oversight

Audit of the Federal Employees Dental and Vision Insurance Program Operations as Administered by EmblemHealth Dental For Contract Years 2014 through 2016

Published by the Office of Personnel Management, Office of Inspector General on 2018-09-21.

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

 Audit of the Federal Employees Dental and Vision Insurance
Program Operations as Administered by EmblemHealth Dental
            For Contract Years 2014 through 2016

               Report Number 1J-0L-00-17-051
                    September 21, 2018
             EXECUTIVE SUMMARY 

        Audit of the Federal Employees Dental and Vision Insurance Program Operations
                            as Administered by EmblemHealth Dental
Report No. 1J-0L-00-17-051                                                                    September 21, 2018


Why Did We Conduct the Audit?             What Did We Find?

The objective of the audit was to         We determined that the Plan needs to strengthen its procedures and
determine whether costs charged to the    controls related to the following audit areas:
Federal Employees Dental and Vision
Insurance Program (FEDVIP) and            Annual Accounting Statement Review
services provided to its members for
contract years 2014 through 2016 were        x   The Plan failed to submit its 2016 Annual Accounting
in accordance with Contract Number
                                                 Statements (AAS) to the U.S. Office of Personnel
OPM01-FEDVIP-01AP-5 and
                                                 Management.
applicable Federal regulations.
                                             x   The Plan understated the amount of premiums received in
                                                 its 2014 AAS and inappropriately categorized two line
What Did We Audit?
                                                 items as expenses in its 2014 through 2016 AAS.
The Office of the Inspector General has
                                          Claims Processing Review
completed a performance audit of
EmblemHealth Dental’s (Plan) annual
accounting statements, claims                x   The Plan paid $10,281 in claims to two debarred providers
processing, fraud and abuse program,             in 2015 and 2016.
performance guarantees, and premium
rate proposals as they relate to FEDVIP   Performance Guarantees Review
operations for contract years 2014
through 2016. We conducted a site visit      x   The Plan failed to track and meet numerous performance
from November 6 through                          standards that it guaranteed for 2014 through 2016.
November 16, 2017, at the Plan’s office
in New York, New York. We                 Premium Rate Proposals Review
completed all audit work at our offices
in Washington, D.C. and Cranberry            x   The Plan was unable to support several pricing assumptions
Township, Pennsylvania.                          used in its 2014 premium rate proposal.




                                                       i
	
               ABBREVIATIONS

AAS        Annual Accounting Statements
Act        The Federal Employee Dental and Vision Benefits Enhancement Act
           of 2004
Contract   Contract Number OPM01-FEDVIP-01AP-5
CY         Contract Year
DHHS       U.S. Department of Health and Human Services
FAR        Federal Acquisition Regulations
FEDVIP     Federal Employees Dental and Vision Insurance Program
FWA        Fraud, Waste, and Abuse
OIG        Office of the Inspector General
OPM        U.S. Office of Personnel Management
Plan       EmblemHealth Dental (formerly GHI Dental)




                               ii
	
                         TABLE OF CONTENTS

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

       ABBREVIATIONS ..................................................................................................... ii
	

I.     BACKGROUND ..........................................................................................................1
	

II.    OBJECTIVE, SCOPE, AND METHODOLOGY ....................................................2
	

III.   AUDIT FINDINGS AND RECOMMENDATIONS.................................................6
	

       A. ANNUAL ACCOUNTING STATEMENT REVIEW............................................6
	

            1. Failure to Submit 2016 Annual Accounting Statements....................................6
	
            2. Errors in Annual Accounting Statements ..........................................................7
	

       B. CLAIMS PROCESSING REVIEW ........................................................................8
	

            1. Payments Made to Debarred Providers..............................................................8
	

       C. FRAUD AND ABUSE PROGRAM REVIEW ....................................................10
	

       D. PERFORMANCE GUARANTEES REVIEW .....................................................10
	

            1. Compliance with Performance Standards ........................................................10
	

       E. PREMIUM RATE PROPOSALS REVIEW ........................................................13
	

            1. Unsupported Pricing Assumptions ..................................................................13
	

       APPENDIX (The Plan’s Response to the Draft Report, dated June 26, 2018) 


       REPORT FRAUD, WASTE, AND MISMANAGEMENT
                             I. BACKGROUND

This report details the results of our audit of the Federal Employees Dental and Vision Insurance
Program (FEDVIP) operations as administered by EmblemHealth Dental (Plan) for contract
years 2014 through 2016. 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 FEDVIP was created on December 23, 2004, by the Federal Employee Dental and Vision
Benefits Enhancement Act of 2004 (Act). The Act provided for the establishment of programs
under which supplemental dental and vision benefits are made available to Federal employees,
retirees, and their dependents.

