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U.S. Department of Health & Human Services
Office of Inspector General
ReportReportSemiannualSemiannualtoto
Office ofInspectorGeneral
Office ofInspectorGeneral
CongressCongressOctober 1, 2010 - March 31, 2011
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DepartmentofHealth&HumanServices
OfficeofInspectorGeneralSemiannualReporttoCongress
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InspectorGeneralsMessageandHighlights
Spring2011|HHSOIGSemiannualReporttoCongress
MessageFromtheInspectorGeneral
ThisSemiannualReporttoCongress,submittedpursuanttothe
InspectorGeneral
Act
of
1978,
as
amended,
summarizes
the
activities
oftheOfficeofInspectorGeneral(OIG),DepartmentofHealth&
HumanServices(HHS),forthe6monthperiodendingMarch31,
2011.
Thispastsixmonthshasbeenaperiodofintenseactivityforouroffice.Wehave
continuedtoconductawiderangeofaudits,evaluations,investigations,and
enforcementandcomplianceactivitiestoprotecttheintegrityoftheMedicare,Medicaid,
publichealth,andhumanservicesprograms.Wehaveledlargescalehealthcarefraud
investigationsincollaborationwithourFederal,State,andlocalpartners. Finally,our
outreachto
external
stakeholders,
including
the
Congress,
has
been
substantial.
This
threefoldapproachtoourdiverseportfoliomakingrecommendationsfor
improvementindepartmentalprograms;leveragingcriticalenforcementresourcesby
workingcloselywithourgovernmentpartners;andtargetingoutreachtoexternal
stakeholderscontinuestobeasuccessfulstrategy.
Ouraudit,evaluation,andinvestigativeactivityoverthepastsixmonthsaddresses
importantprogramvulnerabilitiessuchasquestionablebillingbyskillednursing
facilities,improperpaymentsformedicalsupplies,adverseeventsinhospitals,rebate
concernsintheMedicarePartDprogram,institutionalconflictsofinterestbyNational
InstitutesofHealth(NIH)granteesandallegedfraudbypharmaceuticalmanufacturers.
Wecontinue
to
diligently
monitor
the
impact
of
our
recommendations.
Additionally,
publicdisseminationofourworkalsoheightensourabilitytoeducateabroadrangeof
stakeholders. Forinstance,ourhospitaladverseeventreportwasdownloadedmore
than200,000timesfromourWebsite.
OurpartnershipwithotherlawenforcemententitiesaspartoftheHealthCareFraud
PreventionandEnforcementActionTeam(HEAT)continuestoproducesignificant
results,particularlyinitsStrikeForceactions. ThispastFebruary,StrikeForceteams
engagedinanunprecedentedhealthcarefraudtakedown. Teamsacrossthecountry
arrestedmorethan100defendantsin9citiesfortheirallegedparticipationinMedicare
fraudschemesinvolvingmorethan$225millioninfalsebilling.Notably,morethan
300OIG
special
agents
participated
in
coordination
with
other
Federal
and
State
agencies,includingotherOfficesofInspectorGeneral. Duringthisoperation,OIGand
theCentersforMedicare&MedicaidServices(CMS)workedtoimposepayment
suspensionsthatimmediatelypreventedalossofmorethanaquartermilliondollarsin
claimssubmittedbyStrikeForcetargets.
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InspectorGeneralsMessageandHighlights
Spring2011|HHSOIGSemiannualReporttoCongress
Duringthisreportingperiod,OIGwitnessestestifiedatfivecongressionalhearingsat
whichwehadtheopportunitytotalkaboutourworkfightingMedicarefraud,waste,
andabuseandourrecommendationstostrengthenprogramintegrity.Wealso
highlightedoureffortstoutilizetechnology,enhanceddata,andotherinnovativetools
toidentifyandpreventfraudschemesbeforetheybecomepervasive.
Additionally,ouroutreachtoexternalstakeholdersbroadensourmissiontoeducate
providersregardingtheimportanceofinstitutingeffectivecompliancemeasureswithin
theirorganizations.WerecentlyissuedARoadmapforNewPhysicians:Avoiding
MedicareandMedicaidFraudandAbuse. Thispublicationassistsnewphysiciansand
existinghealthcareprovidersbyofferingimportantinformationabouthowtoavoid
violatinghealthcarefraudandabuselaws.Wearealsocurrentlyleadingaseriesof
ProviderComplianceTrainingsessionsaroundthecountry. Thesesessionshavebeen
verysuccessfulineducatingaudiencesofhealthcareprofessionals,includingsmall
providers,interestedindevelopingorstrengtheningtheircomplianceprograms.
As
we
tackle
an
expanding
mission
to
protect
HHSs
vital
health
and
human
service
programs,IwouldliketoexpressmyappreciationtoCongressandtotheDepartment
fortheirsustainedcommitmenttosupportingtheimportantworkofourOffice.
DanielR.Levinson
InspectorGeneral
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InspectorGeneralsMessageandHighlights
Highlights
Thisedition
of
the
Department
of
Health
&
Human
Services
(HHS)
Office
of
Inspector
General(OIG)SemiannualReporttoCongressaddressesthefirst6monthperiodoffiscal
year(FY)2011. Itdescribestheresultsofourreviewsandlegalandinvestigative
outcomesandpresentsrecommendationsthat,whenimplemented,willsavetaxpayer
dollars,putfundstobetteruse,and/orimproveHHSprogramsandoperationsand
qualityofcare.
SummaryofOIGAccomplishments
ForthefirsthalfofFY2011,wereportedexpectedrecoveriesofabout$3.4billion
consisting
of
$222.4
million
in
audit
receivables
and
$3.2
billion
in
investigative
receivables(whichincludes$620millioninnonHHSinvestigativereceivablesresulting
fromourworkinareassuchastheStatesshareofMedicaidrestitution).
Wereportedexclusionsof883individualsandentitiesfromparticipationinFederal
healthcareprograms;349criminalactionsagainstindividualsorentitiesthatengagedin
crimesagainstHHSprograms;and197civilactions,whichincludedfalseclaimsand
unjustenrichmentlawsuitsfiledinFederaldistrictcourt,civilmonetarypenalties(CMP)
settlements,andadministrativerecoveriesrelatedtoproviderselfdisclosurematters.
Hereisanoutlineofactivitiesandfindingsthatarehighlightedinthissectionofthe
SemiannualReport.
HEAT:HealthCareFraudPrevention&EnforcementActionTeam
TheHealthCareFraudPreventionandEnforcementActionTeam(HEAT)wasstarted
in2009byHHSandtheDepartmentofJustice(DOJ)tostrengthenprogramsandinvest
innewresourcesandtechnologiestopreventandcombathealthcarefraud,waste,and
abuse. OIGsparticipationinMedicareFraudStrikeForceactivitiesisakeycomponent
ofHEAT.
Spring2011|HHSOIGSemiannualReporttoCongress|p.i
MedicareFraudStrikeForceMedicare
Fraud
Strike
Force
teams
coordinate
law
enforcement
operations
among
Federal,State,andlocallawenforcemententities. Theseteams,nowakey
componentofHEAT,havearecordofsuccessfullyanalyzingdatatoquicklyidentify
andprosecutefraudalmostasitoccurs. TheStrikeForcebeganinMarch2007andis
operatinginninemajorcities. Chicago,IllinoisandDallas,Texaswereaddedduring
thisreportingperiod. Duringthissemiannualreportingperiod,StrikeForceefforts
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InspectorGeneralsMessageandHighlights
haveresultedinthefilingofchargesagainst213individualsorentities,
107convictions,and$63.9millionininvestigativereceivables.
