| 5 |
No |
$2,500,022 |
$0 |
|
|
We recommend that the contracting officer require Anthem to return $6,489,556 to the FEHBP for the questioned uncollected claim overpayments, whether recovered or not, as prompt and diligent efforts to recover these overpayments were not made timely. However, since we verified that Anthem subsequently recovered and returned $3,971,282 of these questioned claim overpayments to the FEHBP, the contracting officer only needs to ensure that Anthem returns the remaining questioned overpayments of $2,518,274 to the FEHBP.
|
| 1 |
No |
$39,235,156 |
$0 |
|
|
We recommend that the contracting officer disallow $39,235,156 for the subrogation recovery fees that were charged to the FEHBP for contract year 2018 through June 30, 2023, since these fees included unallowable and/or unreasonable profit charges from Anthem's sister company and subrogation vendor (Carelon).
|
| 13 |
No |
$7,739,902 |
$0 |
|
|
We recommend that the contracting officer require Anthem to return $7,739,902 to the FEHBP for the questioned ACA costs that were overcharged to the FEHBP for contract years 2018 and 2020.
|
| 2 |
No |
$5,638,360 |
$0 |
|
|
We recommend that the contracting officer require Anthem to return $5,638,360 to the FEHBP for applicable LII calculated through June 30, 2025, on the questioned subrogation recovery fees that were charged to the FEHBP, as well as LII accruing after June 30, 2025.
|
| 21 |
No |
$0 |
$0 |
|
|
We recommend that the contracting officer require the Association to provide evidence or supporting documentation demonstrating that Anthem has implemented the necessary corrective actions to ensure that unallowable profits are not charged to the FEHBP. The contracting officer should also require the Association to provide a certification that Anthem has implemented these corrective actions.
|
| 3 |
No |
$0 |
$0 |
|
|
We recommend that the contracting officer require Anthem to also return all subrogation recovery fees, which included unallowable and/or unreasonable profit costs, and that were charged to the FEHBP from July 1, 2023, through the resolution of this audit finding, as well as applicable LII.
|
| 4 |
No |
$0 |
$0 |
|
|
We recommend that the contracting officer require the Association to provide evidence or supporting documentation demonstrating that Anthem has implemented the necessary corrective actions to ensure that unallowable and/or unreasonable profit costs are excluded from the Carelon subrogation recovery fees that are charged to the FEHBP. The contracting officer should also require the Association to provide a certification that Anthem has implemented these corrective actions.
|
| 6 |
No |
$0 |
$0 |
|
|
We recommend that the contracting officer require the Association to provide evidence or supporting documentation demonstrating that Anthem has implemented the necessary corrective actions to ensure that claim overpayments are adequately pursued, monitored, recovered, and returned to the FEHBP, as required by Section 2.3(g) of contract CS 1039. The contracting officer should also require the Association to provide a certification that Anthem has implemented these corrective actions.
|
| 10 |
No |
$357,479 |
$0 |
|
|
Due to Anthem's lack of due diligence with recovery efforts, we recommend that the contracting officer require Anthem to return $658,703 to the FEHBP for the questioned provider offsets where Anthem had not recovered and/or returned funds to the FEHBP for three FEP claim overpayments.
|
| 11 |
No |
$0 |
$0 |
|
|
We recommend that the contracting officer require the Association to provide evidence or supporting documentation demonstrating that Anthem has implemented the necessary corrective actions to ensure that cash receipt refunds are timely returned to the FEHBP (i.e., deposited into the FEP investment account within 30 days after receipt and returned to the LOCA via drawdown adjustments within 60 days after receipt). The contracting officer should also require the Association to provide a certification that Anthem has implemented these corrective actions.
|
| 12 |
No |
$0 |
$0 |
|
|
We recommend that the contracting officer require the Association to provide evidence or supporting documentation demonstrating that Anthem has implemented the necessary corrective actions to ensure that all SPI amounts are timely processed and returned to the FEHBP (i.e., deposited into the FEP investment account within 30 days after receipt and returned to the LOCA via drawdown adjustments within 60 days after receipt). The contracting officer should also require the Association to provide a certification that Anthem has implemented these corrective actions.
|
| 15 |
No |
$0 |
$0 |
|
|
We recommend that the contracting officer require the Association to provide evidence or supporting documentation demonstrating that Anthem has implemented the necessary corrective actions to ensure that the ACA health insurance provider fees and federal income taxes related to ACA health insurance provider fees are correctly calculated and charged to the FEHBP. The contracting officer should also require the Association to provide a certification that Anthem has implemented these corrective actions.
|
| 14 |
No |
$1,438,102 |
$0 |
|
|
We recommend that the contracting officer require Anthem to return $1,438,102 to the FEHBP for the questioned LII calculated through June 30, 2025, on the ACA cost overcharges, as well as additional LII accruing after June 30, 2025.
|
| 18 |
No |
$0 |
$0 |
|
|
We recommend that the contracting officer require the Association to provide evidence or supporting documentation demonstrating that Anthem has implemented the necessary corrective actions to ensure that costs that are directly identifiable to the FEP, such as claim overpayment recovery fees, are charged directly to the FEHBP instead of allocated. The contracting officer should also require the Association to provide a certification that Anthem has implemented the corrective actions.
|
| 19 |
No |
$891,405 |
$0 |
|
|
We recommend that the contracting officer require Anthem to return $891,405 to the FEHBP for the unallowable profits that were charged to the FEHBP for contract year 2018 through June 30, 2023.
|
| 20 |
No |
$143,262 |
$0 |
|
|
We recommend that the contracting officer require Anthem to return $143,262 to the FEHBP for the questioned LII calculated through June 30, 2025, on the unallowable profits charged to the FEHBP, as well as additional LII accruing after June 30, 2025.
|
| 24 |
No |
$0 |
$0 |
|
|
We recommend that the contracting officer require the Association to provide evidence or supporting documentation demonstrating that Anthem has implemented the necessary corrective actions to ensure that unallocable cost center expenses are not charged to the FEHBP. The contracting officer should also require the Association to provide a certification that Anthem has implemented these corrective actions.
|
| 27 |
No |
$0 |
$0 |
|
|
We recommend that the contracting officer require the Association to provide evidence or supporting documentation demonstrating that Anthem has implemented the necessary corrective actions to ensure that unallowable and/or unallocable pension and PRB costs are not charged to the FEHBP. The contracting officer should also require the Association to provide a certification that Anthem has implemented these corrective actions.
|
| 30 |
No |
$0 |
$0 |
|
|
We recommend that the contracting officer require the Association to provide evidence or supporting documentation demonstrating that Anthem has implemented the necessary corrective actions to ensure that employee compensation charges are correctly calculated and charged to the FEHBP. The contracting officer should also require the Association to provide a certification that Anthem has implemented these corrective actions.
|
| 31 |
No |
$0 |
$0 |
|
|
We recommend that the contracting officer require the Association to provide evidence or supporting documentation demonstrating that the Association and Anthem have implemented the necessary corrective actions to meet all communication and reporting requirements of fraud and abuse cases that are contained in the Carrier Letter 2017-13.
|
