U.S. OFFICE OF PERSONNEL MANAGEMENT 

OFFICE OF THE INSPECTOR GENERAL 

OFFICE OF AUDITS 

Final Audit Report

Subject: 

SUPPLEMENTAL REPORT ON THE AUDIT OF 

GLOBAL NON-COVERED AMBULANCE CLAIMS 

FOR BLUECROSS AND BLUESHIELD PLANS 

Report No. 1A-99-00-13-046 

 Date: 

--CAUTION--

This audit report has been distributed to Federal officials who are responsible for the administration of the audited program. This audit 

report may contain proprietary data which is protected by Federal law (18 U.S.C. 1905). Therefore, while this audit report is available 

under the Freedom of Information Act and made available to the public on the OIG webpage, caution needs to be exercised before 

releasing the report to the general public as it may contain proprietary information that was redacted from the publicly distributed copy. 
Federal Employees Health Benefits Program

Service Benefit Plan Contract CS 1039

BlueCross BlueShield Association

Plan Code 10

Global Audit of Non-Covered Ambulance Claims

BlueCross and BlueShield Plans

REPORT NO. 1A-99-00-13-046 DATE: ______________ 

AUDIT REPORT 

 

Michael R. Esser 

Assistant Inspector General 

 for Audits 

--CAUTION--

This audit report has been distributed to Federal officials who are responsible for the administration of the audited program. This audit 

report may contain proprietary data that is protected by Federal law (18 U.S.C. 1905). Therefore, while this audit report is available 

under the Freedom of Information Act and made available to the public on the OIG webpage, caution needs to be exercised before 

releasing the report to the general public as it may contain proprietary information that was redacted from the publicly distributed copy.
i 

EXECUTIVE SUMMARY 

Federal Employees Health Benefits Program

Service Benefit Plan Contract CS 1039

BlueCross BlueShield Association

Plan Code 10

Global Audit of Non-Covered Ambulance Claims

BlueCross and BlueShield Plans

REPORT NO. 1A-99-00-13-046 DATE: ______________ 

This supplemental final report on the Federal Employees Health Benefits Program (FEHBP) 

operations at all BlueCross and BlueShield (BCBS) plans questions $1,423,823 in health benefit 

charges. The BlueCross BlueShield Association (Association) and/or BCBS plans agreed with 

$466,670 and disagreed with $957,153 of the questioned charges. 

The audit report covers health benefit payments from June 1, 2011 through December 31, 2012

as reported on the plans’ Annual Accounting Statements, and supplements our fiscal year 2012 

Global Coordination of Benefits Audit (Report No. 1A-99-00-12-029) where we identified issues 

related to the processing of claims for ambulance services. Specifically, we requested the 

Association to identify all BCBS claims potentially containing non-covered ambulance services 

during the reporting period. We selected for review all 11,834 claims (representing 27,266 claim 

lines), totaling $2,953,809 in health benefit charges to the FEHBP, that the Association identified 

as potentially containing non-covered ambulance services. Based on our review of this sample, 

we determined that BCBS plans incorrectly paid 7,548 claims (representing 15,794 claim lines), 

resulting in $1,423,823 in overcharges to the FEHBP. 
i

CONTENTS 

PAGE 

EXECUTIVE SUMMARY .............................................................................................. i 

 I. INTRODUCTION AND BACKGROUND .....................................................................1 

 II. OBJECTIVE, SCOPE, AND METHODOLOGY ............................................................3 

III. AUDIT FINDING AND RECOMMENDATIONS .........................................................5 

 Non-Covered Ambulance Services ..........................................................................5 

IV. MAJOR CONTRIBUTORS TO THIS REPORT .............................................................9 

 V. SCHEDULES 

 A. SUMMARY OF SELECTIONS BY PLAN 

 B. SUMMARY OF QUESTIONED CHARGES BY PLAN 

 APPENDIX: BlueCross BlueShield Association’s October 1, 2013 reply to the draft 

 audit report, issued June 21, 2013. 
1

I. INTRODUCTION AND BACKGROUND

INTRODUCTION 

This supplemental final audit report details the findings, conclusions, and recommendations 

resulting from our limited scope audit of the Federal Employees Health Benefits Program 

(FEHBP) operations at all BlueCross and BlueShield (BCBS) plans. 

The audit was performed by the Office of Personnel Management’s (OPM) Office of the Inspector 

General (OIG), 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 Healthcare and Insurance 

Office has overall responsibility for administration of the FEHBP. The provisions of the FEHB 

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

890 of the Code of Federal Regulations (CFR). Health insurance coverage is made available 

through contracts with various health insurance carriers. 

The BlueCross BlueShield Association (Association), on behalf of participating BCBS 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 BCBS plans throughout the United States to process the health benefit claims 

of its federal subscribers. There are 64 local BCBS plans participating in the FEHBP. 

The Association has established a Federal Employee Program (FEP1) 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 

BlueCross BlueShield plans, and OPM. 

