U.S. OFFICE OF PERSONNEL MANAGEMENT OFFICE OF THE INSPECTOR GENERAL OFFICE OF AUDITS AUDIT OF THE FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM OPERATIONS AT THE HEALTH PLAN OF NEVADA, INC. Report Number 1C-NM-00-14-056 January 14, 2015 -- CAUTION - This audit •·eport has been distributed to Federal officials who are responsible fo1· the administration of the audited program. This audit report may contain proprieta1-y data which is protected by Federal law (18 U.S.C. 1905). Therefore, while this audit rep011 is available under the Freedom of Information Act and made available to the public on the OIG webpage (http://wn~v.opm.go•>lour-inspector-geuernl), caution needs to be exercised before releasing the •·eport to the general public as it may contain p1·oprietary information that was redacted from the publicly distributed copy. EXECUTIVE SUMMARY Audit ofthe F ederal Employees Health Benefits Program Operations at the Health Plan Inc. Why Did We Conduct The Audit? What Did We Find? The objectives of our audit were to We detennined that the FEHBP rates were developed by the Plan detennine if the Health Plan of in accordance with applicable laws, regulations, and the U.S . Nevada, Inc. (Plan) offered the Office of Personnel Management's Rate Instm ctions to Federal Employees Health Benefits Community-Rated Caniers for the year audited. We therefore did Program (FEHBP) market price rates not issue a draft report and are not making any recommendations. and that the loadings applied to the FEHBP rates were reasonable and equitable. Additional tests were perf01med to detetmine whether the Plan was in compliance with the provisions of the laws and regulations goveming the FEHBP. What Did We Audit? Under contract 1942, the Office of the Inspector General completed a perf01mance audit of the FEHBP's rates offered for contract year 201 2. Our audit was conducted from July 7, 2014 through July 11, 2014 at the Plan's office in Las Vegas, Nevada . Michael R. Esser Assistant Inspector General for Audits ABBREVIATIONS CFR Code of Federal Regulations FEHBP Federal Employees Health Benefits Program FY Fiscal Year OIG Office of the Inspector General OPM U.S. Office of Personnel Management PLAN The Health Plan of Nevada, Inc. SSSG Similarly Sized Subscriber Group U.S.C. United States Code ii TABLE OF CONTENTS Page EXECUTIVE SUMMARY ......................................................................................... i ABBREVIATIONS ................................................................................................ ..... ii I. BACK GROUND ................................................................ .......................................... ! II. OBJECTIVES, SCOPE, AND METHODOLOGY ................................................. .3 III. RESULTS OF THE AUDIT ................................ ....................................................... 5 IV. MAJOR C ONTRIBUTORS TO THE AUDIT .........................................................6 REPORT FRAUD, WAST E, AND MI SMANAGEMENT I. BACKGROUND The Federal Employees Health Benefits Program (FEHBP) was established by the Federal Employees Health Benefits 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. The FEHBP is administered by the U.S . Office of Personnel Management's (OPM) Healthcare and Insmance Office. The provisions of the Federal Employees Health Benefits Act ar e implemented by OPM through regulations codified in Chapter 1, Pali 890 of Title 5, Code of Federal Regulations (CFR). Health insmance coverage is provided through contracts with he alth insmance carriers who provide service benefits, indemnity benefits, or comprehensive medical services. Community-rated carriers patticipating in the FEHBP are subject to various federal, state and local laws, regulations, and ordinances. While most carriers are subject to state jmisdiction, many are fmther subject to the Health Maintenance Organization Act of 1973 (Public Law 93 222), as amended (i.e., many commlmity-rated carriers are federally qualified). In addition, pruticipation in the FEHBP subjects the cruTiers to the Federal Employees Health Benefits Act and implementing regulations promulgated by OPM. The FEHBP should pay a market price rate, which is defmed as the best rate offered to either of the two groups closest in size to the FEHBP. In contracting with community-rated carriers, OPM relies on catTier compliance with appropriate laws and regulations and, consequently, does not negotiate base rates. OPM negotiations relate primarily to the level of coverage and other unique features of the FEHBP. FEHBP Contracts/Members March 31 The chatt to the right shows that the Health Plan ofNevada, Inc. (Plan) rep01ted 2,912 contracts and 5,725 members for the FEHBP as ofMru·ch 31 for contract yeru· 2012. The Plan has pruticipated in the FEHBP since 1984 and provides health benefits to FEHBP members in the Clru·k, Esmeralda and Nye Cmmties ofNevada. The last audit conducted by om office was a full scope audit and covered contract yeru·s 2009 through 2011 . There were no issues identified dming that audit. 