InFebruary2011,StrikeForceteamsengagedinanunprecedentedFederalhealth
carefraudtakedown. Teamsacrossthecountryarrestedmorethan100defendants
in9cities,includingdoctors,nurses,healthcarecompanyownersandexecutives,
andothers,fortheirallegedparticipationinMedicarefraudschemesinvolvingmore
than$225millioninfalsebilling. Thedefendantsareaccusedofvarioushealthcare
relatedcrimesrangingfromviolatingtheantikickbackstatutetomoneylaundering
toaggravatedidentitytheft.Morethan300specialagentsfromOIGparticipatedin
partnershipwithotherFederalandStateagencies,includingfellowOIGs. The
effectivenessoftheStrikeForcemodelisenhancedbyinteragencycollaboration. For
example,werefercredibleallegationsoffraudtotheCentersforMedicare&
MedicaidServices(CMS)soitcansuspendpaymentstotheperpetratorsofthese
schemes. DuringtheFebruaryStrikeForceoperations,OIGandCMSworkedto
imposepaymentsuspensionsthatimmediatelypreventedalossofmorethana
quartermillion
dollars
in
claims
submitted
by
Strike
Force
targets.
MedicareandMedicaidPrescriptionDrugs
GlaxoSmithKlineLLCPays$750MillionToResolveFalseClaimsViolations
GlaxoSmithKlineLLC(GSK)agreedtopay$750millionaspartofaglobalresolution
ofallegationsundertheFalseClaimsAct(FCA),includingcriminalfinesfor
violationsoftheFederalFood,Drug,andCosmeticActof1938(FDCA). The
Governmentalleged
that
between
January
1,
2001,
and
April
1,
2005,
GSK,
via
its
nowclosedsubsidiarySBPharmco,manufactured,distributed,andsoldcertain
batches,lots,orportionsoflotsofdrugsconsistingof: PaxilCRthatcontainedsome
splittabletscausingconsumerstoreceiveeitherproductwithnoactiveingredient
and/orwithonlytheactiveingredientlayerandnocontrolledreleasemechanism;
Avandametthatcontainedsometabletswithhigherorloweramountsof
rosigitazonethanspecified;Kytrilthatwaslabeledassterilebutwas,insomevials,
nonsterile;andBactrobanointmentsandcreamsthat,insomepackages,contained
microorganisms.
Spring2011|HHSOIGSemiannualReporttoCongress|p.ii
AllerganPays$600MillionandEntersGlobalSettlementsAllergan,Inc.,andAllerganUSA,Inc.(collectively,Allergan),agreedtopay
$600millionandenteraglobalcriminal,civil,andadministrativesettlementin
connectionwithimpropermarketingandpromotionpracticesofBotox. Under
thecivilsettlementagreement,AllerganagreedtopaytheFederalGovernment
$225milliontoresolveitsliabilityundertheFCA. Thesettlementresolved
allegationsthatAllerganpromotedthesaleanduseofBotoxforavarietyof
conditionsthatwerenotapprovedbytheFoodandDrugAdministration(FDA),
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InspectorGeneralsMessageandHighlights
suchasheadache,pain,spasticity,andoveractivebladder,andthatAllerganmisled
physiciansaboutdrugsafetyandefficacy,instructedhealthcareprofessionalsto
miscodeclaimstoFederalhealthcareprograms,andofferedandpaidillegal
remunerationtohealthcareprofessionalsasinducements.Aspartofthesettlement,
Allerganenteredintoacomprehensive5yearcorporateintegrityagreement(CIA)
withOIG.
MedicarePartAandPartBHighlights
PatientSafetyandQualityOfthenearlyonemillionMedicarebeneficiariesdischargedfromhospitalsin
October2008,anestimatedoneinseven(13.5percent)experiencedadverseevents
duringtheirhospitalstays.
Toestablishanestimatedadverseincidentrate,weincludedinourreview: the
NationalQuality
Forums
list
of
Serious
Reportable
Events;
Medicare
hospital
acquiredconditions(HAC);andeventsresultinginprolongedhospitalstays,
permanentharm,lifesustainingintervention,ordeath. Theincidencerateprojects
toabout134,000Medicarebeneficiariesexperiencingatleast1adverseeventin
hospitalsduringasinglemonth,withsucheventscontributingtothedeathsofa
projected15,000beneficiaries. Physicianreviewersdeterminedthat44percentof
eventswerepreventable,mostcommonlybecauseofmedicalerrors,substandard
care,andinadequatepatientmonitoringandassessment. Ourrecommendationsto
CMSincludedprovidingincentivesforhospitalstoreducetheincidenceofadverse
eventsthroughtheagencyspaymentandoversightfunctions.Wealsodirected
recommendations
to
the
Agency
for
Healthcare
Research
and
Quality
(AHRQ).
AdverseEventsinHospitals: NationalIncidenceAmongMedicareBeneficiaries.
OEI060900090. FullReport
Spring2011|HHSOIGSemiannualReporttoCongress|p.iii
QuestionableBillingFrom2006to2008,skillednursingfacilities(SNF)increasinglybilledforhigher
payingresourceutilizationgroups,eventhoughbeneficiarycharacteristicsremained
largelyunchanged.
Inthatperiod,MedicarepaymentstoSNFsforultrahightherapyincreasedby
nearly90percent,risingfrom$5.7billionto$10.7billion. Forbillingpurposes,SNFs
categorizeMedicare
beneficiaries
into
resource
utilization
groups
based
on
their
care
andresourceneedsatvariouspointsduringtheirstays. Paymentratesaregenerally
higherforbeneficiarieswhoareingroupsthatrequirephysical,speech,or
occupationaltherapy. SNFsfurthercategorizetheleveloftherapybeneficiariesneed
primarilybythenumberofminutesthattherapyisprovided. Theresource
utilizationgroupsforultrahightherapyapplytothosebeneficiariesneedinghigher
levelsoftherapy.Medicaregenerallypaysthemostforultrahighleveltherapy.
http://dev.oig.cit.nih.gov/oei/reports/oei-06-09-00090.pdfhttp://dev.oig.cit.nih.gov/oei/reports/oei-06-09-00090.pdfhttp://dev.oig.cit.nih.gov/oei/reports/oei-06-09-00090.pdfhttp://dev.oig.cit.nih.gov/oei/reports/oei-06-09-00090.pdfhttp://dev.oig.cit.nih.gov/oei/reports/oei-06-09-00090.pdf8/6/2019 Office of Inspector General Semiannual Report To Congress Spring 2011l
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InspectorGeneralsMessageandHighlights
Thisreviewraisedconcernsaboutthepotentiallyinappropriateuseofhigherpaying
resourceutilizationgroups,particularlythoseforultrahightherapy. Our
recommendationstoCMSincludedstrengtheningitsmonitoringofSNFsthatare
billingforhigherpayingresourceutilizationgroups. QuestionableBillingbySkilled
NursingFacilities. OEI020900202. FullReport
MedicareClaimsforHomeBloodGlucoseTestStripsandLancetsWeestimatedthatabout$169.7millioncouldhavebeensavedincalendaryear
(CY)2007hadcontrolsbeeninplaceatthreeMedicareadministrativecontractors
(MAC)toensurethatclaimsforbloodglucoseteststripsand/orlancetscomplied
withcertainMedicaredocumentationrequirements.
MedicarePartBcoversteststripsandlancetsthatphysiciansprescribefordiabetics.
Medicareutilizationguidelinesallowupto100teststripsand100lancetsevery
monthforinsulintreateddiabeticsandevery3monthsfornoninsulintreated
diabetics.Additionalrequirementsapplyforreimbursementsofclaimsfor
quantitiesofteststripsandlancetsthatexceedtheutilizationguidelines(referredto
highutilizationclaims). OurrecommendationstoCMSsadministrativecontractors
includeddevelopingcosteffectivewaysofdeterminingwhichclaimsshouldbe
furtherreviewedforcompliance.
Followingarethreereportscompletedinthissemiannualperiod: (1)Reviewof
MedicareClaimsforHomeBloodGlucoseTestStripsandLancetsDurableMedical
EquipmentMedicareAdministrativeContractorforJurisdictionB,A090800044,Report;
(2)ReviewofMedicareClaimsforHomeBloodGlucoseTestStripsandLancetsDurable
MedicalEquipmentMedicareAdministrativeContractorforJurisdictionC,A090800045,
Report;
and
(3)
Review
of
Medicare
Claims
for
Home
Blood
Glucose
Test
Strips
and
LancetsDurableMedicalEquipmentMedicareAdministrativeContractorfor
JurisdictionD,A090800046,Report.