OPM has overall responsibility to maintain the FEDVIP website, act as a liaison and facilitate
the promotion of the FEDVIP through Federal agencies, be responsive on a timely basis to the
carriers’ requests for information and assistance, and perform functions typically associated with
insurance commissions such as the review and approval of rates, forms, and educational
materials.

OPM contracts with the Plan to provide dental coverage to Federal beneficiaries enrolled in the
Plan under the FEDVIP. The Plan’s responsibilities under Contract Number OPM01-FEDVIP-
01AP-5 (Contract) are carried out at its office located in New York, New York. Section I.11 of
the Contract includes a provision, Inspection of Services – Fixed Price, which allows for audits
of the Plan’s FEDVIP operations.

This was the OIG’s first audit of the Plan’s FEDVIP operations. The initial results of this audit
were discussed with Plan officials during an exit conference on February 27, 2018. A draft
report was provided to the Plan on May 24, 2018, for its review and comment. The Plan’s
response to the draft report was considered in preparation of this final report and is included as
an Appendix.




                                                 1                    Report No. 1J-0L-00-17-051 

II. OBJECTIVES, SCOPE, AND METHODOLOGY

 OBJECTIVES

 The main objective of the audit was to determine whether costs charged to the FEDVIP and
 services provided to its members for contract years 2014 through 2016 were in accordance with
 the terms of the Contract and applicable Federal regulations.

 Our specific audit objectives were to determine if:

    Annual Accounting Statement Review

    x	 The premiums received were accurately reported in the 2014 through 2016 annual
       accounting statements (AAS).

    x	 Administrative expenses were allowable, allocable, and reasonable in compliance with
       the Contract and Federal Acquisition Regulation (FAR) Subpart 31.2.

    Claims Processing Review

    x	 The Plan paid claims in accordance with the terms of the Contract, its annual benefit
       brochures, and its internal policies and procedures.

    x	 The Plan paid any dental claims to debarred providers.

    Fraud and Abuse Program Review

    x	 The Plan has an effective fraud and abuse program, and if potential fraud cases are being
       reported to OPM in accordance with the FEDVIP Fraud, Waste, and Abuse (FWA)
       Memorandum.

    Performance Guarantees Review

    x   The Plan accurately measured its performance and complied with any standards
        guaranteed in the Contract.




                                                 2		                Report No. 1J-0L-00-17-051 

   Premium Rate Proposals Review 


   x   The Plan accurately developed its 2014 through 2016 FEDVIP premium rates.

SCOPE AND METHODOLOGY

We conducted this 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 the audit objectives. We believe that the evidence obtained provides a
reasonable basis for our findings and conclusions based on the audit objectives.

This performance audit included reviews of the Plan’s AAS, claims processing, fraud and abuse
program, performance guarantees, and premium rate proposals as they relate to FEDVIP
operations for contract years 2014 through 2016. A site visit was conducted at the Plan’s office
in New York, New York from November 6 through 16, 2017. Additional audit work was
completed at our offices in Washington, D.C. and Cranberry Township, Pennsylvania.

The Plan reported the following premium revenue, dental benefits paid, administrative expenses,
and profit for contract years 2014 through 2016 in its AAS:

       Contract         Premium             Benefits       Administrative
                                                                                  Profit
        Year            Revenue               Paid           Expenses
        2014           $11,054,857         $8,173,917         $674,519          $2,703,755
        2015           $12,288,676        $10,084,272       $1,046,301          $1,545,396
        2016           $14,491,476        $10,865,685       $1,073,523          $2,453,573
        Total          $37,835,010        $29,123,874        $2,794,342         $6,702,724

In planning and conducting the audit, we obtained an understanding of the Plan’s internal control
structure to help determine the nature, timing, and extent of our auditing procedures. This was
determined to be the most effective approach to select areas of audit. For those areas selected,
we primarily relied on substantive tests of transactions and not tests of controls. Additionally,
since our audit would not necessarily disclose all significant matters in the internal control
structure, we do not express an opinion on the Plan’s system of internal controls taken as a
whole.