The Association has also established an FEP Operations Center. The activities of the FEP 

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

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

plans, verifying subscriber eligibility, approving or disapproving the reimbursement of local plan 

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

FEHBP claims, and accounting for all program funds. 

Compliance with laws and regulations applicable to the FEHBP is the responsibility of the 

Association and plan management. Also, management of each BCBS plan is responsible for 

establishing and maintaining a system of internal controls. 

 

1

 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. 
2

This is our first global audit of non-covered ambulance claims for the BCBS plans. Our sample 

selections, instructions, and preliminary audit results were presented in detail in a formal 

information request, dated April 1, 2013, and discussed in detail with the Association and BCBS 

plan officials during the entrance conference on June 4, 2013. The Association’s October 1, 

2013 comments offered in response to our draft report, dated June 21, 2013, were considered in 

preparing our final report and are included as the Appendix to this report. Also, additional 

documentation provided by the Association and BCBS plans on various dates through 

February 27, 2014 was considered in preparing our final report. 

 
3

II. OBJECTIVE, SCOPE, AND METHODOLOGY

OBJECTIVE 

The objectives of our audit were to determine whether the BCBS plans charged costs to the 

FEHBP and provided services to FEHBP members in accordance with the terms of the contract. 

Specifically, our objectives were to determine whether the plans complied with contract 

provisions related to claims containing non-covered ambulance services. 

SCOPE 

We conducted our limited scope performance audit in accordance with generally accepted 

government auditing standards. Those standards require that we plan and perform the audit to 

obtain sufficient and appropriate evidence to provide a reasonable basis for our findings and 

conclusions based on our audit objective. We believe that the evidence obtained provides a 

reasonable basis for our findings and conclusions. 

The audit covered health benefit payments from June 1, 2011 through December 31, 2012 as 

reported on the plans’ Annual Accounting Statements. The scope of this audit was limited to the 

review of paid claims that potentially contained non-covered ambulance services related to an 

issue we identified during our fiscal year 2012 global coordination of benefits (COB) audit 

(Report No. 1A-99-00-12-029). We issued a formal information request to the Association on 

December 18, 2012, instructing the FEP Operations Center to identify all paid claims that 

potentially contained non-covered ambulance services during the period of June 1, 2011 through 

December 31, 2012. On April 25, 2013, the Association informed us that 11,834 claims, totaling 

$2,953,809 in charges to the FEHBP, potentially contained non-covered ambulance services. 

We selected for review all 11,834 claims (representing 27,266 claim lines). 

We did not consider each BCBS plan’s internal control structure in planning and conducting our 

auditing procedures. Our audit approach consisted mainly of substantive tests of transactions and 

not tests of controls. Therefore, we do not express an opinion on each BCBS plan’s system of 

internal controls taken as a whole. 

We also conducted tests to determine whether the BCBS plans had complied with the contract, 

laws, and regulations governing the FEHBP as they relate to non-covered ambulance claims. 

The results of our tests indicate that, with respect to claim payments that contained non-covered 

ambulance services, the BCBS plans did not fully comply with the provisions of the contract. 

Exceptions noted are explained 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 BCBS plans 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 Operations Center and the BCBS plans. The BCBS claims data is provided to us on a 

monthly basis by the FEP Operations Center and is uploaded into our internal data warehouse. 

Through audits and a reconciliation process, we have verified the reliability of the claims data in 
4

our data warehouse. However, due to time constraints, we did not verify the reliability of the 

data generated by the FEP Operations Center, which was used to identify the universe of claims 

within this review. 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 performed at our offices in Washington, D.C.; Cranberry Township, Pennsylvania; 

and Jacksonville, Florida from June 2013 through February 2014. 

METHODOLOGY

To test each BCBS plan’s compliance with the FEHBP health benefit provisions, we selected for

review all 11,834 non-covered ambulance claims paid during the period of June 1, 2011 through 

December 31, 2012 that were potentially not priced in accordance with the Service Benefit Plan 

brochure. See Schedule A for a summary of the selections of potentially non-covered ambulance 

claims by BCBS plan.

The sample selections were submitted to each BCBS plan for their review and response. We then 

conducted a limited review of the plans’ “paid incorrectly” responses and an expanded review of 

the plans’ “paid correctly” responses. Specifically, we verified the supporting documentation, the 

accuracy and completeness of the plans’ responses, determined if the claims were paid correctly, 

and/or calculated the appropriate questioned amounts for the claim payment errors. Additionally, 

we reviewed the status of corrective actions that have been implemented by the Association, FEP 

Operations Center and/or the BCBS plans. We did not project the sample results to the universe of 

claims potentially containing non-covered ambulance services. 

