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EXECUTIVE SUMMARY:
The objective of this review was to determine if payments to Aetna (Contract H3951) were appropriate for beneficiaries reported as institutionalized. We determined that Aetna received Medicare overpayments totaling $87,516 for 90 beneficiaries incorrectly reported as institutionalized during the period January 1, 1998 through December 31, 2000. Institutional status requirements specify that a beneficiary must be a resident of a qualifying facility for a minimum of 30 consecutive days immediately prior to the first day of the current reporting month. The 90 beneficiaries included 48 that had admittance or discharge dates during the 30-day residency period and 42 beneficiaries residing in facilities not certified for Medicare or Medicaid.