We also conducted tests of accounting records and other auditing procedures as we considered
necessary to determine compliance with the Contract and 5 Code of Federal Regulations Part
894. Exceptions noted in the areas reviewed are set forth in the “Audit Findings and

                                                3                   Report No. 1J-0L-00-17-051 

Recommendations” section of this report. With respect to the items not tested, nothing came to
our attention that caused us to believe that the Plan had not complied, in all material respects,
with those provisions.

In conducting the audit, we relied to varying degrees on computer-generated data provided by
the Plan. Due to time constraints, we did not verify the reliability of the data generated by the
various information systems involved. However, 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. To determine whether costs charged
to the FEDVIP and services provided to its members for contract years 2014 through 2016 were
in accordance with the terms of the Contract and applicable Federal regulations, we performed
the following audit steps:

   Annual Accounting Statement Review

   x	 We reconciled the Plan’s premiums earned, as reported in the AAS, against the premium
      funds transferred from BENEFEDS to determine if they were accurately reported to
      OPM.

   x	 We met with Plan personnel to determine what allocation methodology was used for
      administrative expenses and reviewed documentation provided to determine
      reasonableness. We reconciled administrative expenses reported in the AAS to the cost
      centers and trial balance to determine if the Plan’s administrative expenses were
      allowable, allocable, and reasonable in compliance with the Contract and FAR Subpart
      31.2. Additionally, we judgmentally selected and reviewed 8 expense accounts for 2014
      through 2016, totaling $1,500,348, out of a universe of 236 expense accounts, totaling
      $2,794,342. Our selection was based on account descriptions with the highest risk of
      being unallowable.

   Claims Processing Review

   x	 Using the EZQuant Random Number Generator, we selected a random sample of 50
      claims per year for 2014 through 2016, totaling 150 claims with an amount paid of
      $29,474, from a universe of 148,061 claims totaling $28,190,583, to determine if they
      were properly paid in accordance with the terms of the Contract, the Plan’s benefit
      brochures, and its internal policies and procedures.

   x	 We ran the U.S. Department of Health and Human Services (DHHS) and OPM’s lists of
      debarred providers against the claims data base to determine if any claims were paid to
      debarred providers.

                                                4		                  Report No. 1J-0L-00-17-051 

   Fraud and Abuse Program Review 


   x	 We met with the Plan to gain an understanding of its fraud and abuse program and
      reviewed policies and procedures for fraud and abuse to ensure that they complied with
      OPM’s FEDVIP FWA Memorandum.

   Performance Guarantees Review

   x	 We compared the Plan’s performance results against each standard that was guaranteed in
      the contract to determine if the Plan met all of the standards and if the performance
      results were accurately reported.

   Premium Rate Proposals Review

   x	 We traced the data used to develop the Plan’s 2014 through 2016 premium rate proposals
      to supporting documentation to determine if the Plan accurately developed its premium
      rates for the FEDVIP.

The samples mentioned above that were selected and reviewed in performing the audit were not
statistically based. Consequently, the results could not be projected to the universe since it is
unlikely that the results are representative of the universe taken as a whole.




                                                5		                  Report No. 1J-0L-00-17-051 

III. AUDIT FINDINGS AND RECOMMENDATIONS

A. Annual Accounting Statement Review

   1. Failure to Submit 2016 Annual Accounting Statements                             Procedural

      The Plan failed to submit its 2016 certified AAS to OPM as required by the Contract.

      Section K.9 of the Contract requires the Plan to submit to OPM a certified AAS summarizing the
      financial results of its FEDVIP operations for the previous fiscal year.
      The Plan did not
                            During the pre-audit process, we requested the Plan’s AAS from OPM and
       report its 2016
                            found that OPM never received the Plan’s 2016 certified AAS. We
     FEDVIP operations
                            notified the Plan of its failure to submit the 2016 certified AAS and
         to OPM as
                            requested a copy for the purpose of our audit. The Plan provided a copy of
      required by the
                            the 2016 AAS to the auditors in September 2017, and stated that the
          Contract.
                            submission of the AAS to OPM was unintentionally delayed due to an
      unexpected staffing change. The auditors provided a copy to OPM for its records.

