1. Review of Medicaid Payments at Age Institute of Massachusetts, Inc. for State Fiscal Years 2007 through 2009.
2. Review of Medicaid Personal Care Services Claims Made by Providers in New York State Audit
3. Review of Head Start Health and Safety Standards at Albany Community Action Partnership
4. Medicare and Medical Fraud and Abuse Training in Medical Education
5. Centers for Medicare & Medicaid Services’ Use of Medicare Fee-for-Service Error Rate Data To Identify and Focus on Error-Prone Providers
6. Quality Improvement Organizations' Final Responses to Beneficiary Complaints
7. Results of Limited Scope Review at Philadelphia Parent Child Center, Inc.
8. Review of Nebraska Medicaid Payments for Home Health Agency Claims
9. Review of Head Start Health and Safety Standards at Advocates for Children and Families, Inc.
10. Review of Head Start Health and Safety Standards at Rolling Plains Management Corporation Audit
    

1. Review of Medicaid Payments at Age Institute of Massachusetts, Inc. for State Fiscal Years 2007 through 2009

Their review found that Massachusetts Executive Office of Health and Human Service, Office of Medicaid (the State agency) made overpayments totaling $151,000 ($81,000 Federal share) to Age Institute of Massachusetts, Inc. during State fiscal years 2007 through 2009.

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2. Review of Medicaid Personal Care Services Claims Made by Providers in New York State Audit

Based on their sample results, the OIG estimated that New York State improperly claimed $100.3 million in Federal Medicaid reimbursement for personal care services claims submitted by providers during calendar years 2004 through 2006.

Of the 100 claims in their sample, 61 complied but 31 did not comply with Federal and State requirements pertaining to nursing assessments, physicians' orders, nursing supervision, in-service training of personal care aides, or documentation of the time spent providing services.

In addition, for the eight remaining claims in their sample, the OIG estimated that the State claimed $15.3 million for Consumer Directed Personal Assistance Program (CDPAP) claims that may not have complied with State requirements regarding physicians' orders and nursing assessments. Personal care services are generally furnished to individuals in their homes. Examples of personal care services include cleaning, shopping, grooming, and bathing.

The OIG recommended that the State:

• Refund $100.3 million to the Federal Government;
• Improve its monitoring of the personal care services program to ensure compliance with
  Federal and State requirements;
• Work with CMS to resolve the eight CDPAP claims and, if applicable, refund the estimated $15.3 million in unallowable payments;
• Promulgate specific regulations related to claims submitted under the CDPAP.
  

The State disagreed with their first recommendation and agreed with their remaining recommendations.

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3. Review of Head Start Health and Safety Standards at Albany Community Action Partnership

As part of a series of reviews requested by the Administration for Children and Families, Office of Head Start, the OIG found that Albany Community Action Partnership (the Grantee), located in New York State, did not fully comply with Federal and State requirements on ensuring the health and safety of children in its care. The major objectives of the Head Start program include promoting school readiness and enhancing the social and cognitive development of low-income children by providing health, educational, nutritional, and social services. In fiscal year (FY) 2009, Congress appropriated $7.1 billion to fund the Head Start program's regular operations. The American Recovery and Reinvestment Act of 2009 provide an additional $2.1 billion for the program during FYs 2009 and 2010.

As of June 2009, the files on 38 of the Grantee's 110 Head Start employees and 1 of the 6 contracted bus drivers showed that the Grantee had not obtained criminal background checks, timely criminal background checks, or child abuse and maltreatment checks, and none of the 6 contracted bus drivers had been screened for tuberculosis. In addition, the Grantee's nine childcare facilities that the OIG reviewed did not meet all Federal Head Start and State regulations on protecting children from unsafe materials and equipment. Finally, four of the nine childcare facilities that the OIG reviewed did not provide a fully secure environment for the children in their care. The Grantee's failure to consistently comply with requirements jeopardized the health and safety of children in its care.

The OIG recommended that the Grantee develop and consistently follow procedures to ensure that:

• All employee and contracted bus driver files contain documentation of timely criminal background checks and child abuse and maltreatment register checks;
• All contracted bus drivers have an initial health examination that includes screening for tuberculosis;
• All unsanitary and unsafe conditions are corrected in a timely manner;
• All facilities are secure.

In comments on their draft report, the Grantee generally concurred with their findings and described its completed and ongoing actions to address deficiencies that the OIG identified.

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4. Medicare and Medical Fraud and Abuse Training in Medical Education

Forty-four percent of medical schools reported providing instruction to students on Medicare and Medicaid fraud and abuse laws in 2010. Furthermore, more than two-thirds of institutions offering residency and fellowship programs reported instructing participants on compliance with Medicare and Medicaid fraud and abuse laws in 2010.

Medicare and Medicaid fraud and abuse cost U.S. taxpayers billions of dollars each year and put the programs' beneficiaries' health and welfare at risk. No current law requires medical schools or hospitals offering physician residency or fellowship programs to provide instruction on compliance with Medicare and Medicaid laws aimed at preventing fraud and abuse. The OIG has dedicated significant resources to promoting the adoption of compliance programs and encouraging health care providers to incorporate integrity safeguards into their organizations as an essential component of a comprehensive antifraud strategy.

