U.S. OFFICE OF PERSONNEL MANAGEMENT
OFFICE OF THE INSPECTOR GENERAL
OFFICE OF AUDITS
Final Audit Report
GLOBAL AUDIT OF
DUPLICATE CLAIM PAYMENTS FOR BLUE
CROSS AND BLUE SHIELD PLANS
Report Number 1A-99-00-16-043
June 21, 2017
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This report has been distributed to Federal officials who are responsible for the administration of the subject program. This non-public
version may contain confidential and/or proprietary information, including information protected by the Trade Secrets Act, 18 U.S.C. §
1905, and the Privacy Act, 5 U.S.C. § 552a. Therefore, while a redacted version of this report is available under the Freedom of
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should not be further released unless authorized by the OIG.
EXECUTIVE SUMMARY
Global Audit of Duplicate Claim Payments
Report No. 1A-99-00-16-043 June 21, 2017
Why Did We Conduct the Audit? What Did We Find?
The objectives of our audit were to Our audit identified $5,967,324 in duplicate claim overpayments. The
determine whether the Blue Cross and majority of the claim payment errors were related to manual processing
Blue Shield (BCBS) plans charged costs errors, which we believe are indicative of systemic internal control
to the Federal Employees Health Benefits problems. Our recurring audits continue to identify claim payment errors
Program (FEHBP) and provided services resulting from manual processing errors, and we therefore recommend
to the FEHBP members in accordance that the contracting office ensure the corrective actions in this report are
with the terms of the BCBS promptly implemented.
Association’s (Association) contract with
the U.S. Office of Personnel We do not believe that the BCBS plans have exercised due diligence in
Management. Specifically, our objective implementing controls to eliminate erroneous duplicate claim payments.
was to determine whether the BCBS As a result, we conclude that these claims were not paid in good faith,
plans complied with contract provisions and therefore were not paid in compliance with the terms of the
relative to duplicate claim payments. Association’s contract with the U.S. Office of Personnel Management.
What Did We Audit?
The Office of the Inspector General has
completed a limited scope performance
audit of the FEHBP operations at all
BCBS plans. The audit covered claim
payments from June 1, 2013, through
March 31, 2016, as reported in the
Association’s Government-wide Service
Benefit Plan Annual Accounting
Statements. Using various search
criteria, we identified and reviewed
claims paid during the audit scope for
potential duplicate payments charged to
the FEHBP.
_______________________
Michael R. Esser
Assistant Inspector General
for Audits
i
ABBREVIATIONS
Association Blue Cross Blue Shield Association
BCBS Blue Cross Blue Shield
FEHB Federal Employees Health Benefits
FEHBP Federal Employees Health Benefits Program
FEP Federal Employee Program
FEP Express Federal Employee Program Claims Processing System
OIG Office of the Inspector General
OPM U.S. Office of Personnel Management
Plan(s) Blue Cross and Blue Shield Plan(s)
ii
IV. MAJOR CONTRIBUTORS TO THIS REPORT
TABLE OF CONTENTS
Page
EXECUTIVE SUMMARY ......................................................................................... i
ABBREVIATIONS ..................................................................................................... ii
I. BACKGROUND ..........................................................................................................1
II. OBJECTIVES, SCOPE, AND METHODOLOGY ..................................................3
III. AUDIT FINDINGS AND RECOMMENDATIONS.................................................6
Duplicate Claim Payments .............................................................................................6
APPENDIX A: Blue Cross Blue Shield Association’s October 13, 2016, response
to the Draft Audit Report, issued June 22, 2016.
REPORT FRAUD, WASTE, AND MISMANAGEMENT
IV. MAJOR CONTRIBUTORS
I. BACKGROUND
TO THIS REPORT
This 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
Blue Cross and Blue Shield (BCBS) plans. The audit was performed by the U.S. Office of
Personnel Management’s (OPM) Office of the Inspector General (OIG), as authorized by the
Inspector General Act of 1978, as amended.
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. Health insurance coverage is made available through
contracts with various health insurance carriers.
The Blue Cross Blue Shield 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
BCBS plans, and OPM.
