Office of Inspector General, Medicare/Medicaid fraud, expenditure statistics and misc.

[Minuteman]

"Place-of-Service Overpayments Refund Verification for Boston Medical Center for Calendar Years 2006 through 2010 (A-01-11-00508)" published 28 November 2011.

http://oig.hhs.gov/oas/reports/region10/11100508.pdf

Excerpt:

We determined that Boston Medical Center (the Hospital) submitted 7,520 claims with overpayments totaling approximately $90,000 for physician services for calendar years 2006 through 2010. The Hospital, billing on behalf of its physicians, incorrectly coded these claims by using nonfacility place-of-service codes for services that were performed in one of the Hospital’s outpatient facilities.

[Minuteman]

"Review of 24 Head Start Grantees' Compliance With Health and Safety Requirements Audit (A-01-11-02503)" published 13 December 2011.

http://oig.hhs.gov/oas/reports/region10/11102503.asp

Executive Summary:

Of the 24 Head Start grantees that we reviewed, none complied fully with Federal Head Start or State requirements to protect children from unsafe materials and equipment, and 21 of 24 grantees did not comply fully with Federal Head Start or State requirements to conduct criminal records checks, conduct recurring background checks, document criminal records checks, conduct checks of childcare exclusion lists, or conduct checks of child abuse and neglect registries. The American Recovery and Reinvestment Act of 2009 provided an additional $2.1 billion for Head Start during fiscal years 2009 and 2010.

The State requirements varied. The Administration for Children and Families (ACF) could adopt some of the State-specific requirements for background checks to better protect the health and safety of children. Those State requirements included periodic fingerprinting, conducting recurring background checks, and developing an exclusion list to deny employment to individuals who have been convicted of certain crimes.

We recommended that ACF (1) ensure through onsite monitoring that Head Start grantees comply with health and safety regulations; (2) perform an analysis to determine whether it should seek a legislative amendment of Federal health and safety requirements that would require periodic background checks for all Head Start employees; and (3) amend current policy and regulations to require that any prospective or current employee be disqualified for or terminated from employment with a Head Start grantee if the individual has been convicted of sexual abuse of a child, other forms of child abuse and neglect, or a violent felony.

In written comments on our draft report, ACF stated that it is analyzing our recommendation to implement periodic background checks of all Head Start employees. In addition, ACF stated that it is analyzing the need for legislative action related to implementing periodic background checks, its regulatory authority to change the current requirements for background checks, and its authority to amend current policies related to background checks.

[Minuteman]

"Vulnerabilities in FDA's Oversight of State Food Facility Inspections Report (OEI-02-09-00430)" published 13 December 2011.

http://oig.hhs.gov/oei/reports/oei-02-09-00430.pdf

Summary:

Although FDA has increasingly relied on States to inspect food facilities, our report identified significant weaknesses in FDA's oversight of these inspections. Notably, in eight States, FDA failed to ensure that the required number of inspections was completed. Moreover, FDA paid for many inspections that were incomplete.

In addition, FDA did not ensure that all inspections were properly classified or that all inspection violations were remedied. Based on the violations found during an inspection, FDA assigns each inspection a classification; an official action indicated (OAI) classification is generally assigned when the most serious violations are identified. We found that FDA officials were often unclear about how to properly classify contract inspections. Specifically, officials responsible for 11 States reported that they would not assign OAI classifications to State inspections under any circumstances, contrary to FDA guidance. Additionally, FDA officials reported that when States are responsible for correcting violations, FDA was not always informed about actions taken by the States. As a result, FDA was unable to ensure that all inspection violations were remedied.

Finally, FDA failed to complete the required number of audits in one-third of the States with inspection contracts. FDA guidance requires that a minimum of 7 percent of a State's contract inspections be audited each year. However, FDA failed to complete the required number of audits in 14 of 41 States. Additionally, the audits in 10 States revealed systemic problems that needed to be corrected; however, FDA initiated corrective action in only 4 of these 10 States.