The determination of the questioned amount is based on the FEHBP contract, the 2011 and 2012 

Service Benefit Plan brochures, and the Association’s FEP Administrative Manual. 
5

III. AUDIT FINDING AND RECOMMENDATIONS 

Non-Covered Ambulance Services $1,423,823 

During our FY 2012 global COB audit, we determined the FEP Direct system (which processes 

and approves all FEP claim payments) and/or BCBS plan local systems were incorrectly 

processing claims containing non-covered ambulance services. Based on our expanded review 

of this error, we determined that the BCBS plans incorrectly paid an additional 7,548 claims 

(representing 15,794 claim lines), resulting in net overcharges of $1,423,823 to the FEHBP. 2

The 2012 BCBS Service Benefit Plan brochure states that ambulance transport services are 

covered under the following circumstances: “when medically appropriate and related to medical 

emergency or accidental injury; or associated with inpatient hospital care or covered hospice.” 

Additionally, non-covered services are defined as, “ambulance and any other modes of 

transportation to or from services including but not limited to physician appointments, dialysis, 

or diagnostic tests not associated with covered inpatient hospital care.”

Contract CS 1039, Part III, section 3.2 (b)(1) 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, “If the 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 . . . . The recovery of any overpayment must be treated as an erroneous 

benefit payment, overpayment, or duplicate payment . . . . regardless of any time period 

limitations in the written agreement with the provider.”

While reviewing the claims for the 2012 global COB audit, we identified a system error in the 

FEP Direct claims processing system that allows payment for non-covered ambulance services as 

defined by the Service Benefit Plan brochure. According to the Association, this system error 

was identified in May 2011, and corrective actions to enhance FEP Direct to defer claims 

containing non-covered ambulance services were implemented on April 1, 2012. Although 

corrective actions were implemented to fix the FEP Direct system, the Association did not 

instruct the BCBS plans to identify, review and/or adjust the claims that were potentially affected 

by this error, or to initiate recoveries for the actual overpayments until after the start of our FY 

2012 global COB audit. 

On December 18, 2012, we issued a formal information request to the Association instructing the 

FEP Operations Center to identify all claims paid during the period of June 1, 2011 through 

December 31, 2012 that potentially contained non-covered ambulance services. Specifically, we 

requested the FEP Operations Center to identify all paid claims containing procedure codes 

A0021, A0080, A0090, A0100, A0110, A0120, A0130, A0140, A0160, A0170, A0180, A0190, A0200, 

A0210, A0420, A0426, or A0428 that did not meet the Service Benefit Plan brochure’s criteria for 

covered ambulance services. On April 25, 2013, the Association informed us that 11,834 claims 

(representing 27,266 claim lines), totaling $2,953,809 in charges to the FEHBP, potentially 

contained non-covered ambulance services. Due to the possible significant impact to the 

 

2

 During our 2012 global COB audit, we questioned 558 claim lines, totaling $221,439 in overcharges to the 

FEHBP. These overcharges are not included in the questioned costs of this supplemental final report. 
6

FEHBP, we expanded our review and requested each BCBS plan to identify and/or review 

claims that were potentially processed and paid incorrectly. We submitted these additional 

11,834 claims for their review and response. 

Based on our expanded review, we determined that 62 of the 64 BCBS plans incorrectly paid an 

additional 15,794 claim lines, totaling $1,423,823 in overcharges to the FEHBP (See Schedule B 

for a summary of questioned charges by BCBS plan).

Our audit disclosed the following for these overpayments: 

 The BCBS plans incorrectly paid 10,733 claim lines because the BCBS plans’ local systems 

and/or FEP Direct system did not defer these claims for review. This resulted in overcharges 

of $1,023,160 to the FEHBP. In most instances, we determined these claims did not contain 

an emergency diagnosis code and the plans did not provide sufficient documentation to 

support payment for these services as described in the Service Benefit Plan brochure. 

Additionally, we determined that 30 percent of the claim payment errors were processed after 

April 1, 2012 (i.e., the date FEP Direct enhancements were implemented) and were related to 

a systematic processing error. 

 The BCBS plans incorrectly paid 4,425 claim lines due to manual processing errors, resulting 

in overcharges of $310,109 to the FEHBP. For 3,946 of these claim lines (89 percent), the 

local plan processors overrode the non-emergency ambulance system deferral “C3P” in FEP 

Direct and allowed payment for these services. The plans did not provide sufficient 

documentation to support payment for these services as described in the Service Benefit Plan 

brochure. 

 The BCBS plans incorrectly paid 636 claim lines due to provider billing errors (e.g., the 

incorrect use of modifiers and procedure codes), resulting in overcharges of $90,554 to the 

FEHBP. 

Association’s Response: 

The Association agrees with $399,231 of the questioned charges. The Association states the 

plans will continue to pursue these overpayments as required by CS 1039, Part II, 

section 2.3(g)(l). 

Regarding the contested amount, the Association disagrees with these questioned charges for the 

following reasons: 

 Claims were for covered accidental injury transport, medical emergency transport, medically 

necessary hospital, skilled nursing home, or hospice transport, or were reviewed and 

approved for medically necessary ambulance transport. 