The Association has also established an FEP Operations Center. The activities of the
FEP Operations Center are performed by CareFirst Blue Cross Blue Shield, 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 file of all FEHBP claims, and maintaining an accounting of all program funds.
1
Throughout this report, when we refer to “FEP,” we are referring to the Service Benefit Plan lines of business at
the Plan(s). When we refer to the “FEHBP,” we are referring to the program that provides health benefits to federal
employees.
1 Report No. 1A-99-00-16-043
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.
Findings from our previous global audit of duplicate claim payments at all BCBS plans
(Report No. 1A-99-00-13-061, dated August 19, 2014) for claims reimbursed from
January 1, 2011, through May 31, 2013, have been resolved.
Our sample selections, instructions, and preliminary audit results of the potential duplicate claim
payments were presented to the Association in a draft report, dated June 22, 2016. 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 BCBS plans on various dates through February 6, 2017, was
considered in preparing our final report.
2 Report No. 1A-99-00-16-043
IV. OBJECTIVES,
II. MAJOR CONTRIBUTORS
SCOPE, ANDTO THIS REPORT
METHODOLOGY
OBJECTIVES
The objectives of our audit were to determine whether the BCBS plans charged costs to the
FEHBP and provided services to the FEHBP members in accordance with the terms of the
contract. Specifically, our objective was to determine whether the BCBS plans complied with
contract provisions relative to duplicate claim payments.
SCOPE
The audit covered health benefit payments from June 1, 2013, through March 31, 2016, as
reported in the Blue Cross and Blue Shield Association’s Government-wide Service Benefit Plan
FEP Annual Accounting Statements. We performed various computer searches on BCBS claims
data to identify potential duplicate payments charged to the FEHBP during the audit scope. Our
searches identified 1,440,425 claim groups2, totaling $80,158,131 in payments that potentially
contained duplicate charges.
Our search results of potential duplicate claim payments are separated into three categories –
“best matches,” “near matches,” and “inpatient facility matches.” Exhibit I, on the following
page, summarizes our claim universe by category. The universe of potential duplicate claim
groups was derived from the following search logic criteria:
Our “best matches” logic identifies and groups unique claim numbers that contain most of the
same claim data, including patient code, procedure code, diagnosis code, and sex code.
Our “near matches” logic identifies and groups unique claim numbers that contain most of the
same claim data, except for patient code, procedure code, diagnosis code, or sex code.
Our “inpatient facility matches” search criteria identifies duplicate or overlapping dates of
service.
2
A claim group represents one claim payment “paid correctly” and one or more potential duplicate payments.
3 Report No. 1A-99-00-16-043
Exhibit I – Universe of Potential Duplicate Claim Payments
Duplicate Potential Overpayment
Duplicate Category
Groups Amount
Best Matches 282,161 $20,175,848
Near Matches 1,157,735 $56,433,507
Inpatient Facility Matches 529 $3,548,776
Total 1,440,425 $80,158,131
To test each BCBS plan’s compliance with the FEHBP health benefit provisions related to
duplicate claim payments, we selected the following claims from this universe for review (see
Exhibit II for a summary of claims selected for review):
All duplicate claim groups with potential overpayments of $1,000 or more; and
A random sample of 12,339 claim lines from all duplicate claim groups with potential
overpayments of less than $1,000.
We did not project the results of this review to the universe of claims paid for potentially
duplicated claim lines.
Exhibit II – Samples Selected for Review by Duplicate Category
Duplicate Potential Overpayment
Duplicate Category
Groups Amount
Best Matches 3,764 $7,339,512
Near Matches 8,179 $7,898,776
Inpatient Facility Matches 423 $3,501,531
Total 12,366 $18,739,819
METHODOLOGY
The claims selected for review were submitted to each BCBS plan for their analysis and
response. We conducted a limited review of the plans’ “paid correctly” responses and an
expanded review of the plans’ “paid incorrectly” responses. Specifically, we verified supporting
documentation, and 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. On a limited test basis we also verified whether the BCBS plans had initiated
4 Report No. 1A-99-00-16-043
recovery efforts, adjusted or voided the claims, and/or completed the recovery process by the
audit request due date (i.e., September 1, 2016) for the claim payment errors in our sample.
