In one instance, the Plan did not properly coordinate a claim with Medicare, 

resulting in an overcharge of $1,022 to the FEHBP. 

•	 In one instance, the Plan used an incorrect rate to price a claim, resulting in an 

undercharge of $426 to the FEHBP. 

19
 
•	 In three instances, the claims processors entered incorrect pricing information, 

resulting in net undercharges of $528 to the FEHBP. Specifically, the Plan overpaid 

one claim by $567 and underpaid two claims by $1,095. 

Due to the high error rate, we selected for review an additional 340 assistant surgeon 

claim groups with potential overpayments totaling $98,718. Our expanded sample 

included all assistant surgeon claim groups with potential overpayments equal to or 

greater than $200 and less than $500. Based on our review, we identified 52 

additional claim payment errors, resulting in net overcharges of $5,884 to the FEHBP. 

Specifically, the Plan overpaid 43 claims by $14,746 and underpaid 9 claims by 

$8,862. These overcharges were primarily due to errors in the calculation ofthe 

assistant surgeon fee, which should have been priced at either 13.6 percent, 16 

percent, or 20 percent ofthe primary surgeon allowed amount. 

Overseas Claims 

For the period January 1, 2006 through October 31, 2008, we identified no assistant 

surgeon claim groups with potential overpayments. 

Association's Response: 

The Association agrees with this finding. The Association states that the Plan has 

initiated recovery efforts for the confirmed overpayments, and as ofFebruary 1, 2010, 

the Plan had recovered and returned $95,450 ($46,081 for the DC Service Area and 

$49,369 for the Maryland Service Area) to the FEHBP. 

The Association also states, "The overpayments related to the non-OBRA '93 

assistant surgeon claims were the result of a local Plan system issue for both the 

.Maryland and DC Plans. This system issue was identified by the Plan before the audit 

began and corrected in the second Quarter of 2009. The payments related to OBRA 

'93 priced Assistant Surgeon Claims were sent to the Plan as a part of the FEP 

Director's Office System-wide Claims Review Listing." 

Recommendation 7 

We recommend that the contracting officer disallow $127,100 for claim overcharges 

and verify that the Plan returns all amounts recovered to the FEHBP. 

Recommendation 8 

We recommend that the contracting officer allow the Plan to charge the FEHBP 

$10,752 if additional payments are made to the providers to correct the underpayment 

errors. 

20 
Recommendation 9 

We recommend that the contracting officer instruct the Association to ensure that the 

Plan corrected the local claim system issue of not applying the 20 percent 

reimbursement rate when pricing assistant surgeon and/or physician assistant claims. 

e. Debarred Provider Payments $15,564 

The Plan made 205 claim payments, totaling $15,564, to 3 debarred providers from 

January 1,2006 through October 31, 2008. 

Contract CS 1039, Part II, Section 2.7 states that if a provider has been barred from 

participating in the FEHBP under Title 5 ofthe U.S. Code, or the provider's services 

under the Code are excluded, the carrier agrees to withhold payments to that provider. 

OPM periodically provides the FEP Director's Office with a list of debarred providers. 

According to the FEP Administrative Manual, the listing is forwarded to the FEP 

Operations Center. The FEP Operations Center will then provide these listings to the 

local Blue Cross and Blue Shield plans and request updates, such as provider 

identification numbers. Based on the updates received from the local plans, the FEP 

Operations Center updates the debarred provider file on the FEP national claims 

system. 

For the period 2006 through October 31,2008, we identified 44 DC and Maryland 

providers that were debarred. From this universe, we selected and reviewed a 

judgmental sample of32 providers for the purpose of determining if the Plan paid any 

claims to these providers after the debarment dates. Based on our review, we 

determined that the Plan made 205 claim payments, totaling $15,564, to 3 providers 

after their debarment dates. The Administrative Sanctions Branch confinued that 

these three debarred providers were posted on OPM's debarred provider website and 

available to the FEP Operations Center to download and distribute to the BlueCross 

BlueShield plans on June 1, 2006, July 6, 2006, and October 2, 2008. 

The Plan stated that the FEP Operations Center did not provide debarred information 

for one of the providers. Therefore, the Plan did not provide an updated provider file 

to the FEP Operations Center to reflect the debarment status, and the FEP Operations 

Center did not make the necessary system changes to the FEP national claims system 

to recognize this provider as debarred and suspend the claims. Consequently, the Plan 

paid 119 claims, totaling $8,069, to this debarred provider. 

In addition, the Plan stated that the FEP Operations Center provided debarred 

information for two of the providers; however, the Plan did not provide an updated 

provider file to the FEP Operations Center to reflect the debarment status. Therefore, 

the FEP Operations Center did not make the necessary system changes to the FEP 

national claims system to recognize these providers as debarred and suspend the 

21
 
claims. Consequently, the Plan paid 86 claims, totaling $7,495, to these debarred 

providers. 

Association's Response: 

The Association agrees with this finding. The Association states that these payments
 

were good faith erroneous benefit payments and fall within the context of CS 1039,
 

Part II, section 2.3(g). Any payments the Plan is unable to recover are allowable
 

charges to the FEHBP. As good faith erroneous payments, LIl does not apply to the
 

claim payment errors identified in this finding.
 

For the two providers that were not updated on the debarred provider listings generated 

by the FEP Operations Center, the Association states, "As a result, no member 

notification was issued; therefore, the refund recovery effort cannot be initiated for the 

affected claims since the members did not receive the required notification. The Plan 

is currently validating the control changes necessary to prevent the updating of these 

providers on the FEP Claims System with a target completion date of first quarter 

2010." 