MedicarePartC
Spring2011|HHSOIGSemiannualReporttoCongress|p.iv
ImpactontheMedicareProgramofInvestmentIncomeThatMedicareAdvantageOrganizationsEarnedandRetainedFromMedicareFunds
TheMedicareprogramlosespotentialsavingsassociatedwiththeinvestment
incomethatMedicareAdvantage(MA)organizationsearnbetweenthetimethey
receiveMedicare
prepayments
and
the
time
the
MA
organizations
pay
for
medical
services.
TheMedicarePartAandPartBtrustfunds(whichfinancetheMAprogram)could
haveearnedapproximately$450millionofinterestincomeinCY2007had
prepaymentstoMAorganizationsbeendelayeduntilafterthebeginningofthe
beneficiaryscoverageperiodbythesamenumberofdaysthatweestimatedMA
organizationsheldMedicarethefundsbeforeusingthemtopayforservices.
http://oig.hhs.gov/oei/reports/oei-02-09-00202.pdfhttp://oig.hhs.gov/oei/reports/oei-02-09-00202.pdfhttp://oig.hhs.gov/oei/reports/oei-02-09-00202.pdfhttp://oig.hhs.gov/oei/reports/oei-02-09-00202.pdfhttp://oig.hhs.gov/oas/reports/region9/90800044.pdfhttp://oig.hhs.gov/oas/reports/region9/90800045.pdfhttp://oig.hhs.gov/oas/reports/region9/90800046.pdfhttp://oig.hhs.gov/oas/reports/region9/90800046.pdfhttp://oig.hhs.gov/oas/reports/region9/90800045.pdfhttp://oig.hhs.gov/oas/reports/region9/90800044.pdfhttp://oig.hhs.gov/oei/reports/oei-02-09-00202.pdf8/6/2019 Office of Inspector General Semiannual Report To Congress Spring 2011l
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InspectorGeneralsMessageandHighlights
Alternatively,weestimatedthatMedicarecouldhavesavedabout$376millionhad
MAorganizationsreducedtherevenuerequirementsinbidproposalstoaccountfor
anticipatedinvestmentincome. OurrecommendationstoCMSincludedpursuing
legislationtoadjustthetimingofMedicaresprepaymentstoMAorganizations.
RollupReviewofImpactonMedicareProgramforInvestmentIncomeThatMedicare
AdvantageOrganizations
Earned
and
Retained
From
Medicare
Funds
in
2007.
A071001080. FullReport
MedicarePartD
ConcernsWithRebatesintheMedicarePartDProgramPartDsponsorsunderestimatedrebatesin69percentoftheirbidsforplanyear2008,
whichledtohigherbeneficiarypremiumsandcausedbeneficiariesandthe
Governmenttooverpayforthebenefit.
Sponsorsbids
to
participate
in
Part
D
include
estimates
of
the
cost
to
provide
benefitstobeneficiaries. Sponsorsalsonegotiatedrugmanufacturerrebatesand
otherpriceconcessionstoreducethecostoftheprogramtobeneficiariesandthe
Governmentandmustincludeanestimateintheirbidsoftherebatestheyexpectto
receivefortheplanyear. CMSusesbidstocalculatebeneficiarypremiumsforeach
plan. Underestimatingrebatesincreasesbeneficiarypremiums. Recommendations
toCMSincludedtakingstepstoensurethatsponsorsmoreaccuratelyincludetheir
expectedrebatesintheirbids. ConcernsWithRebatesintheMedicarePartDProgram.
OEI020800050. FullReport
Medicaid
Spring2011|HHSOIGSemiannualReporttoCongress|p.v
NewYorksMedicaidRehabilitativeServicesClaimsSubmittedbyCommunityResidenceProviders
NewYorkStateimproperlyclaimedanestimated$207.6millioninFederalMedicaid
reimbursementforrehabilitationservicessubmittedbycommunityresidence
rehabilitationprovidersduringCYs2004through2007.
NewYorkStateelectedtoincludecoverageofrehabilitationservicesprovidedto
recipientsresidingincommunityresidences(grouphomesandapartments)inits
Medicaid
program.
Of
the
100
claims
in
our
random
sample,
31
complied
with
FederalandStaterequirements,but69didnot. OurrecommendationstotheState
MedicaidagencyincludedworkingwiththeStatesOfficeofMentalHealthto
implementguidancetophysiciansregardingStateregulationsontheauthorization
ofcommunityresidencerehabilitationservices. ReviewofNewYorksMedicaid
RehabilitativeServicesClaimsSubmittedbyCommunityResidenceProviders.
A020801006. FullReport
http://oig.hhs.gov/oas/reports/region7/71001080.pdfhttp://oig.hhs.gov/oas/reports/region7/71001080.pdfhttp://oig.hhs.gov/oas/reports/region7/71001080.pdfhttp://oig.hhs.gov/oas/reports/region7/71001080.pdfhttp://oig.hhs.gov/oei/reports/oei-02-08-00050.pdfhttp://oig.hhs.gov/oei/reports/oei-02-08-00050.pdfhttp://oig.hhs.gov/oei/reports/oei-02-08-00050.pdfhttp://oig.hhs.gov/oei/reports/oei-02-08-00050.pdfhttp://oig.hhs.gov/oas/reports/region2/20801006.pdfhttp://oig.hhs.gov/oas/reports/region2/20801006.pdfhttp://oig.hhs.gov/oas/reports/region2/20801006.pdfhttp://oig.hhs.gov/oas/reports/region2/20801006.pdfhttp://oig.hhs.gov/oas/reports/region2/20801006.pdfhttp://oig.hhs.gov/oei/reports/oei-02-08-00050.pdfhttp://oig.hhs.gov/oas/reports/region7/71001080.pdf8/6/2019 Office of Inspector General Semiannual Report To Congress Spring 2011l
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InspectorGeneralsMessageandHighlights
InappropriateClaimsforMedicaidPersonalCareServicesOur10StatereviewrevealedthatMedicaidpaidabout$724millionforthe
18percentofpersonalcareservicesclaimsthatwedeterminedwereinappropriate
becausepersonalcareattendantsqualificationswereundocumented.
Thequalifications
most
often
undocumented
were
background
checks,
age,
and
education.WeestimatedthatMedicaidpaidanadditional2percentofclaims
inappropriatelybecausetherespondentshadnorecordofprovidingservicestothe
beneficiaries. RespondentswereagenciesorindividualsthatStateMedicaidagency
officialsindicatedweshouldcontacttorequestdocumentationtosupport
attendantsqualifications.WereviewedclaimspaidfromSeptember1,2006,
throughAugust31,2007. OurrecommendationstoCMSincludedworkingwith
StatestoensurethatMedicaidclaimsforpersonalcareservicesprovidedby
attendantswithundocumentedqualificationsarenotpaid. InappropriateClaimsfor
MedicaidPersonalCareServices. OEI070800430. FullReport
OtherHealthCareInvestigations
DurableMedicalEquipmentSupplierSentencedOliverNkuku,amanagerforK.O.Medical,Inc.(K.O.),andCallistusEdozie,aK.O.
deliveryemployee,weresentencedto120monthsand41monthsofincarceration,
respectively,andorderedtopay$453,112and$80,000inrestitution,jointlyand
severally,fortheirrolesinadurablemedicalequipment(DME)fraudschemerelated
topowerwheelchairsandotherDMEthatweremedicallyunnecessaryand
improperlybilledascatastropherelatedinconnectionwithGulfCoasthurricanes.
Spring2011|HHSOIGSemiannualReporttoCongress|p.vi
PhysicalTherapyClinicSubmittedMultipleFalseClaimstoMedicareBerniceBrown,ownerofDetroitareaphysicaltherapyclinicWayneCounty
TherapeuticInc.(WCT),andDanielSmorynski,WCTvicepresident,wereconvicted
onchargesofhealthcarefraudfortheirleadingrolesinaMedicarefraudscheme.
