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. Review of Medicaid Claims Made By Lake Grove Schools in New York (A-02-06-01001)
2. Graduate Medical Education for Dental Residents Claimed by St. Luke's Episcopal Hospital for Fiscal Years 2000 Through 2002 (A-04-04-06004)
3. Audit of Selected States' Medicaid Payments for Services Claimed To Have Been Provided to Deceased Beneficiaries (A-05-05-00030)
4. Report on the Medicare Drug Discount Card Program Sponsor aClaim, Inc. (A-06-06-00014)
5. Carrier Determination of Copayments for Medicare Mental Health Services (OEI-09-04-00221)
6. Medicaid Provider Enrollment Safeguards: Medical Equipment Providers (OEI-04-05-00180)
7. Duplicate Medicare Payments to Cost-Based Health Maintenance Plan Scott & White Health Plan for the Fiscal Years 2002, Through 2004 (A-05-06-00031)
8. Duplicate Medicare Payments to Cost-Based Health Maintenance Plan Capital Health Plan, Inc. for Fiscal Years 2002 Through 2004 (A-05-06-00029)
9. Review of Medicare Part B Services Rendered by a New Jersey Urologist (A-02-04-01036)
10. Review of University of California, San Francisco Medical Center's Reported Fiscal Year 2004 Wage Data (A-09-05-00039)
11. Review of University of California, Irvine Medical Center's Reported Fiscal Year 2004 Wage Data (A-09-06-00025)
12. Review of the Centers for Medicare and Medicaid Services' Medicaid Financial Management Oversight (OEI-06-04-00480)
13. Review of TriSpan Health Service's Payments to Community Mental Health Centers for Partial Hospitalization Services for the Period August 1, 2000, Through June 30, 2003 (A-06-04-00065)
14. Review of TriSpan Health Service's Payments to Synergy Behavioral Health for Partial Hospitalization Services for the Period August 1, 2000, Through June 20, 2003 (A-06-04-00032)
15. Review of University of California, San Diego Medical Center's Reported Fiscal Year 2004 Wage Data (A-09-06-00027)
16. The Health Care Fraud and Abuse Control (HCFAC) Program annual report for FY 2005
1. Review of Medicaid Claims Made By Lake Grove Schools in New York (A-02-06-01001)
OIG’s objective was to determine whether Medicaid claims submitted by and paid to two Lake Grove Schools in New York (Lake Grove) complied with certain Federal and State requirements. Lake Grove improperly claimed Medicaid reimbursement for 75 students who were attending their schools in Connecticut and Massachusetts, neither of which was enrolled as a provider in New York's Medicaid program. In addition, Lake Grove improperly claimed Medicaid reimbursement for 58 students after their discharge from school. As a result, Lake Grove improperly received $678,402 ($347,911 Federal share) in Medicaid reimbursement.
OIG recommended that New York State: (1) recoup $678,402 from Lake Grove and refund $347,911 to the Federal Government, (2) instruct Lake Grove to cease claiming Medicaid reimbursement for students attending their Connecticut and Massachusetts schools and for students who were discharged, and (3) determine the amount of improper Medicaid reimbursement claimed by Lake Grove for students attending their schools in Connecticut and Massachusetts, and for claims beyond students' discharge, for periods prior to and after OIG’s audit period, and return the Federal share of these overpayments to the Federal Government. The State generally concurred with recommendations.
To access the full article, click here: http://oig.hhs.gov/oas/reports/region2/20601001.pdf
2. Graduate Medical Education for Dental Residents Claimed by St. Luke's Episcopal Hospital for Fiscal Years 2000 Through 2002 (A-04-04-06004)
OIG’s objective was to determine whether St. Luke's Episcopal Hospital (the Hospital) included the appropriate number of dental residents in its full-time equivalent (FTE) resident counts when computing Medicare graduate medical education (GME) payments for fiscal years 2000 through 2002. The Hospital inappropriately included dental residents in its direct and indirect FTE counts used to compute FY 2002 GME payments. The Hospital included FTEs (1) for dental residents not in an approved residency program and (2) for dental residents who had exceeded their initial residency period. The Hospital overstated its direct and indirect GME claims by $19,528 for FY 2002.
