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:
1. Aberrant Billing in South Florida for Beneficiaries with HIV/AIDS (OEI-09-07-00030)
2. Assessing States’ Progress in Meeting State Children’s Health Insurance Program Goals (OEI-05-07-00330)
3. Review of Medicaid Reimbursement of Graduate Medical Education in Missouri (A-07-04-03058)
4. Review of Excessive Payments for Outpatient Services Processed by National Government Services for Calendar Years 2004 and 2005 - Illinois, Indiana, Kentucky and Ohio (A-05-07-00065)
5. Review of Medicare Payments to Connecticut VNA, Inc., for Home Health Services Preceded by a Hospital Discharge (A-01-07-00501)
6. Comparison of First-Quarter 2007 Average Sales Prices to Average Manufacturer Prices: Impact on Medicare Reimbursement for Third Quarter 2007 (OEI-03-07-00530)
7. Review of Administrative and Clerical Costs at Brandeis University for Fiscal Years 2004 and 2005 (A-01-06-01502)
1. Aberrant Billing in South Florida for Beneficiaries with HIV/AIDS (OEI-09-07-00030)
OIG analyzed the claims patterns of HIV/AIDS infusion therapy providers and beneficiaries in three South Florida counties and assessed the effectiveness of past and current efforts to control inappropriate payments to these providers. In the last half of 2006, these counties accounted for half of the total amount, and 79 percent of the amount for drugs, billed nationally for Medicare beneficiaries with HIV/AIDS. Other metropolitan areas exhibited similar patterns of aberrant billing, though to a much lesser extent.
CMS has had limited success controlling the aberrant billing practices of South Florida infusion therapy providers. The approaches CMS and its contractors have used have not proven effective over time as aberrant HIV infusion providers have adjusted their billing patterns and circumvented controls. In addition, CMS has taken limited action to address the enrollment of new infusion providers.
The OIG recommend that CMS mandate site visits for certain providers in high-risk jurisdictions. In addition, the OIG recommend that CMS afford contractors more time to review new applications from certain providers in high-risk jurisdictions, modify the Statement of Work for the jurisdiction that includes South Florida to require activities to fight fraud and abuse, require extensive review all reassignments in high-risk areas to confirm that they are legitimate, and strengthen revocations to prevent further fraud and abuse. CMS generally concurred with the OIG’s recommendations and indicated that it is taking steps to address them.
To view the full report, click here: http://www.oig.hhs.gov/oei/reports/oei-09-07-00030.pdf
2. Assessing States’ Progress in Meeting State Children’s Health Insurance Program Goals (OEI-05-07-00330)
This report is in response to the Balanced Budget Refinement Act of 1999 requirement that every 3 years the Office of Inspector General (1) evaluate whether States are enrolling Medicaid eligible children in their State Children’s Health Insurance Program (SCHIP) and (2) assess States’ progress in reducing the number of uninsured low-income children, including their progress in meeting the strategic objectives and performance goals included in State plans. This report addresses the second mandate. This report (1) assesses States’ progress in reducing the number of uninsured low-income children and (2) assesses States’ progress in meeting performance goals related to SCHIP. The first mandate is addressed in a separate report.
The OIG found that nationally the percentage of uninsured low-income children had a statistically significant decrease from 20 percent in 2002 to 18.5 percent in 2005. However, no State experienced a statistically significant change. The OIG found that 37 States met or made progress in meeting at least half of their performance goals. Of the States that reported progress, the largest number of States reported progress for performance goals related to increasing access to care and increasing the use of preventative care. Despite improvements that the Centers for Medicare & Medicaid Services (CMS) made to the Annual Report template, States’ progress remains difficult to assess. States’ progress in reducing the number of uninsured children is difficult to assess because of U.S. Census Bureau data limitations. Also, States use of nondirectional performance goals, as well as goals and measures missing from Annual Reports, limit the usefulness of the Annual Report in assessing States progress meeting performance goals.
Based on the report findings, the OIG recommend that CMS continue efforts to address concerns regarding U.S. Census Bureau data. The OIG also recommend that CMS provide guidance to States on developing directional performance goals with a target. Lastly, the OIG recommend that CMS ensure that States report on all goals and measures.
In its comments to the OIG’s draft report, CMS indicated general support for the findings and recommendations.
To view the full report, click here: http://www.oig.hhs.gov/oei/reports/oei-05-07-00330.pdf
3. Review of Medicaid Reimbursement of Graduate Medical Education in Missouri (A-07-04-03058)
The OIG’s objective was to determine whether the State agency’s claims for Medicaid reimbursement of graduate medical education (GME) payments to Children’s Mercy Hospital (the hospital) complied with Federal law and the approved State plan.
The State agency’s claims for Medicaid reimbursement of GME payments to the hospital did not fully comply with Federal law or the approved State plan. Of the $5,678,794 ($3,440,926 Federal share) claimed, $3,440,926 ($2,084,984 Federal share) was allowable, and the remaining $2,237,868 ($1,355,942 Federal share) was not allowable. Specifically, the State agency was not entitled to claim certified public expenditures as the State share of GME costs. In addition, the OIG was unable to determine what portion of the certified public expenditures, which were intended for the care of indigent children, related to the provision of GME.