We recommend that FDA: (1) ensure that all contract inspections are completed, properly documented, and appropriately paid for; (2) ensure that contract inspections are properly classified in accordance with FDA guidance; (3) ensure that all inspection violations are remedied by routinely tracking all actions taken to correct violations; (4) ensure that the minimum audit rate is met in all States; and (5) address any systemic problems identified by audits. FDA concurred with four of our recommendations and agreed in part with the fifth.

[Minuteman]

"Medicaid Managed Care: Fraud and Abuse Concerns Remain Despite Safeguards (OEI-01-09-00550)" report published 14 December 2011.

http://oig.hhs.gov/oei/reports/oei-01-09-00550.pdf

Summary:

We found that although managed care entities (MCE) and States are taking steps to address fraud and abuse in managed care, they remain concerned about their prevalence.

States have increasingly adopted managed care in response to Medicaid expenditures, which have nearly doubled in the past decade. CMS requires MCEs to meet specific program integrity requirements as a condition for receiving payment. CMS also requires MCEs to disclose to States certain information, such as ownership and control. States are directly responsible for monitoring MCE operations. CMS's Medicaid Integrity Group (MIG) conducts program integrity reviews of States and MCEs. In 2000, CMS issued guidelines to States for addressing fraud and abuse in Medicaid managed care. The guidelines identified six areas of concern.

We surveyed a purposive sample of 46 MCEs and received responses from 45. We conducted structured telephone interviews with the 13 States that contracted with those MCEs. We also reviewed MIG's files from its program integrity reviews of those 13 States and 46 MCEs.

All MCEs in our sample reported taking steps to meet the Federal program integrity requirements. All 45 MCEs that responded to our questionnaire provided fraud and abuse safeguard training to their staffs in 2010. Most also reported offering such training to their providers. In 2009, 33 MCEs reported cases of suspected fraud and abuse to their State Medicaid agencies, and 20 MCEs recovered payments from providers that resulted from fraud and abuse.

The 13 States in our sample reported taking steps to oversee MCEs' fraud and abuse safeguards. All 13 States conduct desk reviews of MCEs' compliance plans, and 11 States conduct onsite MCE reviews. All 13 States reported requiring that MCEs disclose ownership and control information. Eleven States hold recurring meetings with MCEs and often provide training.

The primary concern about Medicaid managed care fraud and abuse-shared by MCEs and States-related to services billed but not received. The major concerns identified in our review largely fall under only one of the six areas included in CMS's 2000 guidelines.

Managed care presents challenges in addressing fraud that differ from those in fee-for-service Medicaid. As States increasingly use managed care to deliver Medicaid services, implementing safeguards to protect against fraud and abuse remains essential. We recommend that CMS require that State contracts with MCEs include a method to verify with beneficiaries whether they received services billed by providers. CMS could require States to implement one of several options, such as for MCEs to send explanations of medical benefits to beneficiaries. We also recommend that CMS update guidance to reflect concerns expressed by MCEs and States. CMS could also share best practices and innovative methods that States and MCEs have used to address fraud and abuse concerns and strengthen program integrity oversight. CMS concurred with both recommendations.

[Minuteman]

"NIH Administration of the Clinical and Translational Science Awards Program (Report OEI-07-09-00300)" published 20 December 2011.

http://oig.hhs.gov/oei/reports/oei-07-09-00300.pdf

Summary:

For all 38 Clinical and Translational Science Awards (CTSA) cooperative agreements awarded from 2006 through 2008, CTSA program staff did not document awardees' progress in compliance with NIH policy.

CTSA program staff must ensure that awardees submit annual progress reports and financial status reports, determine whether awardee progress remains satisfactory before awardees receive continued funding, and maintain official files in accordance with Department of Health and Human Services (HHS) policy. Additionally, under cooperative agreements, CTSA program staff provide assistance to awardees above and beyond the levels usually required for program stewardship of grants. This level of stewardship is known as substantial involvement. CTSA program staff assign NIH Project Scientists to awardees to provide this substantial involvement through technical assistance, advice, and coordination. Names of substantially involved staff and an annual summary of staff involvement should be documented in the official files.