OIG recommended that the Hospital: (1) file amended cost reports that will result in a refund of $19,528; (2) establish and follow written procedures to ensure that the FTE counts for residents in nonhospital settings include only those FTEs in approved programs and that the FTE counts for residents who exceed their initial residency period are weighted; (3) determine whether errors similar to those identified in OIG’s review occurred in Medicare cost reports after FY 2002 and refund any overpayments; and (4) work with the Centers for Medicare & Medicaid Services to resolve the $103,843 related to FY 2002 FTEs for the didactic time of residents assigned to nonhospital settings. Hospital officials agreed with those recommendations.
To access the full article, click here: http://oig.hhs.gov/oas/reports/region4/40406004.pdf
3. Audit of Selected States' Medicaid Payments for Services Claimed To Have Been Provided to Deceased Beneficiaries (A-05-05-00030)
OIG’s objectives were to (1) consolidate the results of OIG’s audits of 10 States' Medicaid payments for services claimed to have been provided to deceased beneficiaries and (2) determine why the States did not identify and recover the overpayments. In 8 of the 10 States audited, providers received an estimated total of $27.3 million ($15.1 million Federal share) in Medicaid overpayments, which the States never recovered, for services claimed to have been provided after beneficiaries' deaths. Prepayment screening by some States did not successfully identify the overpayments for deceased beneficiaries because the States did not use all available death information and because their payment systems had data entry, matching, and processing problems. Furthermore, postpayment screening did not identify all overpayments associated with deceased beneficiaries.
OIG recommended that CMS: (1) work with States to ensure that they use all available data sources to identify deceased beneficiaries, match those data against paid claims files, and recover identified overpayments; and (2) encourage States to establish postpayment reviews to mitigate the effect of delays in receiving data regarding beneficiaries' dates of death. CMS concurred with OIG’s recommendations.
To access the full article, click here: http://oig.hhs.gov/oas/reports/region5/50500030.pdf
4. Report on the Medicare Drug Discount Card Program Sponsor aClaim, Inc. (A-06-06-00014)
The objectives of OIG’s review were to determine whether aClaim complied with Federal requirements to (1) ensure that beneficiaries did not exceed their transitional assistance (TA) limits, (2) apply TA funds only to covered drugs, (3) pass on negotiated prices to beneficiaries and offer the lower of the negotiated prices or the usual and customary prices, (4) support the expenditures and withdrawals it reported to CMS, and (5) ensure that beneficiaries were enrolled when aClaim filed their claims. AClaim properly supported the expenditures it made on behalf of beneficiaries and the withdrawals from the Payment Management System. For the 45 claims reviewed for enrollment, all of the beneficiaries were enrolled at the time of the service. However, aClaim did not have proper procedures in place to ensure that it always complied with Federal requirements to ensure that beneficiaries did not exceed their TA fund limits, apply TA funds only to covered drugs, and pass on negotiated prices to beneficiaries and charge the lower of the negotiated prices or the usual and customary prices. As a result, CMS overpaid aClaim $792 for beneficiaries who exceeded their TA limits and $8,088 for excluded drugs for the period July 12, 2004, through July 31, 2005.
OIG recommended that aClaim: (1) reimburse CMS for the $792 by which it exceeded TA fund limits; (2) determine whether the amount it reimbursed CMS for excluded drugs included any of the $8,808 in TA funds identified in OIG’s audit and reimburse the difference; and (3) implement policies and procedures, if it continues in Part D, that it does not pay for statutorily excluded drugs with CMS funds and offers negotiated prices to beneficiaries. In its written comments on OIG’s draft report, aClaim did not agree with any of OIG’s findings or recommendations.
