Audit of Claims Processed in Accordance with the Omnibus Budget Reconciliation Acts of 1990 and 1993 at All Blue Cross and Blue Shield Plans for Contract Years 2019 through 2021

Submitting OIG:

Office of Personnel Management OIG

Date Issued:

Tuesday, June 27, 2023

Agency Reviewed / Investigated:

Office of Personnel Management

Submitting OIG-Specific Report Number:

2022-CAAG-035

Component, if applicable:

Federal Employees Health Benefits Program

External entity, if applicable:

Blue Cross and Blue Shield Association

Location(s):

Agency-Wide

Type of Report:

Audit

Questioned Costs:

Funds for Better Use:

Number of Recommendations:

Report updated under NDAA 5274:

View Document:

Attachment	Size
2022-CAAG-035.pdf	391.3 KB

Recommendation Number	Recommendation Status	Significant Recommendation
1	Open	No
We recommend that the contracting officer disallow $437,982 in overcharges to the FEHBP. To date, overpayments totaling $64,461 have been recovered, leaving a remaining amount of $373,521 due to the FEHBP.
2	Open	No
We recommend that the contracting officer disallow $7,166,608 in overcharges to the FEHBP. To date, overpayments totaling $1,305,776 have been recovered, leaving a remaining amount of $5,860,832 due to the FEHBP.
3	Open	No
We recommend that the contracting officer allow $96,784 in underpayments to the FEHBP and direct the Association to instruct the local BCBS Plans to make the necessary adjustments and issue payments to the providers and/or members.
4	Open	No
We recommend that the contracting officer ensure that the Association continues recovery efforts and that the FEHBP is properly credited for all FY 2022 monies recovered for the nine months of FY 2022 not covered by this audit.
5	Open	No
We recommend that the contracting officer disallow $5,509,432 in overcharges to the FEHBP. To date, overpayments totaling $2,266,366 have been recovered, leaving a remaining amount of $3,243,066 due to the FEHBP.
6	Open	No
We recommend that the contracting officer direct the Association to institute policies and procedures to run reports of claims with the X52 errors within 30 days of any software update effecting pricing, to issue to its local BCBS Plans for review and repricing.
7	Open	No
We recommend that the contracting officer disallow $9,464,843 in overpayments estimated from our expanded sample. In addition, we recommend the contracting officer direct the Association to complete its review of the expanded sample and the appropriate amounts to be paid to determine the actual overpayment to the FEHBP.
8	Open	No
We recommend that the contracting officer disallow $340,079 in overcharges to the FEHBP.
9	Open	No
We recommend that the contracting officer direct the Association to update its FAM to instruct local BCBS Plans to manually price claim lines with modifiers requiring medical review/approval at the appropriate Medicare amount with applicable modifier price adjustments.
10	Open	No
We recommend the contracting officer direct the Association to consider requiring its OBRA vendor to return a price for all claims initially, even if the claims require medical review/approval, to ensure that a price is available following the review.

Recommendation Number

Recommendation Status

Significant Recommendation

Additional Details

Open

We recommend that the contracting officer disallow $437,982 in overcharges to the FEHBP. To date, overpayments totaling $64,461 have been recovered, leaving a remaining amount of $373,521 due to the FEHBP.

Open

We recommend that the contracting officer disallow $7,166,608 in overcharges to the FEHBP. To date, overpayments totaling $1,305,776 have been recovered, leaving a remaining amount of $5,860,832 due to the FEHBP.

Open

We recommend that the contracting officer allow $96,784 in underpayments to the FEHBP and direct the Association to instruct the local BCBS Plans to make the necessary adjustments and issue payments to the providers and/or members.

Open

We recommend that the contracting officer ensure that the Association continues recovery efforts and that the FEHBP is properly credited for all FY 2022 monies recovered for the nine months of FY 2022 not covered by this audit.