The OIG recommended that the State agency (1) refund to the Federal Government the $1,355,942 in GME overpayments to the hospital during State fiscal years 1999 through 2001, (2) follow Federal requirements and the State plan when claiming GME costs in the future, and (3) review claims for GME subsequent to the OIG’s audit period and refund any portion that did not comply with Federal requirements and the State plan. The State agency disagreed with the first recommendation but agreed with the two remaining recommendations.
To view the full report, click here: http://www.oig.hhs.gov/oas/reports/region7/70403058.pdf
4. Review of Excessive Payments for Outpatient Services Processed by National Government Services for Calendar Years 2004 and 2005 - Illinois, Indiana, Kentucky and Ohio (A-05-07-00065)
The OIG’s objective was to determine whether high-dollar Medicare payments that National Government Services made to providers for outpatient services were appropriate. Most of the high-dollar Medicare outpatient payments were not appropriate. For calendar years 2004 and 2005 claims, National Government Services made 79 payments of $50,000 or more for outpatient services. The OIG’s analysis indicated that only 13 payments were correct and the remaining 66 payments were inappropriate. At the start of the OIG’s fieldwork in May 2007, 53 payments, totaling $3,338,895, had been refunded by the providers and 13 payments, totaling $513,796, remained outstanding.
The OIG recommended that National Government Services (1) inform us of the status of the recovery of the $513,796 in overpayments that the OIG’s audit identified, (2) identify and recover additional overpayments made on high-dollar outpatient claims paid after calendar year 2005, and (3) use the results of this audit in its provider education activities. National Government Services agreed with the OIG’s recommendations.
To view the full report, click here: http://www.oig.hhs.gov/oas/reports/region5/50700065.pdf
5. Review of Medicare Payments to Connecticut VNA, Inc., for Home Health Services Preceded by a Hospital Discharge (A-01-07-00501)
The OIG’s objective was to determine whether Connecticut VNA, Inc., (the agency) complied with Medicare requirements in billing for fiscal year 2004 and 2005 services for beneficiaries who had been discharged from an acute care hospital in the preceding 14 days. The agency improperly coded 35 claims as if the beneficiaries had not been discharged from an acute care hospital within the 14-day period preceding the home health admission. The Centers for Medicare & Medicaid Services’ prepayment edit corrected 27 of the 35 claims. Overpayments for the eight claims not identified by the edit totaled $3,683.
The OIG recommended that the agency (1) ensure that its adjustments to reimburse Medicare for the $3,683 were processed by the regional home health intermediary and (2) further educate its staff regarding the importance of identifying all facilities that had discharged the beneficiary within 14 days of the home health episode and determining which of these facilities were acute care (including long-term care) hospitals.
To view the full report, click here: http://www.oig.hhs.gov/oas/reports/region1/10700501.pdf
6. Comparison of First-Quarter 2007 Average Sales Prices to Average Manufacturer Prices: Impact on Medicare Reimbursement for Third Quarter 2007 (OEI-03-07-00530)
Pursuant to section 1847A(d)(3) of the Social Security Act (the Act), OIG must notify the Secretary of the Department of Health and Human Services (the Secretary) if the average sales price (ASP) for a particular drug exceeds the drug’s average manufacturer price (AMP) by a threshold of 5 percent. If that threshold is met, section 1847A(d)(3) of the Act grants the Secretary authority to disregard the ASP pricing methodology for that drug and substitute the payment amount for the drug code with the lesser of the widely available market price for the drug (if any) or 103 percent of the AMP. This review is the fourth such comparison conducted by OIG.
The OIG identified 34 of 371 drug codes with ASPs that exceeded AMPs by at least 5 percent in the first quarter of 2007. Of these 34 codes, 20 also met the threshold for price adjustments in prior OIG studies comparing ASPs and AMPs. If reimbursement amounts for all 34 codes had been based on 103 percent of AMP during the third quarter of 2007, the OIG estimates that Medicare expenditures would have been reduced by $9 million.
To view the full report, click here: http://www.oig.hhs.gov/oei/reports/oei-03-07-00530.pdf
7. Review of Administrative and Clerical Costs at Brandeis University for Fiscal Years 2004 and 2005 (A-01-06-01502)
The objective of the OIG’s audit was to determine whether Brandeis University (the University) claimed clerical and administrative costs and other direct costs under the terms and conditions of Department of Health & Human Services grant and contract awards and applicable Federal regulations during the OIG’s audit period of July 1, 2003, through June 31, 2005. The University claimed administrative salaries and wages in accordance with Federal and University requirements.
However, the University misclassified a total of $31,303 to National Institutes of Health (NIH) grants for books, subscriptions, and public relation costs that should have been included in its facilities and administrative (F&A) costs. As a result, the University could have overcharged NIH grants $31,303.
The OIG recommended that the University update its procedures to include books, subscriptions, and other supplies as costs claimed under F&A costs unless adequately justified, budgeted, and approved by NIH as a direct grant cost and work with NIH to resolve the $31,303 in misclassified costs. The University generally agreed with the OIG’s recommendations.
To view the full report, click here: http://www.oig.hhs.gov/oas/reports/region1/10601502.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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