For the provider that was omitted in error from the debarred provider listing generated 

by the FEP Operations Center, the Association states, "The Plan updated its provider 

file as of October 2009 with the debarred status for the Provider in question. However, 

no member notification was issued; therefore, the refund recovery effort cannot be 

initiated for the affected claims since the members did not receive the required 

notification that the Provider was debarred as required by OPM." 

The Association also states, "FEP has implemented additional controls at the 

Operations Center for the generation of the Debarred Provider Listings to Plans. 

. Under the enhanced controls, when the listing is received from CMS and updated on 

the FEP System, it cannot be sent to Plans until the Plan's internal audit department 

has validated that all providers have been included on the listings. This control is 

being implemented during the first quarter 2010." 

Recommendation 10 

We recommend that the contracting officer disallow $15,564 for payments made to 

three debarred providers. 

Recommendation 11 

We recommend that the contracting officer verify that corrective actions were 

implemented by the Association to prevent further payments to these or other debarred 

providers. 

22
 
f. fu:.stem Review 

The Plan incorrectly paid five claims, resulting in net undercharges of $52 to the 

FEHBP. Specifically, the Plan overpaid four claims by $1,948 and underpaid one 

claim by $2,000. 

As previously cited from CS 1039, costs charged to the FEHBP must be actual, 

allowable, allocable, and reasonable. If errors are identified, the Plan is required to 

make a diligent effort to recover the overpayments. 

The following summarizes our system review of claims. 

DC Service Area 

For health benefit claims reimbursed during the period January 1,2008 through 

October 31,2008, we identified 6,959,851 claim lines, totaling $706,014,430 in 

payments, using a standard criteria based on our audit experience. From this 

universe, we selected and reviewed a judgmental sample of 151 claims (representing 

1,536 claim lines), totaling $7,730,798 in payments, to determine ifthe Plan 

adjudicated these claims properly? Our review identified one claim payment error, 

resulting in an undercharge of $2,000 to the FEHBP. This error resulted from a 

claims processor incorrectly pricing the procedure code. 

MD Service Area 

For health benefit claims reimbursed during the period January 1,2008 through 

October 31, 2008, we identified 4,836,420 claim lines, totaling $436,108,524 in 

payments, using a standard criteria based on our audit experience. From this 

universe, we selected and reviewed a judgmental sample of 100 claims (representing 

898 claim lines), totaling $5,519,400 in payments, to determine if the Plan 

adjudicated these claims properly (see footnote 3). Based on our review, we 

determined the Plan properly paid these claims. 

Overseas Claims 

For health benefit claims reimbursed during the period January 1,2008 through 

October 31, 2008, we identified 352,748 claim lines, totaling $52,772,528 in 

payments, using a standard criteria based on our audit experience. From this 

universe, we selected and reviewed a judgmental sample of 50 claims (representing 

364 claim lines), totaling $3,065,582 in payments, to determine if the Plan 

adjudicated these claims properly (see footnote 3). Our review identified four claim 

) We selected our sample from an OIG-generated "Place of Service Report" (SAS application) that stratified the 

claims by place ofservice (POS), such as provider's office and payment category, such as $50 to $99.99. We 

judgmcntally determined the number of sample items to select from each POS stratum based on the stratum's total 

claim dollars paid. 

23 
payment errors, resulting in overcharges of$1,948 to the FEHBP. The claim payment 

errors resulted from the following: 

•	 In one instance, the claims processor overrode the system edits when pricing the 

claim, resulting in an overcharge of $1,663 to the FEHBP. 

•	 The Plan did not apply the deductible when pricing two claims, resulting in 

overcharges of $200 to the FEHBP. 

•	 In one instance, the FEP national claims system did not calculate the appropriate 

co-insurance, resulting in an overcharge of$85 to the FEHBP. We found that the 

FEP national claims system did not apply the correct co-insurance amoWlt to 

outpatient facility claims with 2007 or 2008 dates of service, revenue codes 490 or 

499 (ambulatory surgical care), and an alternate provider network status of"PI" 

(Preferred) or "P2" (Member) when the subscriber had standard option coverage 

and had not met the catastrophic maximum amount for the year. 

Because this is a system error, we requested the Plan to identify all claims that 

were potentially affected by this type of error. Since the total amounts paid for the 

identified claims were immaterial, we did not select additional claims to review. 

Also, the Plan stated that this system eITor was corrected in June 2008. 

Association's Response: 

The Association agrees with this finding. The Association states that the Plan has 

initiated recovery efforts for the confirmed overpaYlllents, and as of February 1, 2010, 

the Plan had recovered and returned $1,748 to the FEHBP. The Association also 

states that these payments were good faith erroneous benefit payments and fall within 

the context of CS 1039, Part II, section 2.3(g). Any payments the Plan is unable to 

recover are allowable charges to the FEHBP. As good faith erroneous payments, LII 

does not apply to the claim payment errors identified in this finding. 

In reference to the $2,000 undercharge (DC Service Area), the Association states that 

the claim has been adjusted appropriately to pay the correct amount. 

Recommendation 12 

We recommend that the contracting officer disallow $1,948 for claim overcharges and 

verify that the Plan returns all amounts recovered to the FEHBP. 

Recommendation 13 

We recommend that the contracting officer allow the Plan to charge the FEHBP 

$2,000 if an additional payment is made to the provider to correct the underpayment 

error. 