CTSA program staff documented a comparison of accomplishments to research objectives for only 1 of 38 awardees throughout our review period. Although reviews for six awardees' files mentioned an inability to fulfill goals, only one file included a note from CTSA program staff regarding resolution. Also, most progress reports and half of financial status reports were late, yet the files contained no evidence that CTSA program staff took action to address timeliness of reports. CTSA program staff did not maintain files in accordance with HHS policy. Finally, no files contained evidence that CTSA program staff provided substantial involvement to awardees in accordance with Federal requirements and NIH policy.

We recommend that NIH ensure that CTSA program staff (1) document their monitoring of awardee progress; (2) ensure timely submission of required reports; (3) maintain official files in accordance with Federal policy; and (4) as required for cooperative agreements, provide substantial involvement to CTSA awardees. NIH concurred with our recommendations.

[Minuteman]

"Review of Arkansas' Reporting Fund Recoveries for Federal and State Medicaid Programs on the CMS-64 Report for State Fiscal Year 2009 (Audit A-06-10-00051)" published 20 December 2011.

http://oig.hhs.gov/oas/reports/region6/61000051.pdf

Executive Summary:

For State fiscal year 2009, the Arkansas Department of Human Services, Division of Medical Services (State agency), did not report or have supporting documentation for Medicaid overpayments totaling $129,000 ($95,000 Federal share). Of the 125 sampled overpayments we reviewed, 7 were partially reported or not reported on the CMS-64 report, and 13 were not supported by documentation that reconciled with the CMS-64 report. Also, the State agency did not report overpayments that were refunded to it on the CMS-64 report for the quarter ended March 31, 2009, resulting in an error of $3.8 million ($2.8 million Federal share). As a result of our audit, the State agency refunded the overpayments on the CMS-64 report for the quarter ended March 31, 2010.

[Minuteman]

"Hospital Incident Reporting Systems Do Not Capture Most Patient Harm (Report OEI-06-09-00091)" published 6 January 2012.

http://oig.hhs.gov/oei/reports/oei-06-09-00091.pdf

Summary:

Hospital incident reporting systems captured only an estimated 14 percent of the patient harm events experienced by Medicare beneficiaries. Hospitals investigated those reported events that they considered most likely to lead to quality and safety improvements and made few policy or practice changes as a result of reported events. Hospital administrators classified the remaining events (86 percent) as either events that staff did not perceive as reportable (61 percent) or as events that staff commonly report but did not report in this case (25 percent).

As a condition of participation in the Medicare program, Federal regulations require that hospitals develop and maintain a Quality Assessment and Performance Improvement (QAPI) program. To satisfy QAPI requirements, hospitals must "track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital." To standardize hospital event reporting, AHRQ developed a set of event definitions and incident reporting tools known as the Common Formats. We requested and reviewed incident reports from hospitals regarding patient harm events. We had previously identified these events from a nationally representative sample of Medicare beneficiaries discharged in October 2008.

All of the hospitals we reviewed had incident reporting systems designed to capture events; hospital administrators we interviewed indicated that they rely heavily on the systems to identify problems. Hospital accreditors reported that they do not investigate event collection methods, such as incident reporting systems, unless evidence of a problem emerges through the survey process.

Because hospitals rely on incident reporting systems to track and analyze events, improving the usefulness of these systems is critical to hospitals' efforts to improve patient safety.

Therefore, we recommend that AHRQ and CMS collaborate to create and promote a list of potentially reportable events for hospitals to use. We further recommend that CMS provide guidance to accreditors regarding their assessments of hospital efforts to track and analyze events. CMS should also suggest that surveyors evaluate the information collected by hospitals using AHRQ's Common Formats. Additionally, CMS should scrutinize survey standards for assessing hospital compliance with the requirement to track and analyze events and reinforce assessment of incident reporting systems as a key tool to improve event tracking.