To access the full article, click here: http://oig.hhs.gov/oas/reports/region6/60600014.pdf
5. Carrier Determination of Copayments for Medicare Mental Health Services (OEI-09-04-00221)
OIG found that beneficiary copayments can be more than double for the same mental health service based on the beneficiary's geographic location. Carriers inconsistently apply the "outpatient mental health treatment limitation" (the limitation), causing these disparities in copayments. In addition, carriers are incorrectly applying the limitation to claims for medical management services for beneficiaries diagnosed with Alzheimer's disease and related disorders. Over a 4-year period, Medicare underpaid $27 million for these services, passing the costs on to beneficiaries in the form of higher copayments.
To address these issues, OIG recommends that CMS issue new guidance to its carriers regarding the limitation and ensure that the limitation is consistently applied among all carriers. In addition, OIG recommends that CMS require its carriers to adjust the copayments for the beneficiaries who were overcharged. CMS plans to issue more precise guidance to its carriers, post educational materials to its Web site, and to the extent it is feasible, require its carriers to reopen and adjust incorrectly processed claims.
To access the full article, click here: http://oig.hhs.gov/oei/reports/oei-09-04-00221.pdf
6. Medicaid Provider Enrollment Safeguards: Medical Equipment Providers
(OEI-04-05-00180)
States are mandated to provide certain basic services to recipients of Medicaid home health services. These services include the provision of medical supplies, equipment, and appliances, which are referred to as durable medical equipment (DME). DME includes many different types of devices, such as wheelchairs, oxygen equipment, and canes. Federal regulations do not define DME for Medicaid, and each State decides what equipment to cover. Each State sets its own standards for enrolling Medicaid providers. State standards for Medicaid DME provider enrollment can range from requiring that the DME business location be accessible during reasonable business hours to requiring that Medicaid applicants enroll in the Medicare program as a condition of Medicaid enrollment. For this study, OIG surveyed 14 States and the District of Columbia (referred to as 15 States) to determine the standards used by these States to enroll Medicaid DME providers and the extent to which States verified that providers met these standards. OIG also determined the extent to which States reenrolled Medicaid providers.
OIG found that the 15 States employed a variety of standards for DME provider enrollment. The goal of some of these standards, such as providers posting a sign and hours of operation, help ensure that an appropriate physical facility is being operated. In addition, standards include licensure of providers and obtaining surety bonds. Also, 7 of the 15 States required Medicaid providers to enroll as a Medicare DME provider, subjecting providers in these States to additional Medicare requirements. Despite the presence of these standards, OIG determined that most of the 15 States were not verifying whether providers met all provider enrollment standards. Only two States in OIG’s review, Florida and New York, verified that providers met all of their standards.
Additionally, 7 of the 15 States did not routinely conduct site visits at enrollment. However, four of these seven States did require Medicare enrollment as a condition of Medicaid enrollment, which subjects Medicaid providers in these States to Medicare site visits. Finally, only 6 of the 15 States reported that they either routinely reenrolled providers, or had recent initiatives to reenroll providers.
To access the full article, click here: http://oig.hhs.gov/oei/reports/oei-04-05-00180.pdf
7. Duplicate Medicare Payments to Cost-Based Health Maintenance Plan Scott & White Health Plan for the Fiscal Years 2002, Through 2004 (A-05-06-00031)
OIG’s objective was to determine whether medical services provided for the Scott and White Health Plan's (SWHP) enrollees by the Clinic and its contracted providers were reimbursed under SWHP's Medicare cost report and also through the Medicare fee-for-service payment system. SWHP's capitated provider filed Medicare claims, for which they were paid on a fee-for-service basis, while under a capitation arrangement with SWHP.
The capitation arrangement, which provides for a per-member, per-month payment to SWHP's capitated provider, covered allowable service performed by the provider to SWHP's enrollees. Medicare reimbursed SWHP for the capitation payments made to the provider via the Medicare cost reports; therefore, the fee-for-service claims paid directly to the provider by Medicare are considered overpayments since Medicare has, in effect, paid twice for the same service. During OIG’s audit period, inappropriate Medicare fee-for-service billings by SWHP's capitated provider amounted to $122,130.
