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

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Date Issued

Monday, October 30, 2023

Submitting OIG

Office of Personnel Management OIG

Other Participating OIGs

Office of Personnel Management OIG

Agencies Reviewed/Investigated

Office of Personnel Management

Components

Federal Employees Health Benefits Program

Report Number

2022-CRAG-037

Report Type

Audit

Agency Wide

Yes

Number of Recommendations

Questioned Costs

Funds for Better Use

External Entity

UnitedHealthcare Insurance Company, Inc.

Open Recommendations

This report has 10 open recommendations.

Recommendation Number	Significant Recommendation	Recommended Questioned Costs	Recommended Funds for Better Use
1	No	$0	$0
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	No	$0	$0
We recommend that the Plan strengthen its internal policies and procedures to ensure that it eliminates variances in its FEHBP rate development components.
14	No	$0	$0
We recommend that the Plan update its FWA referral process to comply with CL 2017-13 and the supplemental guidance to the Guidelines.
5	No	$0	$0
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	No	$0	$0
We recommend the Plan update its system and procedural controls for its claims processing system.
8	No	$0	$0
We recommend that the Plan ensure that appropriate copayments are applied to claims as defined in the FEHBP benefit brochure.
9	No	$0	$0
We recommend that the Plan ensure claims are not processed for out of network providers as stated in the FEHBP benefit brochure.
10	No	$0	$0
We recommend that the Plan ensure that benefits are properly coordinated, when applicable, with Medicare benefits.
12	No	$0	$0
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.
16	No	$0	$0
We recommend that the Plan strengthen its procedures for requesting proof of family member eligibility and removing ineligible family member enrollments as outlined in CL 2020-16.