Good morning to all from Washington, DC. Today OIG posts congressional testimony, four reports and news about enforcement actions. As always, you can use the links provided to go directly to the new material. ------------------------------------------------------------------------------ OIG Regional Inspector General Testifies Today http://go.usa.gov/dwk Robert A. Vito, Regional Inspector General for Evaluation and Inspections testifies this morning before the Subcommittee on Oversight and Investigations of the House Committee on Energy and Commerce concerning Medicare Contractors' Efforts to Fight Fraud - Moving Beyond "Pay and Chase." ------------------------------------------------------------------------------ April Recovery Act Oversight Monthly Report http://go.usa.gov/dwI In this monthly report, OIG recaps its work to assesses whether HHS is using Recovery Act funds in accordance with legal and administrative requirements and is meeting the accountability objectives defined by the Office of Management and Budget. ------------------------------------------------------------------------------ Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles: 2012 (OEI-05-12-00060) http://go.usa.gov/dw5 WHY WE DID THIS STUDY This memorandum report fulfills the annual reporting mandate from the Patient Protection and Affordable Care Act of 2010 (ACA) for 2012. The ACA requires that OIG conduct a study of the extent to which formularies used by stand-alone prescription drug plans and Medicare Advantage prescription drug plans (referred to jointly as Part D plans) under Medicare Part D include drugs commonly used by full-benefit dual-eligible individuals (i.e., individuals who are eligible for both Medicare and Medicaid and who receive full Medicaid benefits and assistance with Medicare premiums and cost-sharing). Pursuant to the ACA, OIG must annually issue a report with recommendations as appropriate. This is the second report the OIG has produced to meet this mandate. HOW WE DID THIS STUDY For this memorandum report, we determined whether the 272 unique formularies used by the 3,107 Part D plans operating in 2012 cover the 200 drugs most commonly used by dual eligibles. We also determined the extent to which those commonly used drugs are subject to utilization management tools. To create the list of the 200 drugs most commonly used by dual eligibles, we used the 2008 Medicare Current Beneficiary Survey. Of these 200 drugs, 191 are eligible for Part D prescription drug coverage and 9 are excluded from coverage by law. WHAT WE FOUND Overall, we found that the rate of Part D plan formularies’ inclusion of the 191 drugs commonly used by dual eligibles is high, with some variation. On average, Part D plan formularies include 96 percent of the 191 commonly used drugs. In addition, 61 percent of the commonly used drugs are included by all Part D plan formularies. These results are largely unchanged from OIG’s findings for formularies reported in the related 2011 mandated annual report. We also found that plan formularies increased the number of unique drugs subject to utilization management tools from 2011 to 2012. On average, formularies applied utilization management tools to 24 percent of the unique drugs we reviewed in 2012, compared to 19 percent of the unique drugs we reviewed in 2011. Most of this increase is due to an increase in the use of quantity limits by plan formularies. This report does not contain recommendations. ------------------------------------------------------------------------------ Medicare Continues To Pay Twice for Nonphysician Outpatient Services Provided Shortly Before or During and Inpatient Stay (A-01-10-00508) http://go.usa.gov/dwN Based on our sample results, we estimated that Medicare contractors made approximately $6.4 million in overpayments to hospital outpatient providers during calendar years 2008 and 2009 for services provided to beneficiaries within 3 days prior to the date of admission for, on the date of admission for, or during (excluding date of discharge) inpatient prospective payment system (IPPS) stays. These overpayments occurred because provider controls failed to prevent or detect incorrect billing, providers were unaware that beneficiaries were inpatients at other facilities, and providers were unaware of or did not understand Medicare requirements. In addition: (1) Medicare contractors were not aware of incoming Common Working File (CWF) alerts because CMS did not notify them it had changed the location of this information on the trailer record, (2) Existing CWF edits did not prevent or detect certain incorrect payments, and (3) Medicare contractors incorrectly overrode Fiscal Intermediary Standard System (FISS) edits or took no action to recover or offset overpayments when they received CWF alerts. Under the IPPS, hospitals are paid a predetermined amount per discharge for inpatient hospital services furnished to Medicare beneficiaries. The amount represents the total Medicare payment for the inpatient operating costs associated with a beneficiary’s hospital stay. Medicare contractors use the FISS to process inpatient and outpatient claims submitted by the hospitals in their designated jurisdictions. After being processed through the FISS, and prior to payment, all Medicare contractor claims are sent to CMS’s CWF system for verification, validation, and payment authorization. Prior Office of Inspector General reviews identified significant overpayments to IPPS hospitals for nonphysician services furnished shortly before or during inpatient stays. We recommended that CMS: (1) instruct its Medicare contractors to: (a) Recover the $340,073 in identified overpayments, to the extent allowed under the law, for the 61 incorrectly billed services; (b) Work with the Office of Inspector General to resolve the remaining 148,175 services with potential overpayments estimated at approximately $6.1 million and recover overpayments to the extent allowed under the law; (c) Take action to reject claims or recoup overpayments when identified by edits; and (d) Remind hospitals of the importance of adequate controls to prevent incorrect billing for services; (2) Communicate with Medicare contractors about changes to the CWF; (3) Modify existing edits to prevent payments for ambulance services provided during inpatient stays; and (4) Modify existing edits to prevent payments that are already included in the basic prospective payment rate for nonphysician outpatient services furnished to beneficiaries after the beneficiaries have exhausted their Part A benefits. CMS concurred in part with our first recommendation, concurred with our next four recommendations, did not concur with our recommendation to modify existing edits to prevent payments for ambulance services provided during inpatient stays as it was stated in the report, and concurred with our final recommendation. ------------------------------------------------------------------------------ WellPoint, Inc. Did Not Always Calculate Enrollees’ True-Out-Of-Pocket Costs in Accordance With Federal Requirements (A-05-11-00018) http://go.usa.gov/dwR WellPoint, Inc. (a Part D drug plan sponsor), did not always calculate true out-of-pocket (TrOOP) costs in accordance with Federal requirements. For calendar years 2008 and 2009, we estimated that the Federal Government (on behalf of enrollees) overpaid while WellPoint underpaid their respective shares of the drug costs by $2.8 million. We recommended that WellPoint: (1) Calculate TrOOP costs in accordance with Federal requirements, (2) Enhance communication with other plans to ensure TrOOP balances are transferred properly, (3) Implement system edits to ensure each claim is processed according to its plan benefits, and (4) Implement system edits to ensure PDE records are adjusted to accurately update TrOOP balances. WellPoint agreed with our findings and described steps it has taken to address our recommendations. ------------------------------------------------------------------------------ June 7, 2012; U.S. Department of Justice Texas-based Medical Device Manufacturer Pays U.S. $34 Million to Settle False Claims Act Allegations http://go.usa.gov/yWn ------------------------------------------------------------------------------ June 7, 2012; U.S. Department of Justice Co-Owner of Detroit-Area Therapy Company Sentenced To 30 Months for Medicare Fraud Scheme http://go.usa.gov/yWn ------------------------------------------------------------------------------ June 7, 2012; U.S. Attorney; Southern District of Texas Recruiter in City Nursing Scheme Pleads Guilty http://go.usa.gov/yWn ------------------------------------------------------------------------------ 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 I hope your week has gone well and you are able to enjoy the upcoming weekend. Marc Wolfson – Office of External Affairs
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OIG Posts Testimony, 4 Reports and News about Enforcement Actions - 6/8
