Audit of the Federal Employee Health Benefits Program Operations at UnitedHealthcare Insurance Company, Inc.

Submitting OIG:

Office of Personnel Management OIG

Date Issued:

Monday, October 30, 2023

Agency Reviewed / Investigated:

Office of Personnel Management

Submitting OIG-Specific Report Number:

2022-CRAG-037

Component, if applicable:

Federal Employees Health Benefits Program

External entity, if applicable:

UnitedHealthcare Insurance Company, Inc.

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-CRAG-037.pdf	1.26 MB

Related Open Recommendations

Recommendation Number	Recommendation Status	Significant Recommendation
1	Open	No
We recommend that the Plan research its ER copayments from 2020 to determine the extent to which members were negatively impacted by the discrepancy and rectify any member overpayments.
4	Open	No
We recommend that the Plan strengthen its internal policies and procedures to ensure that it eliminates variances in its FEHBP rate development components.
5	Open	No
We recommend that the Plan strengthen its internal policies and procedures to ensure that pharmacy rebates are properly allocated to the FEHBP and removed from the pharmacy claims in the premium rate development.
6	Open	No
We recommend the Plan update its system and procedural controls for its claims processing system.
7	Open	No
We recommend that the Plan ensures it maintains adequate supporting documentation in accordance with its Contract and the OPM rating instructions.
8	Open	No
We recommend that the Plan ensure that appropriate copayments are applied to claims as defined in the FEHBP benefit brochure.
9	Open	No
We recommend that the Plan ensure claims are not processed for out of network providers as stated in the FEHBP benefit brochure.
10	Open	No
We recommend that the Plan ensure that benefits are properly coordinated, when applicable, with Medicare benefits.
12	Open	No
We recommend that the Plan develop formal written policies and procedures to notify ASG of claims submitted, whether paid or not, after a provider is debarred or suspended in accordance with the Guidelines.
13	Open	No
We recommend that the Plan revise its written policies and procedures to ensure that claims are paid to debarred providers when they meet the specific exceptions defined in the Guidelines.

Recommendation Number

Recommendation Status

Significant Recommendation

Additional Details

Open

We recommend that the Plan research its ER copayments from 2020 to determine the extent to which members were negatively impacted by the discrepancy and rectify any member overpayments.

Open

We recommend that the Plan strengthen its internal policies and procedures to ensure that it eliminates variances in its FEHBP rate development components.

Open

We recommend that the Plan strengthen its internal policies and procedures to ensure that pharmacy rebates are properly allocated to the FEHBP and removed from the pharmacy claims in the premium rate development.

Open

We recommend the Plan update its system and procedural controls for its claims processing system.