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. Fraud and Abuse Safeguards in Separate State Children's Health Insurance Programs (OEI-06-04-00380)
2. Indian Health Service's Resolution of Audit Recommendations (A-07-06-03077)
3. Review of Medicaid Eligibility in California for the Period January 1 Through June 30, 2005 (A-09-06-00028)
4. Review of Medicaid Eligibility in Florida (A-04-06-00020)
5. Audit of Costs Claimed for the Statewide Automated Child Welfare Information System in California, Sacramento County, January 1, 1999, Through June 30, 2003 (A-09-05-00060)
6. South Florida Suppliers’ Compliance With Medicare Standards: Results From Unannounced Visits (OEI-03-07-00150)
7. Medical Equipment Suppliers: Compliance With Medicare Enrollment Requirements (OEI-04-05-00380)
8. Review of Non-Risk Managed Care Contract Administrative Costs in Utah (A-07-06-01020)
1. Fraud and Abuse Safeguards in Separate State Children's Health Insurance Programs (OEI-06-04-00380)
The study objectives were to assess the extent to which six selected States have established methods and procedures to meet Federal requirements for protecting SCHIPs against fraud and abuse, to assess these States' oversight of SCHIP contractors, and to assess CMS's oversight of States regarding SCHIP fraud and abuse activities in the six selected States. OIG reviewed SCHIP program documentation provided by the six selected States with separate SCHIP programs and documents provided by 17 health plans contracted by these States. OIG also interviewed staff from the sample States and health plans.
OIG found that the six States we reviewed met Federal requirements for prevention and detection of fraud and abuse by assigning responsibilities to SCHIP contractors. However, one of the six States has not met Federal requirements for investigation of suspected SCHIP fraud and abuse and referral of such cases to law enforcement. OIG found that common State oversight mechanisms address Federal requirements but do not always allow States to know how well health plans are performing fraud and abuse safeguards activities. OIG also found that CMS relies primarily on States for oversight of SCHIP fraud and abuse safeguards, although CMS has completed some onsite reviews of States.
To address the noncompliance by one State identified in this report, OIG recommended that CMS ensure that the noncompliant State institutes procedures to meet Federal requirements for investigating cases of suspected SCHIP fraud and abuse and referring cases to law enforcement. Additionally, to address other potential areas of improvement, OIG recommended that CMS take steps to strengthen Federal and State oversight of separate SCHIP fraud and abuse safeguards. In comments to the draft report, CMS stated that it did not dispute the findings in the report, suggested clarifying language to emphasize that SCHIP statute is not prescriptive in describing Federal oversight of fraud and abuse, and noted its recent efforts to assist States in strengthening fraud and abuse efforts.
To access the full article, click here: http://oig.hhs.gov/oei/reports/oei-06-04-00380.pdf
2. Indian Health Service's Resolution of Audit Recommendations (A-07-06-03077)
OIG’s objectives were to determine whether the Indian Health Service (IHS) had (1) resolved all audit recommendations as of December 31, 2005, and (2) resolved audit recommendations in a timely manner during calendar years (CY) 2003-2005.
As of December 31, 2005, IHS had not resolved 6,653 audit recommendations, of which 94 percent were past due for resolution. During CYs 2003-2005, IHS resolved 2,840 of the 9,493 audit recommendations that were outstanding during this period. However, it did not resolve 2,727 of the 2,840 recommendations within the required 6-month period.
OIG recommended that IHS (1) resolve the backlog of outstanding audit recommendations and (2) resolve all audit recommendations within 6 months of receiving the audit reports as required. IHS concurred with both recommendations.
To access the full article, click here: http://oig.hhs.gov/oas/reports/region7/70603077.pdf
3. Review of Medicaid Eligibility in California for the Period January 1 Through June 30, 2005 (A-09-06-00028)
This report is part of a multistate review requested by the Centers for Medicare and Medicaid Services (CMS) and the Office of Management and Budget. OIG’s objective was to determine the extent to which the State agency made Medicaid payments on behalf of beneficiaries who did not meet Federal and State eligibility requirements.