 Claims were paid incorrectly; however, recovery was not initiated due to the threshold of 

recovery (less than $100) or the plans were unable to initiate recovery as a result of provider 

contract limitations. 
7

Regarding corrective actions to reduce claim payment errors, the Association states, “The FEP 

Direct claim system was updated on April 1, 2012 to include a system edit to prevent certain 

non-emergency ambulance transport claims from paying without plan medical review. However, 

[the Association] expects to evaluate the results of this audit to identify additional corrective 

actions that will further reduce the occurrence of the overpayments in the future. We expect to 

have this activity completed by November 30, 2013.”

OIG Comments: 

After reviewing the Association’s response and additional documentation provided by the BCBS 

plans, we determined that 62 BCBS plans incorrectly paid 7,548 claims, resulting in overcharges 

of $1,423,823 to the FEHBP. Based on the Association’s response and the BCBS plans’ 

additional documentation, we determined that the Association and/or plans agree with $466,670 

and disagree with $957,153 of these questioned overcharges. Although the Association only 

agrees with $399,231 of these questioned overcharges in its response, the BCBS plans’ 

documentation supports concurrence with $466,670.

Based on the Association’s response and/or the BCBS plans’ documentation, the contested 

amount of $957,153 is comprised of the following items: 

 $746,154 represents 6,673 claim line overpayments where the BCBS plans’ local system 

and/or FEP Direct did not defer these claims for review and the plans did not provide 

sufficient documentation to support payment for these services as described in the Service 

Benefit Plan brochure. 

 $210,999 represents 2,932 claim line overpayments where the BCBS local plan processors 

overrode the non-emergency ambulance deferral in FEP Direct and the plans did not provide 

sufficient documentation to support payment for these services as described in the Service 

Benefit Plan brochure. 

Recommendation 1 

We recommend that the contracting officer disallow $1,423,823 for claim overcharges and verify 

that the BCBS plans return all amounts recovered to the FEHBP. 

Recommendation 2 

Due to the volume of claims identified after FEP Direct enhancements for non-covered 

ambulance services were implemented, we recommend that the contracting officer require the 

Association to have the FEP Operations Center identify the reason(s) why FEP Direct continues 

to allow non-covered ambulance claims to process and pay. Also, we recommend that the 

contracting officer require the Association to provide evidence or supporting documentation 

ensuring that the FEP Operations Center implemented the appropriate system modifications.
8

Recommendation 3 

We recommend that the contracting officer require the Association to consider discontinuing the 

use of modifiers as a source of edits on non-covered ambulance claims that allow the claims to 

process and pay. Instead, the FEP Operations Center should develop programming 

enhancements that rely on the patient’s history to evaluate compliance with the Service Benefit 

Plan brochure criteria (i.e., when medically appropriate and related to medical emergency or 

accidental injury; or associated with inpatient hospital care or covered hospice care) before 

processing the claim payment. 

Recommendation 4 

Due to the volume of claims where the local plan processors overrode the FEP Direct system 

edits for non-covered ambulance claims, we recommend that the contracting officer require the 

Association to provide education and/or detailed training to the local BCBS plans related to 

FEHBP coverage for non-covered ambulance services. Also, we recommend that the contracting 

officer require the Association to provide evidence or supporting documentation ensuring that 

the Association implemented the corrective actions.
9

IV. MAJOR CONTRIBUTORS TO THIS REPORT

Information Systems Audits Group 

 Chief 

 Senior Team Leader 

, Auditor-in-Charge 

, Auditor 

, Auditor 

Experience-Rated Audits Group 

, Chief 

Office of Management 

, Senior Information Technology Specialist 

 Senior Information Technology Specialist 
V. SCHEDULES

SCHEDULE A

Page 1 of 2

Site Claim Total Claim Total Claim Total

Number Plan Name State Claims Lines Amounts Paid Claims Lines Amounts Paid Claims Lines Amounts Paid