BrownandSmorynskiweresentencedto12yearsand7monthsand9yearsin
prison,respectively,andwereorderedtopay$6.7millioninrestitutionjointlyand
severally. FromOctober2002toApril2007,WCTcausedthesubmissionofmultiple
claimstotheMedicareprogramforphysicaltherapy,occupationaltherapy,and
psychotherapyservicespurportedlyprovidedandsupervisedbyWCTstaffwhen,in
fact,such
services
were
not
professionally
provided
or
supervised.
http://oig.hhs.gov/oei/reports/oei-07-08-00430.pdfhttp://oig.hhs.gov/oei/reports/oei-07-08-00430.pdfhttp://oig.hhs.gov/oei/reports/oei-07-08-00430.pdfhttp://oig.hhs.gov/oei/reports/oei-07-08-00430.pdfhttp://oig.hhs.gov/oei/reports/oei-07-08-00430.pdf8/6/2019 Office of Inspector General Semiannual Report To Congress Spring 2011l
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InspectorGeneralsMessageandHighlights
PublicHealthReviews
CentersforDiseaseControlandPreventionsComplianceWithAppropriationsLawsandAcquisitionRegulations
Fourresearch
and
development
and
information
technology
contracts
with
the
CentersforDiseaseControlandPrevention(CDC)didnotfullycomplywithoneor
moreappropriationslawsandacquisitionregulationswithrespecttocompetition,
funding,andpricing.
Pursuanttoacongressionalrequest,weareconductingaseriesofreviewsofCDCs
contractingpractices. Duringthissemiannualperiod,wearereportingtheresultsof
ourreviewsoffourcontractors. Ourrecommendationsincludedadheringto
establishedproceduresanddevelopingandimplementingpoliciesandprocedures
toaddresscompliancewithappropriationsstatutesandacquisitionregulations.
Followingarethereportsthatwerecompletedinthissemiannualperiod: Reviewof
theCenters
for
Disease
Control
and
Preventions
Compliance
With
Appropriations
Laws
and
AcquisitionRegulationsContractorB,A020902005,Report;ReviewoftheCentersfor
DiseaseControlandPreventionsComplianceWithAppropriationsLawsandAcquisition
RegulationsContractorC,A020902006,Report;ReviewoftheCentersforDisease
ControlandPreventionsComplianceWithAppropriationsLawsandAcquisition
RegulationsContractorD,A040901066,Report;andReviewoftheCentersforDisease
ControlandPreventionsComplianceWithAppropriationsLawsandAcquisition
RegulationsContractorE,A040906108,Report.
Spring2011|HHSOIGSemiannualReporttoCongress|p.vii
InstitutionalConflictsofInterestatNationalInstitutesofHealthGranteesThe
National
Institutes
of
Health
(NIH)
lacks
information
on
the
number
of
institutionalconflictsthatexistamongitsgranteeinstitutionsandtheimpactthese
conflictsmayhaveonNIHsponsoredresearch.
Institutionalconflictsofinterestmayarisewheninstitutionsfinancialinterests
(e.g.,royalties,equity,stockholdings,andgifts)orthoseofseniorofficialsposerisks
ofundueinfluenceondecisionsinvolvingtheinstitutionsresearch. NoFederal
regulationsrequireNIHgranteeinstitutionstoidentifyandreportinstitutional
conflictstoNIH.Wesurveyed250granteeinstitutionsandrequestedinformationon
anyinstitutionalfinancialinterestsrelatedtoNIHgrantsawardedinFY2008.
DespitethelackofFederalrequirements,70of156respondingNIHgrantee
institutionshadwrittenpoliciesandproceduresaddressingtheseinterests.Wealsofoundthatalthoughnotrequiredforinstitutionalconflicts,69of156responding
NIHgranteeinstitutionshadwrittenpoliciesandproceduresaddressingsuch
conflicts. Fiftynineofthesixtynineinstitutionsdefined,inwriting,what
constitutesaninstitutionalconflict.WerecommendedthatNIHpromulgate
regulationsthataddressinstitutionalfinancialconflictsofinterest. Institutional
ConflictsofInterestatNIHGrantees. OEI030900480. FullReport
http://oig.hhs.gov/oas/reports/region2/20902005.pdfhttp://oig.hhs.gov/oas/reports/region2/20902006.pdfhttp://oig.hhs.gov/oas/reports/region4/40901066.pdfhttp://oig.hhs.gov/oas/reports/region4/40906108.pdfhttp://oig.hhs.gov/oei/reports/oei-03-09-00480.pdfhttp://oig.hhs.gov/oei/reports/oei-03-09-00480.pdfhttp://oig.hhs.gov/oei/reports/oei-03-09-00480.pdfhttp://oig.hhs.gov/oei/reports/oei-03-09-00480.pdfhttp://oig.hhs.gov/oei/reports/oei-03-09-00480.pdfhttp://oig.hhs.gov/oas/reports/region4/40906108.pdfhttp://oig.hhs.gov/oas/reports/region4/40901066.pdfhttp://oig.hhs.gov/oas/reports/region2/20902006.pdfhttp://oig.hhs.gov/oas/reports/region2/20902005.pdf8/6/2019 Office of Inspector General Semiannual Report To Congress Spring 2011l
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InspectorGeneralsMessageandHighlights
EducationandOutreachActivities
RoadmapforNewPhysiciansArecentOIGsurveyindicatedthatalmosthalfofmedicalschoolsandmorethan
twothirdsofinstitutionsofferingresidencyandfellowshipprogramsreported
instructingparticipantsaboutcompliancewithMedicareandMedicaidfraudand
abuselaws.WedevelopedaguidecalledARoadmapforNewPhysicians:Avoiding
MedicareandMedicaidFraudandAbuse(Roadmap). Thepackageincludesaslide
presentationandspeakernotes. YoucanviewthesurveyandRoadmaponourWeb
siteathttp://www.oig.hhs.gov.
TheRoadmapsummarizesthefivemainFederalfraudandabuselawsandinstructs
physicianshowtoupholdtheselawsintheirrelationshipswithpayerssuchasthe
Medicare
and
Medicaid
programs,
vendors
such
as
drug,
biologic,
and
medical
devicecompanies,andfellowproviderssuchashospitals,nursinghomes,and
physiciancolleagues.
ProviderComplianceTrainingSessionsIn2011,OIGimplementedaProviderComplianceTraininginitiative. Theinitiative
providesfree,highqualitycompliancetrainingsessionsformedicalprovidersand
suppliers,complianceprofessionals,andattorneysatlocationsthroughoutthe
country.Weheldthreetrainingsessionsinthepast6months. Representativesfrom
OIG,DOJ,CMS,andStateMedicaidFraudControlUnits(MFCU)educate
communities
about
fraud
risks
and
share
compliance
best
practices
to
assist
providersinstrengtheningtheircomplianceefforts.
Spring2011|HHSOIGSemiannualReporttoCongress|p.viii
MostWantedFugitivesListForthefirsttime,wepublishedaMostWantedFugitiveslistonourWebsite,and
capturesweresoonreported. The10individualsontheoriginallistallegedly
defraudedtaxpayersofmorethan$126.6million.AsofMarch31,2011,four
fugitivesfromourlisthadbeencapturedandmorewereadded.
http://oig.hhs.gov/oei/reports/OEI-01-10-00140.pdfhttp://www.oig.hhs.gov/fraud/PhysicianEducation/http://www.oig.hhs.gov/http://www.oig.hhs.gov/fugitives/http://www.oig.hhs.gov/fugitives/http://www.oig.hhs.gov/fugitives/http://www.oig.hhs.gov/fugitives/http://www.oig.hhs.gov/fugitives/http://www.oig.hhs.gov/fugitives/http://www.oig.hhs.gov/http://www.oig.hhs.gov/fraud/PhysicianEducation/http://oig.hhs.gov/oei/reports/OEI-01-10-00140.pdf8/6/2019 Office of Inspector General Semiannual Report To Congress Spring 2011l
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InspectorGeneralsMessageandHighlights
Spring2011|HHSOIGSemiannualReporttoCongress|p.ix
CongressionalTestimonyDuringthissemiannualperiod,wetestifiedatfivehearingsconductedbycommitteesof
Congress
on
aspects
of
waste,
fraud,
and
abuse
in
Medicare
and
Medicaid.
