4. Review of High-Dollar Inpatient Claims Processed by Cahaba Government Benefit Administrators Fiscal Intermediary No. 00011 for the Period January 1, 2004, Through December 31, 2006
 
5. Review of Medicaid Outpatient Drug Expenditures in Tennessee for the Period October 1, 2003, Through September 30, 2005
 
6. Review of Medicaid Outpatient Drug Expenditures in Connecticut for the Period October 1, 2003, Through September 30, 2005
 
7. Review of High-Dollar Payments for Medicare Outpatient Services Processed by Pinnacle Business Solutions, Inc., During Calendar Year 2005

8. Iowa’s Medicaid Payments Claimed for Children’s Remedial Services

9. Review of High-Dollar Payments for Missouri Medicare Part B Claims Processed by Pinnacle Business Solutions, Inc., for the Period January 1 Through December 31, 2004

Review of Retiree Drug Subsidy Costs Reported by the City of Boston for Plan Years 2006 and 2007

For plan years 2006 and 2007, the City of Boston, Massachusetts, correctly reported drug costs to the Retiree Drug Subsidy program that were incurred under its Master Medical Carve Out AB plan within the effective and termination dates of each qualifying covered retiree’s (1) plan coverage and (2) subsidy period approved by the Centers for Medicare & Medicaid Services.  Accordingly, this report contains no recommendations.

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Review of Medicaid Overpayments at Victorian Villa Rehabilitation & Living Center for Calendar Years 2004 Through 2006

Maine made overpayments totaling $207,000 ($132,000 Federal share) to Victorian Villa Rehabilitation & Living Center during calendar years 2004-2006 because Maine did not adjust its Medicaid per diem payments by the amount of beneficiaries' cost-of-care contributions from other resources, such as Social Security and pensions.

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Review of Medicaid Overpayments at Ledgeview Living Center for Calendar Years 2004 Through 2006

Maine made overpayments totaling $250,000 ($161,000 Federal share) to Ledgeview Living Center during calendar years 2004–2006 because Maine did not adjust its Medicaid per diem payments by the amount of beneficiaries’ cost-of-care contributions from other resources, such as Social Security and pensions. 

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Review of High-Dollar Inpatient Claims Processed by Cahaba Government Benefit Administrators Fiscal Intermediary No. 00011 for the Period January 1, 2004, Through December 31, 2006

During calendar years 2004-2006, Cahaba Government Benefit Administrators Fiscal Intermediary No. 00011 (Cahaba GBA) overpaid hospitals in Iowa $17,000.  Contrary to Federal guidance, hospitals reported excessive units of service and charges that resulted in inappropriate payments.  Generally, hospitals attributed the overpayments to incorrect claims data.  Cahaba GBA made the incorrect payments because neither the Fiscal Intermediary Standard System nor the Common Working File had sufficient edits in place to detect and prevent the overpayments.

The OIG recommended that Cahaba GBA recover the $17,000 in identified overpayments, use the results of this audit in its provider education activities related to data entry procedures and proper documentation of charges, and consider implementing controls to identify and review all payments greater than $200,000 for inpatient services.  In written comments on the draft report, Cahaba GBA stated that it no longer had this workload and therefore could not act upon the OIG’s recommendations.

Subsequently, Wisconsin Physician Services acknowledged that it had assumed responsibility for the State of Iowa and associated Cahaba GBA processing activity earlier in 2008.  Wisconsin Physician Services stated that it intended to recoup the overpaid amounts, use the results of the audit in future educational activities, and evaluate current controls to determine whether additional controls are needed.

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Review of Medicaid Outpatient Drug Expenditures in Tennessee for the Period October 1, 2003, Through September 30, 2005

The State's claims for reimbursement of Medicaid outpatient drug expenditures for fiscal years 2004 and 2005 did not fully comply with Federal requirements.  Of the $4.5 billion ($3 billion Federal share) claimed, $8 million (Federal share) represented expenditures for drug products that were not eligible for Medicaid coverage because they were either terminated drugs for which the termination dates were listed on the Centers for Medicare & Medicaid Services (CMS) quarterly drug tape before the drugs were dispensed or less-than-effective drugs.  An additional $13.2 million (Federal share) represented expenditures for drug products that were not listed on the quarterly drug tapes. 

The OIG recommended that the State refund $8 million to the Federal Government for drug expenditures that were not eligible for Medicaid coverage, work with CMS to determine whether the $13.2 million in payments for drugs that were not listed on the quarterly drug tapes was eligible for Medicaid coverage, and strengthen internal controls to ensure that claimed Medicaid drug expenditures comply with Federal requirements.  In written comments on the OIG’s draft report, the State agreed in part with their first recommendation and did not directly address their second and third recommendations.  After reviewing the State's comments, the OIG continues to support their findings and recommendations.

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Review of Medicaid Outpatient Drug Expenditures in Connecticut for the Period October 1, 2003, Through September 30, 2005

For fiscal years 2004 and 2005, Connecticut claimed $122,000 ($62,000 Federal share) in Medicaid reimbursement for drugs that were no longer eligible for reimbursement.  The State agency also claimed $18.5 million ($9.4 million Federal share) for drug products that were not listed on the Centers for Medicare and Medicaid Services quarterly drug tapes and thus may not have been allowable for Medicaid reimbursement. 

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Review of High-Dollar Payments for Medicare Outpatient Services Processed by Pinnacle Business Solutions, Inc., During Calendar Year 2005

None of the four payments of $50,000 or more that Pinnacle made to providers for outpatient services during calendar year 2005 were appropriate.  Three of the claims were adjusted prior to the start of the OIG’s audit; for the remaining claim, Pinnacle overpaid the provider $46,000. 

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Iowa’s Medicaid Payments Claimed for Children’s Remedial Services

The Iowa Department of Human Services (State agency) claimed $2,000 ($1,300 Federal share) of unallowable children’s remedial services for the period of February 1, 2007, through March 31, 2008.

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Review of High-Dollar Payments for Missouri Medicare Part B Claims Processed by Pinnacle Business Solutions, Inc., for the Period January 1 Through December 31, 2004