003 BlueCross BlueShield of New Mexico (HCSC) NM 1 4 $226 48 95 $13,435 49 99 $13,661

005 WellPoint BlueCross BlueShield of Georgia GA 42 127 $11,246 315 672 $46,221 357 799 $57,467

006 CareFirst BlueCross BlueShield (Maryland Service Area) MD 5 10 $620 667 1406 $69,742 672 1,416 $70,362

007 BlueCross BlueShield of Louisiana LA 16 58 $8,698 73 171 $25,595 89 229 $34,293

009 BlueCross BlueShield of Alabama AL 22 44 $2,275 510 1112 $86,086 532 1,156 $88,360

010 BlueCross of Idaho Health Service ID 3 9 $2,075 19 47 $3,053 22 56 $5,128

011 BlueCross BlueShield of Massachusetts MA 10 20 $551 304 664 $113,605 314 684 $114,156

012 BlueCross BlueShield of Western New York NY 0 0 $0 77 156 $23,127 77 156 $23,127

013 Highmark BlueCross BlueShield NY 1 2 $59 585 1325 $84,458 586 1,327 $84,517

015 BlueCross BlueShield of Tennessee TN 59 133 $8,624 733 1531 $91,107 792 1,664 $99,732

016 BlueCross BlueShield of Wyoming WY 10 20 $2,866 9 18 $3,802 19 38 $6,668

017 BlueCross BlueShield of Illinois (HCSC) IL 8 16 $2,888 438 1035 $157,701 446 1,051 $160,589

021 WellPoint BlueCross BlueShield of Ohio OH 23 91 $34,095 420 917 $82,566 443 1,008 $116,661

024 BlueCross BlueShield of South Carolina SC 11 33 $1,052 20 39 $3,232 31 72 $4,284

027 WellPoint BlueCross BlueShield of New Hampshire NH 1 1 $73 48 94 $17,955 49 95 $18,028

028 BlueCross BlueShield of Vermont VT 0 0 $0 27 63 $10,028 27 63 $10,028

029 BlueCross BlueShield of Texas (HCSC) TX 34 104 $16,234 876 2140 $462,047 910 2,244 $478,281

030 WellPoint BlueCross BlueShield of Colorado CO 8 17 $10,729 48 115 $27,058 56 132 $37,787

031 Wellmark BlueCross BlueShield of Iowa IA 42 186 $22,018 74 202 $13,064 116 388 $35,082

032 BlueCross BlueShield of Michigan MI 3 19 $1,316 225 483 $49,360 228 502 $50,675

033 BlueCross BlueShield of North Carolina NC 42 196 $16,046 384 799 $57,213 426 995 $73,259

034 BlueCross BlueShield of North Dakota ND 2 8 $317 21 46 $26,043 23 54 $26,360

036 Capital BlueCross PA 11 24 $3,851 0 0 $0 11 24 $3,851

037 BlueCross BlueShield of Montana (HCSC) MT 12 33 $6,564 19 41 $12,744 31 74 $19,307

038 BlueCross BlueShield of Hawaii HI 0 0 $0 11 22 $5,638 11 22 $5,638

039 WellPoint BlueCross BlueShield of Indiana IN 36 202 $19,306 167 419 $34,649 203 621 $53,954

040 BlueCross BlueShield of Mississippi MS 0 0 $0 67 197 $28,952 67 197 $28,952

041 Florida Blue FL 1 2 $61 372 827 $85,123 373 829 $85,185

042 BlueCross BlueShield of Kansas City (Missouri) MO 0 0 $0 80 169 $17,211 80 169 $17,211

043 Regence BlueShield of Idaho ID 0 0 $0 4 16 $469 4 16 $469

044 BlueCross BlueShield of Arkansas AR 4 19 $879 68 144 $28,369 72 163 $29,248

045 WellPoint BlueCross BlueShield of Kentucky KY 9 11 $1,113 177 395 $27,850 186 406 $28,964

047 WellPoint BlueCross BlueShield United of Wisconsin WI 4 51 $852 45 102 $9,943 49 153 $10,794

048 Empire BlueCross BlueShield (WellPoint) NY 1 2 $55 259 585 $32,018 260 587 $32,073

049 Horizon BlueCross BlueShield of New Jersey NJ 96 302 $65,691 1003 2376 $117,736 1,099 2,678 $183,427

050 WellPoint BlueCross BlueShield of Connecticut CT 0 0 $0 72 144 $27,156 72 144 $27,156

052 WellPoint BlueCross of California CA 5 19 $2,069 0 0 $0 5 19 $2,069

053 BlueCross BlueShield of Nebraska NE 7 12 $4,401 19 38 $5,352 26 50 $9,753

054 Mountain State BlueCross BlueShield WV 5 10 $626 112 231 $16,927 117 241 $17,552

055 Independence BlueCross PA 0 0 $0 0 0 $0 0 0 $0

056 BlueCross BlueShield of Arizona AZ 1 2 $47 99 263 $72,268 100 265 $72,316

058 Regence BlueCross BlueShield of Oregon OR 1 2 $392 53 93 $28,251 54 95 $28,643

059 WellPoint BlueCross BlueShield of Maine ME 12 150 $25,158 60 125 $12,079 72 275 $37,236

060 BlueCross BlueShield of Rhode Island RI 0 0 $0 208 434 $17,085 208 434 $17,085

061 Wellpoint BlueCross BlueShield of Nevada NV 2 14 $2,193 26 54 $14,719 28 68 $16,912

062 WellPoint BlueCross Blue Shield of Virginia VA 10 89 $7,186 403 843 $52,589 413 932 $59,775

064 Excellus BlueCross BlueShield of the Rochester Area NY 0 0 $0 31 66 $6,796 31 66 $6,796

066 Regence BlueCross BlueShield of Utah UT 0 0 $0 28 75 $12,753 28 75 $12,753

067 BlueShield of California CA 0 0 $0 386 934 $190,587 386 934 $190,587

068 Triple-S Salud, Inc of Puerto Rico PR 0 0 $0 0 0 $0 0 0 $0

069 Regence BlueShield (Washington) WA 0 0 $0 216 501 $51,947 216 501 $51,947

070 BlueCross BlueShield of Alaska AK 0 0 $0 34 74 $23,304 34 74 $23,304

074 Wellmark BlueCross BlueShield of South Dakota SD 0 0 $0 22 62 $5,787 22 62 $5,787

075 Premera BlueCross WA 5 24 $5,284 22 52 $7,900 27 76 $13,184

FACILITY CLAIMS PROFESSIONAL CLAIMS TOTAL

GLOBAL AUDIT OF NON-COVERED AMBULANCE CLAIMS

BLUECROSS AND BLUESHIELD PLANS

SUMMARY OF SELECTIONS BY PLAN
SCHEDULE A

Page 2 of 2

Site Claim Total Claim Total Claim Total

Number Plan Name State Claims Lines Amounts Paid Claims Lines Amounts Paid Claims Lines Amounts Paid