The
full
text
ofthetestimonyisavailableonourWebsiteathttp://www.oig.hhs.gov/testimony.asp.
March17,2011HouseofRepresentativesCommitteeonAppropriations,SubcommitteeonLabor,HealthandHumanServices,Education,and
RelatedAgencies.
DanielR.Levinson,InspectorGeneral,testifiedaboutoureffortstomonitorand
makerecommendationstoreduceimproperpaymentsinMedicareandMedicaid,to
overseeHHSsmeasurementofimproperpaymentsandtoprevent,detect,and
recoup
wasteful
payments.
Testimony
March9,2011UnitedStatesSenateCommitteeonHomelandSecurity&GovernmentalAffairs,SubcommitteeonFederalFinancialManagement,
GovernmentInformation,FederalServices,andInternationalSecurity
DanielR.Levinson,InspectorGeneral,testifiedaboutoureffortsandthoseofour
partnerstocombatwaste,fraud,andabuseinMedicareandMedicaid. Testimony
March2,2011UnitedStatesSenateCommitteeonFinanceDanielR.Levinson,InspectorGeneral,testifiedaboutpreventinghealthcarefraud:
newtools
and
approaches
to
combat
old
challenges.
Testimony
March2,2011HouseofRepresentativesCommitteeonWaysandMeans,SubcommitteeonOversight
LewisMorris,ChiefCounseltotheInspectorGeneral,testifiedaboutimproving
effortstocombathealthcarefraud. Testimony
March2,2011HouseofRepresentativesCommitteeonEnergy&Commerce,SubcommitteeonOversightandInvestigations
GeraldRoy,DeputyInspectorGeneralforInvestigations,testifiedaboutwaste,fraud,andabuse: acontinuingthreattoMedicareandMedicaid. Testimony OmarPerez,AssistantSpecialAgentinCharge,OIGMiamiRegionalOffice,testifiedaboutwaste,fraud,andabuse: acontinuingthreattoMedicareand
Medicaid. Testimony
http://www.oig.hhs.gov/testimony.asphttp://www.oig.hhs.gov/testimony/docs/2011/levinson_testimony_03172011.pdfhttp://www.oig.hhs.gov/testimony/docs/2011/levinson_testimony_03092011.pdfhttp://www.oig.hhs.gov/testimony/docs/2011/levinson_testimony_03092011.pdfhttp://www.oig.hhs.gov/testimony/docs/2011/levinson_testimony_03022011.pdfhttp://www.oig.hhs.gov/testimony/docs/2011/levinson_testimony_03022011.pdfhttp://www.oig.hhs.gov/testimony/docs/2011/morris_testimony_03022011.pdfhttp://www.oig.hhs.gov/testimony/docs/2011/morris_testimony_03022011.pdfhttp://www.oig.hhs.gov/testimony/docs/2011/roy_testimony_03022011.pdfhttp://www.oig.hhs.gov/testimony/docs/2011/roy_testimony_03022011.pdfhttp://www.oig.hhs.gov/testimony/docs/2011/perez_testimony_03022011.pdfhttp://www.oig.hhs.gov/testimony/docs/2011/perez_testimony_03022011.pdfhttp://www.oig.hhs.gov/testimony/docs/2011/perez_testimony_03022011.pdfhttp://www.oig.hhs.gov/testimony/docs/2011/roy_testimony_03022011.pdfhttp://www.oig.hhs.gov/testimony/docs/2011/morris_testimony_03022011.pdfhttp://www.oig.hhs.gov/testimony/docs/2011/levinson_testimony_03022011.pdfhttp://www.oig.hhs.gov/testimony/docs/2011/levinson_testimony_03092011.pdfhttp://www.oig.hhs.gov/testimony/docs/2011/levinson_testimony_03172011.pdfhttp://www.oig.hhs.gov/testimony.asp8/6/2019 Office of Inspector General Semiannual Report To Congress Spring 2011l
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TableofContents
OutlineofMajorPartsandAppendixes
PartI: MedicareReviewsPartII: MedicaidReviewsPartIII: LegalandInvestigativeActivitiesRelatedto
MedicareandMedicaidPartIV: PublicHealth,HumanServices,and
DepartmentwideIssues
AppendixA: ReportingRequirementsoftheInspectorGeneralActof1978,asAmended
AppendixB: QuestionedCostsandFundsToBePuttoBetterUse
AppendixC: PeerReviewResultsAppendixD: SummaryofSanctionAuthoritiesAppendixE: AcronymsandAbbreviations
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PartI:MedicareReviews
PartI:MedicareReviewsMedicarePartAandPartB ............................................................................................1
Hospitals..................................................................................................................................1 AdverseEventsinHospitals:NationalIncidenceAmongMedicareBeneficiaries.........................................................................................................................1
PaymentsExceedingChargesforOutpatientServicesProcessedbyWisconsinPhysiciansServiceInsuranceCorporationforCalendarYears
2004through2007...............................................................................................................2Nursing
Homes ......................................................................................................................3
PaymentsforAmbulatorySurgicalCenterServicesProvidedtoBeneficiariesinSkilledNursingFacilityStaysCoveredUnderMedicare
PartA ....................................................................................................................................3 QuestionableBillingbySkilledNursingFacilities.......................................................3 NursingFacilitiesEmploymentofIndividualsWithCriminalConvictions..........................................................................................................................4
OtherMedicareServices.......................................................................................................5 QuestionableBillingforMedicareOutpatientTherapyServices..............................5Medicare
Market
Shares
of
Order
Diabetic
Testing
Strips................................5
MedicareClaimsforHomeBloodGlucoseTestStripsandLancets ........................6PartBPrescriptionDrugs .....................................................................................................7
MedicarePaymentsforNewlyAvailableGenericDrugs...........................................7 ComparisonofAverageSalesPricesandAverageManufacturerPrices:ImpactonMedicareReimbursementofPartBPrescriptionDrugs..........................8
QuestionableBillingforBrandNameInhalationDrugs............................................9 PaymentforDrugsundertheHospitalOutpatientProspectivePaymentSystem...................................................................................................................................9
MedicarePartAandPartBAdministration ...................................................................10 UseofPaymentSuspensionstoPreventInappropriateMedicarePayments............................................................................................................................10
MedicareandMedicaidFraudandAbuseTraininginMedicalEducation..........11
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QualityImprovementOrganizationsFinalResponsestoBeneficiaryComplaints.........................................................................................................................11
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PartI:MedicareReviews
Spring2011|HHSOIGSemiannualReporttoCongress
UseofMedicareFeeforServiceErrorRateDataToIdentifyandFocusonErrorProneProviders................................................................................................12
ComplaintsReceivedThroughthe1800HHSTIPSHotline..................................12 MedicareContractorInformationSecurityProgramEvaluationsforFiscalYear2008 .................................................................................................................12
MedicarePartC ..............................................................................................................13 ImpactonMedicareProgramofInvestmentIncomeThatMedicareAdvantageOrganizationsEarnedandRetainedFromMedicareFundsin
2007 .....................................................................................................................................13MedicarePartD..............................................................................................................14
MedicarePartDPharmacyDiscountsfor2008 ..........................................................14 TerminatedDrugsintheMedicarePartDProgram..................................................15 ErectileDysfunctionDrugsintheMedicarePartDProgram..................................15 ConcernsWithRebatesintheMedicarePartDProgram.........................................16 OversightofthePrescriberIdentifierFieldinPartDPrescriptionDrugEventDataforScheduleIIDrugs..................................................................................17
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PartII:MedicaidReviews
Spring2011|HHSOIGSemiannualReporttoCongress
PartII:
MedicaidReviews
MedicaidServices ..................................................................................................................1 NewYorksMedicaidRehabilitativeServicesClaimsSubmittedbyCommunityResidenceProviders ...................................................................................1
WashingtonStatesMedicaidClaimsforNonqualifiedAliens..................................1 FamilyPlanningServicesClaimedbyWashingtonState ...........................................2 InappropriateClaimsforMedicaidPersonalCareServices.......................................3 PersonalCareServicesProvidedbyTriStateHomeHealthandEquipmentServices,Inc.,intheDistrictofColumbia.................................................3
FederalReimbursementClaimedbyNorthCarolinaforMedicaidPersonal
Care
Services
Claims
Submitted
by
Shipman
Family
Home
Care,Inc................................................................................................................................4 MedicaidPersonalCareServicesClaimsMadebyProvidersinNewYorkState.......................................................................................................................................5
MedicaidRecoveryActReviews.........................................................................................5 QuarterlyMedicaidStatementofExpendituresfortheMedicalAssistancePrograminIndianafortheQuarterEndingMarch31,2009 .................5
IllinoisPromptPayComplianceUndertheAmericanRecoveryandReinvestmentAct................................................................................................................6
MedicaidPromptPayRequirementsinNewHampshire..........................................6 AlabamasComplianceWiththeReserve,orRainyDay,FundRequirementfortheIncreasedFederalMedicalAssistancePercentage
UndertheAmericanRecoveryandReinvestmentAct ...............................................7MedicaidAdministration.....................................................................................................8
OversightandEvaluationoftheFiscalYear2008PaymentErrorRateMeasurementProgram......................................................................................................8
IndianasReportingofFundRecoveriesforFederalandStateMedicaidProgramsontheFormCMS64forFederalFiscalYears2000Through
