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:
1. OIG Today Posts a New Advisory Opinion to the Website
2. A Comparison of Average Sales Price to Widely Available Market Prices: Fourth Quarter 2005 (OEI-03-05-00430)
3. Audit of Illinois ' Medicaid Payments for Skilled Professional Medical Personnel for the Period October 1, 2003 through September 30, 2004 (A-05-05-00051)
4. Review of Medicare Claims for Air Ambulance Services Paid to Allegheny General Hospital (A-03-04-00014)
5. Recent OIG Administrative Enforcement Actions and Background on OIG's Civil Monetary Penalty Authority (CMP)
In This Issue:
1. OIG Today Posts a New Advisory Opinion to the Website.
To access the Advisory Opinion document, 06-07 (concerning a proposal by a municipality, which provides emergency medical services through a municipally owned and operated ambulance service, to treat revenue received from local taxes as payment of otherwise applicable cost-sharing amounts due from municipal residents) go here:
http://www.oig.hhs.gov/fraud/docs/advisoryopinions/2006/AdvOpn06-07.pdf
For the index of recent OIG Advisory Opinions, follow this link: http://oig.hhs.gov/fraud/advisoryopinions/opinions.html.
2.A Comparison of Average Sales Price to Widely Available Market Prices: Fourth Quarter 2005 (OEI-03-05-00430)
According to Section 1847A(d)(3)(C) of the Social Security Act, OIG shall inform the Secretary if OIG finds that the ASP for a drug or biological exceeds widely available market price for such drug or biological by 5 percent. If this criterion is met, the lesser of 103 percent of the AMP for the drug or the widely available market price for the drug shall be substituted for the ASP-based payment amount. OIG found that 5 of the 9 procedure codes included in our sample met or surpassed the 5-percent threshold defined by the Act. For these 5 codes, the difference between ASP and widely available market price ranged from 17 to 185 percent. OIG estimates that Medicare expenditures would be reduced by as much as $67 million in 2006 if reimbursement amounts were lowered to the widely available market price for these five codes. CMS shares OIG's concern that Medicare pay appropriately for Part B drugs, and states that our findings are helpful to its ongoing efforts to enhance implementation of the ASP methodology. However, CMS believes that Medicare savings would be substantially less than the amount originally estimated in the report because the report does not reflect the downward trend in drug prices and Medicare reimbursement that has occurred for some drugs since our analysis.
To access the full article click here: http://www.oig.hhs.gov/oei/reports/oei-03-05-00430.pdf
3. Audit of Illinois ' Medicaid Payments for Skilled Professional Medical Personnel for the Period October 1, 2003 through September 30, 2004 (A-05-05-00051)
The objective of the audit was to determine whether the Illinois Department of Healthcare and Family Services (State agency) properly claimed Medicaid funding at the 75 percent enhanced Federal funding rate for skilled professional medical personnel for the period October 1, 2003 , through September 30, 2004 . The State agency improperly claimed enhanced reimbursement for skilled professional medical personnel costs and was overpaid $62,648 in Federal funds for wage and travel expenses for 56 contractors that were not State agency employees. In addition, the State agency improperly classified and claimed $9,460,819 ($2,365,205 Federal share) in school based administrative costs as skilled professional medical personnel. Although CMS disallowed enhanced reimbursement for these claims, the State agency did not reclassify and reduce its claim for skilled professional medical personnel.
OIG recommended that the State agency: (1) refund $62,648 for the overpayments; (2) develop and implement procedures to ensure only qualifying individuals are claimed as skilled professional medical personnel; and (3) reclassify the $9,460,819 in school based administrative costs inappropriately claimed for enhanced reimbursement as skilled professional medical personnel and appropriately charge those costs as other Medicaid administrative costs. Illinois officials agreed to the first two recommendations. The State did not agree with OIG’s recommendation to reclassify the $9,460,819 in school based administrative costs.
To access the full article click here: http://www.oig.hhs.gov/oas/reports/region5/50500051.pdf
4. Review of Medicare Claims for Air Ambulance Services Paid to Allegheny General Hospital (A-03-04-00014)
OIG’s objective was to determine whether Allegheny General Hospital (Allegheny) claimed Medicare air ambulance services during calendar year 2002 in accordance with Medicare requirements. Contrary to Medicare billing requirements, Allegheny transported patients beyond the nearest hospital with appropriate facilities on 45 of 100 sampled claims, and transported a patient by air ambulance when a ground ambulance could have transported the patient on one of the sampled claims (medically inappropriate ambulance service).
OIG recommended Allegheny refund $10,134 to the Medicare program for air ambulance overpayments, exclude mileage beyond the nearest hospital with appropriate facilities from Medicare air ambulance claims, and bill Medicare for only medically appropriate air transports. Allegheny disagreed with our findings and recommendations. Allegheny sited Federal locality requirements, and claimed Federal Emergency Medical Treatment and Active Labor Act (EMTALA) requirement's were inconsistent with requirements to transport to the nearest appropriate facility. Allegheny did not support its comments about locality with documentation, and Federal EMTALA requirements are not inconsistent with requirements to transport to the nearest appropriate facility.
To access the full article click here: http://www.oig.hhs.gov/oas/reports/region3/30400014.pdf
5. Recent OIG Administrative Enforcement Actions and Background on OIG's Civil Monetary Penalty Authority (CMP).
The OIG generally reaches settlement with persons against whom the OIG is seeking, or considering seeking, CMPs. The settlement agreements described in this section resulted from OIG investigations and represent a compromise by the OIG and the settling party. Unless specifically identified as an administrative or court decision, all the matters described in this section are settlement agreements. In all of these settled cases, the OIG alleged that certain facts existed and that those facts formed the basis for the OIG to seek a CMP
To access the full article click here: http://www.oig.hhs.gov/fraud/enforcement/administrative/cmp/cmp.html#1
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.htm
For more information regarding the OIG's Exclusion Program, please follow this link: http://oig.hhs.gov/exclusions/index.asp
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. |
