Good morning to all from Washington, DC. Today OIG posts seven reports and provides news about enforcement actions. As always, you can use the links provided to go directly to the new material. ------------------------------------------------------------------------------ New York Claimed Some Unallowable Costs for Services by New York City Providers under the State’s Developmental Disabilities Waiver Program (A-02-10-01027) http://go.usa.gov/rk8V The New York State Department of Health (DOH) claimed Federal Medicaid reimbursement for some Office for People With Developmental Disabilities (OPWDD) waiver program services provided by New York City providers that did not comply with certain Federal and State requirements. Based on our sample results, we estimate that DOH improperly claimed $7.8 million in Federal Medicaid reimbursement for OPWDD waiver program services during calendar years 2006 through 2008. Federal law authorizes Medicaid home and community-based services (HCBS) waiver programs. A State’s HCBS waiver program must be approved by CMS and allows a State to claim Federal reimbursement for services not usually covered by Medicaid. Of the 100 beneficiary-months in our random sample, DOH properly claimed Medicaid reimbursement for OPWDD waiver program services during 86 beneficiary-months. However, DOH claimed Medicaid reimbursement for services that did not comply with certain Federal and State requirements for the remaining 14 beneficiary-months. The claims for unallowable services were made because DOH and OPWDD’s policies and procedures for overseeing and administering the waiver program were not adequate to ensure that (1) providers claimed reimbursement only for services actually provided and maintained all the required documentation to support services billed and (2) OPWDD waiver program services were provided only to beneficiaries pursuant to written plans of care. We recommended that DOH: (1) Refund $7.8 million to the Federal Government and (2) Work with OPWDD to strengthen policies and procedures to ensure that (a) providers claim reimbursement only for OPWDD waiver program services actually provided and maintain the required documentation to support services billed and (b) OPWDD waiver program services are provided pursuant to written plans of care. DOH and OPWDD concurred with our recommendations. ------------------------------------------------------------------------------ Medicare Contractors’ Payments to Providers in Jurisdiction 11 for Full Vials of Herceptin Were Often Incorrect (A-03-11-00013) http://go.usa.gov/rk9P Most payments for one or more full vials of Herceptin that the Medicare contractors made to providers in Jurisdiction 11 (North Carolina, South Carolina, Virginia, and West Virginia) from January 2008 through December 2010 were incorrect. Herceptin (trastuzumab) is a Medicare-covered biological drug used to treat breast cancer that has spread to other parts of the body. Of the 2,507 selected line items, 2,029 were incorrect and included overpayments totaling $2.4 million that the providers had not identified or refunded by the beginning of our audit. Providers refunded overpayments on 138 line items totaling $131,000 before our fieldwork. The remaining 340 line items were correct. The 2,029 incorrect line items included incorrect units of service and a lack of supporting documentation. The providers attributed the incorrect payments to chargemaster errors, clerical errors, and billing systems that could not prevent or detect the incorrect billing of units of service. In some cases, providers could not store unused doses for later use because their pharmacies incorrectly reconstituted the Herceptin. When this occurred, the providers billed Medicare for the entire vial, including waste. The Medicare contractors made these incorrect payments because neither the Fiscal Intermediary Standard System nor the Common Working File had sufficient edits in place during our audit period to prevent or detect the overpayments. We recommended that Palmetto GBA, LLC (Palmetto), the Medicare Administrative Contractor for Jurisdiction 11: (1) Recover the $2.4 million in identified overpayments, (2) Implement a system edit that identifies for review line items for multiuse-vial drugs with units of service equivalent to one or more entire vials, and (3) Use the results of this audit in its provider education activities. Palmetto concurred with our findings and recommendations and described corrective actions that it had taken or planned to take. ------------------------------------------------------------------------------ Texas Did Not Report Excess Contractor Profits in Accordance With Federal Regulations (A-06-10-00062) http://go.usa.gov/rkXW A Medicaid Management Information System (MMIS) is a system of software and hardware used to process Medicaid claims and manage information about Medicaid beneficiaries, services, and providers. The Texas Health and Human Services Commission (State agency) contracts with a fiscal agent, Affiliated Computer Services/Texas Medicaid Health Partnership (ACS/TMHP), to process claims through the MMIS. The contract between the State agency and ACS/TMHP requires a prospective price redetermination (PPR) audit to establish whether ACS/TMHP earned profit in excess of the 11 percent allowed by the contract. We found that the State agency did not refund $2.6 million (Federal share) of the $26.7 million in excess profits identified through the PPR audit in accordance with Federal requirements. During fiscal year 2009, the State agency claimed expenditures for 20 MMIS projects with total costs of $71.3 million. All of these expenditures were allowable and claimed at the appropriate reimbursement rate; however, the State agency did not obtain prior approval for 2 of the 20 projects. Also, the