FACILITY CLAIMS PROFESSIONAL CLAIMS TOTAL

GLOBAL AUDIT OF NON-COVERED AMBULANCE CLAIMS

BLUECROSS AND BLUESHIELD PLANS

SUMMARY OF SELECTIONS BY PLAN

076 WellPoint BlueCross BlueShield of Missouri MO 22 81 $4,335 114 240 $21,594 136 321 $25,928

078 BlueCross BlueShield of Minnesota MN 22 85 $9,867 59 124 $45,439 81 209 $55,306

079 Excellus BlueCross BlueShield of Central New York NY 0 0 $0 7 16 $1,910 7 16 $1,910

082 BlueCross BlueShield of Kansas KS 10 20 $2,158 43 96 $11,298 53 116 $13,456

083 BlueCross BlueShield of Oklahoma (HCSC) OK 0 0 $0 166 360 $36,518 166 360 $36,518

084 Excellus BlueCross BlueShield of Utica-Watertown NY 0 0 $0 11 22 $530 11 22 $530

085 CareFirst BlueCross BlueShield (DC Service Area) DC 4 8 $572 749 1581 $107,895 753 1,589 $108,467

088 BlueCross of Northeastern Pennsylvania PA 1 2 $256 0 0 $0 1 2 $256

089 BlueCross BlueShield of Delaware DE 0 0 $0 68 140 $5,133 68 140 $5,133

092 CareFirst BlueCross BlueShield (Overseas Area) DC 0 0 $0 9 13 $5,872 9 13 $5,872

624 2,262 $304,925 11,210 25,004 $2,648,884 11,834 27,266 $2,953,809

Number of BCBS Plans Reviewed = 62

TOTALS
SCHEDULE B

Page 1 of 2

Site Plan Plan

Number Plan Name State Claim Lines Total Charges 2011 2012 Agrees Disagrees

003 BlueCross BlueShield of New Mexico (HCSC) NM 55 $6,635 $713 $5,923 $0 $6,635

005 WellPoint BlueCross BlueShield of Georgia GA 606 $47,530 $19,979 $27,551 $30,740 $16,791

006 CareFirst BlueCross BlueShield (Maryland Service Area) MD 1062 $47,790 $18,484 $29,306 $4,919 $42,871

007 BlueCross BlueShield of Louisiana LA 96 $10,051 $4,524 $5,527 $7,144 $2,907

009 BlueCross BlueShield of Alabama AL 700 $57,066 $44,150 $12,916 $29,139 $27,928

010 BlueCross of Idaho Health Service ID 22 $1,435 $691 $744 $578 $857

011 BlueCross BlueShield of Massachusetts MA 212 $28,856 $5,575 $23,281 $10,541 $18,315

012 BlueCross BlueShield of Western New York NY 87 $11,772 $7,123 $4,648 $263 $11,508

013 Highmark BlueCross BlueShield NY 455 $17,690 $7,500 $10,190 $6,338 $11,352

015 BlueCross BlueShield of Tennessee TN 849 $97,964 $26,128 $71,836 $96,984 $980

016 BlueCross BlueShield of Wyoming WY 5 $1,263 $0 $1,263 $0 $1,263

017 BlueCross BlueShield of Illinois (HCSC) IL 624 $85,664 $34,392 $51,272 $3,719 $81,945

021 WellPoint BlueCross BlueShield of Ohio OH 639 $55,358 $17,777 $37,581 $23,080 $32,278

024 BlueCross BlueShield of South Carolina SC 18 $1,433 $186 $1,247 $844 $589

027 WellPoint BlueCross BlueShield of New Hampshire NH 74 $14,035 $5,428 $8,607 $1,781 $12,254

028 BlueCross BlueShield of Vermont VT 27 $3,906 $469 $3,437 $49 $3,856

029 BlueCross BlueShield of Texas (HCSC) TX 1396 $143,599 $55,142 $88,457 $8,946 $134,653

030 WellPoint BlueCross BlueShield of Colorado CO 84 $35,486 $21,554 $13,932 $6,809 $28,677

031 Wellmark BlueCross BlueShield of Iowa IA 148 $15,787 $6,780 $9,007 $7,917 $7,870

032 BlueCross BlueShield of Michigan MI 209 $13,353 $5,327 $8,026 $2,308 $11,045

033 BlueCross BlueShield of North Carolina NC 766 $60,472 $15,112 $45,360 $43,654 $16,818

034 BlueCross BlueShield of North Dakota ND 32 $17,133 $7,724 $9,409 $317 $16,816

036 Capital BlueCross PA 4 $1,690 $0 $1,690 $0 $1,690

037 BlueCross BlueShield of Montana (HCSC) MT 26 $7,176 $125 $7,051 $75 $7,102

038 BlueCross BlueShield of Hawaii HI 10 $2,533 $1,562 $971 $517 $2,017

039 WellPoint BlueCross BlueShield of Indiana IN 276 $21,255 $10,231 $11,024 $8,182 $13,073

040 BlueCross BlueShield of Mississippi MS 93 $15,385 $11,455 $3,930 $6,265 $9,120

041 Florida Blue FL 389 $36,678 $12,186 $24,493 $6,512 $30,166

042 BlueCross BlueShield of Kansas City (Missouri) MO 76 $7,181 $1,661 $5,521 $3,169 $4,013