24
 
2< Miscellaneous Payments and Credits 

a. Provider Audit Vendor Fees $15,249 

The Plan paid commission fees to a vendor for FEP recoveries that were not realized, 

resulting in overcharges of$15,249 to the FEHBP. 

The provider audit services contract, effective November 20,2001, between the Plan 

and AIM HeaIthcare Services, Inc. (vendor) states, "Fees shall be ... for 

overpayments identified and recovered tluough the on-site credit balance review 

process ...." 

As previously cited from CS 1039, costs charged to the FEHBP must be actual, 

allowable, allocable, and reasonable. 

The Plan's vendor audit fees are calculated by applying a predetermined commission 

percentage to the overpayments identified and recovered. Therefore, the vendor 

should only charge the Plan for audits resulting in actual claim recoveries. Ifthere are 

no claim overpayment recoveries, then there should be no charge to the Plan and no 

charge to the FEHBP. During our review ofprovider audit recoveries, we identified 

two audited FEP claims (from the DC Service Area) where the commission 

percentage was applied to the identified overpayments, however, no recovery or only 

a partial recovery occurred. Since there was no recovery or only a partial recovery for 

these two overpayments, the vendor charges of $15,249 are not chargeable to the 

FEHBP. 

Association's Response: 

The Association agrees with this finding. The Association states, "The Plan has 

recovered the vendor overpayment. A Special Plan Invoice (SPI) was submitted on 

February 19,2010. The funds were wired to the BCBSA Joint Operating Account on 

February 18, 20ID." 

Recommendation 14 

We recommend that the contracting officer disallow $15,249 for the provider audit 

vendor overcharges and verify that the Association returned these funds to the 

FEHBP. 

25
 
b. Fraud Recovery Returned Untimely $5,136 

In one instance. the Plan did not timely return a fraud recovery to the FEHBP. As a 

result ofthis finding. the Plan credited the FEHBP $5.136 for LII on this recovery. 

Based on an agreement between aPM and the Association. dated March 26, 1999, 

BlueCross and BlueShield plans have 30 days to return health benefit refunds and 

recoveries to the FEHBP ifreceived after March 31, 1999. 

48 CFR 52.232-17(a) states. "all amounts that become payable by the Contractor ... 

shall bear simple interest from the date due ... The interest rate shall be the interest 

rate established by the Secretary of the Treasury as provided in Section 611 of the 

Contract Disputes Act of 1978 (Public Law 95-563), which is applicable to the period 

in which the amount becomes due, as provided in paragraph (e) of this clause, and 

then at the rate applicable for each six-month period as fixed by the Secretary until the 

amount is paid." 

For the period 2004 through 2008, there were 534 fraud recoveries totaling 

$4,555,776 for the DC and Maryland Service Areas and Overseas claims. From this 

universe, we judgmentally selected a sample of 30 fraud recoveries, totaling 

$3,060,473, for the purpose of determining whether the Plan returned these recoveries 

to the FEHBP in a timely maImer. Our sample included all fraud recoveries with 

recovery amounts of $40,000 or more. 

Based on our review, we determined that the Plan did not timely return one fraud 

recovery (from the Maryland Service Area) to the FEHBP. Specifically, although the 

Plan returned this fraud recovery to the FEHBP letter of credit account (LOCA), the 

.funds were not timely deposited into the FEP investment account. Therefore, we 

calculated that the FEHBP is due $5,136 for LII on this untimely returned fraud 

recovery. 

Association's Response: 

The Association agrees with this finding. The Association states, "The Plan 

submitted a Special Plan Invoice (SPI) to BCBSA for the Lost Investment Income 

(LII) due the FEHBP. The funds were transferred to the Plan's FEP investment 

account on June 25,2009 and adjusted against the LOCA on July 7, 2009." 

Recommendation 15 

Since we verified that the Plan credited the LOCA $5,136 for LII on the untimely 

returned fraud recovery, no further action is required for this questioned amount. 

26
 
B. ADMINISTRATIVE EXPENSES 

1. BluesNet Charges $60,561 

The Plan charged the FEHBP for BluesNet expenses that had already been charged to the 

FEHBP by the FEP Operations Center. As a result, the FEHBP is due $60,561, 

consisting of$56,846 for duplicate BIuesNet charges and $3,715 for LIl on these charges. 

Contract CS 1039, Part III, Section 3.2(b)(I) states, "The Carrier may charge a cost to the 

contract for a contract term if the cost is actual, allowable, allocable, and reasonable." 

48 CFR 52.232-17(a) states, "all amounts that become payable by the Contractor ... shall 

bear simple interest from the date due ... The interest rate shall be the interest rate 

established by the Secretary ofthe Treasury as provided in Section 611 ofthe Contract 

Disputes Act of 1978 (Public Law 95-563), which is applicable to the period in which the 

amount becomes due, as provided in paragraph (e) ofthis clause, and then at the rate 

applicable for each six-month period as fixed by the Secretary until the amount is paid." 

For the period 2004 through 2008, the Plan allocated administrative expenses of 

$393,375,343 to the FEHBP from 1,834 cost centers. From this universe, we selected a 

judgmental sample of 58 cost centers to review, which totaled $153,990,363 in expenses 

allocated to the FEHBP. We selected the cost centers based on high dollar amounts, our 

nomenclature review, and significant dollar amount fluctuations from year to year. We 

reviewed the expenses from these cost centers for allowability, allocability, and 

reasonableness. Based on our review, we identified one cost center that included BluesNet 

charges, totaling $56,846 ($37,677 for the DC Service Area and $19,169 for the Maryland 

Service Area), that had already been charged to the FEHBP by the FEP Operations Center. 

