1. Availability of Medicare Part D Drugs to Dual-Eligible Nursing Home Residents  (OEI-02-06-00190) 

This final report provides an assessment of the availability of Medicare Part D drugs to dual-eligible nursing home residents.  The OIG’s review focused on ongoing implementation issues as opposed to the issues related to the transition from Medicaid to Medicare that arose in the early stages of the benefit.  The study is based on structured interviews with a sample of nursing home administrators, medical directors, and directors of operations for long-term care pharmacies. 

According to most respondents, dual-eligible nursing home residents are receiving all necessary Part D drugs.  However, nursing homes and long-term care pharmacies sometimes pay for Part D drugs that are not covered by plans.  Administrators and pharmacy directors explained that the drugs they most commonly pay for either are not on the residents’ plans’ formularies or require prior authorization.  In addition, respondents express concerns that formularies, the prior authorization process, and copayments may pose problems for dual-eligible nursing home residents.  Concerns also exist that long-term care pharmacies generally do not disclose to physicians the rebates that they receive from drug manufacturers. 

The OIG recommended that CMS work with plans to ensure that formularies meet the needs of dual-eligible nursing home residents; continue to work with plans to improve the prior authorization process; ensure that copayments for dual-eligible nursing home residents are fully subsidized, as appropriate; and consider methods to encourage long-term care pharmacies to disclose to physicians information about rebates that they receive from drug manufacturers.  CMS concurred with the OIG’s first two recommendations and the intent of the OIG’s third recommendation; it did not concur with the OIG’s last recommendation. 

> To view the full report, click here: http://www.oig.hhs.gov/oei/reports/oei-02-06-00190.pdf

2. Role of Nursing Homes and Long Term Care Pharmacies in Assisting Dual-Eligible Residents With Selecting Part D Plans  (OEI-02-06-00191) 

The information provided in the memorandum report is based on an analysis of structured interviews with a sample of nursing home administrators and directors of operations for long term care pharmacies.  Based on the OIG’s interviews, the OIG found that nursing homes and long term care pharmacies provide different types of assistance to dual-eligible residents who are selecting their Part D plans.

Specifically, 38 percent of nursing home administrators and 26 of the 79 pharmacy directors whom the OIG interviewed reported that their nursing home or long-term care pharmacies identified multiple plans that met dual-eligible residents’ needs or provided a general list of plans that the pharmacy recommended to all residents.  About 9 percent of nursing home administrators and 6 of the 79 pharmacy directors whom the OIG interviewed reported enrolling most dual-eligible residents in a single plan or recommended one plan to each resident.  The remaining nursing home administrators and pharmacy directors reported that they provided only general information about the benefit or no assistance at all. 

It appears that some of these practices may not be in accordance with CMS guidance that does not allow nursing homes to request, require, coach, or steer residents to select plans.

> To view the full report, click here: http://www.oig.hhs.gov/oei/reports/oei-02-06-00191.pdf

3. Review of Federal Medicaid Claims Made for Beneficiaries in the Family Planning Benefit Program in New York State (A-02-07-01001)

New York State improperly received Federal reimbursement for claims made on behalf of beneficiaries enrolled in a State program that expands Medicaid eligibility to low-income individuals.  The Family Planning Benefit Program (FPBP) provides only Medicaid-reimbursed family planning services, exclusive of abortions, for individuals with incomes at or below 200 percent of the Federal poverty level. 

Of the 147 FPBP claims in the OIG’s sample, 37 were not eligible for Federal Medicaid reimbursement.  This occurred because:  (1) prior to May 2003, the State’s computerized Medicaid payment system did not adequately identify FPBP claims that were not related to family planning; (2) some providers incorrectly claimed services as family planning; and (3) some providers did not properly complete a sterilization consent form.  As a result, the State improperly received nearly $1 million in Federal Medicaid funds.

The OIG recommended that the State refund the overpayment, reemphasize to providers that only family planning services may be billed to Medicaid for FPBP beneficiaries, and reinforce guidance regarding sterilization consent forms.  The State generally concurred with the OIG’s recommendations but indicated that it would like to review the OIG’s working papers prior to refunding improper Federal Medicaid funds.

> To view the full report, click here: http://www.oig.hhs.gov/oas/reports/region2/20701001.pdf

4. Follow-Up Audit of the Medicaid Drug Rebate Program in New Mexico (A-06-07-00071)

In a follow-up audit of New Mexico’s Medicaid drug rebate program, the OIG found that the State had implemented the recommendations from the OIG’s prior audit that related to devoting more resources to the drug rebate program and implementing a sufficiently detailed accounts receivable system.  Manufacturers may make their outpatient drugs eligible for Federal Medicaid funding by entering into a rebate agreement with the Centers for Medicare & Medicaid Services (CMS) and paying quarterly rebates to the States.

The OIG also found that the State had partially implemented the recommendations that related to interest, dispute resolution, and Form CMS-64.9R reconciliation; had not implement the recommendation related to segregation of duties for the receipt of drug rebate funds; and had established controls over collecting rebates for single-source drugs administered by physicians.

