A biweekly publication from the Healthcare Group at Feeley & Driscoll, P.C.
Please visit us at OIG’s 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:
1OIG Posts New Exclusions, Reinstatement Files
2. Medicare’s Program Safeguard Contractors: Activities To Detect and Deter Fraud and Abuse (OEI-03-06-00010)
3. Medicaid Enhanced Payments for Illinois State-Employed Physicians for April 1, 2002, Through June 30, 2004 (A-05-06-00042)
4. Payments for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Made on Behalf of Beneficiaries in Skilled Nursing Facility Stays Covered Under Medicare Part A (A-01-05-00511)
5. OIG posts the Fiscal Year 2006 Annual Report of the State Medicaid Fraud Control Units (MFCU)
6. Review of Training Costs for Title IV-E Foster Care and Adoption Assistance Programs in Rhode Island for State Fiscal Years 2003 Through 2005 (A-01-06-02509)
7. Review of New Hampshire's Medicaid Disproportionate Share Hospital Payments During Federal Fiscal Year 2004 (A-01-05-00001)
8. Administrative Costs Projected by Windsor Health Plan of TN for Calendar Year 2007 (A-04-07-06001)
9. Review of Medicaid Credit Balances at Baystate Franklin Medical Center for the Period Ending June 30, 2006 (A-01-07-00002)
10. Review of Medicaid Disproportionate Share Hospital Payments to University Behavioral Healthcare Center, University of Medicine and Dentistry of New Jersey: July 1, 1995, Through June 30, 2001 (A-02-04-01024)
11. Review of Mutual of Omaha Medicare Payments to Long-Term Care Hospitals From January Through May 2003 (A-01-07-00510
OIG Posts New Exclusions, Reinstatement Files
The OIG posted the new 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 June of 2007. 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
Medicare’s Program Safeguard Contractors: Activities To Detect and Deter Fraud and Abuse (OEI-03-06-00010)
OIG found program safeguard contractors (PSC) differed substantially in the number of new investigations and case referrals to law enforcement; some had minimal activity in these primary workload categories. Neither the size of a PSC’s budget nor its oversight responsibility (dollar amount of Medicare paid claims) was strongly correlated with the number of new investigations nor the number of new case referrals produced in 2005. OIG also found that most PSCs had minimal results from proactive data analysis. In addition, OIG found no consistency across PSCs regarding the level of detail about proactive data analysis included in the monthly status reports.
To view the full article, click here: http://www.oig.hhs.gov/oei/reports/oei-03-06-00010.pdf
Medicaid Enhanced Payments for Illinois State-Employed Physicians for April 1, 2002, Through June 30, 2004 (A-05-06-00042)
The OIG’s objective was to determine whether the Department of Healthcare and Family Services (the State agency) made enhanced payments for services provided by physicians employed by the University of Illinois at Chicago College of Medicine (UIC) and the Southern Illinois University School of Medicine (SIU) in accordance with the approved State plan amendment (SPA) and Federal regulations.
The State agency generally made enhanced payments for services provided by UIC and SIU physicians in accordance with its SPA and Federal regulations. However, the State agency overpaid the universities $304,726 ($152,363 Federal share) due to a computer program error used to calculate the enhanced payment for 8,844 claims within a portion of the OIG’s audit period. The computer program error occurred on claims that had a third party liability payment that exceeded the cost of services. The OIG recommended that the State agency refund the overpayment of $152,363 to the Federal Government and correct the computer program error that caused the overpayments and ensure that claims with third party liability payments that exceed the cost of services do not receive a standard Medicaid fee or an enhanced payment. The State agency concurred with the findings and recommendations of the OIG.
To view the full article, click here: http://www.oig.hhs.gov/oas/reports/region5/50600042.pdf
Payments for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Made on Behalf of Beneficiaries in Skilled Nursing Facility Stays Covered Under Medicare Part A (A-01-05-00511)
For calendar years (CY) 1999–2002, before Common Working File edits were fully operational, Medicare Part B made $100.8 million in potential overpayments to suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) on behalf of beneficiaries in Part A-covered skilled nursing facility stays. For CY 2003, after the edits were fully operational, OIG’s computer match identified potential DMEPOS overpayments valued at $15.4 million. A statistical sample showed that the durable medical equipment regional carriers (DMERC) had not recovered approximately 69 percent of these overpayments. As a result, OIG estimated that the DMERCs had not recovered $11.2 million of the $15.4 million in potential CY 2003 overpayments.