We received comments on the draft report from AHRQ and CMS. AHRQ concurred with our recommendation, stating that it will collaborate with CMS to create a list of potentially reportable events and provide technical assistance to hospitals in using the list. CMS also concurred with our recommendations, stating that strengthening hospital reporting systems and practices is an essential component of efforts to prevent patient harm. CMS stated that a voluntary list of adverse events used for informational purposes could be highly beneficial for improving incident reporting practices. CMS also stated that it is developing draft guidance for surveyors regarding assessment of patient safety improvement efforts within hospitals.

[Minuteman]

"Local Public Health Preparedness for Radiological and Nuclear Incidents (OEI-04-10-00250)" OIG report dated January 2012.

http://oig.hhs.gov/oei/reports/oei-04-10-00250.pdf

Summary:

Why We Did This Study

According to the 2010 National Security Strategy, the American people face no greater or more urgent danger than a terrorist attack with a nuclear weapon. If State and local public health officials do not plan for such incidents, local public health departments will not be adequately prepared to quickly respond and protect the public. Although the Nuclear Regulatory Commission requires nuclear powerplants to have emergency plans for their facilities and the immediate surrounding area, no Federal entity requires States or localities to have public health emergency plans for nonpowerplant radiological and/or nuclear (RN) incidents, such as a terrorist attack.

How We Did This Study

Using information requests and conducting document reviews, we determined the extent to which 40 localities from the Nation’s most populous metropolitan statistical areas (referred to as the “selected localities”) used local risk assessments to prioritize planning for RN incidents. We also determined whether the selected localities planned for RN incidents by engaging in five RN-specific public health planning areas; coordinating with Federal, State, and local partners; and using Federal guidance sources.

What We Found

Thirty-six of the forty selected localities had conducted risk assessments, but RN-specific public health planning did not always correspond to localities’ prioritized threats. For example, of the four localities that categorized RN incidents as a high-priority threat, only one had RN-specific plans. Twenty-one of the forty selected localities conducted RN-specific public health planning in at least one of the five public health areas of responsibility we examined, but planning in the five areas varied. Localities also varied in the extent to which they coordinated with Federal, State, and local partners for RN-specific public health planning. Most State and local officials were aware of Federal guidance sources available to aid RN-specific public health planning, but requested more comprehensive and specific planning tools.

What We Recommend

Our report made four recommendations to CDC. First, work with selected localities to more closely align their incident-specific planning with risk assessments. Second, provide more specific guidance outlining the public health areas of responsibility to include in RN-incident planning. Third, provide more guidance on coordination with other entities for RN-incident planning. Finally, provide more training to selected localities about the unique aspects of an RN incident not addressed in all-hazards planning. CDC agreed with all four of our recommendations.

[Minuteman]

"Review of Medicaid Payments for School-Based Health Services Made to Manchester, New Hampshire Audit (A-01-10-00014)" published 19 January 2012.

http://oig.hhs.gov/oas/reports/region1/11000014.pdf

Executive Summary:

The New Hampshire Department of Health and Human Services, Office of Medicaid Business and Policy (State agency) did not always claim Federal Medicaid reimbursement for school-based health services submitted by the Manchester School Administrative Unit (SAU) in accordance with Federal and State requirements during calendar years 2006 through 2008. Of the 100 student months in our random sample, 34 student months met Federal and State requirements. However, the remaining 66 student months had one or more school-based health services that were not reimbursable. Based on our results, we estimated that the State agency improperly claimed approximately $984,000 ($495,000 Federal share) for Medicaid payments made to the Manchester SAU.

[Minuteman]

"Review of Acute Care Inpatient Same-Day Readmissions at St. Mary's Hospital Audit (A-03-11-00009)" published 23 January 2012.

http://oig.hhs.gov/oas/reports/region3/31100009.pdf

Executive Summary:

St. Mary's Hospital did not always bill same-day readmissions in accordance with Federal requirements. For 17 of the 53 same-day readmissions in our review, St. Mary's Hospital incorrectly billed the second admission as a separate inpatient stay instead of a continuous stay based on the first admission, resulting in $89,000 in overpayments. These overpayments occurred because St. Mary's Hospital did not have adequate training to review same-day readmissions and prevent incorrect billings.