The determination of the questioned amount is based on the FEHBP contract, the 2013 through
2016 Service Benefit Plan brochures, and the Association’s FEP Procedures Administrative
Manual.
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 objectives. We believe that the evidence obtained provides a
reasonable basis for our findings and conclusions based on our audit objectives.
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
and the laws and regulations governing the FEHBP as they relate to duplicate claim payments.
The results of our tests indicate that, with respect to the items tested, the BCBS plans did not
fully comply with the provisions of the contract relative to duplicate claim payments.
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 Director’s Office, the FEP Operations Center, and the BCBS plans. Through audits and
a reconciliation process, we have verified the reliability of the BCBS claims data in our data
warehouse, which was used to identify the universe of potential duplicate claim payment errors.
The BCBS claims data is provided to us on a monthly basis by the FEP Operations Center, and
after a series of internal steps, uploaded into our data warehouse. However, due to time
constraints, we did not verify the reliability of the data generated by the BCBS plans’ local
claims systems. While utilizing the computer-generated data during our audit, nothing came to
our attention to cause us to doubt its reliability. We believe that the data was sufficient to
achieve our audit objectives.
Audit fieldwork was performed at our offices in Washington, D.C.; Cranberry Township,
Pennsylvania; and Jacksonville, Florida through April 2017.
5 Report No. 1A-99-00-16-043
IV. AUDIT
III. MAJORFINDINGS
CONTRIBUTORS TO THIS REPORT
AND RECOMMENDATIONS
The sections below detail the results of our global audit of duplicate claim payments. As
mentioned in the Scope section above, our review included a total of 12,366 claim groups,
totaling $18,739,819 in potential overcharges to the FEHBP (see Exhibit II on page 4).
Duplicate Claim Payments $5,967,324
Our review determined that the BCBS plans incorrectly paid 3,089 claim lines, totaling
$5,967,324 in overcharges to the FEHBP. See Exhibit III for a summary of the questioned costs
sorted by category and Exhibit IV for a summary of questioned costs sorted by cause of error.
Exhibit III – Summary of Questioned Costs by Category
Claim Amount
Category
Lines Overcharged
Best Matches 1,528 $3,155,137
Near Matches 1,473 $2,086,216
Inpatient
88 $725,971
Matches
Total 3,089 $5,967,324
Exhibit IV – Questioned Costs by Cause of Error
Claim Total
Cause of Error Percentage
Payments Overpayment
Manual Processor
1,303 $2,456,141 41%
Errors
Provider Billing Errors 947 $1,696,306 29%
System Errors (Local
374 $966,212 16%
and FEP Express)
Non-Duplicate Pricing
465 $848,665 14%
Errors
TOTALS 3,089 $5,967,324 100%
Additional detail regarding the cause of error follows:
1,303 duplicate payments, totaling $2,456,141, were overcharged to the FEHBP as the result
of manual processor errors. In most cases, the potential duplicate payment was detected by
6 Report No. 1A-99-00-16-043
the Federal Employee Program Claims Processing System (FEP Express) (i.e., FKA3 denial
code). However, the processors manually overrode the system to allow these claims to be
paid.
947 duplicate payments, totaling $1,696,306, were overcharged to the FEHBP as the result of
various provider billing errors such as incorrectly billing with a modifier code, submitting the
claim with an incorrect provider address, or providing an incorrect provider identification. In
these instances, the provider re-billed the claim with the correct information; however, the
processors overrode FEP Express and allowed the services to be paid twice.
374 duplicate claim payments, totaling $966,212, were overcharged to the FEHBP as a result
of the local plan’s claim system and/or FEP Express failing to detect the duplicate payment.
465 non-duplicate claim payments, totaling $848,665, were overcharged to the FEHBP due
to various pricing errors such as incorrect pricing allowances, incorrect member liability
calculations, or incorrect coordination of other benefits.
