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Feeley & Driscoll's OIG Update: March 2011 The Department of Health and Human Services Office of the Inspector General (HHS-OIG) was established by Congress in 1976 to identify and eliminate fraud, abuse, and waste in HHS programs and to promote efficiency and economy in departmental operations. The OIG is responsible for conducting audits, evaluations, and both criminal and civil investigations for all HHS agencies. These functions are performed by the OIG's Office of Audit Services (OAS). Feeley & Driscoll's OIG Update is a compilation of the latest and greatest additions from the OIG's website, listed in approximate order of greatness rather than lateness. This update is a monthly publication from the Healthcare Group at Feeley & Driscoll, P.C.
1. Nursing Facilities' Employment of Individuals with Criminal Convictions The OIG’s analysis of criminal history records maintained by the Federal Bureau of Investigation (FBI) revealed that 92 percent of nursing facilities employed at least one individual with at least one criminal conviction. Overall, 5 percent of nursing facility employees had at least one criminal conviction. Federal regulation prohibits Medicare and Medicaid nursing facilities from employing individuals found guilty of abusing, neglecting, or mistreating residents by a court of law, or who have had a finding entered into the State nurse aide registry concerning abuse, neglect, or mistreatment of residents or misappropriation of their property. Interpretive guidelines from CMS for this regulation state that "[nursing] facilities must be thorough in their investigations of the past histories of individuals they are considering hiring." Despite this guidance, Federal law does not require that nursing facilities conduct FBI or statewide criminal background checks. Although FBI maintained criminal history records provide a comprehensive source of criminal histories, the records do not contain information on whether the victim of a crime was a nursing facility resident and therefore cannot be used by themselves to determine whether a conviction disqualifies an individual from nursing facility employment. >Click here to view the full report 2. Review of Jurisdiction 5 Payments for Inpatient Rehabilitation Facility Claims Billed with Patient Status Code 05 for Calendar Year 2007 IRFs incorrectly coded 24 of the 53 claims that the OIG reviewed with patient status code 05. Because IRFs did not use the appropriate transfer codes on these claims, Medicare made $245,000 in overpayments for miscoded transfers to 11 IRFs in CY 2007. >Click here to view the full report 3. Review of Family Planning Services Claimed by Washington State during the Period October 1, 2005, through September 30, 2008 The OIG’s review found that Washington State was overpaid $8.5 million for Medicaid family planning services and supplies during the period October 1, 2005, through September 30, 2008. This overpayment occurred because the State agency's Medicaid Management Information System (MMIS) controls did not properly distinguish claims eligible for reimbursement at the 90-percent rate from claims eligible for reimbursement at the regular Federal medical assistance percentage (FMAP) rate. The Federal share of the Medicaid program is determined by the FMAP, which was 50 percent during the OIG’s audit period; family planning claims were reimbursed at 90 percent. The OIG recommends that the State:
The State concurred with the OIG’s findings and the OIG’s first recommendation. Regarding the OIG’s second recommendation, the State said that because it had implemented a new MMIS in May 2010, it was unable to review medical claims submitted before December 2005 or pharmacy claims submitted before April 2006. >Click here to view the full report 4. Review of the Pension Segmentation Requirements for the Managerial Pension Plan at Wisconsin Physicians Service Insurance Corporation for the Period of January 1, 1989, to January 1, 2008 Wisconsin Physicians Service Insurance Corporation (WPS), a Center for Medicare & Medicaid Services (CMS) contractor, overstated the Medicare segment pension assets by $2.3 million for the period of January 1, 1989, to January 1, 2008. WPS administered Medicare Part A and Part B operations under cost reimbursement contracts with CMS. >Click here to view the full report 5. Review of Colorado's Monitoring of Community Services Block Grants The Colorado Department of Local Affairs (State agency) did not establish adequate internal controls for assessing and monitoring eligible entities provided with Community Services Block Grant (CSBG) funds under the American Recovery and Reinvestment Act of 2009 (Recovery Act). Specifically, the State agency did not conduct full onsite reviews at all eligible entities within a 3-year period, ensure that CSBG funds were used to provide services only to eligible clients, conduct initial Recovery Act onsite reviews at each eligible entity that received Recovery Act funding, adequately document Recovery Act onsite reviews, ensure that risk assessments performed by eligible entities were accurate before they were submitted to ACF, and accurately report Recovery Act accomplishments. These deficiencies occurred because the State agency lacked written policies and procedures to ensure compliance with the provisions of the CSBG Act and the Recovery Act. The OIG recommends that the State agency:
The State agency agreed with the OIG’s recommendations and described corrective actions that it had implemented or planned to implement. >Click here to view the full report 6. Review of Medicaid Hospice Payments Made by Massachusetts for State Fiscal Years 2007 and 2008 The OIG’s review found that the Massachusetts Executive Office of Health and Human Services (the State agency) did not use the correct per diem rate, make the appropriate payment reduction, or reduce Medicaid payments to hospices by the amount of beneficiaries' financial contributions for 2,056 of the 5,304 claims the OIG reviewed for State fiscal years 2007 and 2008. As a result, the State agency's Federal claim was overstated by a total of $1.7 million ($826,000 Federal share). >Click here to view the full report 7. Las Vegas Woman Pleads Guilty to Acting as the Straw Owner of a Los Angeles Medical Supply Company That Submitted More Than $3.5 Million in False Claims to Medicare A Las Vegas woman pleaded guilty today to falsely representing to Medicare that she owned a Los Angeles-area durable medical equipment (DME) company that was actually owned and operated by her brother, and used by her brother and others to submit more than $3.5 million in false claims to Medicare, the Departments of Justice and Health and Human Services (HHS) announced. Jummal Joy Ibrahim, 55, pleaded guilty today before U.S. District Judge George H. King in the Central District of California. Ibrahim admitted that between January 2006 and September 2009, she allowed her brother, Christopher Iruke, to use her identity to conceal his ownership and control of Contempo Inc., dba Contempo Medical Supplies. Contempo was a fraudulent DME supply company located in Inglewood, Calif., which Iruke and others used to submit false claims to Medicare for expensive, high-end power wheelchairs and other DME. >Click here to view the full report 8. Results of Limited Scope Review at the Community Action Agency of New Haven, Inc. The OIG reviewed the financial condition of the Community Action Agency of New Haven, Inc. (CAANH), as part of a nationwide series of reviews of Community Action Agencies that have received funding under the American Recovery and Reinvestment Act of 2009. The OIG believes that CAANH's current financial condition makes its financial viability uncertain. Significant operating deficiencies also existed at CAANH that impact its ability to manage and account for Federal funds and its capability to carry out Community Services Block Grant (CSBG) Recovery Act programs in compliance with Federal requirements. Specifically, CAANH did not ensure that:
In addition, CAANH did not fully comply with Federal requirements for bank deposits and whistleblower protection. The deficiencies occurred because CAANH did not establish adequate controls and procedures. As a result, CSBG Recovery Act funds may be at risk of not being properly accounted for or expended in accordance with Federal requirements. The OIG recommends that the Administration for Children and Families work with Connecticut's Department of Social Services to ensure that CAANH establishes adequate controls and procedures to comply with Federal requirements. In addition, the OIG recommends that CAANH make financial adjustments or produce adequate documentation for unallowable services, activities, and costs. >Click here to view the full report 9. Results of Limited Scope Review at San Luis Valley Community Action Agency The OIG reviewed the financial condition of San Luis Valley Community Action Agency (SLVCAA) as part of a nationwide series of reviews of Community Action Agencies that have received funding under the American Recovery and Reinvestment Act of 2009. Based on the OIG’s assessment, the OIG believes that SLVCAA is not financially viable and does not have the capacity to manage and account for Federal funds and to operate its Community Services Block Grant (CSBG) program in accordance with Federal regulations. Specifically, SLVCAA did not have an independent organizational structure and was not capable of managing its CSBG program. Moreover, SLVCAA's use of a sub-recipient local government body to manage SLVCAA's CSBG program created a conflict of interest. The OIG recommends that the Administration for Children and Families consider the information presented in this report in assessing SLVCAA's ability to operate the CSBG program in accordance with Federal regulations. In written comments on the OIG’s draft report, SLVCAA agreed with the OIG’s findings and described corrective actions that it had implemented or planned to implement. The OIG did not verify the corrective actions. >Click here to view the full report 10. Medicare Compliance Review of South Shore Hospital for Calendar Years 2008 and 2009 South Shore Hospital (the Hospital) did not fully comply with Medicare billing requirements for selected inpatient and outpatient claims. Specifically, of 389 sampled claims, 249 claims had billing or coding errors, resulting in overpayments totaling approximately $341,000 for CYs 2008 and 2009. These overpayments occurred primarily because the Hospital did not have adequate controls to prevent incorrect billing and coding of Medicare claims and did not fully understand the Medicare billing requirements. >Click here to view the full report 11. Family Planning Services Claimed by Ohio from October 1, 2007, through September 30, 2009 The Ohio Department of Job and Family Services improperly claimed enhanced Federal reimbursement of $321,000 for family planning services provided from October 1, 2007, through September 30, 2009. >Click here to view the full report 12. Review of Erectile Dysfunction Drugs in the Medicare Part D Program Of approximately $133 billion in gross drug costs included in private prescription drug plans' and Medicare Advantage plans' (collectively known as sponsors) prescription drug event (PDE) data for calendar years (CY) 2007 and 2008, CMS accepted PDE data totaling $3.1 million in gross Medicare Part D drug costs for erectile dysfunction (ED) drugs approved only for the treatment of sexual or erectile dysfunction. Pursuant to Federal requirements, Part D should not have covered these drugs. According to CMS officials, the software edit in place in CMS's Medicare Drug Data Processing System during the OIG’s audit period did not prevent CMS from accepting PDE data for some ED drugs in CY 2007 and most of CY 2008 because the Part D program used an incomplete list of excluded drugs as the basis for the edit. Although the officials indicated that CMS had updated its list of ED drugs in CY 2008, CMS accepted PDE data for some ED drugs during the OIG’s entire audit period. The OIG recommends that CMS:
CMS partly agreed and partly disagreed with the OIG’s recommendations. Nothing in CMS's comments caused us to change the OIG’s findings or recommendations. |
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