A biweekly publication from the Healthcare Group at Feeley & Driscoll, P.C.
Please visit us at our website: www.fdcpa.com/healthcare.htm. This OIG Update is also accessible from the F&D website, by visiting www. fdcpa.com/oig.updates.htm.
In This Issue
- Physical Therapy Billed by Physicians (OEI-09-02-00200)
- Review of Ambulance Services Provided by American Medical Response of Massachusetts, Inc. (A-01-04-00502)
- Monitoring Medicare Part B Drug Prices: A Comparison of Average Sales Prices to Average Manufacturer Prices (OEI-03-04-00430)
- Review of Controls to Report Wage Data at Citrus Memorial Hospital for the Period of October 1, 2002 , Through September 30, 2003 (A-04-05-02003)
- Also today OIG posts updated exclusion and reinstatement files, to the website.
- Medicaid Graduate Medical Education in Texas (A-06-06-00027)
- OIG Notifies Tenet of Potential Exclusion of Alvarado Hospital
- Review of Medicaid Claims for Assisted Living Program Beneficiaries Who Are Hospitalized (A-02-05-01003)
- Review of the Saint Francis Hospital's Controls to Ensure Accuracy of Wage Data Used for Calculating Inpatient Prospective Payment System Wage Indexes (A-02-05-01004)
- Graduate Medical Education for Dental Residents Claimed by Ohio State University Hospital for Fiscal Years 2000 through 2002 (A-04-04-06009)
- Review of St. Joseph Hospital 's Reported Fiscal Year 2004 Wage Data (A-09-05-00040)
- Review of Medicare Inpatient Wage Rate Assignment at Lehigh Valley Hospital , Allentown , Pennsylvania (A-03-05-00003)
- Review of Medicaid Support for Graduate Medical Education in Iowa (A-07-04-03055)
- University of Maryland Medical Center 's Organ Acquisition Costs for State Fiscal Year 2003 (A-03-04-00010)
1. Physical Therapy Billed by Physicians (OEI-09-02-00200)
The OIG found that approximately 91 percent of physical therapy billed by physicians in the first 6 months of 2002 did not meet program requirements. These inappropriately paid services cost the program and its beneficiaries approximately $136 million. Because of inadequate documentation, reviewers had difficulty assessing the quality of the therapy services. In addition, the OIG identified aberrances in physicians' billing patterns and unusually high volumes of claims that suggest physical therapy is vulnerable to abuse. Finally, physical therapy billed "incident to" physicians' professional services and rendered by unskilled and/or unlicensed personnel represent a vulnerability that could be placing beneficiaries at risk of receiving services that do not meet professionally recognized standards of care. To address these issues, the OIG recommends CMS should consider revisions, clarifications, and further study of the "incident to" rule to ensure that Medicare beneficiaries are receiving skilled services from appropriately trained and licensed staff and that the services meet professionally recognized standards of care.
To access the full article: http://www.oig.hhs.gov/oei/reports/oei-09-02-00200.pdf
2. Review of Ambulance Services Provided by American Medical Response of Massachusetts, Inc. (A-01-04-00502)
The OIG’s objective was to determine whether Medicare payments for ambulance transports and services provided by American Medical Response of Massachusetts, Inc., and (AMR) met Medicare reimbursement requirements. For 43 of 100 sampled beneficiaries, medical reviewers determined that AMR received $11,690 in Medicare payments for ambulance transports for the period July 1 through December 1, 2002 . The OIG recommended that AMR develop better controls and work with the Massachusetts carrier to reimburse the Medicare program for the estimated overpayment. In its response to the OIG’s draft report, AMR stated that it has adequate controls in place as a result of its compliance program established under its Corporate Integrity Agreement. AMR agreed with $2,357, or about 20 percent, of the OIG’s sampled errors.