The State agency (1) made some Medicaid payments on behalf of beneficiaries who did not meet Federal and State eligibility requirements and (2) did not ensure that the county offices always adequately documented eligibility determinations. Of the 199 payments in our statistical sample, 17 payments totaling $480 (Federal share) were unallowable because the beneficiaries were ineligible for Medicaid. In addition, for nine sampled payments totaling $423 (Federal share), the case files were missing or did not contain adequate documentation supporting eligibility determinations. As a result, for the 6-month audit period, OIG estimates that the State agency made 4,705,170 payments totaling $132,727,302 (Federal share) on behalf of ineligible beneficiaries. OIG also estimates that case file documentation did not adequately support eligibility determinations for an additional 2,490,972 payments totaling $117,020,338 (Federal share).
OIG recommended that the State agency use the results of this review to help ensure compliance with Federal and State Medicaid eligibility requirements. Specifically, the State agency should (1) reemphasize to beneficiaries the need to provide accurate and timely information and (2) require county office employees to verify eligibility information and maintain appropriate documentation in all case files.
The State agency agreed with OIG’s recommendation, but disagreed with OIG’s findings that one beneficiary was ineligible for the specific service received and that certain cases lacked adequate documentation to support eligibility determinations. The State agency also disagreed with the fiscal projection of the Federal share associated with the findings, but it acknowledged that supporting documentation was missing from certain case files.
To access the full article, click here: http://oig.hhs.gov/oas/reports/region9/90600028.pdf
4. Review of Medicaid Eligibility in Florida (A-04-06-00020)
The audit objective was to determine the extent to which Florida made Medicaid payments on behalf of beneficiaries who did not meet Federal and State eligibility requirements. The audit period covered January 1 through June 30, 2005, when the State made more than 26 million payments totaling $3.4 billion ($2 billion Federal share) on behalf of Medicaid beneficiaries.
The State generally made Medicaid payments on behalf of beneficiaries who met Federal and State eligibility requirements and provided adequate documentation of eligibility determinations. OIG attributes the low number of eligibility and documentation errors to the effectiveness of the Florida Department of Children and Families (DCF) policies and procedures.
OIG recommends that DCF use the results of this review to help ensure compliance with Federal and State Medicaid eligibility requirements. Specifically, DCF should continue to verify eligibility information and maintain appropriate documentation in all case files. DCF agreed.
To access the full article, click here: http://oig.hhs.gov/oas/reports/region4/40600020.pdf
5. Audit of Costs Claimed for the Statewide Automated Child Welfare Information System in California, Sacramento County, January 1, 1999, Through June 30, 2003 (A-09-05-00060)
OIG’s objective was to determine whether Child Welfare Services Case Management System (CWS/CMS)-related operating costs that Sacramento County (Sacramento) claimed for Title IV-E reimbursement were allowable under Federal and State regulations.
During the period January 1, 1999, through June 30, 2003, Sacramento claimed $11,181,417 as CWS/CMS-related operating costs for reimbursement under Title IV-E. OIG found that $3,984,138 was not allowable under Federal and State regulations, and OIG could not determine the allowability of the remaining $7,197,279.
OIG recommended that California: (1) refund the $1,992,069 Federal share of the $3,984,138 of unallowable costs claimed, (2) work with the Administration for Children and Families to determine what portion of the $7,197,279 ($3,598,640 Federal share) is allowable for reimbursement under Title IV-E and refund the Federal share of any unallowable costs identified, (3) review costs that Sacramento claimed for reimbursement under Title IV-E subsequent to the audit period for issues similar to those identified and refund the Federal share of any unallowable costs identified, and (4) instruct Sacramento to strengthen its internal controls.
California partly agreed and partly disagreed with OIG's first two recommendations and did not directly comment on OIG's final two recommendations.
To access the full article, click here: http://oig.hhs.gov/oas/reports/region9/90500060.pdf
6. South Florida Suppliers’ Compliance With Medicare Standards: Results From Unannounced Visits (OEI-03-07-00150)
At the time of this OIG review, suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) had to comply with 21 Medicare DMEPOS supplier standards to enroll in the Medicare program. OIG worked collaboratively with CMS and the National Supplier Clearninghouse to conduct unannounced site visits to 1,581 DMEPOS suppliers located in Miami-Dade, Broward, and Palm Beach Counties to determine whether the suppliers were in compliance with five requirements from three selected Medicare DMEPOS supplier standards.