Among the Federal statutes addressing fraud and abuse are the civil False Claims Act, the anti-kickback statute, and the physician self-referral statute. For this report, the OIG surveyed all accredited allopathic and osteopathic medical schools and institutions offering physician residency and fellowship programs to determine the extent to which they provided instruction on compliance with these three laws.

The OIG found that about two-thirds of the medical schools that provided instruction specifically reported covering the False Claims Act, the physician self-referral law, and the anti-kickback statute. Over three-quarters of the institutions that provided instruction reported covering these laws. Almost all medical schools and institutions offering residency and fellowship programs are interested in receiving the OIG-provided instructional materials relating to Medicare and Medicaid fraud and abuse.

Opportunities exist for the OIG to provide additional educational materials addressing these topics. The OIG plans to:

• Prepare educational materials appropriate for medical schools and institutions offering residency and fellowship programs;
• Distribute the materials to those medical schools and institutions that sponsor residency and fellowship programs;
• Seek feedback from the medical schools and institutions offering residency and fellowship programs on ways to improve the materials. Such feedback could include emerging compliance challenges that physicians, hospitals, and other providers face.

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5. Centers for Medicare & Medicaid Services’ Use of Medicare Fee-for-Service Error Rate Data To Identify and Focus on Error-Prone Providers

The Improper Payments Information Act of 2002 requires the head of a Federal agency with a program that may be susceptible to significant improper payments to report to Congress the agency's estimate of the improper payments. During their audit period, fiscal years (FY) 2005 through 2008, CMS used two programs to estimate improper Medicare fee-for-service (FFS) payments: the Hospital Payment Monitoring Program (HPMP) and the Comprehensive Error Rate Testing (CERT) program.

The OIG found that CMS and its contractors did not use historical HPMP and CERT error rate data to identify and focus on error-prone providers. The OIG defined "error-prone providers" as providers that had at least one error in each of the 4 years of their audit period. Although payment contractors developed corrective actions based on the HPMP and CERT error rate data, they typically did not focus on error-prone providers for review and corrective action.

Using the reported error rate data for FYs 2005 through 2008, the OIG identified 740 error-prone providers. Specifically, an analysis of the HPMP error rate data disclosed that 554 providers (21 percent of all HPMP providers with at least 1 claim sampled in each of the 4 years) accounted for 59 percent of the dollars in error for those providers. A similar analysis of the CERT error rate data for the same period disclosed that 186 providers (1.81 percent of all CERT providers with at least 1 claim sampled in each of the 4 years) accounted for 25 percent of the dollars in error for those providers. Focusing on error-prone providers for corrective action and repayment of improper payments could improve the effectiveness of CMS's efforts to reduce improper payments.

The OIG recommended that CMS:

• Use available error rate data to identify error-prone providers;
• Require error-prone providers to identify the root causes of claim errors and to develop and implement corrective action plans;
• Monitor provider-specific corrective action plans;
• Share error rate data with its contractors to assist in identifying improper payments.

CMS concurred with their recommendations.

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6. Quality Improvement Organizations' Final Responses to Beneficiary Complaints

The OIG found that of the 120 Quality Improvement Organizations (QIO) final responses to Medicare beneficiaries the OIG reviewed in detail 116 met statutory requirements.

QIOs have a statutory responsibility to review written complaints from Medicare beneficiaries about the quality of care the beneficiaries received. At the conclusion of a complaint review, the QIO sends to the beneficiary a final response summarizing the findings of the review. If the care under review involved a specific practitioner, that practitioner can decline to give consent for the QIO to identify him or her in its response to the beneficiary. When this is the case, the QIO's final response contains less information than if the practitioner consents to disclosure. In 2003, the U.S. Court of Appeals decided that QIO responses must inform beneficiaries whether their care met professional standards, regardless of whether the practitioners consented to disclosure. CMS requires additional elements in QIO responses when the practitioner consents to disclosure.

The OIG found that QIOs completed 4,500 complaint reviews between August 1, 2008, and December 31, 2009. From those reviews, QIOs made 2,768 requests to practitioners for consent to disclosure, and 52 percent (1,449) of those practitioners consented.

The OIG also reviewed in detail 120 final responses that QIOs sent to beneficiaries to determine whether the responses met program requirements. Of these 120 responses, all but 2 stated whether care met professional standards. All of the 60 responses with practitioner consent contained a summary of the medical record, and 58 of them described the corrective action that the QIO took in response to a confirmed quality-of-care concern.

Their review showed that most QIO responses to complainants are meeting the 2003 court decision and CMS criteria regarding professional standards, as well as CMS's additional criteria. However, QIOs do not obtain consent for disclosure from almost half of the practitioners involved (Medicare regulations allow practitioners to decline consent). Requiring practitioner consent remains a barrier to providing beneficiaries with more complete information about their complaints. Their review also showed that 6 of the 60 responses exceeded CMS's criteria. The fact that at least one QIO is already providing such a response to beneficiaries without adverse consequences suggests that disclosure might not impose an undue burden on practitioners and that other QIOs could make the complaint process more transparent to all beneficiaries.