To access the full article: http://www.oig.hhs.gov/oas/reports/region1/10400502.pdf
3. Monitoring Medicare Part B Drug Prices: A Comparison of Average Sales Prices to Average Manufacturer Prices (OEI-03-04-00430)
In 2005, Medicare began paying for most Part B drugs using a new methodology based on average sales prices (ASP). Pursuant to section 1847A(d)(3) of the Social Security Act, OIG must notify the Secretary of the Department of Health and Human Services if the ASP for a particular drug exceeds the drug's average manufacturer price (AMP) by a threshold of 5 percent. If that threshold is met, the Secretary has the authority to lower the reimbursement amount for the drug to 103 percent of the AMP. In this inspection, OIG found that ASPs for certain payment codes exceeded AMPs by at least 5 percent; however, the payment codes that met the threshold differed depending on the method used to calculate volume-weighted ASPs and AMPs. OIG believes that the way CMS currently calculates the ASP for a payment code is incorrect, and has proposed an alternate method for calculating the ASP. For 34 payment codes, the volume-weighted ASP exceeded the volume-weighted AMP by at least 5 percent regardless of whether CMS's or OIG's calculation was used. An additional four codes met the 5-percent threshold using OIG's calculation but not CMS's calculation. Another 17 codes met the 5-percent threshold using CMS's calculation but not OIG's calculation.
The OIG believes it is critical that CMS modify its ASP calculation as soon as possible, both to ensure that reimbursement amounts are calculated correctly and to ensure that future comparisons between ASPs and AMPs yield the most meaningful results. CMS indicated that the information in the OIG’s report would be helpful in its continuing efforts to monitor payment adequacy under the ASP methodology. However, CMS did not address either the incorrect calculation or the impact it has on the comparison between ASPs and AMPs. Although CMS acknowledges the Secretary's authority to adjust the ASP payment limits when certain conditions are met, it believes that other issues should be considered, including the timing and frequency of pricing comparisons, stabilization of ASP reporting, the effective date and duration of rate substitution, and the accuracy of the ASP and AMP data.
To read the full article: http://www.oig.hhs.gov/oei/reports/oei-03-04-00430.pdf
4. Review of Controls to Report Wage Data at Citrus Memorial Hospital for the Period of October 1, 2002, Through September 30, 2003 (A-04-05-02003)
The objective of the OIG’s review was to determine whether Citrus Memorial Hospital (the hospital) complied with Medicare requirements for reporting wage data in its fiscal year (FY) 2003 Medicare cost report. The hospital did not fully comply with Medicare requirements for reporting wage data in its FY 2003 Medicare cost report. The hospital overstated its wage data by $2,365,729 and 57,897 hours. The OIG recommended that the hospital submit a revised FY 2003 Medicare cost report to the fiscal intermediary and implement review and reconciliation procedures to ensure that the wage data reported on future Medicare cost reports is accurate, supportable, and in compliance with Medicare requirements. In written comments on the draft report, the hospital agreed with the OIG’s findings and recommendations.
To read the full article: http://www.oig.hhs.gov/oas/reports/region4/40502003.pdf
5. Also today OIG posts updated exclusion and reinstatement files, to the website.
This is the full "Updated LEIE" database file reflecting all OIG exclusion and reinstatement actions up to, and including, those taken in April of 2006. This new, "Updated LEIE" (List of Excluded Individuals and Entities) is a complete database file containing all exclusions currently in effect. Individuals and entities that have been reinstated to the federal health care programs are not included in this file.
This is meant to REPLACE the "Updated LEIE" file made available for download last month. The new file is complete and should NOT be used in conjunction with the monthly exclusion and reinstatement supplements. You can download the full "Updated LEIE" from here: http://oig.hhs.gov/fraud/exclusions/database.html#1
If, though, you are one of the few continuing to use the "Standard LEIE" database file you will need to add the exclusion as well as the reinstatement actions taken in April. These monthly supplement files, which have other uses as well, are both available for download from here: http://oig.hhs.gov/fraud/exclusions/database.html#2
All of these downloadable files are zipped, self-extracting .dbf files, meaning that they will not open automatically when you click on the links. After you have downloaded the files to your computer (or "disk" in technospeak) and inflated them, the files must be opened into either a spreadsheet program such as Excel, or a database program such as Access.
Basic download instructions are provided on the OIG website here: http://oig.hhs.gov/fraud/exclusions/instructions.html. If you would like to have some more comprehensive download instructions emailed to you, just let us know.