This audit highlights longstanding procedural issues regarding the controls that BCBS has in
place to prevent duplicate claim payment errors. Our recurring global duplicate claims paid
audits (performed since 2004) routinely show that manual processing errors are the primary
reason for these material duplicate claim payments. Although the Association has reportedly
taken steps to implement prior OIG audit recommendations related to duplicate claim errors, the
results of this audit do not indicate that these corrective actions have had a substantial impact in
reducing the amount of errors. Considering the length of time that these material errors occurred
after the issue had been brought to the Association’s attention, the OIG does not believe that these
erroneous claim payment errors were paid in good faith. Therefore, we recommend that the entire
questioned amount be returned to the FEHBP regardless of the plans’ ability to recover the funds
from the providers. The contracting officer should also continue monitoring the Association’s
ongoing system enhancements and efforts to reduce duplicate payment errors.
The following criteria were used to support our questioning of these claim payments:
Contract CS 1039, Part III, section 2.3 (8)(i) states, “The Carrier may charge the contract for
benefit payments made erroneously but in good faith . . . .”
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
3
FKA refers to the denial code automatically applied by FEP Express when it detects a possible duplicate of a
charge previously reported on a claim that has already processed through the system.
7 Report No. 1A-99-00-16-043
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 … , overpayment, or duplicate payment … regardless of any
time period limitations in the written agreement with the provider.”
Association Response:
In response to the draft audit report, which questioned $17,356,434 in potential overpayments,
the Association stated that, $10,200,056 in claim payments paid correctly and $3,859,536 in
duplicate claim payments were identified by the audit. $251,614 in claim payment errors
resulted from the use of an incorrect allowance when originally paying the claim, and
$3,045,227 in duplicate payments were identified before the audit started and were either
returned to the Program, are still in collections, or were determined to be uncollectible.
“For duplicate claims and other claims identified during the audit, Plans will initiate recovery
where possible.”
Regarding corrective actions, the Association indicated that to reduce duplicate payments or to
timely detect duplicate payment errors, the Association has implemented and updated the
following:
“Enhanced the current duplicate edit in 3rd quarter 2015 to defer claims incurred on the
same day, for the same service, that were paid by different providers.
Enhanced the BCBSA [Association] post payment duplicate reports in 3rd quarter 2014 to
better improve identification of potential duplicate payments for Plan review and
adjustment.
Scheduled additional modification to the duplicate edits for 1st Quarter 2017 to defer
claims with the same incurred date and procedure code (or revenue code) but paid on a
different bill type (i.e., professional claim versus a facility claim). See Attachment 1 for a
description of this enhancement.
Beginning 4th quarter 2016, BCBSA [Association] will also enhance its review of Plan
responses to the BCBSA post payment duplicate reports to ensure that Plans are
responding timely and appropriately to the potential duplicate payments identified.
Provided a sample of the duplicate payment errors to the FEP Operations Center
(FEPOC) for review and determination as to why the duplicate payments did not defer for
Plan review. After the FEPOC completes their review, BCBSA [Association] will
8 Report No. 1A-99-00-16-043
implement any additional deferrals determined to be necessary to reduce duplicate
payments.”
OIG Comments:
The Association’s response and supporting documentation indicated that the BCBS plans
acknowledge that $5,967,324 in claim overpayments were made during the scope of our audit. If
claim overpayments were identified by the BCBS plans before our audit notification date (i.e.,
June 1, 2016) and adjusted or voided by the draft report response due date (i.e., September 1,
2016), we did not consider these as claim payment errors in the final report.
Acknowledged Claim Overpayments
The $5,967,324 of acknowledged claim overpayments is comprised of the following:
$4,839,538 represents claim overpayments for which the BCBS plans have committed to
pursue recovery; and
$1,127,786 represents claim overpayments for which the BCBS plans state the recovery
efforts have been exhausted; however, we continue to question these costs.
Recommendation 1
We recommend that the contracting officer disallow $5,967,324 for claim overpayments and
verify that the BCBS plans return all amounts questioned to the FEHBP, regardless of the plans’
ability to recover the claim payments from providers.