      The Plan’s failure to submit a certified AAS for 2016 caused OPM to approve the next year’s
      premium rates without knowing the Plan’s financial operations, accuracy of the prior year’s
      premium rates, or profit margin.

      Recommendation 1

      We recommend the Plan implement policies and procedures to ensure a timely submission of its
      certified AAS to OPM by June of each year.

      Plan Response:

      The Plan agrees with the recommendation and says it has implemented a timeline tracking grid
      to ensure timely submissions of the certified AASs by June of each year.

      Recommendation 2

      We recommend that OPM implement procedures to collect and verify the submission of the
      carrier’s AAS for FEDVIP operations in a timely manner, thereby allowing OPM’s Office of
      Actuaries and Program Office the necessary time to assess the carrier’s prior year financial
      results before approving its premium rates.

                                                 6                    Report No. 1J-0L-00-17-051 

   Plan Response:

   The Plan agreed to work with OPM on implementing procedures to collect and verify
   submissions of the AAS in a timely manner.

2. Errors in Annual Accounting Statements                                              Procedural

   The Plan understated premiums received by approximately $2.1 million in its 2014 AAS and
   improperly classified several accounts as expenses in its 2014 through 2016 AAS.

   Section K.9 of the Contract requires the Plan to submit AAS that show the financial results
   for its FEDVIP operations, including actual income received by the Plan and its incurred
   costs that are allowable in accordance with the Federal Acquisition Regulation.

   To determine the accuracy of the net premium received, as reported in the Plan’s AAS, we
   compared the premium amounts that were credited to the Plan by BENEFEDS, FEDVIP’s
   third party administrator, with the premium amounts that were reported in the Plan’s AAS for
   calendar year’s (CY) 2014 through 2016. Our review showed that the Plan understated its
   net premiums received for FEDVIP operations in CY 2014 by $2,092,328. The Plan stated
   that this variance was due to it using a formula to calculate the net premium in its AAS
   (incurred claims plus total expenses minus service charge) instead of reporting actual
   premium received from BENEFEDS during the CY.

   Additionally, we reviewed the claims and administrative expenses reported in the Plan’s
   AAS by recalculating the amounts and tracing the expenses to supporting documentation.
   During this analysis, we determined the Plan improperly included OPM and BENEFEDS
   service charges under the expense category, along with a statutory reserve amount of one
   percent, on the 2014 through 2016 AAS. The service charge is for          The Plan misstated
   OPM’s and BENEFEDS administrative fee, which is collected by                 premiums and
   BENEFEDS and paid directly to OPM with that premium amount                expenses in its AAS
   never going to the Plan. Since the Plan reports net premium, or             that would have
   total premium less BENEFEDS and OPM’s service charge, the Plan              shown a higher
   should not be reporting the service charge as an expense. The Plan               profit.
   also should not be reporting a one percent statutory reserve as an expense. This statutory
   reserve amount is required by state law to help pay claims in the event that the Plan becomes
   insolvent. This amount is held in reserve from the Plan’s profit, is classified as a reserve and
   not an expense, and by law cannot be disbursed except to pay claims in the case of the Plan’s
   insolvency. The Plan stated that these reporting errors were due to the absence of formal
   instructions or a uniform template from OPM.


                                                7                    Report No. 1J-0L-00-17-051 

     By misstating premiums and expenses in its AAS, the Plan did not accurately report its
     profit, which is considered by OPM when approving premium rates.

     Recommendation 3

     We recommend that the Plan create policies and procedures to ensure that its certified AAS
     accurately reports premiums received from BENEFEDS and expenses incurred for FEDVIP
     operations during the CY in accordance with the Federal Acquisition Regulation.

     Plan Response:

     The Plan agrees with the recommendation and states it has created policies and procedures to
     ensure that its certified AAS accurately reports premiums received and expenses incurred for
     FEDVIP operations during the CY in accordance with Federal regulations.

     Recommendation 4

     We recommend that the Plan submit a revised 2014 certified AAS to OPM’s Program Office
     and Office of Actuaries that accurately reports the premiums received and expenses incurred
     during CY 2014.

     Plan Response: 


     The Plan agrees with the recommendation and has submitted a revised AAS for CY 2014. 


     OIG Response:

     After reviewing the revised 2014 AAS, we recommend that the Plan also submit a revised 2015
     and 2016 AAS to accurately show its financial results from FEDVIP operations.

