u.s. OFFICE OF PERSONNEL MANAGEMENT OFFICE OF THE INSPECTOR GENERAL OFFICE OF AUDITS Final Audit Report Subject: Audit of the Federal Employees Health Benefits Program Operations at Aetna Open Access - Plan Code PI Report No. lC-PI-OO·10-045 Date: October 19. 2010 -- CAUTION - This audit report has been distributed to Federal officials wbo are respons.ible for the administration of the audited program. This audit report may contain proprietary data whicb is protected by Federal law (18 U.S.C. 1905). Therefore, while tbis 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 tbat was redacted from tbe publicly distributed copy. UNITED STATES OFFICE OF PERSONNEL MANAGEMENT Washington, DC 20415 Office of the Inspector General AUDiT REPORT Federal Employees Health Benefits Program Community-Rated Health Maintenance Organization Aetna Open Access Contract Number 2867 - Plan Code PI Blue Bell, Pennsylvania Report No. IC-PI-OO-IO-045 Date: October J 9i 201 0 MichaelR~ Assistant Inspector General for Audits www.opm.gov www,usajobs.gov UNITED STATES OFFICE OF PERSONNEL MANAGEMENT Washington, DC 20415 Office of the lnspcetor General EXECUTIVE SUMMARY Federal Employees Healtb Benefits Program Community-Rated Healtb Maintenance Organization Aetna Open Access Contract Number 2867 - Plan Code PI Blue Bell, Pennsylvania Report No. IC-PI-00-I0-045 Date: October 19, 2010 The Oflice of the Inspector General perfonned an audit of the Federal Employees Heallh Benefits Program (FEHBP) operations at Aetna Open Access - Plan Code P1 (Plan). The audit covered CODll-aCt years 2005 through 2009 and was conducted at the Plan's office in Blue Bell, Pennsylvania. We found that the FEHBP rates were developed in accordance with applicable laws, regulations. and the Office of Personnel Management's raling instructions for the years audited. 1 WWw.opl1l.g0Y www.usajobs.go... CONTENTS Page EXECUTIVE SUMMARY i I. INTRODUCTION AND BACKGROUND 1 IT. OBJECTIVES, SCOPE, AND METHODOLOGY 3 III. RESULTS OF THE AUDIT 5 IV. MAJOR CONTRIBUTORS TO THIS REPORT 6 T. INTRODUCTION AND BACKGROUND Introduction We completed an audit of the Federal Employees Health Benefits Program (FEHBP) operations at Aetna Open Access - Plan Code P I (Plan). The audit covered contract years 2005 through 2009 and was conducted at the Plan's office in Blue Bell, Pennsylvania. The audit was conducted pursuant to the provisions of Contract CS 2867; 5 U.S.C. Chapter 89; and 5 Code of Federal Regulations (CFR) Chapter I, Part 890. The audit was performed by the Office of Personnel Management's (OPM) Office of the Inspector General (orG), as established by the Inspector General Act of 1978, as amended. Background The 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 OPM's Retirement and Benefits Office. The provisions of the Federal Employees Health Benefits Act are implemented by OPM through regulations codified in Chapter I, Part 890 of Title 5, CFR. Health insurance coverage is provided through cOntracts with various health insurance carriers that provide service benefits, indemnity benefits, or comprehensive medical services. Community-rated carriers participating in the FEHEP are subject to various federal, state and local laws, regulations, and ordinances. While most carriers are subject to state jurisdiction, many are further subject to the Health Maintenance Organization Act of 1973 (public Law 93 222), as amended (i.e., many community-rated carriers are federally qualified). In addition, participation in the FEHBP subjects the carriers to the Federal Employees Health Benefits Act and implementing regulations promulgated by OPM. The FEHBP should pay a market price rate, FEHBP ConlractsiMembers which is defined as the best rate offered to March 31 either of the two groups closest in size to 10,000 the FEHBP. In contracting with community-rated carriers, OPM relies On 8,000 carrier compliance with appropriate laws 6,000 and regulations and, consequently, does not negotiate base rates. OPM negotiations 4,000 relate primarily to the level of coverage and other unique features of the FEHBP. 2,000 The chart to the right shows the number of o 2005 2006 2007 2008 2009 FEHBP contracts and members reported by 3,700 3,849 3,615 3,188 • Contracts 2.958 the Plan as of March 31 for each contract o Members 6,893 8,594 8,829 7,735 6,376 year audited. 