OIG recommended that SWHP recover the $122,130 in duplicate Medicare fee-for-service claims made to the capitated provider and its subcontracted providers and that SWHP develop an efficient and effective billing process system to preclude and detect duplicate payments. SWHP agreed with OIG’s findings and will adjust their next cost report to correct the overpayments. SWHP does not believe that their internal control system failed in detecting the duplicate payments. They believe that they are unable to detect some duplicate payments because the Carrier is not sending explanation of Medicare benefits for all the services that were paid for on a fee-for-service basis.
To access the full article, click here: http://oig.hhs.gov/oas/reports/region5/50600031.pdf
8. Duplicate Medicare Payments to Cost-Based Health Maintenance Plan Capital Health Plan, Inc. for Fiscal Years 2002 Through 2004 (A-05-06-00029)
OIG’s objective was to determine whether medical services provided for Capital Health Plans, Inc.'s (Capital) enrollees by providers were reimbursed under Capital's Medicare capitation agreement and also through the Medicare fee-for-service payment system. OIG determined that Capital's capitated providers filed Medicare claims, for which they were paid on a fee-for-service basis, while under a capitation arrangement with Capital. The capitation arrangement, which provides for a per-member, per-month payment to Capital's capitated provider, covered allowable service performed by the provider to Capital's enrollees.
Medicare reimbursed Capital for the capitation payments made to the provider via the Medicare cost reports; therefore, the fee-for-service claims paid directly to the provider by Medicare are considered overpayments since Medicare has, in effect, paid twice for the same service. During OIG’s audit period, inappropriate Medicare fee-for-service billings by Capital's capitated provider amounted to $132,075.
OIG recommended that Capital recover the $132,075 in duplicate Medicare fee-for-service claims and that Capital develop an efficient and effective billing process system to preclude and detect duplicate payments. Capital agreed with OIG’s findings and is taking corrective actions to enhance their ability to identify and detect potential duplicate payments. Capital states that the effectiveness of their corrective action is contingent upon their having access to automated physician information that they have previously requested from CMS and its carriers.
To access the full article, click here: http://oig.hhs.gov/oas/reports/region5/50600029.pdf
9. Review of Medicare Part B Services Rendered by a New Jersey Urologist (A-02-04-01036)
The objective of OIG’s review was to determine whether Medicare payments made to a urologist in New Jersey complied with Medicare reimbursement requirements. The urologist was paid for services that did not comply with Medicare reimbursement requirements. Of the 100 claims in OIG’s statistical sample, 90 claims for 185 services were unallowable for one or more reasons. As a result, for calendar year 2003, OIG estimates that the urologist improperly claimed $230,258 in Medicare reimbursement.
OIG recommended that the urologist (1) work with the New Jersey carrier to reimburse the Medicare program for the estimated overpayment of $230,258, and (2) establish effective controls to ensure that only services rendered sufficiently documented, and correctly coded are billed to Medicare. The urologist disputed the medical review results for 84 of the 90 claims identified as overpayments in OIG’s audit. He agreed with the results for the remaining 6 claims.
To access the full article, click here: http://oig.hhs.gov/oas/reports/region2/20401036.pdf
10. Review of University of California, San Francisco Medical Center's Reported Fiscal Year 2004 Wage Data (A-09-05-00039)
OIG’s objective was to determine whether the University of California, San Francisco Medical Center (the Medical Center) complied with Medicare requirements for reporting wage data in its fiscal year (FY) 2004 Medicare cost report. CMS will use the FY 2004 Medicare cost report to develop the FY 2007 wage index. The Medical Center did not fully comply with Medicare requirements for reporting wage data in its FY 2004 Medicare cost report. Specifically, the Medical Center reported inaccurate data, which affected the wage rate calculation and resulted in overstated wages of $72,311,155 and understated hours totaling 144,796.