B. CLAIMS PROCESSING REVIEW

  1. Claims Paid to Debarred Providers                                                     $10,281

     The Plan paid $10,281 in claims to two debarred providers listed on both OPM-OIG’s
     Debarment and Sanctions Listing and the DHHS Listing of Excluded Providers.

     The DHHS website (https://oig.hhs.gov/faqs/exclusions-faq.asp) states that “OIG’s [List of
     Excluded Individuals/Entities] provides information to the health care industry, patients and


                                                 8                    Report No. 1J-0L-00-17-051 

  the public regarding individuals and entities currently excluded from participation in 

  Medicare, Medicaid and all other Federal health care programs.”
	

  Additionally, the Plan stated in its internal policies and procedures “On a periodic basis, [the
  OPM] debarment listings are reviewed against the records of all EmblemHealth participating
  dental providers maintained in the Fastrak provider file system.”

                          As part of our claims review, we ran a match of debarred dental
FEDVIP claims were
                          providers from OPM-OIG’s Debarment and Sanctions Listing against
     paid to two
                          the Plan’s paid dental claims for 2014 through 2016. This review
providers that were
                          identified claims totaling $10,281 that were paid to two providers that
 debarred for felony
                          were debarred on OPM-OIG’s Debarment and Sanctions Listing in
   healthcare and
                          2015 and 2016 for felony healthcare and program related convictions.
  program related
                          We also identified the same two providers on the DHHS Listing of
    convictions.
                          Excluded Providers.

  The Plan was unaware of this issue and determined the cause to be a breakdown in its
  debarment review process. The Plan also reported that it will take action by updating its
  records to reflect the debarred status of the two providers and by establishing protocols to
  ensure appropriate actions are taken going forward.

  Because the Plan failed to identify these two providers as being debarred by both the OPM-
  OIG and DHHS, the FEDVIP had $10,281 of Federal employee funds inappropriately paid to
  these two debarred providers, along with an increased risk to patient safety.

  Recommendation 5

  We recommend that the Plan immediately stop payments to these two debarred providers,
  remove them from the Plan’s network, and notify affected members of the patient safety risk.

  Plan Response:

  The Plan agrees with the recommendation and states that it has stopped payments to these
  providers and removed them from the Plan’s network.

  Recommendation 6

  We recommend that the Plan initiate recoveries for the $10,281 that was paid to the debarred
  providers.


                                               9                     Report No. 1J-0L-00-17-051 

     Plan Response:

     The Plan agrees with the recommendation and states that it has initiated recoveries for the
     $10,281 paid to the debarred providers.

     Recommendation 7

     We recommend that OPM create new guidance requiring all Plans to check for debarred
     providers on a monthly basis using the DHHS Listing of Excluded Providers and the OPM-
     OIG’s Debarment and Sanctions Listing (when applicable).

     Plan Response:

     The Plan agreed to work with OPM to create new guidance requiring all Plans to check
     for debarred providers on a monthly basis using the DHHS Listing of Excluded Providers
     and the OPM-OIG’s Debarment and Sanctions Listing, when applicable.

C. FRAUD AND ABUSE PROGRAM REVIEW

  Our review of the Plan’s fraud and abuse program determined that it had sufficient policies and
  procedures in place to help reduce fraud, waste and abuse.

D. PERFORMANCE GUARANTEES REVIEW

  1. Compliance with Performance Standards                                             Procedural

     The Plan failed to track and meet numerous performance standards that it guaranteed in the
     Contract for 2014 through 2016.

     Page 71 and 72 of the Plan’s Response to the FEDVIP Solicitation, which became
     incorporated into the Contract, guaranteed the following performance standards during the
     initial enrollment and on an ongoing basis:                            The Plan did not
                                                                             provide customers
         x   85 percent of calls answered in 30 seconds or less;               with the level of
         x   1 percent or less call abandonment rate;                        performance that it
         x   75 percent of written inquiries answered within 7 days           guaranteed in the
             from receipt;                                                        Contract.
         x   100 percent of written inquiries answered within 30 days
             from receipt;
         x   7.1 day average response rate for written inquiries;
                                                 10                     Report No. 1J-0L-00-17-051 

   x   100 percent of email inquiries answered within 2 days from receipt not requiring
       additional review;
   x   100 percent of email inquiries answered within 7 days from receipt when requiring
       additional review; and
   x   3.3 day average response rate for email inquiries.