Finally, it should be added, the full LEIE database -- complete with these updates -- is included in the OIG "Online Searchable Database" which is very user-friendly and may be accessed here: http://exclusions.oig.hhs.gov/search.html
As always, if you are not completely comfortable with these procedures you might want to call your local, friendly computer person who can do the download -- or give us a holler (contact information below).
Also, today, OIG updates the corporate integrity agreement section of the website with the following changes. You can reach the CIA listings -- and from there the full agreements -- through this link: http://oig.hhs.gov/fraud/cia/index.html
NOTE: Documents on the OIG's CIA site printed in black, not underlined and not "clickable" are not "Stand-Alone OIG CIAs" but actually "Settlements with Integrity Provisions". These settlement agreements are issued by the Department of Justice (DOJ) and their full text is not available from the HHS OIG.
Some background on CIAs can be found under "General Information" by following this link: http://oig.hhs.gov/fraud/cias.html. A listing of some Frequently Asked Questions related to OIG CIAs is here: http://oig.hhs.gov/fraud/cia/docs/ciafaq1.html
6. Medicaid Graduate Medical Education in Texas (A-06-06-00027)
The OIG’s objectives were to analyze Texas's Medicaid Graduate Medical Education (GME) payment formula and the methods Texas used to establish the amount of funds that individual hospitals would receive and to determine whether (1) Texas followed the approved State plan in administering the Medicaid GME program and (2) intergovernmental transfers (IGTs) included any program funds. The State made unallowable Medicaid GME payments to ineligible hospitals totaling $318,778 ($175,323 Federal share). The OIG recommended that Texas refund $318,778 ($175,323 Federal share) to CMS for the overpayments made to ineligible hospitals and review the eligibility of each teaching hospital annually. Texas partially agreed with the OIG’s findings and recommendations. State officials have recouped $256,735 and plan to recoup an additional $14,739. State officials will review the remaining $47,304 and recoup any unallowable amounts.
To read the full article: http://www.oig.hhs.gov/oas/reports/region6/60600027.pdf
7. OIG Notifies Tenet of Potential Exclusion of Alvarado Hospital
Inspector General Daniel R. Levinson announced today that the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) has notified Alvarado Hospital Medical Center (Alvarado) and its parent company, Tenet HealthSystem Hospitals, Inc., of OIG's intent to exclude Alvarado from participation in Medicare, Medicaid, and all other Federal health care programs. Today's notice is based on OIG's allegation that Alvarado knowingly and willfully paid kickbacks in order to induce referrals of patients to Alvarado for the furnishing of items and services payable by Federal health care programs.
To get to the full release: http://www.oig.hhs.gov/publications/docs/press/2006/Alvarado%20MW%20Press%20Release%205.8.061.pdf
To access the Advisory Opinion document, 06-05 (concerning a research hospital's practice of providing drugs and supplies to its affiliates for administration to the hospital's patients receiving treatment at the affiliates) go here:
http://www.oig.hhs.gov/fraud/docs/advisoryopinions/2006/AdvOpn06-05.pdf
8. Review of Medicaid Claims for Assisted Living Program Beneficiaries Who Are Hospitalized (A-02-05-01003)
The OIG’s objective was to determine whether Assisted Living Programs ( ALPs ) within New York State were improperly claiming Medicaid reimbursement when their residents were in hospitals or nursing homes. State regulations prohibit Medicaid claims for ALP residents who are hospitalized or in nursing homes. Assisted Living Programs improperly claimed Medicaid reimbursement for their residents who were in hospitals, but not in nursing homes. The OIG’s report recommended that the State: (1) institute eMedNY edits and ensure that they are effective to prevent ALPs from claiming and receiving Medicaid reimbursement when their residents are hospitalized, (2) utilize the OIG’s database of 2,615 potentially improper claims to determine the amount of improper Medicaid reimbursement claimed by the ALPs for their residents who were in hospitals and return the Federal share of these overpayments to the Federal Government, and (3) reinforce its guidance to ALP providers that State regulations prohibit claims for their residents who are hospitalized. The State disagreed with the OIG’s findings and two of the OIG’s three recommendations. The OIG believe that the OIG’s findings and recommendations are valid.