State agency did not obtain prior approval for 16 additional projects. The total budgets for the 18 projects for which the State agency did not obtain prior approval totaled $59 million ($32.9 million Federal share). We recommended that the State agency: (1) Refund to the Federal Government $2.6 million for excess profits related to the PPR audit, (2) Ensure that prior approval is obtained on future projects as required by Federal regulations, and (3) Obtain retroactive approval for the 18 projects that did not have the required prior approval from the Centers for Medicare & Medicaid Services (CMS). The State agency agreed with our first and third recommendations and described corrective actions it had taken or planned to take. Regarding our second recommendation, the State agency described the process by which it seeks CMS approval for certain projects. ------------------------------------------------------------------------------ Review of Medicare Outpatient Billing for Selected Drugs at Self Regional Healthcare (A-09-12-02032) http://go.usa.gov/rkXd For the 61 line items reviewed, Self Regional Healthcare did not bill Medicare for injections of selected drugs in accordance with Federal requirements, resulting in overpayments totaling $130,000. ------------------------------------------------------------------------------ Review of Medicare Outpatient Billing for Selected Drugs at Methodist Healthcare – Memphis Hospitals (A-09-12-02022) http://go.usa.gov/rkNY For 60 of the 82 line items reviewed, Methodist Healthcare – Memphis Hospitals did not bill Medicare for injections of selected drugs in accordance with Federal requirements, resulting in overpayments totaling $178,000. ------------------------------------------------------------------------------ Medicare Part D Made Some Incorrect Payments to Community Insurance Inc. for Institutional Beneficiaries in 2008 (A-05-11-00042) http://go.usa.gov/rkNB The Medicare Part D program incurred drug costs for Medicare Advantage beneficiaries during Skilled Nursing stays that should have been covered under Part C in 2008. Community Insurance Inc’s incurrence of the $23,000 in gross drug costs as Part D costs had an overpayment effect of $13,000 as well as a $9,000 reconciliation effect at year end. ------------------------------------------------------------------------------ North Shore Community Health, Inc., Claimed Unallowable Costs Against Recovery Act Grants (A-01-11-01502) http://go.usa.gov/rk85 We could not determine whether $2 million in American Recovery and Reinvestment Act of 2009 (Recovery Act) grant costs claimed by North Shore Community Health, Inc. (North Shore), was allowable under the terms of the grants and applicable Federal regulations. North Shore did not track and account for Recovery Act expenditures separately from other (Federal and non-Federal) operating expenses; therefore, it could not demonstrate that it spent Recovery Act grant funds for allowable costs. This deficiency occurred because North Shore did not: (1) Maintain a financial management system that provided for accurate, current, and complete disclosure of the financial results of its Recovery Act grants and (2) Separately track and account for Recovery Act funds. We recommended that the Health Resources and Services Administration (HRSA) require North Shore to refund $2 million to the Federal Government, or work with North Shore to determine whether any of the costs that it claimed against Recovery Act grants were allowable, and ensure North Shore: (1) Develops a financial system that provides for the accurate, current, and complete disclosure of the financial results of each HHS-sponsored project or program and (2) Tracks and accounts for each grant’s expenditures separately from other operating expenditures. North Shore stated that it adjusted its internal financial reporting process to be in compliance with Federal requirements. Under the Recovery Act, P.L. No. 111-5, enacted February 17, 2009, HRSA received $2.5 billion, including $2 billion to expand the Health Center Program to serve more patients, stimulate new jobs, and meet the expected increase in demand for primary health care services among the Nation’s uninsured and underserved populations. ------------------------------------------------------------------------------ August 21, 2012; U.S. Department of Justice Medical Equipment Company Owner Sentenced in Louisiana to 180 Months in Prison for Medicare Fraud Scheme http://go.usa.gov/yWn ------------------------------------------------------------------------------ August 21, 2012; U.S. Department of Justice Florida Assisted Living Facility Owner Sentenced to 30 Months in Prison for Medicare Fraud Scheme http://go.usa.gov/yWn ------------------------------------------------------------------------------ August 21, 2012; U.S. Attorney; Middle District of Louisiana New Orleans Resident Convicted Of Health Care Fraud and Conspiracy to Pay and Receive Illegal Remunerations http://go.usa.gov/yWn ------------------------------------------------------------------------------ August 20, 2012; U.S. Attorney; Southern District of Texas Houston Doctor Arrested on Charges of Health Care Fraud http://go.usa.gov/yWn ------------------------------------------------------------------------------ August 17, 2012; U.S. Attorney; Southern District of Mississippi Mississippi Doctor Sentenced To 168 Months in Prison for Health Care Fraud http://go.usa.gov/yWn ------------------------------------------------------------------------------ State Enforcement Actions Updated http://go.usa.gov/pqp ------------------------------------------------------------------------------ That’s all we have for today. 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OIG Posts 7 Reports and News About Enforcement Actions - 8/22