1 Rep01t No. 1C-NM-00-14-056 The preliminary results of this audit were discussed with Plan officials at an exit conference and in subsequent correspondence. Since the audit concluded that the Plan’s rating of the FEHBP was in accordance with applicable laws, regulations, and OPM Rate Instructions to Community- Rated Carriers (rate instructions), a draft report was not issued. 2 Report No. 1C-NM-00-14-056 II. OBJECTIVES, SCOPE, AND METHODOLOGY Objective The primary objectives of the audit were to determine if the Plan offered the FEHBP market price rates and that the loadings to the FEHBP rates were reasonable and equitable. Additional tests were perf01m ed to dete1mine whether the Plan was in compliance with the provisions of the laws and regulations goveming the FEHBP. Scope and Methodology We conducted this perfonnance audit in accordance with generally accepted govemment auditing stan dards. Those stan dards require that we plan and perf01m the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for om findings and conclusions based on om audit objectives. We believe that the evidence obtained provides a reasonable basis for om findings and conclusions based on om audit objectives. This perf01mance audit covered contract year 2012 . For that year, the FEHBP paid approximately $24 .5 million in premiums to the Plan. OIG audits of community-rated caniers are designed to test cruTier compliance with the FEHBP contract, applicable laws and regulations, and the rate instmctions. These audits are also designed to provide reasonable assmance of detecting en ors, inegulru·ities, and illegal acts. We obtained an understanding of the Plan's intem al control structure, but we did not use this inf01m ation to dete1mine th e natme, timing, and extent of om audit procedm es. However, the audit included such tests of the Plan's rating system and such other auditing procedm es considered necessa1y under the circumstan ces. Om review of intem al conti·ols was limited to the procedmes the Plan has in place to ensme that: • The appropriate Similarly Sized Subscriber Groups (SSSG) were selected; • the rates chru·ged to the FEHBP were the m ru·ket price rates (i.e., equivalent to the best rate offered to the SSSGs); an d • the loadings to the FEHBP rates were reasonable and equitable. In conducting the audit, we relied to vruying degrees on computer-generated billing, emolhnent, and claims data provided by the Plan. We did not verify the reliability of the data generated by th e vru·ious infonnation systems involved. However, nothing came to om attention dming om audit testing utilizing the computer-generated data to cause us to doubt its reliability. We believe that the available data was sufficient to achieve om audit objectives. Except as noted above, the 3 Rep01i N o. 1C-NM-00-14-056 audit was conducted in accordance with generally accepted government auditing standards, issued by the Comptroller General of the United States. The audit fieldwork was performed at the Plan’s office in Las Vegas, Nevada in July 2014. We examined the Plan’s federal rate submission and related documents as a basis for validating the market price rates. In addition, we examined the rate development documentation and billings to other groups, such as the SSSGs, to determine if the market price was actually charged to the FEHBP. Finally, we used the contract, the Federal Employees Health Benefits Acquisition Regulations, and the rate instructions to determine the propriety of the FEHBP premiums and the reasonableness and acceptability of the Plan’s rating system. To gain an understanding of the internal controls in the Plan’s rating system, we reviewed the Plan’s rating system policies and procedures, interviewed appropriate Plan officials, and performed other auditing procedures necessary to meet our audit objectives. 4 Report No. 1C-NM-00-14-056 III. RESULTS OF THE AUDIT Our audit showed that the Plan ' s rating of the FEHBP was in accordance with applicable laws, regulations, and the rate instm ctions for contract year 2012. Consequently, the audit did not identify any questioned costs and no conective action is necessary. 5 Rep01i No. 1C-NM-00-14-056 IV. MAJOR CONTRIBUTORS TO THE AUDIT COMMUNITY-RATED AUDITS GROUP , Auditor-in-Charge , Chief , Senior Team Leader Report No. 1C-NM-00-14-056 Report Fraud, Waste, and Mismanagement Fraud, waste, and mismanagement in Government concerns everyone: Office of the Inspector General staff, agency employees, and the general public. We actively solicit allegations of any inefficient and wasteful practices, fraud, and mismanagement related to OPM programs and operations. You can report allegations to us in several ways: By Internet: http://www.opm.gov/our-inspector-general/hotline-to- report-fraud-waste-or-abuse By Phone: Toll Free Number: (877) 499-7295 Washington Metro Area: (202) 606-2423 By Mail: Office of the Inspector General U.S. Office of Personnel Management 1900 E Street, NW Room 6400 Washington, DC 20415-1100 -- 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 (http://www.opm.gov/our-inspector-general), 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. Report No. 1C-NM-00-14-056
Audit of the Federal Employees Health Benefits Program Operations at the Health Plan of Nevada, Inc.
Published by the Office of Personnel Management, Office of Inspector General on 2015-01-14.
Below is a raw (and likely hideous) rendition of the original report. (PDF)