Recommendation 2
Due to the substantial amount of manual processor errors found in this audit, we recommend that
the contracting officer require the Association to disallow manual processing overrides for the
FKA master file deferral code. We also recommend that the contracting office require the
Association to perform training on this new process to instruct the processors how to deny claims
that are incorrectly billed by providers and/or deny claims that are billed twice.
Recommendation 3
Due to the significant number of provider billing errors identified, we recommend that the
contracting officer require the Association to perform a risk analysis to determine high-risk areas
related to duplicate provider billing errors. This should include determining the cost efficiency
of implementing a system edit(s) in the plans’ local systems and FEP Express to prevent these
9 Report No. 1A-99-00-16-043
types of errors from occurring in the future. If the analysis results in material savings to the
FEHBP, we recommend that the contracting officer require the Association to add the system
edits to the local plans' systems and/or FEP Direct to defer future provider billing errors for
payment.
10 Report No. 1A-99-00-16-043
APPENDIX A
October 13, 2016 Federal Employee Program
1310 G Street, N.W.
Washington, D.C. 20005
202.626.4800
Senior Team Leader
Information Systems Audits Group
OPM Office of the Inspector General
1900 E. Street
Washington, D.C. 20415
Reference: Global Potential Duplicate Claims Draft Report
Audit Report #1A-99-00-16-043
Dear :
This is in response to the above – referenced U.S. Office of Personnel Management (OPM)
Draft Audit Report concerning the Global Duplicate Claims Payments for claims paid from
June 1, 2013 through March 31, 2016. Our comments concerning the findings in the report
are as follows:
Recommendation 1
We recommend that the contracting officer disallow $17,356,434 in duplicate payments and
have the BCBS plans return all amounts recovered to the FEHBP.
BCBSA Response
BCBS Plans reviewed the claim samples provided by the OIG totaling $17,356,434 and noted
the following:
$10,200,056 in claim payments paid correctly.
$3,859,536 in duplicate claim payments identified by the audit.
$251,614 in claim payment errors resulting from the use of an incorrect allowance when
originally paying the claim.
$3,045,227 in duplicate payments that were identified before the audit started that were
either returned to the Program, are still in collections or were determined to be
uncollectible before the audit started.
For duplicate claims and other claims identified during the audit, Plans will initiate recovery
where possible.
Recommendation 2
We recommend that the contracting officer instruct the Association to perform a risk
analysis on the duplicate payments identified as a result of our audit. A description of the
Report No. 1A-99-00-16-043
corrective actions identified during this analysis needed to reduce these types of claim
payment errors from occurring in the future should be included in the Association’s
response to the draft report.
BCBSA Response
The following corrective actions have either been implemented or are currently in progress
to either reduce duplicate payments or to timely identify duplicate payments once they have
occurred include the following:
Enhanced the current duplicate edit in 3rd quarter 2015 to defer claims incurred on the
same day, for the same service, that were paid by different providers.
Enhanced the BCBSA post payment duplicate reports in 3rd quarter 2014 to better
improve identification of potential duplicate payments for Plan review and adjustment.
Scheduled additional modification to the duplicate edits for 1st Quarter 2017 to defer
claims with the same incurred date and procedure code (or revenue code) but paid on a
different bill type (i.e., professional claim versus a facility claim). See Attachment 1 for a
description of this enhancement.
Beginning 4th quarter 2016, BCBSA will also enhance its review of Plan responses to the
BCBSA post payment duplicate reports to ensure that Plans are responding timely and
appropriately to the potential duplicate payments identified.
Provided a sample of the duplicate payment errors to the FEP Operations Center
(FEPOC) for review and determination as to why the duplicate payments did not defer
for Plan review. After the FEPOC completes their review, BCBSA will implement any
additional deferrals determined to be necessary to reduce duplicate payments.
If you have any questions, please contact me at or at
.
Sincerely,
Managing Director, FEP Program Assurance
Report No. 1A-99-00-16-043
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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
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Global Audit of Duplicate Claim Payments for Blue Cross and Blue Shield Plans
Published by the Office of Personnel Management, Office of Inspector General on 2017-06-21.
Below is a raw (and likely hideous) rendition of the original report. (PDF)