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OIG posts 3 Reports - 6/25

New content posted on OIG.HHS.GOV

Good morning to all from Washington, DC. Today OIG posts three reports. As always, you can use the links provided to go directly to the new material.

Report Recap

What Where Issue
New York Medicaid Fraud Control Unit New York $750 million in recoveries
Improper Medicare Payments for Outpatient Services Montana Unallowable Medicaid payments of $1.5 million
Excess Capitation Payments Pennsylvania Refund $8 million the returned excess capitation payments

New York State Medicaid Fraud Control Unit: 2011 Onsite Review (OEI-02-11-00440)

http://go.usa.gov/vG6

WHY WE DID THIS STUDY

OIG is responsible for overseeing the activities of all Medicaid Fraud Control Units (MFCU or Unit). As part of this oversight, the Office of Evaluation and Inspections conducts periodic reviews of all Units and prepares public reports based on those reviews. The reviews describe the Units' caseloads; assess performance in accordance with the 12 MFCU performance standards, identifying any opportunities for improvement; identify any instances of noncompliance with laws, regulations, or policy transmittals; and highlight any noteworthy practices.

HOW WE DID THIS STUDY

We based our review on an analysis of data from seven sources:

  1. a review of policies and procedures and documentation on the Unit's operations, staffing, and caseload;
  2. structured interviews with key stakeholders;
  3. a survey of Unit staff;
  4. structured interviews with the Unit's management;
  5. an onsite review of case files; (6) an onsite review of financial documentation; and
  6. an onsite review of Unit operations.

WHAT WE FOUND

From fiscal years 2008 to 2010, the New York Unit filed criminal charges against more than 400 defendants, obtained over 400 convictions, and was awarded more than $750 million in recoveries. Although the number of referrals to the Unit increased during this time, the number of cases that the Unit opened and closed decreased. Additionally, the Unit did not establish annual training plans for each of the three professional disciplines-i.e., for auditors, investigators, or attorneys-and provided limited training opportunities to staff. The Unit also lacked policies and procedures to reflect many of its current practices, and its case files lacked consistency and uniform supervisory reviews. Finally, the Unit lacked a number of internal controls.

At the same time, our review found no evidence of significant noncompliance with applicable laws, regulations, or policy transmittals. Further, Unit managers, staff, and stakeholders cited a number of the Unit's noteworthy practices, including its approach to patient abuse and neglect cases, its list of ongoing investigations (created to avoid conflicts among investigating agencies), and its use of technology.

WHAT WE RECOMMEND

We recommend that the New York MFCU:

  1. seek to expand staff sizes to reflect the number of staff approved in the Unit's budget;
  2. establish annual training plans and increase the number of training opportunities available to staff;
  3. ensure that its memorandum of understanding, policies, and procedures reflect current practices;
  4. ensure that its case files are maintained with greater consistency and reviewed more frequently; and
  5. establish written policies and procedures for certain internal controls.

The New York Unit concurred with all five of our recommendations.

Montana Did Not Properly Pay Medicare Part B Deductibles and Coinsurance for Outpatient Services (A-07-11-03172)

http://go.usa.gov/vGM

We estimated that the Department of Public Health and Human Services (State agency) claimed unallowable Medicaid payments of $1.5 million ($1.1 million Federal share) during fiscal year (FY) 2009. The State agency did not always claim Medicaid payments for Medicare Part B deductibles and coinsurance for services whose payments are limited to State Medicaid plan rates in accordance with Federal requirements and the approved State plan. Specifically, for 79 of the 100 claims in our sample, the State agency did not limit payment of Medicare Part B deductibles and coinsurance to State Medicaid plan rates as required under the State plan.

These discrepancies occurred because the State agency did not compare the Medicare payment to the State Medicaid plan rate. The State agency did not make this comparison because it did not have policies and procedures requiring it to do so.

We recommended that the State agency:

  1. refund $1.1 million to the Federal Government for unallowable Medicaid payments for Medicare Part B deductibles and coinsurance and
  2. develop and implement policies and procedures to ensure that it compares the Medicare payment to the State Medicaid plan rate to determine the allowable Medicare Part B deductibles and coinsurance for each crossover claim for outpatient services.

The State agency disagreed with our finding and recommendations.

Pennsylvania Did Not Refund the Full Federal Share of Recouped Excess Capitation Payments from Themedicaid Behavioral Healthchoices Program (A-03-10-00204)

http://go.usa.gov/vGe

Pennsylvania recouped $39.6 million in excess capitation payments from 12 of 24 reviewed counties' Risk and Contingency and Reinvestment funds but did not refund the full Federal share in accordance with Federal requirements. (At the time of our audit, the State had not identified excess capitation payments to be recouped for the 12 remaining counties.) The State identified $24.6 million of recouped excess capitation payments in 11 of the 12 counties we reviewed and properly refunded the Federal share of $13 million. However, the State designated as State-only funds $15 million recouped from Philadelphia County's Reinvestment Fund and, therefore, did not refund the Federal share.

Section 1915(b) of the Act allows States to seek waivers to implement managed care delivery systems or otherwise limit an individual's choice of provider under the Medicaid program. Managed care entities agree to provide specific services to enrolled Medicaid beneficiaries, usually in return for a predetermined periodic payment, known as a capitation payment, for each beneficiary. Under Pennsylvania's section 1915(b) waiver, the Behavioral HealthChoices program provides mental health services to beneficiaries in 25 of the State's counties.

The State did not develop and implement effective internal controls to identify and return to the Federal Government the Federal share of excess capitation payments recouped from the counties' Risk and Contingency and Reinvestment funds. Because Philadelphia's Reinvestment account commingled excess capitation payments for both Federal Medicaid and State General Assistance enrollees, the State was unable to identify the amount of State-only funds recouped from Philadelphia County. Accordingly, the State must refund the $8 million Federal share of the returned excess capitation payments.

We recommended that the State:

  1. refund $8 million (Federal share) of excess capitation payments returned by Philadelphia County and
  2. develop procedures to ensure that the State properly refunds the Federal share of excess capitation payments recouped from the Risk and Contingency and Reinvestment funds.

The State partly agreed and partly disagreed with our recommendations.

That's all we have for today. If we can be of any further assistance, please send an email to public.affairs@oig.hhs.gov

Dee Ellison - Office of External Affairs

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