OIG recommended that CMS (1) direct the DMERCs to review the $100.8 million in potential overpayments for CYs 1999–2002 and make appropriate recoveries, (2) direct the DMERCs to initiate recovery of the estimated $11.2 million in CY 2003 overpayments, and (3) ensure that all DMERCs have established proper controls to recover overpayments that the Common Working File edits identify. CMS concurred with the recommendations.
To view the full article, click here: http://www.oig.hhs.gov/oas/reports/region1/10500511.pdf
OIG posts the Fiscal Year 2006 Annual Report of the State Medicaid Fraud Control Units (MFCU)
The enactment of the Medicare and Medicaid Anti-Fraud and Abuse Amendments of 1977 authorized the establishment of, and Federal funding for, the State Medicaid Fraud Control Units (SMFCUs). Currently, 49 States and the District of Columbia participate in the Medicaid fraud control grant program through their established SMFCU. The majority of the Units are located within the Office of State Attorneys General. A small number of the Units are located in various other State Agencies. The mission of the Medicaid fraud units is to investigate and prosecute Medicaid provider fraud and incidences of patient abuse and neglect.
You can get to the MFCU report by going here: http://www.oig.hhs.gov/publications/docs/mfcu/MFCU%20FY%202006%20Annual%20Report.pdf
Review of Training Costs for Title IV-E Foster Care and Adoption Assistance Programs in Rhode Island for State Fiscal Years 2003 Through 2005 (A-01-06-02509)
The OIG’s objective was to determine whether the Rhode Island Department Children, Youth, and Families (the State agency) properly claimed Federal reimbursement at the enhanced rate for Title IV-E training costs from July 1, 2002, through June 30, 2005. The State agency properly claimed training costs totaling $3.2 million ($2.4 million Federal share) for Federal reimbursement at the enhanced 75-percent rate under Title IV-E. However, the State agency overstated the Federal share of foster care and adoption assistance training costs by $238,441 by claiming training expenses at the enhanced rate that were only allowable at the 50-percent rate.
The OIG recommended that the State agency make a financial adjustment of $238,441 on its next Quarterly Report of Expenditures, establish procedures to ensure that only qualified training expenses are claimed at the enhanced rate, and review training costs claimed for Federal reimbursement after the audit period to ensure compliance with Federal requirements. The State agency agreed with the OIG’s recommendations.
To view the full article, click here: http://www.oig.hhs.gov/oas/reports/region1/10602509.pdf
Review of New Hampshire's Medicaid Disproportionate Share Hospital Payments During Federal Fiscal Year 2004 (A-01-05-00001)
The State agency claimed Medicaid disproportionate share hospital (DSH) payments for fiscal year 2004 that did not comply with the hospital-specific DSH limits imposed by Federal requirements and the State plan. Of the $194,145,507 that the State agency claimed, $123,494,571 was allowable. However, the remaining $70,650,936 ($35,325,468 Federal share) was unallowable. The OIG attributes the excess DSH payments to the State agency's lack of policies and procedures to ensure that its methodology for developing the cost-to-charge ratios used to calculate hospital-specific DSH limits complied with Federal requirements and the State plan.
The OIG recommended that the State agency (1) refund $35,325,468 to the Federal Government, (2) work with CMS to review DSH payments claimed after the OIG’s audit period and refund any overpayments, and (3) establish policies and procedures to ensure that it complies with Federal requirements and the State plan in calculating future hospital-specific DSH limits. The State agency disagreed with these recommendations.