To determine if the Plan met its performance standards in 2014 through 2016, we requested
copies of its performance results and compared them to the guarantees listed in the Contract.
Our review showed that the Plan failed to track and meet the following standards.

   x	 Eighty-five percent of calls answered in 30 seconds or less – The Plan was unable to
      answer customer service calls timely in all three years, averaging only 56 to 77
      percent of calls answered in 30 seconds or less with each year getting progressively
      worse.
   x	 One percent or less call abandonment rate – The Plan had a call abandonment rate
      between 2 and 6 percent during the three year audit scope, with 2016 having a
      significant increase in lost calls.
   x	 Seventy-five percent of written inquiries answered within seven days – The Plan
      never tracked or measured this guarantee.
   x	 One hundred percent of written inquiries answered within 30 days – The Plan was
      only able to answer an average of 63 to 80 percent of written inquiries within a 30-
      day period during the three years of our scope.
   x	 Seven point one day average response rate for written inquiries – The Plan never
      tracked or measured this guarantee.
   x	 One hundred percent of email inquiries answered within two days – The Plan
      answered an average of 42 to 87 percent of email inquiries during the three-year
      period with 2016 having the fastest turn around.
   x	 One hundred percent of email inquiries requiring review answered within seven days
      – The Plan never tracked or measured this guarantee.
   x	 Three point three day average response rate for email inquiries – The Plan never
      tracked or measured this guarantee.

When we asked the Plan why the above performance standards were not being tracked or
met, we found that the Plan was unaware that it guaranteed any performance standards in the
Contract.

As a result of the Plan not tracking or meeting the above performance standards, FEDVIP
members did not receive the level of service that was paid for and agreed to in the Contract.



                                            11		                 Report No. 1J-0L-00-17-051 

Recommendation 8

We recommend that the Plan implement corrective action to improve each performance
standard that was not met. The corrective action should include better training, faster
systems, or more customer service staff to properly meet the performance guarantees. There
should be no additional cost to the FEDVIP members for the improvement areas since the
level of customer service was guaranteed under a fixed-price contract.

Plan Response:

The Plan states that there are no performance standards in the current contract, but it is
willing to update the contract with trackable performance standards where appropriate.

OIG Response:

The OIG disagrees with the Plan’s assertion that there are no performance standards in its
current contract with OPM. It clearly states on the second page of the Contract that the
FEDVIP Solicitation and the Plan’s technical cost proposal (Response to the FEDVIP
Solicitation dated February 25, 2013) are incorporated into the Contract. As referenced in
the finding above, pages 71 and 72 of the Plan’s response to the FEDVIP Solicitation (dated
February 25, 2013) states the standards that the Plan guaranteed in the initial enrollment
period and on an ongoing basis. These are the standards the Plan needs to meet to be
compliant with the Contract.

Recommendation 9

We recommend that the Plan update its policies and procedures to properly measure all
performance standards that were guaranteed in the Contract.

Plan Response:

As noted in response to recommendation 8, the Plan will track and report the new
performance standards once the contract is updated.

OIG Response:

The OIG would like to reiterate that the current Contract has performance standards that were
guaranteed for the initial enrollment period and on an ongoing basis. These are the standards
that the Plan needs to properly measure.


                                           12                   Report No. 1J-0L-00-17-051 

     Recommendation 10

     We recommend that OPM review the Plan’s performance standards on a semi-annual basis
     until all of the performance guarantees are being met.

     Plan Response:

     The Plan agreed to work with OPM to review the performance standards on a semi-annual
     basis until all of the performance guarantees are being achieved.

E. PREMIUM RATE PROPOSALS REVIEW

  1.		 Unsupported Pricing Assumptions                                                Procedural

     The Plan was unable to provide sufficient documentation to support the development of its
     2014 FEDVIP rates.

     Section A.6 (Administration and Systems) of the Contract states, "The Contractor must keep
     all records, including enrollment, claims and financial records, for the current year and an
     additional six years."