The OIG recommended that the State update accounts receivable data from January 1991 through February 2007 and attempt to recover any unpaid rebate balances, including interest, and follow procedures to reconcile all amounts reported on the Form CMS-64.9R to its accounts receivable records.  The OIG also reiterated the OIG’s recommendation that the State implement policies, procedures, and controls to segregate duties for the receipt of drug rebate funds.  In comments on the draft report, the State agency described how it was addressing the recommendations.

> To view the full report, click here: http://www.oig.hhs.gov/oas/reports/region6/60700071.pdf

5. Medicaid Payments for Services Provided to Beneficiaries With Concurrent Eligibility in Florida and Georgia for July 1, 2005, Through June 30, 2006 (A-04-08-03034)

For the period July 1, 2005, through June 30, 2006, the OIG estimate that the Florida Agency for Health Care Administration (the State agency) paid $3.7 million ($2.2 million Federal share) on behalf of beneficiaries who should not have been eligible due to their Medicaid eligibility in Georgia.  Medicaid eligibility in each State is based on residency.  If a resident of one State subsequently establishes residency in another State, the beneficiary’s Medicaid eligibility in the previous State should end.  From a statistical random sample of 100 beneficiary-months totaling $77,000 in Medicaid services, the State agency made payments for 68 beneficiary-months totaling $68,000 for services provided to beneficiaries who should not have been eligible to receive Medicaid benefits in Florida.  Twenty-five beneficiary-months were for services to beneficiaries who were eligible to receive the benefit.  For the remaining seven beneficiary-months totaling $522, the OIG could not determine the beneficiaries’ eligibility based on the documentation that the State provided.

The OIG recommended that the State agency work with the Georgia Medicaid agency to share available Medicaid eligibility information for use in determining accurate beneficiary eligibility status and reducing the amount of payments made on behalf of beneficiaries residing in Georgia.  The OIG also recommended that the State agency work with CMS to determine the residency of beneficiaries whose eligibility could not be determined.  The State agency deferred formal comments to the Florida Department of Children and Families (DCF), which DCF generally disagreed with the OIG’s findings and recommendations.  However, nothing in the comments prompted changes to the OIG’s findings or recommendations. 

To view the full report, click here: http://www.oig.hhs.gov/oas/reports/region4/40803034.pdf

6. Review of Medicaid Overpayments at First Atlantic Nursing Facilities in Maine for Calendar Years 2004 Through 2006 (A-01-07-00009)

The Maine Department of Health and Human Services made overpayments totaling $1.2 million ($742,000 Federal share) to First Atlantic Healthcare Corporation (First Atlantic) on behalf of an average of 75 Medicaid beneficiaries each month during calendar years 2004–2006.  Medicaid requires States to use any additional resources that a beneficiary has, including Social Security payments, to reduce Medicaid payments to nursing homes.  However, because of problems with its new computer system, the State did not adjust its Medicaid per diem payments to First Atlantic by the amount of beneficiaries’ cost-of-care contribution from other resources, such as Social Security and pensions.  The OIG recommended that the State collect overpayments totaling $1.2 million from First Atlantic; refund the $742,000 Federal share of these overpayments; and continue its efforts to ensure that Medicaid overpayments to nursing homes are identified, collected, and refunded.  The State concurred with the OIG’s finding and recommendations. 

> To view the full report, click here: http://www.oig.hhs.gov/oas/reports/region1/10700009.pdf

7. Review of Medicaid Services Provided on the Day of Admission to an Inpatient Hospital or During an Inpatient Stay in New York State (A-02-04-01006)

New York State did not claim Medicaid ancillary services in accordance with Federal and State requirements from October 1, 2000, through September 30, 2002.  Medicaid claims for inpatient hospital care are paid at an all-inclusive rate that covers costs of services, including ancillary services (e.g., laboratory, radiology, surgical services), furnished to beneficiaries during hospital stays.  However, of the 196 ancillary services in the OIG’s sample, the State separately reimbursed Medicaid providers for 138 services provided during a beneficiary’s inpatient hospital stay or on the day the beneficiary was admitted to an inpatient hospital.  For 61 of the 138 services, the State did not recoup payment through its postpayment review process.  As a result, the OIG estimated that the State improperly claimed $293,000 ($147,000 Federal share) for ancillary services.  This overpayment occurred because the State’s computerized payment system and postpayment review process did not identify ancillary services separately billed during a beneficiary’s hospital stay.

The OIG recommended that the State (1) refund $147,000 to the Federal Government and (2) improve its internal controls to preclude Medicaid payments for ancillary services during a hospital stay or on the day of admission.  The State agency disagreed with the OIG’s first recommendation and generally agreed with the OIG’s second recommendation.  Nothing in the State’s response caused the OIG to alter its recommendations.

> To view the full report, click here: http://www.oig.hhs.gov/oas/reports/region2/20401006.pdf