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7. Results of Limited Scope Review at Philadelphia Parent Child Center, Inc.

The OIG reviewed the financial conditions at Philadelphia Parent Child Center, Inc. (the Center), Head Start program, as requested by the Administration for Children and Families (ACF), Office of Head Start, for use in its overall assessment of Head Start grantees that have applied for additional funding under the American Recovery and Reinvestment Act of 2009 (Recovery Act).

Based on their assessment, the OIG believe that the Center currently is not financially viable, has limited ability to account for Federal funds, and is not capable of operating a Head Start program in accordance with Federal requirements. Their review identified weaknesses relating to the Center’s financial viability, fiscal staff, accounting system certification, in-kind valuation and reporting, and the reasonableness of employee compensation.

The OIG recommended that ACF, in determining whether the Center should be awarded additional Head Start and Recovery Act grant funding, consider the information presented in the report in assessing the Center’s ability to account for and manage Federal finds and to operate a Head Start program. In written comments on out draft report, the Center neither agreed nor disagreed with their findings. However, the Center provided information as to action it had taken since their review, as well as additional information related to some of their findings.

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8. Review of Nebraska Medicaid Payments for Home Health Agency Claims

The OIG estimated that the Nebraska Department of Health & Human Services (State agency) improperly claimed $56,000 ($37,000 Federal share) for home health agency (HHA) services provided by 84 HHA providers that did not comply with Federal and State requirements.  Although the State agency had controls in place to ensure that payments were appropriate for HHA claims, these controls did not always prevent the overpayments.

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9. Review of Head Start Health and Safety Standards at Advocates for Children and Families, Inc.

As part of a series of reviews requested by the Administration for Children and Families (ACF), Office of Head Start, the OIG found that Advocates for Children and Families, Inc. (the Grantee), located in Texas, did not fully comply with Federal and State requirements on ensuring the health and safety of children in its care. The major objectives of the Head Start program include promoting school readiness and enhancing the social and cognitive development of low-income children by providing health, educational, nutritional, and social services.

In fiscal year (FY) 2009, Congress appropriated $7.1 billion to fund the Head Start program's regular operations. The American Recovery and Reinvestment Act of 2009 provides an additional $2.1 billion for the program during FYs 2009 and 2010.

As of February 2010, the files on 28 of the Grantee's 130 employees did not contain evidence of all required background checks. Although the files on the 102 remaining employees contained evidence of the required background checks, the Grantee did not always request these checks when they were due. In addition, 13 of the Grantee's 15 childcare facilities that the OIG visited did not meet all Federal Head Start and State requirements on protecting children from unsafe materials and equipment. Finally, 7 of the Grantee's 15 childcare facilities that the OIG visited did not provide a fully secure environment for the children in their care. The Grantee's failure to consistently comply with requirements jeopardized the health and safety of children in its care.

The OIG recommended that the Grantee share this report with Community Development Institute (CDI), which currently operates the Grantee's Head Start program, to ensure that:

• Required background checks are completed when due;
• All unsafe conditions are corrected and all necessary repairs are addressed in a timely manner;
• All facilities are secure.
  

The Grantee stated that it had no staff to verify whether the deficiencies noted in the report had been corrected because ACF had suspended financial assistance to the Grantee's Head Start program. The Grantee added that CDI, ACF's national interim management contractor, would operate the Head Start program during the suspension. The OIG revised their recommendations to reflect CDI's role during the grant suspension period.

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10. Review of Head Start Health and Safety Standards at Rolling Plains Management Corporation Audit

As part of a series of reviews requested by the Administration for Children and Families, Office of Head Start, the OIG found that Rolling Plains Management Corporation (the Grantee), located in Texas, did not fully comply with Federal and State requirements on ensuring the health and safety of children in its care. The major objectives of the Head Start program include promoting school readiness and enhancing the social and cognitive development of low-income children by providing health, educational, nutritional, and social services. In fiscal year (FY) 2009, Congress appropriated $7.1 billion to fund the Head Start program's regular operations. The American Recovery and Reinvestment Act of 2009 provide an additional $2.1 billion for the program during FYs 2009 and 2010.

As of January 2010, the files on 6 of the Grantee's 75 employees and contractors did not contain evidence of all required background checks. The files on the 69 remaining employees and contractors contained evidence of the required background checks, but the checks were not always requested when they were due. In addition, the Grantee's 11 childcare facilities did not meet all Federal Head Start and State requirements on protecting children from unsafe materials and equipment. Finally, three of the Grantee's childcare facilities did not provide a fully secure environment for the children in their care. The Grantee's failure to consistently comply with requirements jeopardized the health and safety of children in its care.

The OIG recommended that the Grantee develop and consistently follow procedures to ensure that:

• Required background checks are completed when due;
• All unsafe conditions are corrected and all necessary repairs are addressed in a timely manner;
• All facilities are secure. In comments on their draft report, the Grantee agreed with most of their findings and described actions that it had taken or planned to take to address most of the deficiencies that the OIG identified.

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