The Association operates a telecommunication system called BluesNet. BluesNet is a 

BlueCross BlueShield system-wide data communications network utility. The network 

uses data communication equipment and telecommunication carrier services to provide the 

physical cOJUlection and communication protocols necessary to exchange information 

among the local BCBS plans. The Association's expenses for maintaining the BluesNet 

system are allocated and charged to the FEP Operations Center through baseline charges. 

From 2002 through 2006, the Association individually charged each Plan for BluesNet 

baseline charges. Effective January 2007, the Association began charging the FEP 

Operations Center for FEHBP's portion of the BluesNet baseline charges. Therefore, the 

BeBS plans may not allocate BluesNet baseline charges to the FEHBP after 2006. 

Through cost center 13133 (DC data hardware), the Plan charged the FEHBP $27,808 

and $29,038 in years 2007 and 2008, respectively, for BluesNet base line charges. 

As a result of this oversight, the Plan inappropriately charged the FEHBP $56,846 for 

BluesNet base line charges that were already charged to the FEHBP by the FEP 

Operations Center. The Plan also determined that the FEHBP is due $3,715 for LII on 

27 
these duplicate charges. Based on our review of the Plan's LIl calculation, we agree with 

the amount determined by the Plan and will not assess additional LH. 

Association's Response: 

The Association agrees with this finding. The Association states, "The Plan submitted 

the necessary Prior Period Adjustments (PPA's) and SPI's for the LIl due the FEHBP to 

BCBSA on September 29,2009. The funds were wired to the BCBSA Joint Operating 

account on September 29,2009." 

Recommendation 16 

We recommend that the contracting officer disallow $56,846 for duplicate BluesNet 

charges and verify that the Association returned these funds to the FEHBP. 

Recommendation 17 

We recommend that the contracting officer verify that the Plan returned $3,715 to the 

FEHBP for LII on the duplicate BluesNet charges. 

C. CASH MANAGEMENT 

Overall, we concluded that the Plan handled FEHBP funds in accordance with Contract CS 

1039 and applicable laws and regulations, except for the findings pertaining to cash 

management noted in the "Miscellaneous Payments and Credits" section. 

D. LOST INVESTMENT INCOME ON AUDIT FINDINGS $1,554 

As a result ofthe audit findings presented in this report, the FEHBP is due LIl of$1,554 from 

January 1, 2008 through December 31, 2009. 

48 CFR 52.232-17(a) states, "all amounts that become payable by the Contractor ... shall 

bear simple interest from the date due ... The interest rate shall be the interest rate 

established by the Secretary of the Treasury as provided in Section 611 of the Contract 

Disputes Act of 1978 (Public Law 95-563), which is applicable to the period in which the 

amount becomes due, as provided in paragraph (e) of this clause, and then at the rate 

applicable for each six-month period as fixed by the Secretary until the amount is paid." 

We computed investment income that would have been earned using the semiannual rates 

specified by the Secretary of the Treasury. Our computations show that the FEHBP is due 

LII of$I,554 from January 1,2008 through December 31, 2009 on questioned costs for 

contract year 2007 (see Schedule C). 

28
 
Association's Response: 

The draft audit report did not include an audit finding for LB. Therefore, the Plan did not 

address this item in its reply. 

Recommendation 18 

We recommend that the contracting officer direct the Plan to credit $1,554 (plus interest 

accruing after December 31, 2009) to the Special Reserve for LB on audit findings. 

29
 
IV. MAJOR CONTRIBUTORS TO THIS REPORT 

Experience-Rated Audits Group 

Auditor 

Auditor 

Auditor 

Lead Auditor 

Auditor 

Auditor 

Auditor 

Chief 

Senior Team Leader 

30
 
SCHEDULE A 

CONTRACT CHARGES 2004 2005 2006 2007 2008 

A. HEALTH BENEFIT CHARGES" 

DC SERVICE AREA: 

PLAN CODES 080/0811580/582 

MISCELLANEOUS PAYMENTS 

TOTAL I 

$723,239,877 

4601943 

$727,841,820 

$779,156,681 

6559,136 

$785 715.817 

$808,539,914 

3660507 

$812,200 421 

$881,811,033 

5187558 

$886998591 

$950,884,620 

7841131 

$958725751 

MARYLAND SERVICE AREA: 

PLAN CODES 190/690 

MISCELLANEOUS PAYMENTS 

TOTAL I 

388,749,424 

2742.835 

$391 492.259 

434,921,166 

4096714 

$439017880 

467,856,613 

4195539 

$472.052 152 

523,890,148 

3741 464 

$527631612 

572,976,865 

5311391 

$578 288.256 

OVERSEAS CLAIMS: 

PLAN CODE 082 

MISCELLANEOUS PAYMENTS 

TOTAL I 

35,003.937 

0 

$35.003.937 

40,389,347 

0 

$40,389347 

44,181,062 

0.656) 

$44179.406 

52,104,727 

0 

$52104727 

58,486,709 

$58486.709 

TOTAL HEALTH BENEFIT CHARGES I $1 154338016 $I 265123.044 $1.328431.979 $1 466 734 930 $1 595 500 116 

B. ADMINISTRATlVE EXPENSE CHARGES 

PLAN CODES 080/190'''' 

PRIOR PERIOD ADJUSTMENTS 

BUDGET SETTLEMENT REDUCTION 

BUDGET SETTLEMENT REVISION 

$77,280,430 

(96.125) 