OIG recommended that the Medical Center: (1) submit a revised FY 2004 Medicare cost report to the fiscal intermediary to correct the overstated wages totaling $72,311,155 and the understated hours totaling 144,796 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 Medical Center generally disagreed with OIG’s findings and recommendations, but agreed with some of OIG’s recommended adjustments to the FY 2004 Medicare cost report.
To access the full article, click here: http://oig.hhs.gov/oas/reports/region9/90500039.pdf
11. Review of University of California, Irvine Medical Center's Reported Fiscal Year 2004 Wage Data (A-09-06-00025)
The objective of OIG’s review was to determine whether the University of California, Irvine Medical Center (the Medical Center) complied with Medicare requirements for reporting wage data for pension and postretirement benefit costs in its fiscal year (FY) 2004 Medicare cost report. The Medical Center did not fully comply with Medicare requirements for reporting wage data for pension and postretirement benefit costs. Specifically, the Medical Center reported inaccurate data, which affected the numerator of the wage rate calculation and overstated the Medicare Center's wage data by $31,373,369.
OIG recommended that the Medical Center: (1) submit a revised FY 2004 Medicare cost report to the fiscal intermediary to correct the overstated pension and postretirement benefit wage data totaling $31,373,369 and (2) implement review and reconciliation procedures to ensure that the wage data for pension and postretirement benefit costs reported in future Medicare cost reports are accurate, supportable, and in compliance with Medicare requirements. The Medical Center disagreed with OIG’s findings and recommendations.
To access the full article, click here: http://oig.hhs.gov/oas/reports/region9/90600025.pdf
12. Review of the Centers for Medicare and Medicaid Services' Medicaid Financial Management Oversight (OEI-06-04-00480)
The report was prepared by Ernst & Young (E&Y) under a contract with OIG. E&Y conducted this review to provide recommendations for improving the financial management of the Medicaid program. E&Y reviewed the current CMS management structure, examined prior studies and audits, compared the financial management structures and activities of Medicare to those of Medicaid, held discussions with various stakeholders, and analyzed the issues identified through these activities. The E&Y report contains a series of findings, conclusions, and recommendations.
To access the full article, click here: http://oig.hhs.gov/oei/reports/oei-06-04-00480.pdf
13. Review of TriSpan Health Service's Payments to Community Mental Health Centers for Partial Hospitalization Services for the Period August 1, 2000, Through June 30, 2003 (A-06-04-00065)
OIG’s objective was to determine whether TriSpan Health Services (TriSpan) calculated Medicare outlier and per diem payments to CMHCs in accordance with Medicare reimbursement requirements. TriSpan did not always calculate Medicare outlier and per diem payments to CMHCs in accordance with Medicare reimbursement requirements. When TriSpan initially established CMHC payments under the outpatient prospective payment system, it: (1) used incorrect cost report information to compute some cost-to-charge ratios, (2) incorrectly entered one cost-to-charge ratio in the outpatient provider-specific file within the claim-processing system, and (3) assigned the wrong geographic wage index factor to certain CMHCs. In addition, TriSpan did not update some CMHCs' cost-to-charge ratios in accordance with CMS guidelines.
OIG recommended that TriSpan: (1) recover $7,958,659 in improper outlier and per diem payments for services rendered between August 1, 2000, and June 30, 2003; (2) review claims with dates of service subsequent to OIG’s audit period and make any necessary financial adjustments; and (3) implement internal controls to ensure that future outlier and per diem payments are calculated with the correct cost-to-charge ratio, effective date, and wage index factor. TriSpan disagreed in part that it made errors when it initially established CMHC payments and disagreed with OIG’s first and last recommendations. However, TriSpan agreed that it had assigned the wrong geographic wage index factor and that it had not updated cost-to-charge ratios in accordance with CMS instructions. TriSpan did not fully address the second recommendation to review all claims subsequent to OIG’s audit period because TriSpan stated that it was limited to reviewing and adjusting the claims available on the system. TriSpan's comments did not provide any additional information that would lead us to change the findings, causes, or recommendations included in the draft report.