043 BlueShield of Idaho ID 5 $235 $46 $190 $46 $190

044 BlueCross BlueShield of Arkansas AR 83 $11,736 $5,385 $6,351 $428 $11,308

045 WellPoint BlueCross BlueShield of Kentucky KY 305 $22,318 $9,537 $12,780 $7,473 $14,845

047 WellPoint BlueCross BlueShield United of Wisconsin WI 56 $5,515 $1,811 $3,704 $2,299 $3,216

048 Empire BlueCross BlueShield (WellPoint) NY 390 $18,531 $7,197 $11,334 $11,842 $6,690

049 Horizon BlueCross BlueShield of New Jersey NJ 1870 $86,673 $54,806 $31,867 $71,823 $14,850

050 WellPoint BlueCross BlueShield of Connecticut CT 84 $11,891 $3,205 $8,686 $2,621 $9,269

052 WellPoint BlueCross of California CA 3 $1,070 $99 $972 $972 $99

053 BlueCross BlueShield of Nebraska NE 28 $3,410 $194 $3,216 $0 $3,410

054 Mountain State BlueCross BlueShield WV 94 $5,284 $2,111 $3,174 $1,597 $3,687

055 Independence BlueCross PA 0 $0 $0 $0 $0 $0

GLOBAL AUDIT OF NON-COVERED AMBULANCE CLAIMS

BLUECROSS AND BLUESHIELD PLANS

SUMMARY OF QUESTIONED CHARGES BY PLAN

Total Questioned Amounts Questioned by Year
SCHEDULE B

Page 2 of 2

Site Plan Plan

Number Plan Name State Claim Lines Total Charges 2011 2012 Agrees Disagrees

GLOBAL AUDIT OF NON-COVERED AMBULANCE CLAIMS

BLUECROSS AND BLUESHIELD PLANS

SUMMARY OF QUESTIONED CHARGES BY PLAN

Total Questioned Amounts Questioned by Year

056 BlueCross BlueShield of Arizona AZ 100 $25,916 $8,252 $17,664 $2,240 $23,675

058 Regence BlueCross BlueShield of Oregon OR 32 $9,725 $4,471 $5,254 $1,072 $8,654

059 WellPoint BlueCross BlueShield of Maine ME 103 $15,632 $5,950 $9,681 $2,882 $12,750

060 BlueCross BlueShield of Rhode Island RI 322 $13,118 $9,258 $3,859 $899 $12,219

061 Wellpoint BlueCross BlueShield of Nevada NV 31 $9,942 $2,671 $7,271 $2,747 $7,196

062 WellPoint BlueCross Blue Shield of Virginia VA 634 $29,778 $10,795 $18,983 $3,615 $26,163

064 Excellus BlueCross BlueShield of the Rochester Area NY 28 $2,792 $0 $2,792 $486 $2,307

066 Regence BlueCross BlueShield of Utah UT 8 $848 $0 $848 $0 $848

067 BlueShield of California CA 419 $79,281 $16,784 $62,497 $114 $79,168

068 Triple-S Salud, Inc. of Puerto Rico PR 0 $0 $0 $0 $0 $0

069 Regence BlueShield (Washington) WA 279 $36,410 $13,847 $22,563 $4,333 $32,077

070 BlueCross BlueShield of Alaska AK 28 $10,214 $0 $10,214 $0 $10,214

074 Wellmark BlueCross BlueShield of South Dakota SD 26 $5,480 $1,792 $3,688 $2,414 $3,066

075 Premera BlueCross WA 23 $4,290 $917 $3,373 $0 $4,290

076 WellPoint BlueCross BlueShield of Missouri MO 150 $16,907 $4,157 $12,750 $7,943 $8,964

078 BlueCross BlueShield of Minnesota MN 76 $29,750 $6,062 $23,688 $1,776 $27,974

079 Excellus BlueCross BlueShield of Central New York NY 4 $105 $50 $54 $0 $105

082 BlueCross BlueShield of Kansas KS 69 $8,504 $5,064 $3,440 $539 $7,965

083 BlueCross BlueShield of Oklahoma (HCSC) OK 181 $17,732 $5,346 $12,386 $628 $17,104

084 Excellus BlueCross BlueShield of Utica-Watertown NY 22 $530 $432 $99 $0 $530

085 CareFirst BlueCross BlueShield (DC Service Area) DC 1217 $69,365 $33,434 $35,931 $22,338 $47,027

088 BlueCross of Northeastern Pennsylvania PA 2 $256 $0 $256 $256 $0

089 BlueCross BlueShield of Delaware DE 78 $2,286 $1,532 $755 $647 $1,639

092 CareFirst BlueCross BlueShield (Overseas Area) DC 4 $2,118 $1,852 $267 $1,852 $267

15,794 $1,423,823 $559,035 $864,788 $466,670 $957,153

Number of BCBS Plans with Overpayments = 62

TOTALS
•• Appendix 

' . 

~ 

' 

BlueCross Blu eShield 

Association 

An Association oflndependent 

Blue Cross and Blue Shield Plans 

federal Employee Program 

13 10 G. Street, NW 

Washington, DC 20005 

202 .942.1000 

Fa.'< 202.942.1125

October 1, 2013 