0 

0 

$76,912,687 

(310,308) 

(1,960,193) 

(817,406) 

$81,196,640 

9,805,212 

(1,557,054) 

3,067,585 

$85,345,703 

0 

0 

0 

$83,697,824 

TOTAL ADMINISTRATIVE EXPENSE CHARGES I $77,184305 $73824.780 $92512 383 $85.345703 $83453411 

TOTAL CONTRACT CHARGES I $1 231,522321 $1 338947,824 $1 420.944 362 $1552.080633 $1 678,954 127 

V. SCHEDULES 

CAREFIRST BLUECROSS BLUESHIELD
 

WASHINGTON, D.C. AND MARYLAND SERVICE AREAS AND OVERSEAS CLAIMS
 

OWINGS MILLS, MARYLAND
 

CONTRACT CHARGES 

" We reviewed claim payments from January 1,2006 through October 31,2008 (through September 30, 2009 for expanded claim reviews).
 

** Plan code 080 includes administrative expense charges for the DC Service Area and Overseas Claims; and Plan code 190 only includes the Maryland Service Area.
 

TOTAL 

$4,143,632,125 

27850275 

$4 171 482 400 • 

2,388,394,216 

20.087943 

$2 408,482 159 

230,165,782 

0 (1656 

$230,164 126 :. 

$6810.128685 

$404,433,284 

(244,413) 9,154,366 

0 (3,517,247) 

0 2,250,179 

$412 320 582 II 

$7 222 449 267 ill 

II 

I 
SCHEDULED 

,CAREFIRST BLUECROSS BLUESHIELD
 

WASHINGTON, D.C.AND MARYLAND SERVICE AREAS AND OVERSEAS CLAIMS
 

OWINGS MILLS, MARYLAND
 

QUESTIONED CHARGES 

AUDIT FINDINGS 2004 2005 2006 2007 

A. HEALTH BENEFIT CHARGES 

1. Claim Payments 

a. Amounts Paid Greater than Covered Charges $0 SO $38,395 

b. Inpatient Facility Payments - Duplicate or Overlapping Dates of Service 0 0 39,618 

c. Omnibus Budget Reconciliation Act of 1990 Review 0 73,596 

d. Assistant Surgeon Review 0 

°

0 19,083 

e. Debarred Provider Payments 0 0 8,706 

f. System Review 0 0 0 

Total Claim Payments I $0 $0 5179,398 Sl94,837 

2. Miscellaneous Payments and Credits 

a. Provider Audit Vendor Fees* SO $0 $0 

b. Fraud Recovery Returned Untimely** 0 0 0 

Total Miscellaneous Payments and Credits I $0 SO SO 

TOTAL HEALTH BENEFIT CHARGES I SO $0 5179,398 5213 493 

B. ADMINISTRATIVE EXPENSES 

1. BluesNet Charges*** SO SO SO 

TOTAL ADMINISTRATIVE EXPENSES I SO SO SO 

C. CASH MANAGEMENT I SO SO $0 

D. LOST INVESTMENT INCOME ON AUDIT FINDINGS SO SO SO 

TOTAL QUESTIONED CHARGES I SO SO $179.398 5241,301 

* This audit finding is subject to lost investment income (LIl). 

** No additional LII is applicable for this audit finding. 

*** This audit finding also includes LII of53,715. 

2008 2009 TOTAL 

532,453 $612,649 $1,160 $684,657 

64,698 141,558 51,861 297,735 

49,747 46,054 0 169,397 

44,292 52,973 0 116,348 

3,647 2,999 212 15,564 

0 (52) 0 (52) 

$856,181 $53,233 $1,283,649 

515,249 SO SO $15,249 

3,407 1,729 0 5,136 

518,656 51,729 $0 $20,385 

5857.910 553.233 51,304034 

527,808 530,430 52,323 560,561 

$27808 530.430 $2.323 S60561 

SO SO $0 SO 

$0 $753 $801 SI,554 

$889093 $56.357 $1.366149 
A. 

B. 

CAREFlRST BLUECROSS BLUESHIELD 

WASHINGTON, D.C. AND MARYLAND SERVICE AREAS AND OVERSEAS CLAIMS 

OWINGS MILLS, MARYLAND 

SCHEDULEC 

LOST INVESTMENT INCOME CALCULAnON 

2004 2005 2006 2007 2008 2009 TOTAL 

QUESTIONED CHARGES (Subject to Lost Investment Income) 

Provider Audit Vendor Fees I SO SO SO SIS 249 SO SO SIS 249 

LOST INVESTMENT INCOME CALCULAnON 

a. Prior Years Total Questioned (Principal) 

b. Cumulative Total 

c. Total 

SO 

Q 

SO 

SO 

Q 

SO 

SO 

!! 

SO 

SO 

!! 

SO 

S15,249 

!! 

S15,249 

SO 

15,249 

$1"5,249 

d. Treasury Rate: January I - June 30 4.000% 4.250% 5.125% 5.250% 4.750% 5.625% 

e. Interest (d * c) SO SO SO SO S362 $429 S791 

f. Treasury Rate: July 1 • December 31 4.500% 4.500% 5.750% 5.750% 5.125% 4.875% 

g. Interest (f * c) SO $0 SO SO $391 S372 5763 

Total Interest By Year (e +g) I SO SO SO SO 5753 $801 S1554 
APPENDIX 

BlueCros8 BlueSWeld 

Association 

An As.sodalion ofIndependent 

Blue Cross and Blue ShIeld Plans February 19, 2010 

Group Chief Federal Employee Program 

Experience-Rated Audits Group 1310 G Street, N.W. 