2008 .......................................................................................................................................8OtherMedicaidRelatedReviews.......................................................................................9
ContractSignaturesfortheHurricaneKatrinaHealthCareRelatedProfessionalWorkforceSupplyGrantfortheGreaterNewOrleansArea..............9
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PartIII: LegalandInvestigativeActivitiesforMedicareandMedicaid
PartIII:
LegalandInvestigativeActivities
RelatedtoMedicareandMedicaid
InvestigativeOutcomes ........................................................................................................1AdvisoryOpinionsandOtherGuidance ..........................................................................1EducationandOutreachActivities.....................................................................................2
RoadmapforNewPhysicians..........................................................................................2 ProviderComplianceTrainingSessions ........................................................................2 MostWantedFugitivesList..............................................................................................2
HEAT: HealthCareFraudPrevention&EnforcementActionTeam...........................3 MedicareFraudStrikeForce ............................................................................................3
OtherCriminalandCivilEnforcementActivities...........................................................4 PharmaceuticalManufacturersandPharmacies..........................................................5 Hospitals ..............................................................................................................................6 DurableMedicalEquipmentSuppliers..........................................................................7 Practitioner...........................................................................................................................8 PhysicalTherapyClinic.....................................................................................................8 Laboratory ...........................................................................................................................8 HomeHealthServices.......................................................................................................9 SkilledNursingFacility.....................................................................................................9
MedicaidFraudControlUnits.............................................................................................9 JointInvestigations...........................................................................................................10
ProviderSelfDisclosureProtocol.....................................................................................10 SelfDisclosureGuidancetoHealthCareProviders..................................................11 SelfDisclosureCases .......................................................................................................11
OfficeofInspectorGeneralAdministrativeSanctions................................................12 ProgramExclusions .........................................................................................................12 CorporateIntegrityAgreements....................................................................................13 CivilMonetaryPenaltiesLaw........................................................................................13 PatientDumping ..............................................................................................................14
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PartIV: PublicHealth,HumanServices,andDepartmentwideIssues
PartIV:
PublicHealth,HumanServices,
andDepartmentwideIssues
PublicHealth ....................................................................................................................1CentersforDiseaseControlandPrevention ....................................................................1
CentersforDiseaseControlandPreventionsAccountabilityforProperty............1 CentersforDiseaseControlandPreventionsComplianceWith
AppropriationsLawsandAcquisitionRegulations ....................................................2FoodandDrugAdministration...........................................................................................4
FDAsApprovalStatusofDrugsPaidforbyMedicaid...............................................4HealthResourcesandServicesAdministration...............................................................5
RyanWhiteTitleIIFundinginPennsylvania...............................................................5 RyanWhiteTitleIIAIDSDrugAssistanceProgramFundinginNew
Jersey.....................................................................................................................................5 IndianHealthService............................................................................................................6
AuditoftheIndianHealthServicesInternalControlsOverMonitoringofRecipientsComplianceWithRequirementsoftheLoanRepayment
Program................................................................................................................................6 AuditoftheIndianHealthServicesInternalControlsOverMonitoring
ofRecipientsComplianceWithRequirementsofNursingProgram
Scholarships.........................................................................................................................7NationalInstitutesofHealth...............................................................................................7
InstitutionalConflictsofInterestatNIHGrantees ......................................................7 AppropriationsFundingforNationalHeart,Lung,andBloodInstitute
ContractHHSN268200800012CWithInformationManagement
Services,Inc. ........................................................................................................................8PublicHealthRelatedLegalActionsandInvestigations ..............................................9
HealthEducationAssistanceLoanProgram.................................................................9
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HEALExclusions................................................................................................................9
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PartIV: PublicHealth,HumanServices,andDepartmentwideIssues
Spring2011|HHSOIGSemiannualReporttoCongress
HumanServices..............................................................................................................10 FosterCare.............................................................................................................................10
AlleghenyCountyTitleIVEFosterCareClaimsFromOctober1997ThroughSeptember2002 ................................................................................................10
HeadStart..............................................................................................................................10 DistrictofColumbiaDepartmentofParksandRecreationsCompliance
WithHealthandSafetyRegulationsforHeadStartPrograms ...............................10JobandFamilyServices......................................................................................................12
OhioDepartmentofJobandFamilyServicesClaimsforCostsReportedbytheHamiltonCountyDepartmentofJobandFamilyServices .........................12
ChildSupportEnforcement...............................................................................................12 ChildSupportTaskForces .............................................................................................12 ChildSupportInvestigations.........................................................................................13
DepartmentwideIssues................................................................................................13 DepartmentalFinancialStatementAudit ....................................................................13 NonFederalAudits .........................................................................................................15 ContractAudits.................................................................................................................15 GranteeFraudandMisconduct.....................................................................................16 RecoveryActRetaliationComplaintInvestigation....................................................16 LegislativeandRegulatoryReviews.............................................................................16
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PartI:MedicareReviews
PartI:
Spring2011|HHSOIGSemiannualReporttoCongress
MedicareReviews
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PartI:MedicareReviews
PartI:
MedicareReviews
TheOfficeofInspectorGeneral(OIG)reliesontheDepartmentofHealth&Human
Services(HHS)management,otherpolicymakersintheexecutivebranch,States,and
Congresstoimplementtherecommendationsthatarisefromourreviews.Manyofour
recommendationsaredirectlyimplementedbyorganizationswithinHHS,andsomeare
actedonbyStatesthatcollaboratewithHHStoadminister,operate,and/oroverseejoint
programs,suchasMedicaidandHeadStartprogramgrants. Congressoften
incorporatesourrecommendationsintolegislativeactions,resultinginsubstantial
improvementsinHHSprogramsandoperationsandinfundsbeingmadeavailablefor
betteruse.
MedicarePartAandPartB
Hospitals
Medicare > PartAandPartB > Hospitals > AdverseEvents
AdverseEventsinHospitals: NationalIncidenceAmongMedicareBeneficiaries
Ofthe
nearly
1million
Medicare
beneficiaries
who
were
discharged
from
hospitals
inOctober2008,anestimatedoneinseven(13.5percent)experiencedadverseevents
duringtheirhospitalstays.
Toestablishanestimatedadverseeventsincidentrate,weincludedinourreview:
theNationalQualityForumsSeriousReportableEvents; Medicarehospitalacquiredconditions(HAC);and eventsresultinginprolongedhospitalstays,permanentharm,lifesustainingintervention,ordeath.
Spring2011|HHSOIGSemiannualReporttoCongress|I1
Theincidencerateprojectstoabout134,000Medicarebeneficiariesexperiencingat
least1adverseeventinhospitalsduringasinglemonth,withsuchevents
contributingtothedeathsofaprojected15,000beneficiaries. Physicianreviewers
determinedthat44percentofeventswerepreventable,mostcommonlybecauseof
medicalerrors,substandardcare,andinadequatepatientmonitoringand
assessment.
