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Feeley & Driscoll's OIG Update: April 2012 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 additions from the OIG's website. This update is a monthly publication from the Healthcare Group at Feeley & Driscoll, P.C. Contents
1. Massachusetts Generally Complied with Federal and State Requirements for Medicaid Payments to Wingate Healthcare The Massachusetts Executive Office of Health and Human Services, Office of Medicaid (State agency), did not always adjust its Medicaid per diem payments to Wingate Healthcare by the amount of beneficiaries' cost-of-care contributions from resources, such as Social Security and pensions. As a result, the State agency's Federal claim was overstated by a total of $112,000 ($62,000 Federal share). The OIG attributed the incorrect Medicaid payments to clerical and billing errors. >Click here to view the full report 2. Medicare Compliance Review of Kent County Hospital for Calendar Years 2009 and 2010 Kent County Hospital (the Hospital), located in Warwick, Rhode Island, complied with Medicare billing requirements for 155 of the 171 claims the OIG reviewed. However, the Hospital did not fully comply with Medicare billing requirements for the remaining 16 claims, resulting in overpayments totaling $27,000. These overpayments occurred primarily because the Hospital did not have adequate controls to prevent the incorrect billing of Medicare claims and did not fully understand Medicare billing requirements. >Click here to view the full report 3. Review of Medicare Contractor’s Pension Segmentation Requirements for the Durable Medical Equipment Regional Carrier Segment at HealthNow New York, Inc., a Terminated Medicare Contractor, for the Period January 1, 2002, to January 1, 2007 HealthNow New York, Inc. (HealthNow), a Centers for Medicare & Medicaid Services (CMS) contractor, understated the Durable Medical Equipment Regional Carrier (DMERC) Medicare segment pension assets by $498,000 and understated Medicare's share of the DMERC Medicare segment excess pension assets, as a result of the termination of the DMERC Medicare contracts, by $122,000. HealthNow administered Medicare Part B and DMERC operations under cost reimbursement contracts with CMS. >Click here to view the full report 4. Review of Medicaid Payments for Services Provided Under New Jersey’s Section 1915 (c) Community Care Waiver at Bancroft NeuroHealth from January 1, 2005, through December 31, 2007 The OIG estimated that New Jersey (the State) improperly claimed approximately $2.7 million in Federal Medicaid reimbursement for Community Care Waiver (CCW) program services provided by Bancroft NeuroHealth (Bancroft) that did not comply with certain Federal and State requirements during calendar years 2005 through 2007. The CCW program allows States to claim Medicaid reimbursement for home and community-based services provided to mentally retarded or developmentally disabled individuals who would otherwise require institutionalization in an Intermediate Care Facility for the Mentally Retarded (ICF/MR). The claims for unallowable services were made because:
The OIG recommends that the State:
The State partly agreed and partly disagreed with the OIG's recommendations. >Click here to view the full report 5. Review of Medicare Payments Exceeding Charges for Outpatient Services Processed by Wisconsin Physicians Service Insurance Corporation but Transitioned to TrailBlazer Health Enterprises, LLC, in Jurisdiction 4 for the Period January 1, 2006, through June 30, 2009 The OIG's audit found that 267 of the 408 selected line items for which Wisconsin Physicians Service Insurance Corporation (WPS) made Medicare payments to providers for outpatient services during the period January 2006 through June 2009 were incorrect. The line items included items totaling approximately $1.6 million, which the providers had not refunded by the beginning of the OIG's audit. Providers refunded overpayments on 13 line items totaling $459,000 before the OIG's fieldwork. The remaining 128 line items were correct. Effective October 2010, the claims that were originally processed by WPS in Jurisdiction 4 were transitioned to TrailBlazer Health Enterprises, LLC (TrailBlazer). Medicare uses an outpatient prospective payment system to pay certain outpatient providers. In this method of reimbursement, the Medicare payment is not based on the amount that the provider charges. Billed charges generally exceed the amount that Medicare pays the provider. Therefore, a Medicare payment that significantly exceeds the billed charges is likely to be an overpayment. The deficiencies in the 267 incorrect line items included incorrect units of service, Healthcare Common Procedure Coding System (HCPCS) codes that did not reflect the procedures performed, a combination of incorrect number of units of service claimed and incorrect HCPCS codes, unallowable services, and a lack of supporting documentation. The OIG recommends that TrailBlazer:
TrailBlazer agreed with the OIG's recommendations and described actions that it had taken or planned to take to address them. >Click here to view the full report 6. Iowa Improperly Claimed Some Child Care and Development Targeted Funds The Iowa Department of Human Services (State agency) did not comply with Federal requirements when claiming some of the Child Care and Development Fund (CCDF) targeted funds for fiscal years (FY) 2004 through 2008. Specifically, the State agency (1) improperly reobligated $2.5 million of FY 2004 targeted funds after the obligation period had ended, (2) improperly obligated $134,000 of FY 2006 CCDF targeted funds to another entity at the same level in the State government as the State agency, and (3) did not refund to the Federal Government the $55,000 of targeted funds that either were returned by the grantee after the obligation period had ended or remained unliquidated after the liquidation period ended. The OIG recommends that the State agency:
The State agency partially concurred with the OIG's recommendations; the OIG maintains that all of its findings and recommendations are valid. >Click here to view the full report 7. Review of Resident Data Reported in the Intern and Resident Information System for Medicare Cost Reports Submitted to Highmark Medicare Services, Inc., and National Government Services, Inc. Hospitals in Medicare Administrative Contractor (MAC) Jurisdiction 12 did not always claim Medicare graduate medical education (GME) reimbursement for residents in accordance with Federal requirements. Medicare makes two types of payments to teaching hospitals to support GME programs for physicians and other practitioners. Direct GME payments are Medicare's share of the direct costs of training interns and residents. Indirect GME payments cover the additional operating costs that teaching hospitals incur in treating inpatients. The OIG found that 36 hospitals overstated direct and/or indirect full-time equivalent (FTE) counts on cost reports covering fiscal years (FY) 2006 and 2007 for residents who were also included in the FTE counts on cost reports submitted by hospitals in MAC Jurisdiction 12. As a result, 29 of these 36 hospitals received excess Medicare GME reimbursement totaling $222,000 for residents who were also claimed by hospitals in MAC Jurisdiction 13 for the same period and counted in the Intern and Resident Information System (IRIS) as more than 1 FTE. For the remaining seven hospitals, the FTE overstatements did not have an effect on the hospitals' Medicare GME reimbursement. The overstated FTE counts and excess reimbursement occurred because there was no Federal requirement for Highmark to compare IRIS data submitted by hospitals in its jurisdiction to IRIS data submitted by hospitals in other MAC jurisdictions to detect whether a resident had overlapping rotational assignments. As a result, Highmark did not have procedures to ensure that residents working at hospitals in all other MAC jurisdictions were not counted as more than one FTE in the calculation of Medicare GME payments. The OIG recommends that Highmark:
Highmark did not concur with the OIG's recommendations. >Click here to view the full report 8. Review of Resident Data Reported in the Intern and Resident Information System for Medicare Cost Reports Submitted to National Government Services, Inc., and Highmark Medicare Services, Inc. Hospitals in Medicare Administrative Contractor (MAC) Jurisdiction 13 did not always claim Medicare graduate medical education (GME) reimbursement for residents in accordance with Federal requirements. Medicare makes two types of payments to teaching hospitals to support GME programs for physicians and other practitioners. Direct GME payments are Medicare's share of the direct costs of training interns and residents. Indirect GME payments cover the additional operating costs that teaching hospitals incur in treating inpatients. The OIG found that 34 hospitals overstated direct and/or indirect full-time equivalent (FTE) counts on cost reports covering fiscal years (FY) 2006 and 2007 for residents who were also included in the FTE counts on cost reports submitted by hospitals in MAC Jurisdiction 12. As a result, 24 of these 34 hospitals received excess Medicare GME reimbursement totaling $475,000 for residents who were also claimed by hospitals in MAC Jurisdiction 12 for the same period and counted in the Intern and Resident Information System (IRIS) as more than 1 FTE. For the remaining 10 hospitals, the FTE overstatements did not have an effect on the hospitals' Medicare GME reimbursement. The overstated FTE counts and excess reimbursement occurred because there was no Federal requirement for National Government Services (NGS) to compare IRIS data submitted by hospitals in its jurisdiction to IRIS data submitted by hospitals in other MAC jurisdictions to detect whether a resident had overlapping rotational assignments. As a result, NGS did not have procedures to ensure that residents working at hospitals in all other MAC jurisdictions were not counted as more than one FTE in the calculation of Medicare GME payments. The OIG recommends that NGS:
NGS did not concur with the OIG's recommendations. >Click here to view the full report 9. Medicare Compliance Review of Bay Medical Center for Calendar Years 2009 and 2010 Bay Medical Center (the Hospital), located in Panama City, Florida, complied with Medicare billing requirements for 149 of the 197 inpatient and outpatient claims that the OIG reviewed. However, the Hospital did not fully comply with Medicare billing requirements for the remaining 48 claims, resulting in overpayments totaling $290,000. Specifically, 43 inpatient claims had billing errors, resulting in net overpayments totaling $271,000, and 5 outpatient claims had billing errors, resulting in net overpayments totaling $18,000. Overpayments occurred primarily because the Hospital did not have adequate controls to prevent incorrect billing of Medicare claims, and its staff did not fully understand Medicare billing requirements. >Click here to view the full report 10. Review of Colorado Direct Medical Service and Specialized Transportation Costs for the Medicaid School Health Services Program for State Fiscal Year 2008 Not all of the costs that the Colorado Department of Health Care Policy and Financing (State agency) claimed for School Health Services (SHS) during the period July 1, 2008, through June 30, 2009, were reasonable, allowable, and adequately supported pursuant to applicable Federal regulations and State requirements. Specifically, of the $1.8 million (Federal share) that the State agency claimed in costs for the Greeley and Aurora school districts for this period, $248,000 (Federal share) was unallowable for Federal reimbursement due to a variety of errors. In addition, errors identified during the OIG's review of the audited (Greeley and Aurora) school districts impacted not only these school districts, but also other Colorado school districts and the State agency. As a result of these errors, these other Colorado school districts received a total of $467,000 (Federal share) in unallowable Medicaid payments for the period July 1, 2008, through June 30, 2009. As an additional result of these errors, the State agency received a total of $156,000 (Federal share) in unallowable Medicaid payments for the same period. These errors totaling $871,000 (Federal share) in questioned costs occurred because the State agency did not have adequate policies and procedures to monitor the SHS program and to ensure that all costs claimed met Federal requirements. >Click here to view the full report 11. Claim Modifier Did Not Prevent Medicare from Paying Millions in Unallowable Claims for Selected Durable Medical Equipment Medicare Part B provides for the coverage of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). For certain DMEPOS, suppliers must use the KX modifier on filed claims. The KX modifier indicates that the claim meets Medicare coverage criteria and the supplier has the required documentation on file. This report summarizes the results of individual reviews of the 4 contractors that processed the DMEPOS claims for Jurisdictions A through D (which included all 50 States, 5 territories, and the District of Columbia). The KX modifier was not effective in ensuring that suppliers of DMEPOS that submitted Medicare claims had the required supporting documentation on file. Based on the OIG's sample, the OIG estimated that the contractors paid approximately $316.4 million to suppliers that did not have the required documentation on file to support the DMEPOS items with 2007 dates of service. These errors occurred because the contractors' electronic edits could not determine whether suppliers had the required documentation on file when they used the KX modifier on claims. The OIG recommends that CMS:
CMS concurred with the OIG's recommendations and listed actions it intends to take in response to them, consistent with its policies and procedures. >Click here to view the full report 12. Centers for Disease Control and Prevention Did Not Meet Program Expansion Supplement Requirements for Awarding One Affordable Care Act Grant From the OIG's sample of 31 Affordable Care Act grants, CDC awarded 30 grants in accordance with the terms and conditions of the funding opportunity announcements and with applicable grant administration requirements for awarding grants. However, CDC awarded one grant that was not in accordance with certain applicable administrative requirements. CDC did not meet these administrative requirements because communication was inadequate among the offices responsible for grant administration. As a result, CDC could not ensure that its use of ACA-related funding for one grant, totaling $500,000, was most advantageous to the goals of the ACA program. >Click here to view the full report Share This Article |
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