Office of the Inspector General	 Washington, D.C. 20005 

2.02.942.1000 U.S. Office of Personnel Management Fax 202.942.1125 

1900 E Street, Room 6400 

Washington, DC 20415-1100 

Reference:	 OPM DRAFT AUDIT REPORT 

Carefirst Blue Cross Blue Shield 

Audit Report Number 1A-1 0-85-09-023 

(Dated December 3. 2009 and Received December 4. 2009) 

Dear 

This is our response to the above referenced U.S. Office of Personnel Management 

(OPM) Draft Audit Report covering the Federal Employees' Health Benefits Program 

(FEHBP) concerning CareFirst BlueCross BlueShield. Our comments concerning the 

findings in the report are as follows: 

General Plan Comment: 

OPM questioned a total of $1,585,661 as incorrect charges to the FEHBP. These 

charges relate to (1) health benefit payments covering 2006-09, and (2) miscellaneous 

payments and administrative charges covering 2004;..08. These questioned charges 

equate to 0.0113% of the total claims payments/administrative charges during the audit 

period. .	 . 

A. HEALTH BENEFIT CHARGES 

1) Claim Payment Errors 

a) Amount Paid Greater than Covered Charges 

DC Service Area 

The Plan contests $71,321 of the questioned amount but does not contest $605,925. 

There were two claims that comprised the total questioned dollar amount-. The Plan 

contests a portion of the questioned overpayment amount for the following reasons: 

(1) on the first claim, the OIG auditors questioned billed charges ($563,760) instead 

of the Plan's DRG allowance ($512,739) for this admission. This resulted in a 

variance of $71,041. (2) The second incorrect dollar amount was cited as $83,075 

instead of the Plan's DRG allowance. This resulted in a variance of $280. The total 

variance equals $71,321 ($71,041 + $280). 
Group Chief 

February 19, 2010 

Page 2 

The confirmed overpayment of $605,925 has been adjusted and credited to the
 

Program.
 

The overpayments were the results of Claims Examiner errors and were used as 

training tools in the recent re-fresher training session. In additic;m, the Plan has a quality 

review area that reviews claims and identifies payment errors. The identified payment 

errors are then discussed with the management in the Operations Areas. The objective 

is to determine whether individual examiners may need further training or if there is a 

pattern of inconsistency in the adjudication process for multiple Claim Examiners. The 

identified errors are used to determine the focus of the training for the group. 

In addition, the FEP Director's Office sends the System-wide Claims Review Listing to 

the Plan which also includes an Amount Paid Greater Than Covered Charges Listing. 

The Plan in compliance with the "FEP Overpayment Recovery Action Plan," reviews 

the listing and returns the results of its review to the FEP Director's Office as required. 

Where appropriate, refunds are initiated. However, there appe~rs to be a difference in 

the claim selection criteria used to select these claims for OPM and the criteria used to 

generate the System-wide Claims Listing. We will re-evaluate our selection criteria to 

determine if any changes are required to bring it more in line with the OPM claim 

selection criteria. 

Maryland Service Area 

The Plan does not contest $25,841 from the original sample and $10,342 from the 

expanded Medicare Claims Review. The Plan has initiated Refund recovery efforts 

where appropriate for the confirmed overpayments. As of February 1, 2010, the Plan 

has recovered and returned $14,000 to the Program from the original sample and 

$1,386 from the expanded claims review. 

Overseas Claims 

The Plan does not contest this finding. The Plan has initiated Refund recovery efforts 

where appropriate for the confirmed overpayments. The overpayments were the result 

of Claims Examiner error and were used as training tools in the recent re-fresher 

training session. In addition, the Plan has a quality review area that reviews claims and 

identifies payment errors. The identified payment errors are then discussed with the 

management in the Operations Areas. The objective is to determine whether individual 

examiners may need further training or if there is a pattern of inconsistency in the 

adjudication process for multiple Claims Examiners. The identified errors are used to 

determine the focus of the training for the group. 
Group Chief 

February 19, 2010 

Page 3 

In addition, the FEP Director's Office sends the System-wide Claims Review Listing to 

the Plan which also includes an Amount Paid Greater Than Covered Charges Listing. 

The Plan reviews and returns the results of its review to the FEP Director's Office as 

required. Where appropriate, refunds are initiated. However, there appears to be a 

difference in the claim selection criteria used to select these claims for OPM and the 

selection criteria used to generate the FEP Director's Office System-wide Claims 

Review Listing. We will re-evaluate our selection criteria to determine if any changes 

are required to bring it more in line with the OPM claim selection criteria. 

Accordingly, to the extent that errors did occur, the payments are good faith.erroneous 

benefits payments and fall within the context of CS 1039, Section 2.3(g). Any benefit 

payments the Plan is unable to recover are allowable charges to the Program. In 

addition, as good faith payments, the Plan continues to initiate recovery in a timely 

manner for confirmed overpayments. Because these are good faith erroneous 

payments, they are not subject to lost investment income. 

1a All Service Areas - Expanded Review of 2006 Non-Par Provider 

Maryland Service Area 

The Plan contests $31,314 of the questioned amount as one claim was for an 

inpatient admission that was coded incorrectly ($31,314). The necessary 

documentation to support the Plan's position was provided to the OPM auditors 

with the overlapping Spreadsheet on February 9,2010. 