Group Chief 	

Experience-Rated Audits Group 

Office of the Inspector General 

U.S. Office of Personnel Management 

1900 E Street, Room 6400 

Washington , DC 20415-1100 

Reference: 	 OPM DRAFT AUDIT REPORT 

No n-Covered Ambulance Services Global Audit 

Audit Re port #1A-99-00-13-046 

Dear 

This is in response to the above- referenced U.S. Office of Personnel Management 

(OPM) Draft Audit Report concerning the Global Coordination of Benefits Audit for 

claims paid from June 1, 2011 through December 31, 2012. Our comments 

concerning the findings in the report are as fo llows: 

Rec ommendat ions 1, 2 and 3: 

Non-Covered Ambulance Service C harges 	 $2,953,809 

The OPM OIG submitted their sample of potential non covered Ambulance Service 

payment errors to the Blue Cross Blue Shield Association (BCBS) on July 1, 2013. 

The BCBS Association and/or the BCBS Plans were requested to review these 

potential errors and provide responses by September 30, 20 13. The sample 

included claims reimbursed from Ju ne 1, 2011 through December 31 , 20 12. OPM 

O IG selected the entire population of 11 ,834 FEP claims, totaling $2,953,809 in 

potential claim overpayments for review. 

Blue Cross Blue Sh ield Association (BCBSA) Response: 

After reviewing the OIG listing of potential non-covered Ambulance services totaling 

$2,953,809, the BCBS Association identified the following : 

• 	 Claims were paid correctly for covered accidental injury transport. 

• 	 Claims were paid correctly for covered medical emergency transport. 

• 	 Claims were paid correctly for medically necessary hospital/skilled nursing 


home/hospice transport. 


• 	 Cla ims were paid correctly for claims reviewe d and approved for medically 


necessary ambulance transport. 

~ Page 2 

Plans disagreed to $5,472 in potential non-covered Ambulance services because 

the overpayment was below the threshold for recovery (ove rpayments ranged from 

.01 to $100) or because Plans were unable to initiate recovery as a result of provider 

contract limits on recovery initiation. 

Plans agreed that $399,231 of the questioned amount was paid in error and the 

error was not identified by the start of the audit. These claims were paid in error as 

a result of: 

• Processor error for overpayments totaling $56,158. 

• Provider bill ing errors for overpayments totaling $107,044. 

• Plan local system pricing errors for overpayments totaling $53,488 . 

• FEP Claim system pricing error for overpayments totaling $139 ,946. 

• Other miscellaneous reasons totaling $42,595 . 

The Plans will continue to pursue the remaining overpayments as requ ired by CS 

1039, Section 2.3(g ) (1) . 

Documentation to support all potential non-covered ambulance services were 

provided on September 30 , 2013 . In addition, we have attached a schedule listed as 

Attachment A that shows the amount questioned , contested , and agreed to by each 

Plan location . 

The FEPDirect claim system was updated on April1 , 2012 to include a 

system ed it to prevent certain non-emergency ambulance transport claims 

from paying without Plan medical rev iew. However, BCBSA expects to 

evaluate the results of this audit to identify additional corrective actions that 

will further reduce the occurrence of these overpayments in the future. We 

expect to have this activity completed by November 30, 2013. 

We appreciate the opportunity to provide our response to this Draft Audit 

Report and would request that our comments be included in their entirety as 

part of the Final Audit Report. 

Managing Director 

FEP Program Assurance 

Attachments