To read the full article: http://www.oig.hhs.gov/oas/reports/region2/20501003.pdf
9. Review of the Saint Francis Hospital's Controls to Ensure Accuracy of Wage Data Used for Calculating Inpatient Prospective Payment System Wage Indexes (A-02-05-01004)
The objective of the OIG’s review was to determine whether Saint Francis Hospital (the hospital) complied with Medicare requirements for reporting wage data in its fiscal year (FY) 2003 Medicare cost report. The hospital did not fully comply with Medicare requirements for reporting wage data in its FY 2003 Medicare cost report. The hospital overstated its salaries by $310,562 and understated its hours by 10,940.
The OIG recommended that the hospital (1) submit a revised FY 2003 Medicare cost report to the fiscal intermediary and (2) implement review and reconciliation procedures to ensure that the wage data reported on future Medicare cost reports are accurate, supportable, and in compliance with Medicare requirements. The hospital concurred with four of the OIG’s findings, but disagreed with the OIG’s finding on unfunded pension and postretirement benefit costs.
To read the full article: http://www.oig.hhs.gov/oas/reports/region2/20501004.pdf
10. Graduate Medical Education for Dental Residents Claimed by Ohio State University Hospital for Fiscal Years 2000 through 2002 (A-04-04-06009)
The OIG’s objective was to determine whether Ohio State University Hospital (the Hospital) included the appropriate number of dental residents in its full-time equivalent (FTE) counts when computing Medicare graduate medical education (GME) payments for fiscal years (FYs) 2000 through 2002. The Hospital inappropriately included a total of 75.04 direct GME FTEs and 92.29 indirect GME FTEs in the counts for FYs 2000 through 2002 without incurring all of the costs of training dental residents in nonhospital sites for those years. As a result, the Hospital overstated its direct and indirect GME claims by a total of $3.5 million for FYs 2000 through 2002.
The OIG recommended: that the Hospital file an amended cost report that will result in a refund of $3,524,633; that the Hospital establish and follow written procedures to ensure that the FTE counts for residents in nonhospital settings include only those FTEs for which the Hospital has incurred all or substantially all of the training costs; and that the Hospital determine whether errors similar to those identified in the OIG’s review occurred in Medicare cost reports after FY 2002 and refund any overpayments. The Hospital generally disagreed with the OIG’s findings and recommendations.
To read the full article: http://www.oig.hhs.gov/oas/reports/region4/40406009.pdf
11. Review of St. Joseph Hospital 's Reported Fiscal Year 2004 Wage Data (A-09-05-00040)
The objective of the OIG’s review was to determine whether St. Joseph Hospital (the hospital) complied with Medicare requirements for reporting wage data in its fiscal year (FY) 2004 Medicare cost report. The hospital did not fully comply with Medicare requirements for reporting wage data in its FY 2004 Medicare cost report. Specifically, the hospital overstated wage data by $1,747,585 and 473,370 hours. As a result of the OIG’s review, the hospital filed an amended FY 2004 Medicare cost report, which adjusted the wage data by $471,941 and 446,117 hours. However, $1,275,644 of wages and 27,253 related hours remained overstated in the cost report.
The OIG recommended that the hospital: (1) submit a revised FY 2004 Medicare cost report to the fiscal intermediary to correct the remaining wage data overstatements totaling $1,275,644 and 27,253 hours, and (2) implement review and reconciliation procedures to ensure that the wage data reported in future Medicare cost reports are accurate, supportable, and in compliance with Medicare requirements. The hospital agreed with the OIG’s findings and recommendations.