The Plan does not contest $3,090. The Plan has initiated and recovered the 

confirmed overpayment. As of February 1, 2010, the funds have been returned to 

the Program 

Overseas Claims 

The Plan does not contest this finding. The Plan has initiated refund rec()very 

efforts where appropriate for the confirmed overpayment. As of 

February 1, 2010, the Plan has recovered and returned $2,772 to the Program. 

DC Service Area 

The Plan contests one claim totaling $2,492 because this is a claim for service in 

the Maryland designated service area. It was also included in the Maryland listing. 

However, the Plan does not contest that 12 claims totaling $2,772 for the DC 

service area were overpaid. The Plan has initiated recovery efforts for the 

overpayments. As of February 1, 2010, $1,615 has been recovered and returned 

to the Program. 
Group Chief 

February 19, 2010 

Page 4 

b) Duplicate Claim Payment'Overlapping Dates of Service $421,315 

Overseas Claims 

The Plan contests $285,024 of the questioned amount based on the fact that 

the services were for different patients or the dates of services were incorrectly 

coded. However, the Plan does not contest that $136,291 was overpaid. The 

Plan has initiated refund recovery efforts where appropriate for the confirmed 

overpayments. As of February 1, 2010, the Plan had recovered and returned 

$4,556 to the Program. 

Expanded Listings 

DC Service Area $1.964.223 

The Plan contests $1,882,200 of the questioned amount based on the fact that 

these services were for different patients or were coding errors. The necessary 

documentation to support the Plan's position was provided to the aPM auditors 

with the overlapping Spreadsheet on February 9,2010. The Plan does not 

contest $82,023 that may have been overpaid. The Plan has initiated refund 

recovery efforts where appropriate for the confirmed overpayments. As of 

February 1, 2010. the Plan had recovered and returned $22,040 to the 

Program. 

Maryland Service Area $456,979 

The Plan contests $413,453 of the questioned amount based on the fact that 

these services were for different patients or were coded incorrectly. The Plan 

does not contest $31,985. The necessary documentation to support the Plan's 

position was prOVided to the aPM auditors with the overlapping Spreadsheet 

on February 9,2010. . 

The Plan has initiated Refund recovery efforts where appropriate for the 

confirmed overpayments. As of February 1, 2010, the Plan had recovered and 

returned $31,985 to the Program. The Plan is still reviewing the remaining 

questioned amount of $11,541 to determine whether the claims were paid 

correctly. This review should be completed by February 16,2010 and will be 

submitted at that time. 

The FEP Claims System includes an edit that is designed to defer inpatient 

claims with overlapping dates of services. However, a review of this issue 

indicates that this edit only generates a deferral if the claims are from the same 

provider. As a result of this finding, the FEP Director's Office is modifying this 

edit to defer all inpatient claims with overlapping dates of service regardless of 
Group Chief 

whether the Provider is the same or not. We expect this system enhancement 

to be implemented later in 2010. 

In addition, the Plan has included the claims that were incorrectly coded as part 

of the training program for the Claims Examiners. Lastly, the Plan will provide 

additional training to all Claims Examiners by the second quarter of 2010 with 

an emphasis on the importance of coding claims correctly. The FEP Director's 

Office will also add these claim types to its System-wide claims listings that are 

sent to all Plans. . 

Accordingly, to the extent that errors did occur, the payments are good faith 

erroneous benefits payments and fall within the context of 

CS 1039, Section 2.3(g). Any benefit payments the Plan is unable to recover are 

allowable charges to the Program. In addition, as good faith payments, the Plan 

continues to initiate recovery in a timely manner for confirmed overpayments. 

Because these are good faith erroneous payments, they are not subject to lost 

investment income. 

c) Omnibus Budget Reconciliation Act of 1990 Review $169.397 

DC Service Area 

The Plan does not contest this finding and refund recovery efforts have been 

initiated where appropriate for confirmed overpayments. As of February 1, 

2010, the Plan had recovered and returned $86,617 to the Program. 

When the claims were originally submitted to the Operations Center, there were 

coding discrepancies. These payment differences occurred because the 

examiners did not submit the correct information when the claims were initially 

manually processed. The claims were paid in error because Claims Examiners 

entered incorrect fields for Medicare Part B payment information; incorrectly 

coded split admission between two claims and adjusted an original OBRA '90 

priced claim incorrectly. To reduce these types of pricing errors in the future, 

the Plan has implemented and updated its Policy & Procedure for OBRA '90 

claim processing. Request for refunds have been initiated to recover payment 

errors and any amounts recovered will be returned to the Program. Also, the 

FEP Director's Office includes potential OBRA '90 priced claims in its periodic 

. System-wide Claims Review to facilitate early identification and recovery of 

OBRA '90 claim payment errors. Completion of these periodic reports assists 

in the timely identification and recovery of OBRA '90 claim payment errors. 

Accordingly, to the extent that errors did occur, the payments are good faith 

erroneous benefits payments and fall within the context of 

CS 1039, Section 2.3(9). Any benefit payments the Plan is unable to recover 

are allowable charges to the Program. In addition, as good faith payments, the 
Group Chief 

February 19,2010 

Page 6 

Plan continues to initiate recovery in a timely manner for confirmed . 

overpayments. Because these are good faith erroneous payments, they are 

not subject to lost investment income. 

d) Assistant Surgeon Review $116,926 

DC Service Area 

The Plan does not contest this finding. Refund recovery efforts have been 

initiated where appropriate for the confirmed overpayments. As of 

February 1, 2010, the Plan had recovered and returned $46,081 to the 

Program. 

