Office of Personnel Management, Office of Inspector General | U.S. Office of Personnel Management | Audit of the Federal Employees Health Benefits Program Operations at Aetna Open Access

Audit of the Federal Employees Health Benefits Program Operations at Aetna Open Access - Pittsburgh and Western Pennsylvania

Published by the Office of Personnel Management, Office of Inspector General on 2014-03-14.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

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 –
Pittsburgh and Western Pennsylvania

Report No. 1C-YE-00-13-067

Date: March 14, 2014

-- 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.
AUDIT REPORT

Federal Employees Health Benefits Program
Community-Rated Health Maintenance Organization
Aetna Open Access – Pittsburgh and Western Pennsylvania
Contract Number CS 2867 - Plan Code YE
Blue Bell, Pennsylvania

Report No. 1C-YE-00-13-067 Date: 3/14/14

Michael R. Esser
Assistant Inspector General
for Audits

Report No. 1C-YE-00-13-067 Date: 3/14/14

The Office of the Inspector General performed an audit of the Federal Employees Health
Benefits Program (FEHBP) operations at Aetna Open Access – Pittsburgh and Western
Pennsylvania (Plan). The audit covered contract years 2007 through 2011, and was conducted
from our offices located in Washington, D.C.; Cranberry Township, Pennsylvania; and
Jacksonville, Florida. We found that the FEHBP rates were developed in accordance with
applicable laws, regulations, and the Office of Personnel Management’s Rate Instructions to
Community-Rated Carriers for the years audited.

i
CONTENTS

Page

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

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

II. OBJECTIVES, SCOPE, AND METHODOLOGY ......................................................... 3

III. RESULTS OF THE AUDIT ............................................................................................ 5

IV. MAJOR CONTRIBUTORS TO THIS REPORT ............................................................ 6
I. INTRODUCTION AND BACKGROUND
Introduction

We completed an audit of the Federal Employees Health Benefits Program (FEHBP) operations
at Aetna Open Access – Pittsburgh and Western Pennsylvania (Plan). The audit covered contract
years 2007 through 2011, and was conducted from our offices located in Washington, D.C.;
Cranberry Township, Pennsylvania; and Jacksonville, Florida. 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 1, Part 890. 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 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 Healthcare and Insurance Office. The provisions of the Federal Employees Health
Benefits Act are implemented by OPM through regulations codified in Chapter 1, Part 890 of
Title 5, CFR. Health insurance coverage is provided through contracts with health insurance
carriers who provide service benefits, indemnity benefits, or comprehensive medical services.

Community-rated carriers participating in the FEHBP 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 FEHBP Contracts/Members
March 31
rate, which is defined as the best rate
offered to either of the two groups closest 5,000
in size to the FEHBP. In contracting with 4,500
community-rated carriers, OPM relies on 4,000
carrier compliance with appropriate laws 3,500
and regulations and, consequently, does 3,000
2,500
not negotiate base rates. OPM negotiations
2,000
relate primarily to the level of coverage
1,500
and other unique features of the FEHBP. 1,000
500
The chart to the right shows the number of 0
FEHBP contracts and members reported by 2007 2008 2009 2010 2011
Contracts 893 1,274 1,628 1,807 1,943
the Plan as of March 31 for each contract Members 2,344 3,234 3,891 4,207 4,682
year audited.

1
The Plan has participated in the FEHBP since 2002 and provides health benefits to FEHBP
members in Pittsburgh and Western Pennsylvania. This is 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
in subsequent correspondence. Since the audit concluded that the Plan’s rating of the FEHBP
was in accordance with applicable laws, regulations, and OPM’s Rate Instructions to Community
Rated Carriers (rate instructions), a draft report was not issued.

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.

Scope
FEHBP Premiums Paid to Plan

We conducted this performance audit in
accordance with generally accepted government $20
$18
auditing standards. Those standards require that $16

Millions
we plan and perform the audit to obtain $14
$12
sufficient, appropriate evidence to provide a $10
reasonable basis for our findings and conclusions $8
based on our audit objectives. We believe that $6
$4
the evidence obtained provides a reasonable $2
basis for our findings and conclusions based on $0
2007 2008 2009 2010 2011
our audit objectives. Revenue $6.0 $9.7 $12.7 $15.0 $19.0

This performance audit covered contract years
2007 through 2011. For these years, the FEHBP paid approximately $62.4 million in premiums
to the Plan, as shown on the chart above.

OIG audits of community-rated carriers are designed to test carrier compliance with the FEHBP
contract, applicable laws and regulations, and the 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 that:

 The appropriate similarly sized subscriber groups (SSSG) were selected;

 the rates charged to the FEHBP were the market price rates (i.e., equivalent to the best
rate offered to the SSSGs); and

 the loadings to the FEHBP rates were reasonable and equitable.

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
3
that the available data was sufficient to achieve our audit objectives. Except as noted above, the
audit was conducted in accordance with generally accepted government auditing standards,
issued by the Comptroller General of the United States.

The audit fieldwork was conducted from our offices located in Washington, D.C.; Cranberry
Township, Pennsylvania; and Jacksonville, Florida.

Methodology

We examined the Plan’s Federal rate submissions 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
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 instructions for contract years 2007 through 2011. 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

, Auditor –in-Charge

, Lead Auditor

, Auditor

Chief

Senior Team Leader