1 The Plan has participated in the FEHBP since 2004 and provides health benefits to FEHBP members throughout Austin and San Antonio, Texas. This was the first audit of the Plan conducted by our office. The preliminary results of this audit were discussed with Plan officials at an exit conference and through subsequent correspondence. Since the audit showed that the Plan's rating of the FEHBP was in accordance with applicable laws, regulations, and instructions, we did not issue a draft report. 2 II. OBJECTIVES, SCOPE, AND METHODOLOGY Objectives The primary objectives of the audit were to verifY that the Plan offered market price rates to the FEHBP and to verifY that the loadings to the FEHBP rates were reasonable and equitable. Additional tests were performed to determine whether the Plan was in compliance with the provisions of the laws and regulations governing the FEHBP. FEHBP Premiums Paid to Plan We conducted this performance audit in accordance with generally accepted government auditing standards. Those $40 standards require that we plan and perform the audit to obtain sufficient, 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. This performance audit covered contract years 2005 through 2009. For these years, the FEHBP paid approximately $148.1 million in premiums to the Plan. The premiums paid • Revenue for each contract year audited are shown on the chart to the right. OlG audits of commwlity-rated carriers are designed to test carrier compliance with the FEHEP contract, applicable laws and regulations, and OPM rate instructions. These audits are also designed to provide reasonable assurance of detecting errors, irregularities, and illegal acts. We obtained an understanding of the Plan's internal control structure, but we did not use this information to determine the nature, timing, and extent of our audit procedures. However, the audit included such tests of the Plan's rating system and such other auditing procedures considered necessary under the circumstances. Our review of internal controls was limited to the procedures the Plan has in place to ensure thai: • The appropriate sinlilarly sized subscriber groups (SSSG) were selected; • the rates charged to the FEHBP were the market price rates (i.e., equivalent to the best mte offered 10 SSSGs); and • the loadings to the FEHEP rates were reasonable and equitable. 3 In conducting the audit, we relied to varying degrees on computer-generated billing, enrollment, and claims data provided by the Plan. We did not verifY the reliability of the data generated by the various information systems involved. However, nothing came to our attention during our audit testing utilizing the computer-generated data to cause us to doubt its reliability. We believe that the available data was sufficient to achieve our audit objecti.ves. Except as noted above, the audit was performed 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 Blue Bell, Pennsylvani.a, during May 20 JO. Additional audit work was completed at our offices in Jacksonville, Florida, and Washington, D.C. Methodology We examined the Plan's federal rate submissions and related documents as a basis for validating the market price rates. Further, we examined claim payments to verifY that the cost data used to develop the FEHBP rates was accurate, complete, and valid. 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 OPM's Rate Instructions to Community-Rated Carriers 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's policies and procedures, interviewed appropriate Plan officials, and performed other auditing procedures necessary to meet our audit objectives. 4 III. RESULTS OF mE AUDIT Our audit showed that the Plan's rating of the FEHBP was in accordance with applicable Jaws, regulations, and OPM's rating instructions io carriers for contract years 2005 through 2009. Consequently, the audit did not identify any questioned costs and no corrective action is necessary. 5 IV. MAJOR CONTRIBUTORS TO THIS REPORT Community-Rated Audits Group Auditor-in-Charge ~uditor Auditor Chief Senior Team Leader 6
Audit of the Federal Employees Health Benefits Program Operations at Aetna Open Access -Plan Code P1
Published by the Office of Personnel Management, Office of Inspector General on 2010-10-19.
Below is a raw (and likely hideous) rendition of the original report. (PDF)