     For each year of our audit scope, we reviewed the Plan’s premium rates to determine if
     accurate pricing assumptions were used based on supporting documentation. During this
     review, we found the following two instances where the Plan failed to maintain proper
     documentation to support data and assumptions used in the development of its 2014 premium
     rates.

        x	 The Plan used 2012 enrollment statistics for its 2014 proposed rates, in which it
           applied an 8 percent increase for each year after 2012. When the OIG requested
           documentation to support the actual 2012 enrollment statistics and the 8 percent
           increase, the Plan did not have supporting documentation.

        x	 To develop the 2014 premium rates, the Plan increased its 2012 base rate by 1.5
           percent for 2013 and 3.0 percent for 2014 (4.5 percent overall) to account for a
           preferred fee schedule change in each year. When the OIG requested support for the
           4.5 percent rate increase from 2012 to 2014, the Plan reported to the OIG that it does
           not have documentation for the 4.5 percent increase since it was only an estimate.

     Because the Plan failed to maintain supporting documentation for the data and assumptions
     used to develop its 2014 premium rates, we were unable to assess the accuracy of the Plan’s

                                                13		                 Report No. 1J-0L-00-17-051 

base rates for its seven year fixed-price contract. Additionally, we determined that there is an
increased risk that Federal enrollees may be overcharged by the Plan in future years as it
changes its pricing strategies and assumptions over time without maintaining proper
documentation.

Recommendation 11

We recommend that the Plan implement policies and procedures to ensure that all data and
assumptions used to develop each year’s premium rates are properly maintained in
accordance with the Contract’s records retention clause.

Plan Response:

The Plan agrees with the recommendation and states that it will work with OPM to ensure
compliance with any policies and procedures to properly maintain all data and
assumptions used to develop each year’s premium rates.




                                            14                    Report No. 1J-0L-00-17-051 

                                                                APPENDIX

    EmblemHealth 

    55 Water Street, New York, New York 10041-8190




    June 26, 2018



    Chief Special Audits Group
    Office of Personnel Management
    1900 "E" Street, N.W. Room 6400
    Washington, DC 20414

    Re: Federal Employees Dental and Vision Insurance Program (FEDVIP)
       Audit # 1J-0L-00-17-051

    Dear                   ,

    On behalf of the EmblemHealth Federal Employees Dental Insurance Program (FEDVIP), please
    find our responses to the 2014 2016 Draft Audit #1J-0L-00-17-051 findings.

    We appreciate the opportunity to provide comments to the audit findings. The attached
    documentation includes our responses and any additional information asked for.

    Please contact me with any additional questions.




Group Health Incorporated (GHI). HIP Health Plan of New York (HIP). HIP Insurance Company of New York and EmblemHealth Services Company. LLC are EmblemHealth companies 

                                     EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies. 



                                                                                                                 Report No. 1J-0L-00-17-051
                               Audit of the Federal Employees 

                      Dental and Vision Insurance Program Operations 

                         As Administered by EmblemHealth Dental 

                           For Contract Years 2014 through 2016 

                              Report Number 1J-0L-00-17-051 


                     EmblemHealth responses to Audit Findings

Finding:
Failure to Submit 2016 Annual Accounting Statements, EmblemHealth Dental (Plan) failed to
submit its 2016 certified annual accounting statements (AAS) to the U.S. Office of Personnel
Management (OPM)

Recommendation 1:
We recommend the Plan implement policies and procedures to ensure a timely submission of its
certified AAS to OPM by June of each year.

The Plan is in agreement with recommendation 1: The Plan has implemented a timeline
tracking grid to ensure timely submissions of its certified AAS to OPM by June of each year.

Recommendation 2:
We recommend that OPM implement procedures to collect and verify the submission of the
carrier’s AAS for FEDVIP operations in a timely manner, thereby allowing OPM’s Office of
Actuaries and Program Office the necessary time to assess the carrier’s prior year financial results
before approving its premium rates.

The Plan will work with OPM on any recommendation of implementing procedures to collect
and verify the submission of the carrier’s AAS for FEDVIP operations in a timely manner.

Finding:
Errors in Annual Accounting Statements (Procedural), the Plan understated premiums received by
approximately $2.1 million in its 2014 AAS and improperly classified several accounts as
expenses in its 2014 through 2016 AAS

Recommendation 3:
We recommend that the Plan create policies and procedures to ensure that its certified AAS
accurately reports premiums received from BENEFEDS and expenses incurred for FEDVIP
operations during the CY in accordance with the Federal Acquisition Regulations.