WerecommendedthatAdministrationforHealthcareResearchandQuality(AHRQ)
andtheCentersforMedicare&MedicaidServices(CMS)broadenpatientsafety
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PartI:MedicareReviews
effortstoincludealltypesofadverseeventsandenhanceeffortstoidentifyevents.
WealsorecommendedthatCMSprovidemoreincentivesforhospitalstoreduce
adverseeventsthroughitspaymentandoversightfunctions,including
strengtheningtheMedicareHACpolicyandholdinghospitalsaccountablefor
adoptingevidencebasedpractices.AHRQandCMSconcurredwithour
recommendations.Adverse
Events
in
Hospitals:
National
Incidence
Among
Medicare
Beneficiaries. OEI060900090. FullReport
Medicare > PartAandPartB >Hospitals >HospitalBasedOutpatientServices
Spring2011|HHSOIGSemiannualReporttoCongress|I2
PaymentsExceedingChargesforOutpatientServicesProcessedbyWisconsinPhysiciansServiceInsuranceCorporationforCalendarYears
2004through2007
WisconsinPhysiciansServiceInsuranceCorporation(WPS),aMedicarecontractor,
madeincorrectMedicarepaymentstohospitalsinexcessoftheirchargesfor
outpatientservices
for
calendar
years
(CY)
2004
through
2007.
The
incorrect
paymentsincludedoverpaymentstotaling$9.2million,whichhospitalshadnot
refundedbythestartofouraudit.
Medicarepayshospitalsforoutpatientservicesusingthehospitaloutpatient
prospectivepaymentsystem. Inthismethodofreimbursement,theMedicare
paymentisnotbasedontheamountthatthehospitalcharges. Consequently,the
billedcharges(thepricesthatahospitalsetsforitsservices)donotaffectthecurrent
Medicarepaymentamounts. Billedchargesgenerallyexceedtheamountthat
Medicarepaysthehospital. Therefore,aMedicarepaymentthatsignificantly
exceedsthebilledchargesisathighriskofoverpayment. Theincorrectpayments
involvedexcessiveunitsofservice,HealthcareCommonProcedureCodingSystem(HCPCS)codesthatdidnotreflecttheproceduresperformed,unallowableservices,
andlackofsupportingdocumentation.
WerecommendedthatWPSrecoverthe$9.2millioninidentifiedoverpaymentsand
usetheresultsofthisauditinitshospitaleducationactivities.WPSdescribed
actionsthatithadtakenorplannedtotaketoaddressourrecommendations. Review
ofPaymentsExceedingChargesforOutpatientServicesProcessedbyWisconsinPhysicians
ServiceInsuranceCorporationforCalendarYears2004Through2007.A071004167.
FullReport
http://dev.oig.cit.nih.gov/oei/reports/oei-06-09-00090.pdfhttp://dev.oig.cit.nih.gov/oei/reports/oei-06-09-00090.pdfhttp://dev.oig.cit.nih.gov/oei/reports/oei-06-09-00090.pdfhttp://dev.oig.cit.nih.gov/oei/reports/oei-06-09-00090.pdfhttp://oig.hhs.gov/oas/reports/region7/71004167.pdfhttp://oig.hhs.gov/oas/reports/region7/71004167.pdfhttp://oig.hhs.gov/oas/reports/region7/71004167.pdfhttp://oig.hhs.gov/oas/reports/region7/71004167.pdfhttp://oig.hhs.gov/oas/reports/region7/71004167.pdfhttp://dev.oig.cit.nih.gov/oei/reports/oei-06-09-00090.pdf8/6/2019 Office of Inspector General Semiannual Report To Congress Spring 2011l
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PartI:MedicareReviews
NursingHomes
Medicare > PartAandPartB > NursingHomes > PartBPaymentsDuringPartAStays
PaymentsforAmbulatorySurgicalCenterServicesProvidedtoBeneficiaries
in
Skilled
Nursing
Facility
Stays
Covered
Under
Medicare
PartA
Medicarecontractorsmadeatleastanestimated$6.6millioninoverpaymentsto
ambulatorysurgicalcenters(ASC)forservicesprovidedtobeneficiariesduring
PartAskillednursingfacility(SNF)staysinCYs2006through2008.
All100servicesthatwereviewed,totaling$103,000,werealreadyincludedinthe
SNFsPartApaymentsbutwereneverthelessbilledtoMedicarePartB.Asaresult,
Medicarepaidtwicefortheseservices.
WerecommendedthattheCMSinstructitsMedicarecontractorsto:(1)recoverthe
$103,000inoverpaymentsforthe100incorrectlybilledservicesthatweidentified;(2)reviewthe20,806servicesthatwedidnotreviewandrecoveroverpayments
estimatedtototalatleast$6.5million;and(3)provideguidancetoASCson
consolidatedbillingrequirementsandtheneedfortimelyandaccurate
communicationbetweenASCsandSNFsaboutbeneficiariesMedicarePartAstatus.
WealsorecommendedthatCMSestablishaneditintheCommonWorkingFile
(CWF)topreventPartBpaymentsforASCservicesthataresubjecttoconsolidated
billing. PaymentsforAmbulatorySurgicalCenterServicesProvidedtoBeneficiariesin
SkilledNursingFacilityStaysCoveredUnderMedicarePartAinCalendarYears2006
through2008.A010900521. FullReport
Medicare > PartAandPartB > NursingHomes > SNFPaymentRules
Spring2011|HHSOIGSemiannualReporttoCongress|I3
QuestionableBillingbySkilledNursingFacilitiesFrom2006to2008,SNFsincreasinglybilledforhigherpayingresourceutilization
groups,eventhoughbeneficiarycharacteristicsremainedlargelyunchanged.
Inthatperiod,MedicarepaymentstoSNFsforultrahightherapyincreasedby
nearly90percent,risingfrom$5.7billionto$10.7billion. Forbillingpurposes,SNFs
categorizeMedicarebeneficiariesintoresourceutilizationgroups(RUG)basedon
theircareandresourceneedsatvariouspointsduringtheirstays. Paymentratesare
generallyhigherforbeneficiarieswhoareingroupsthatrequirephysical,speech,or
occupationaltherapy. TheRUGsforultrahightherapyapplytothosebeneficiaries
needinghigherlevelsoftherapy.Medicaregenerallypaysthemostforultrahigh
leveltherapy. Thisreviewraisedconcernsaboutthepotentiallyinappropriateuseof
higherpayingRUGs,particularlythoseforultrahightherapy.
http://oig.hhs.gov/oas/reports/region1/10900521.pdfhttp://oig.hhs.gov/oas/reports/region1/10900521.pdfhttp://oig.hhs.gov/oas/reports/region1/10900521.pdfhttp://oig.hhs.gov/oas/reports/region1/10900521.pdfhttp://oig.hhs.gov/oas/reports/region1/10900521.pdf8/6/2019 Office of Inspector General Semiannual Report To Congress Spring 2011l
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PartI:MedicareReviews
WerecommendedthatCMS:(1)monitoroverallpaymentstoSNFsandadjustrates,
ifnecessary;(2)changethecurrentmethodfordetermininghowmuchtherapyis
neededtoensureappropriatepayments;(3)strengthenmonitoringofSNFsthatare
billingforhigherpayingRUGs;and(4)followupontheSNFsidentifiedashaving
questionablebilling. CMSconcurredwiththreeofthefourrecommendations. Itdid
notconcur
with
the
recommendation
to
change
the
method
for
determining
how
muchtherapyisneededbutstatedthatitiscommittedtopursuingimprovementsto
theSNFpaymentsystem.Weremainconcernedthatthepaymentsystemcontinues
toprovideincentivestoSNFstobillformoretherapythanisneeded,andwe
stronglyencourageCMStopursuetheoptionswerecommendedtoreducethis
vulnerability. QuestionableBillingbySkilledNursingFacilities. OEI020900202. Full
Report
Medicare > PartAandPartB > NursingHomes > BackgroundChecksofEmployees
Spring2011|HHSOIGSemiannualReporttoCongress|I4
Nursing
Facilities
Employment
of
Individuals
With
Criminal
Convictions
Almostall(92percent)ofnursingfacilitiesinourreviewemployedatleastone
individualwithatleastonecriminalconviction.