To read the full article: http://www.oig.hhs.gov/oas/reports/region9/90500040.pdf
12. Review of Medicare Inpatient Wage Rate Assignment at Lehigh Valley Hospital , Allentown , Pennsylvania (A-03-05-00003)
The objective of the OIG’s review was to determine whether Lehigh Valley Hospital (the hospital) complied with Medicare requirements for reporting wage data in its FY 2003 Medicare cost report. The hospital did not fully comply with Medicare requirements for reporting wage data in its FY 2003 Medicare cost report. Specifically, the hospital misstated salaries and hours, which understated wage data by $37,798 and 15,326 hours; understated excluded area salaries and hours, which overstated wage data by $37,069 and 1,363 hours; overstated excluded contract services for intern and resident costs, which understated wage data by $326; and overstated physician Part A hours, which overstated wage data by 52 hours. These errors occurred because the hospital did not sufficiently review and reconcile wage data to ensure that all amounts reported were accurate, supportable, and in compliance with Medicare regulations and guidance. As a result, the hospital understated its wage data by $1, 055 and 13,911 hours for the FY 2003 Medicare cost report period. The OIG’s correction of the hospital's errors reduced the average hourly wage rate 0.23 percent from $28.39 to $28.32. The OIG recommended that the hospital implement review and reconciliation procedures to ensure that the wage data reported on future Medicare cost reports are accurate, supportable, and in compliance with Medicare requirements. The hospital concurred with the findings and recommendation.
To read the full article: http://www.oig.hhs.gov/oas/reports/region3/30500003.pdf
13. Review of Medicaid Support for Graduate Medical Education in Iowa (A-07-04-03055)
The objective of the OIG’s review was to determine if intergovernmental transfers between Iowa and publicly owned hospitals included any Medicaid graduate medical education funds. The OIG found that Medicaid graduate medical education funds were included in intergovernmental transfers between Iowa and the University of Iowa Hospitals. The University of Iowa Hospitals (a publicly owned hospital) returned Medicaid graduate medical education funds of $24.1 million to the State as intergovernmental transfers with no assurance that funds would be used for the graduate medical education program or to provide services to Medicaid-eligible individuals. Since the entire $24.1 million graduate medical education payment was returned, Iowa incurred no liability for the overall graduate medical education program and actually realized a net gain of $6.6 million. The OIG provided the State agency with an opportunity to respond to the audit findings. Because the audit did not contain any recommendations, the State agency elected not to submit written comments on the audit results in this report.
To read the full article: http://www.oig.hhs.gov/oas/reports/region7/70403055.pdf
14. University of Maryland Medical Center 's Organ Acquisition Costs for State Fiscal Year 2003 (A-03-04-00010)
The objective of this self-initiated audit was to determine whether the University of Maryland Medical Center (Medical Center) complied with Medicare and Maryland laws, regulations, and guidelines for allocating costs to organ acquisition and for maintaining adequate documentation to support those costs, and to estimate the effect on Medicare reimbursement for State Fiscal Year (SFY) 2003 when costs claimed were unallowed or unsupported. The Medical Center did not always comply with Medicare laws, regulations, and guidelines for reporting its costs, including organ acquisition costs, to the Commission. Specifically, the Medical Center did not have systems that could allocate organ acquisition costs separately from non-organ acquisition costs and other hospital activities. Because the Medical Center did not properly allocate costs totaling $2,562,132 between organ acquisition and all other cost, higher organ reimbursement rates resulted. The OIG estimated that the Medicare portion of those costs is approximately 40 percent, or $1,024,852. The OIG recommend that the Commission ensure that the Medical Center adheres to Medicare laws, regulations, and guidelines by properly identifying organ acquisition costs in the cost data provided to the Commission. In its written comments to their draft report, the Commission, the Medical Center , and the Centers for Medicare and Medicaid Services concurred with their findings and recommendations.
To read the full article: http://www.oig.hhs.gov/oas/reports/region3/30400010.pdf
For the index of recent OIG Advisory Opinions, follow this link: http://oig.hhs.gov/fraud/advisoryopinions/opinions.html
To see "Frequently Asked Questions" (FAQs) on the OIG Advisory Opinion process, go here: http://oig.hhs.gov/fraud/advisoryopinions/aofaq.html
For more information regarding the OIG's Exclusion Program, please follow this link:
http://oig.hhs.gov/fraud/exclusions.html
If you have any questions or would like to discuss any of these issues with one of Feeley & Driscoll’s healthcare specialists, please contact us at (617) 742-7788 or via e-mail at info@fdcpa.com. |