                                                                      Report No. 1J-0L-00-17-051
The Plan is in agreement with recommendation 3: The Plan has created policies and procedures to
ensure that it’s certified AAS accurately reports premiums received from BENEFEDS and expenses
incurred for FEDVIP operations during the CY in accordance with the Federal Acquisition
Regulations. The Premium for the FEDVIP Program is taken from the GHI General Ledger for the
12 months ended at December 3f. The premium in the general ledger for the FEDVIP Program
represents premium billed and received during the calendar year. Claims Incurred- Claims incurred
represents the paid claims plus the change in the 1BNR for the 12 month period ended December
315`. This amount is taken from the general ledger for the GHI FEDVIP Plan. Administrative
Expenses — Administrative expenses for the FEDVIP Plan represent all allowable and
reasonable expenses incurred relating to the Plan for the 12 month period ended December
and is consistent with the FAR guidance provided by OPM.

Recommendation 4:
We recommend that the Plan submit a revised 2014 certified AAS to OPM’s Program Office and
Office of Actuaries that accurately reports the premiums received and expenses incurred during
CY 2014.

The Plan is in agreement with recommendation 4: The Plan attached a revised 2014 AAS reports to
OPM’s Program Office and Office of Actuaries that accurately reports the premiums received and
expenses incurred during CY 2014.

Finding:
Claims Paid to Debarred Providers, the Plan paid $10,281 in claims to two debarred providers in
2015 and 2016.

Recommendation 5:
We recommend that the Plan immediately stop payments to these two debarred providers remove
them from the Plan’s network, and notify affected members who received services of the patient
safety risk.

The Plan is in agreement with recommendation 5: The plan has stopped payments to these two
debarred providers and removed the providers from the Plan’s network.

Recommendation 6:
We recommend that the Plan initiate recoveries for the $10,281 that was paid to the
debarred providers.

The Plan is in agreement with recommendation 6: The Plan has initiated recoveries for the
$10,281 that was paid to the debarred providers.

                                                                      Report No. 1J-0L-00-17-051
Recommendation 7:
We recommend that OPM create new guidance requiring all Plans to check for debarred
providers on a monthly basis using the DHHS Listing of Excluded Providers and the OPM-
01G’s Debarment and Sanctions Listing (when applicable).

The Plan is willing to work with OPM to create new guidance requiring all Plans to check for
debarred providers on a monthly basis using the DHHS Listing of Excluded Providers and the
OPM-OIG’s Debarment and Sanctions Listing (when applicable).

Finding:
Compliance with Performance Standards, the Plan failed to track and meet numerous
performance standards that it guaranteed for 2014 through 2016.

Recommendation 8:
We recommend that the Plan implement corrective action to improve each performance standard
that was not met. The corrective action should include better training, faster systems, or more
customer service staff to properly meet the performance guarantees. There should be no
additional cost to the FEDVIP members for the improvement areas since the level of customer
service was guaranteed under a fixed-price contract.

The Plan notes that there are no performance standards in the current contract with OPM. The
Plan is more than willing to engage with the contract to suggest and track performance standards
as recommended and appropriate.

Recommendation 9:
We recommend that the Plan update its policies and procedures to properly measure all
performance standards that were guaranteed in the Contract.

As noted in the above response to recommendation # 8, upon completion of the updated
contract, the Plan will track and report the established performance standards.

Recommendation 10:
We recommend that OPM review the Plan’s performance standards on a semi-annual basis until
all of the performance guarantees are being met.

The Plan will work with OPM and will review the Plan’s performance standards on a semi-
annual basis until all of the performance standards are being achieved.




                                                                    Report No. 1J-0L-00-17-051
Finding: Premium Rate Proposal Review, the Plan was unable to support several pricing
assumptions used in its 2014 premium rate proposal.

Recommendation 11:
We recommend that the Plan implement policies and procedures to ensure that all data and
assumptions used to develop each year’s premium rates are properly maintained in accordance
with the Contract’s records retention clause.

The Plan is in agreement with recommendation 11: The Plan will work with OPM to ensure
that we comply with any policies and procedures to ensure that all data and assumptions used
to develop each year’s premium rates are properly maintained.

                            Attachment -2014 Revised AAS 

                         Removed by OIG for Reporting Purposes
	




                                                                 Report No. 1J-0L-00-17-051
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              Mismanagement
	
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