MaryJand Service Area 

The Plan contests $578 based on the fact that a different claim was adjusted. 

The spreadsheet to support the Plan's position is included as Attachment I. 

However, the Plan does not contest $59,385. Refund recovery efforts have 

been initiated where appropriate for the confirmed overpayments. As of 

February 1,2010, the Plan had recovered and returned $49,369 to the 

Program. 

The overpayments related to the non-OBRA '93 Assistant Surgeon claims were 

the result of a local Plan system issue for both the Maryland and DC Plans. 

This system issue was identified by the Plan before the audit began and 

corrected in the second quarter of 2009. The payments related to OBRA '93 

priced Assistant Surgeon claims were sent to the Plan as a part of the FEP 

Director's Office System-wide Claims Review Listing. Refund recovery efforts 

have been initiated where appropriate for the confirmed overpayments. 

e) Debarred Provider Payments $15,564 

DC SelVice Area 

The Plan does not contest this finding. The Plan has updated the Provider 

Files with the debarred status of the two providers for which the incorrect 

payments were made. 

Upon investigation, it was determined that the two debar.red providers were not 

updated on the Debarred Provider Listing generated by the Operations Center. 

As a result, no member notification was issued; therefore, the refund recovery 

effort cannot be initiated for the affected claims since the members did not 

receive the required notification. The Plan is currently validating the control 

changes necessary to prevent the updating of these providers on the FEP 

Claims System with a target completion date of first quarter 2010. 
Group Chief 

February 19, 2010 

Page? 

Maryland Service Area 

The Plan does not contest this finding. The Provider in question for this finding 

was omitted in error from the Debarred Provider Listing generated by·the 

FEP Operations Center. The Plan updated its provider file as of October 2009 

with the debarred status for the Provider in question. However, no member 

notification was issued; therefore, the refund recovery effort cannot be initiated 

for the affected claims since the members did not receive the required 

notification that the Provider was debarred as required by OPM. 

FEP has implemented additional controls at the Operations Center for the 

generation of the Debarred Provider Listings to Plans. Under the enhanced 

controls, when the listing is received from eMS and updated on the FEP 

System, it cannot be sent to Plans until the Plan's internal audit department has 

validated that all proViders have been included on the listings. This control is 

being implemented during the first quarter 2010. 

Accordingly, to the extent that errors did occur, the payments are good faith 

erroneous benefits payments and fall within the context of 

CS 1039, Section 2.3(g). Any benefit payments the Plan is unable to.recover are 

allowable charges to the Program. In addition, as good faith payments, the Plan 

continues to initiate recovery in a timely manner for confirmed overpayments. 

Because these are good faith erroneous payments, they are not subject to lost 

investment income. 

f) System Review 

The Plan does not contest this finding which is a net of an Overseas claim and 

a DC Plan claim. 

Overseas Claims 

The Plan has initiated recovery efforts for the confirmed overpayments. As of 

February 1,2010, the Plan had recovered and returned $1,748 of the $1,948 

questioned amount to the Program 

DC Service Area 

The Plan does not contest the $2,000 undercharge for this finding. This claim 

has been adjusted appropriately to pay the correct amount. The errors were 

the result of the Claims Examiners incorrectly coding the claims. The Plan has 

provided additional training to Claims Examiners in an effort to reduce future 

errors. 
Group Chief 

February 19, 2010 

Page 8 

Accordingly, to the extent that errors did occur, for findings 1a - 1f, the payments 

are good faith erroneous benefit payments and fall within the context of 

CS 1039, Section 2.3(g). Any benefit payments the Plan is unable to recover are 

allowable charges to the Program. In addition, as good faith payments, the Plan 

continues to initiate recovery in a timely manner for confirmed overpayments. 

Because these are good faith erroneous payments, they are not subject to lost 

investment income. 

Accordingly, to the extent that errors did occur, the payments are good faith 

erroneous benefits payments and fall within the context of CS 1039, Section 2.3(g). 

Any benefit payments the Plan is unable to recover are allowable charges to the 

Program. In addition, as good faith payments, the Plan continues to initiate 

recovery in a timely manner for confirmed overpayments. Because these are good 

faith erroneous payments, they are not subject to lost investment income. 

2) Miscellaneous Payments and Credits 

a) Provider Audit Vendor Fees $15.249 

The Plan does not contest this finding. The Plan has recovered the vendor 

overpayment. A Special Plan Invoice (SPI) was submitted on February 19, 

2010. The funds were wired to the SCBSA Joint Operating Account on 

February 18, 2010. 

b) Fraud Recovery Returned Untimely $5.136 

The Plan does not contest this finding. The Plan submitted a Special Plan 

Invoice (SPI) to BCBSA for the Lost Investment Income (L1I) due the FEHBP. 

The funds were transferred to the Plan's FEP investment account on June 25, 

2009 and adjusted against the LOCA on July 7, 2009. The documentation that 

supports the transfer of the funds is included as Attachment II. 

8. ADMINISTRATIVE EXPENSES 

1) BluesNet Charges $56.846 

The Plan does not contest this finding. The Plan submitted the necessary Prior 

Period Adjustments (PPA's) and SPI's for the LIt due the FEHBP to BCSSA on 

September 29, 2009. The funds were wired to the SeSSA Joint Operating account 

on September 29, 2009. The supporting documentation relating to this finding is 

included as Attachment III. 
Group Chief 

We appreciate the opportunity to provide our response to this Draft Audit Report and 

request that our comments be included in their entirety as an amendment to the Final 

Attachments 

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