OIG found that 31 percent of suppliers in the 3 South Florida counties did not maintain physical facilities or were not open and staffed during unannounced site visits conducted during posted or reasonable business hours. Another 14 percent of suppliers did not meet at least 1 of the 3 additional requirements for the standards we reviewed. OIG recommends that CMS strengthen the Medicare DMEPOS supplier enrollment process and ensure that suppliers meet Medicare supplier standards. CMS agreed with or will consider the options we recommended for strengthening the Medicare DMEPOS supplier enrollment process and ensuring that suppliers meet Medicare supplier standards.
To access the full article, click here: http://oig.hhs.gov/oei/reports/oei-03-07-00150.pdf
7. Medical Equipment Suppliers: Compliance With Medicare Enrollment Requirements (OEI-04-05-00380)
Durable medical equipment, prosthetics, orthotics, and supply (DMEPOS) suppliers undergo site inspections from the National Supplier Clearinghouse (NSC) on a 3-year cycle at the time of enrollment and reenrollment into the Medicare program. For this study, OIG conducted site visits that were out-of-cycle with the NSC schedule of 169 DMEPOS suppliers. OIG determined if the suppliers physically existed at their listed addresses, and OIG attempted to gain access to the suppliers to determine if they were open to conduct business. Through OIG’s out-of-cycle site visits, they found that 10 of the 169 DMEPOS suppliers did not physically exist.
The 10 absent suppliers should have been located in 6 of the 27 counties where OIG conducted their site visits, and represented 13 percent (1 of 8) to 40 percent (2 of 5) of the total number of suppliers that we visited in each of those counties. Because these suppliers were not randomly selected, our results are not representative of the entire six counties where the absent suppliers should have been located. The 10 absent DMEPOS suppliers billed Medicare almost $393,000 in the 2 months after OIG had determined that they were absent. Of the nearly $393,000 in submitted claims, the suppliers received almost $197,000 in reimbursements as of December 31, 2005. OIG also found that 6 of the 169 DMEPOS suppliers physically existed, but were closed during their posted hours of operation at the time of our single site visits. These six suppliers collectively billed Medicare almost $102,000 in the 2 months after OIG discovered that they were closed, and received almost $52,000 in reimbursements as of December 31, 2005.
While this study did not uncover supplier noncompliance with Medicare requirements in all areas visited, OIG’s findings suggest that out-of-cycle site visits of targeted DMEPOS suppliers may be warranted in other areas of the country. By helping to ensure the legitimacy of DMEPOS suppliers, out-of-cycle site visits may help to prevent fraud, waste, and abuse in the Medicare program. CMS may want to consider the findings of OIG’s study as they determine how and to what extent out-of-cycle site visits of DMEPOS suppliers will occur. CMS concurred with the basic findings of this report. CMS agreed that out-of-cycle site visits can identify suppliers who are no longer in business or do not meet basic supplier standards.
To access the full article, click here: http://oig.hhs.gov/oei/reports/oei-04-05-00380.pdf
8. Review of Non-Risk Managed Care Contract Administrative Costs in Utah (A-07-06-01020)
The objective of OIG’s review was to determine whether, for the period July 1, 2002, through September 30, 2005, Utah claimed administrative costs for its non‑risk managed care contracts pursuant to Federal regulations. Utah claimed some administrative costs for its non‑risk managed care contracts that were not in accordance with Federal regulations. Specifically, Utah incorrectly claimed administrative costs at the medical rates (between 70 and 74.19 percent) instead of at the 50-percent administrative rate. For July 2002 through September 2005, Utah reported $31.0 million of administrative costs, for which it claimed $22.7 million in Federal reimbursement, at medical rates rather than at administrative rates. Prior to OIG's audit, Utah recognized that its initial claim was incorrect. Accordingly, it attempted to adjust and lower its claim of the Federal share to the 50-percent administrative rate, which reduced its reimbursement from $22.7 million to $15.5 million. However, OIG’s review indicated that Utah did not identify all of the overpayments before making that adjustment.
OIG recommended that Utah: (1) refund $625,489 to the Federal Government and (2) develop adequate policies and procedures to ensure that future claims for administrative costs for non-risk managed care contracts comply fully with Federal regulations. Utah concurred with OIG’s findings and recommendations.
To access the full article, click here: http://oig.hhs.gov/oas/reports/region7/70601020.pdf
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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. |