To access the full article, click here: http://oig.hhs.gov/oas/reports/region6/60400065.pdf
14. Review of TriSpan Health Service's Payments to Synergy Behavioral Health for Partial Hospitalization Services for the Period August 1, 2000, Through June 20, 2003 (A-06-04-00032)
OIG’s objective was to determine whether TriSpan Health Services (TriSpan) calculated Medicare outlier and per diem payments to Synergy Behavioral Health (Synergy) in accordance with Medicare reimbursement requirements. TriSpan did not calculate Medicare outlier and per diem payments to Synergy in accordance with Medicare reimbursement requirements. In calculating outlier payments, TriSpan (1) used incorrect cost report information to compute Synergy's cost-to-charge ratio, and (2) incorrectly entered the ratio in the outpatient provider-specific file within the claim-processing system. In calculating per diem payments, TriSpan assigned the wrong geographic wage index factor to Synergy.
OIG recommended that TriSpan: (1) recover from Synergy improper outlier and per diem payments totaling $8,193,433; (2) review claims with dates of service subsequent to OIG’s audit period to ensure that they were paid in accordance with Medicare reimbursement requirements and make any necessary financial adjustments; and (3) implement internal controls to ensure that future outlier and per diem payments are calculated with the correct cost-to-charge ratio, effective date, and wage index factor. In its comments on OIG’s draft report, TriSpan did not agree with most of the findings, the cause, or the first and last recommendations. However, TriSpan agreed that by using the Medicare charges on a particular cost report worksheet, it computed a higher cost-to-charge ratio that resulted in larger outlier payments. TriSpan also agree that it had assigned the wrong geographic wage index factor to Synergy.
To access the full article, click here: http://oig.hhs.gov/oas/reports/region6/60400032.pdf
15. Review of University of California, San Diego Medical Center's Reported Fiscal Year 2004 Wage Data (A-09-06-00027)
The objective of OIG’s review was to determine whether the University of California, San Diego Medical Center (the Medical Center) complied with Medicare requirements for reporting wage data for pension and postretirement benefit costs in its fiscal year (FY) 2004 Medicare cost report. The Medical Center did not fully comply with Medicare requirements for reporting wage data for pension and postretirement benefit costs in its FY 2004 Medicare cost report. Specifically, the Medical Center reported inaccurate data, which affected the numerator of the wage rate calculation and overstated the Medicare Center's wage data by $47,773,319.
OIG recommended that the Medical Center: (1) submit a revised FY 2004 Medicare cost report to the fiscal intermediary to correct the overstated pension and postretirement benefit wage data totaling $47,773,319 and (2) implement review and reconciliation procedures to ensure that the wage data for pension and postretirement benefit costs reported in future Medicare cost reports are accurate, supportable, and in compliance with Medicare requirements. The Medical Center disagreed with OIG’s findings and recommendations.
To access the full article, click here: http://oig.hhs.gov/oas/reports/region9/90600027.pdf
16. The Health Care Fraud and Abuse Control (HCFAC) Program annual report for FY 2005.
Background on HCFAC from OIG's website:
Efforts to combat fraud were consolidated and strengthened under Public Law 104-191, the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Act established a comprehensive program to combat fraud committed against all health plans, both public and private. The legislation required the establishment of a national Health Care Fraud and Abuse Control Program (HCFAC), under the joint direction of the Attorney General and the Secretary of the Department of Health and Human Services (HHS) acting through the Department's Inspector General (HHS/OIG). The HCFAC program is designed to coordinate Federal, State and local law enforcement activities with respect to health care fraud and abuse. The Act requires HHS and DOJ detail in an Annual Report the amounts deposited and appropriated to the Medicare Trust Fund, and the source of such deposits.
To get to the full document: http://oig.hhs.gov/publications/docs/hcfac/hcfacreport2005.pdf
For the List of Excluded Individuals/Entities (LEIE), follow this link:
http://oig.hhs.gov/fraud/exclusions/listofexcluded.html
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/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. |