To view the full article, click here: http://www.oig.hhs.gov/oas/reports/region1/10500001.pdf
Administrative Costs Projected by Windsor Health Plan of TN for Calendar Year 2007 (A-04-07-06001)
The OIG’s objective was to determine whether Windsor Health Plan of TN, Inc.'s (Windsor) anticipated administrative costs were actuarially supported and reasonably and equitably reflected revenue requirements in accordance with Federal regulations. Bid summary forms submitted by Windsor contained revenue estimates, including administrative costs, required for each plan. Windsor projected $24,517,598 in administrative costs for calendar year 2007 that were actuarially supported and reasonably and equitably reflected revenue requirements in accordance with Federal regulations. Therefore, the OIG did not make any recommendations.
To view the full article, click here: http://www.oig.hhs.gov/oas/reports/region4/40706001.pdf
Review of Medicaid Credit Balances at Baystate Franklin Medical Center for the Period Ending June 30, 2006 (A-01-07-00002)
The OIG’s objective was to determine whether the credit balances recorded in Baystate Franklin Medical Center's (the Hospital) accounting records for inpatient and outpatient services for Medicaid beneficiaries represented overpayments more than 60 days old that the Hospital should have returned to the Medicaid program. The OIG identified 306 overpayments more than 60 days old that the Hospital should have returned to the Medicaid program. As a result, the Hospital did not promptly return Medicaid overpayments totaling $80,272 ($40,136 Federal share) to the Medicaid program in accordance with State Medicaid requirements. The OIG recommended that the Hospital return to the Massachusetts Medicaid program overpayments totaling $80,272 ($40,136 Federal share) and continue efforts to identify and return all overpayments to Medicaid in accordance with State requirements. The Hospital agreed substantially with the OIG’s observations and findings.
To view the full article, click here: http://www.oig.hhs.gov/oas/reports/region1/10700002.pdf
Review of Medicaid Disproportionate Share Hospital Payments to University Behavioral Healthcare Center, University of Medicine and Dentistry of New Jersey: July 1, 1995, Through June 30, 2001 (A-02-04-01024)
The objective of this audit was to determine whether Medicaid disproportionate share hospital (DSH) payments to University Behavioral Healthcare Center (UBHC) for State fiscal years 1996 through 2001 complied with the hospital-specific limits imposed by section 1923(g) of the Social Security Act (the Act) and the approved State plan.
DSH payments to UBHC exceeded the hospital-specific limits imposed by section 1923(g) of the Act and the approved State plan by $20,075,738 ($10,037,869 Federal share). Further, the OIG was unable to determine the reasonableness of $9,881,400 ($4,940,700 Federal share) of costs included in UBHC's hospital-specific DSH limits because the contractor included an undetermined amount of costs for patients with private insurance coverage. New Jersey officials told the OIG that they had relied on the contractor to prepare the DSH claims and that, contrary to Federal requirements, they had not ensured the veracity of those claims before submitting them for Federal reimbursement.
The OIG recommended that New Jersey (1) refund $10,037,869 to the Federal Government, (2) work with the Centers for Medicare and Medicaid Services (CMS) to resolve $4,940,700 in set-aside costs, (3) adhere to Federal law and State plan requirements when submitting DSH claims subsequent to June 2001 for Federal reimbursement, and (4) review all work performed by consultants to ensure the veracity of future Medicaid claims to the Federal Government. New Jersey officials generally agreed with the findings and recommendations.
To view the full article, click here: http://www.oig.hhs.gov/oas/reports/region2/20401024.pdf
Review of Mutual of Omaha Medicare Payments to Long-Term Care Hospitals From January Through May 2003 (A-01-07-00510)
The objective of the OIG’s review was to determine whether Mutual of Omaha (the Intermediary) paid long-term care hospitals' (LTCH) claims in accordance with Medicare requirements when beneficiaries had used all of their regular covered benefit days. The Intermediary did not always pay LTCH claims in accordance with Medicare requirements when the beneficiaries had used all of their regular covered benefit days. As a result, the Intermediary made overpayments totaling $374,945 for 33 claims to 21 LTCHs for services provided from January 1 through May 31, 2003. The OIG recommended that the Intermediary recover the $374,945 in overpayments and work with CMS to determine the appropriate actions for recovering the portion of the overpayments related to the beneficiaries' coinsurance payments. The Intermediary generally agreed to implement the OIG’s recommendations.
To view the full article, click here: http://www.oig.hhs.gov/oas/reports/region1/10700510.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 they 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
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.
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