WeanalyzedcriminalhistoryrecordsmaintainedbytheFederalBureauof
Investigation(FBI)andfoundthatoverall,5percentofnursingfacilityemployees
hadatleastonecriminalconviction. Fortyfourpercentofemployeeswithcriminal
convictionscommittedcrimesagainstpropertysuchasburglary,shoplifting,and
writingbadchecks.Mostconvictionsoccurredpriortoemployment.Wefoundthat
theFBIsrecordsdonotcontaininformationonwhetherthevictimofacrimewasa
nursingfacilityresidentandthereforecannotbeusedbythemselvestodetermine
whetheraconviction
disqualifies
an
individual
from
nursing
facility
employment.
WealsofoundthatmostStatesrequired,and/ornursingfacilitiesreported
conducting,sometypeofbackgroundcheck.
ThePatientProtectionandAffordableCareActof2010(AffordableCareAct)
requirestheSecretaryofHHStocarryoutanationwideprogramforStatesto
conductnationalandstatewidecriminalbackgroundchecksfordirectpatientaccess
employeesofnursingfacilitiesandotherproviders. Statesmayparticipateinthe
nationalbackgroundcheckprogrambyenteringintoagreementswiththeSecretary.
InlightofthebackgroundcheckprogramthattheAffordableCareActcreated,we
recommended
that
CMS
develop
background
check
procedures,
including
(1)
clearly
definingtheemployeeclassificationsthataredirectpatientaccessemployeesand
(2)workingwithparticipatingStatestodevelopalistofconvictionsthatdisqualify
anindividualfromnursingfacilityemploymentundertheFederalregulationand
timeframesinwhicheachconvictionbarstheindividualfromemployment. CMS
agreedwithourrecommendation. NursingFacilitiesEmploymentofIndividualsWith
CriminalConvictions. OEI070900110. FullReport
http://oig.hhs.gov/oei/reports/oei-02-09-00202.pdfhttp://oig.hhs.gov/oei/reports/oei-02-09-00202.pdfhttp://oig.hhs.gov/oei/reports/oei-02-09-00202.pdfhttp://oig.hhs.gov/oei/reports/oei-02-09-00202.pdfhttp://oig.hhs.gov/oei/reports/oei-07-09-00110.pdfhttp://oig.hhs.gov/oei/reports/oei-07-09-00110.pdfhttp://oig.hhs.gov/oei/reports/oei-07-09-00110.pdfhttp://oig.hhs.gov/oei/reports/oei-07-09-00110.pdfhttp://oig.hhs.gov/oei/reports/oei-07-09-00110.pdfhttp://oig.hhs.gov/oei/reports/oei-02-09-00202.pdfhttp://oig.hhs.gov/oei/reports/oei-02-09-00202.pdf8/6/2019 Office of Inspector General Semiannual Report To Congress Spring 2011l
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OtherMedicareServices
Medicare > PartAandPartB > OutpatientTherapyServices
QuestionableBillingforMedicareOutpatientTherapyServicesMedicaresperbeneficiaryspendingonoutpatienttherapyservicesinFloridas
MiamiDadeCountywasthreetimesthenationalaveragein2009.
Weidentified20highutilizationcountiesthathad,in2009,(1)thehighestaverage
Medicarepaymentperbeneficiaryand(2)morethan$1millionintotalMedicare
paymentsforoutpatienttherapy.WeanalyzedMiamiDadeCountyseparatelyfrom
theother19countiesbecauseithadthehighestaverageMedicarepaymentsper
beneficiaryamongthehighutilizationcountiesandthehighesttotalMedicare
paymentsforoutpatienttherapyin2009.Medicaresperbeneficiaryspendingon
outpatienttherapyservicestothe19otherhighutilizationcountiesasagroupwas
72percent
greater
than
the
national
average.
We
found
that
for
five
of
six
questionablebillingcharacteristicsthatmayindicatefraud,MiamiDadeslevels
wereatleastthreetimesthenationallevels. Theother19countiesalsoexhibited
questionablebilling.Asagroup,theother19countieshadatleasttwicethenational
levelsforfiveofthesixquestionablebillingcharacteristics.
WerecommendthatCMS(1)targetoutpatienttherapyclaimsinhighutilization
areasforfurtherreview,(2)targetoutpatienttherapyclaimswithquestionable
billingcharacteristicsforfurtherreview,(3)reviewgeographicareasandproviders
withquestionablebillingandtakeappropriateactionbasedonresults,and(4)revise
thecurrenttherapycapexceptionprocess. CMSconcurredwiththe
recommendations.Questionable
Billing
for
Medicare
Outpatient
Therapy
Services.
OEI040900540. FullReport
Medicare > PartAandPartB >MedicalEquipmentandSupplies > DiabeticTestingStrips
Spring2011|HHSOIGSemiannualReporttoCongress|I5
MedicareMarketSharesofMailOrderDiabeticTestingStripsWefoundthatsupplierssubmittedclaimsforatleast75typesofmailorderdiabetic
testingstripsduringthe3monthperiodendingDecember2009.Weprojectedthat
2typesaccountedforapproximately26percentoftheMedicaremailordermarket
share,7typesaccountedforapproximately50percent,and19typesaccountedfor
approximately81
percent.
Section154(d)(3)(B)oftheMedicareImprovementsforPatientsandProvidersAct
(MIPPA)requiresOIGtocompletethisreviewtodeterminemarketsharesof
diabetictestingstrips.MIPPArequiresthatfutureroundsofCompetitiveBidding
Programcontractsformailorderdiabetictestingstripsbeawardedtosupplierswho
provideatleast50percent,byvolume,ofalltypesofmailorderdiabetictesting
strips(theMIPPA50percentrequirement). Ourfindingsmayhelpindetermining
http://oig.hhs.gov/oei/reports/oei-04-09-00540.pdfhttp://oig.hhs.gov/oei/reports/oei-04-09-00540.pdfhttp://oig.hhs.gov/oei/reports/oei-04-09-00540.pdfhttp://oig.hhs.gov/oei/reports/oei-04-09-00540.pdfhttp://oig.hhs.gov/oei/reports/oei-04-09-00540.pdf8/6/2019 Office of Inspector General Semiannual Report To Congress Spring 2011l
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whetherfutureroundsofsuppliersmailorderdiabeticteststripbidscomplywith
theMIPPA50percentrequirement. Ourreportprovidedthedatarequestedby
MIPPAbutdidnotmakerecommendations.MedicareMarketSharesofMailOrder
DiabeticTestingStrips. OEI041000130. FullReport
Medicare>Part
A
and
Part
B
>Medical
Equipment
and
Supplies
>Blood
Glucose
Test
Strips
and
Lancets
MedicareClaimsforHomeBloodGlucoseTestStripsandLancetsWeestimatedthatabout$169.7millioncouldhavebeensavedforCY2007had
controlsbeeninplaceatfourMedicareadministrativecontractorstoensurethat
claimsforbloodglucoseteststripsand/orlancetscompliedwithcertainMedicare
documentationrequirements.
MedicarePartBcoversteststripsandlancetsthatphysiciansprescribefordiabetics.
Medicareutilizationguidelinesallowupto100teststripsand100lancetsevery
monthfor
insulin
treated
diabetics
and
every
3months
for
non
insulin
treated
diabetics.Additionalrequirementsapplyforreimbursementsofclaimsfor
quantitiesofteststripsandlancetsthatexceedtheutilizationguidelines(referredto
ashighutilizationclaims).
TohelpachievepotentialsavingsfortheMedicareprograminthefuture,we
recommendedthatthecontractors(1)implementsystemeditstoidentifyhigh
utilizationclaimsforteststripsand/orlancetsandworkwithCMStodevelopcost
effectivewaysofdeterminingwhichclaimsshouldbefurtherreviewedfor
compliancewithMedicaredocumentationrequirements;(2)implementsystemedits
toidentifyclaimsforteststripsand/orlancetsthathaveoverlappingservicedates
forthesamebeneficiary;and(3)enforceMedicaredocumentationrequirementsfor
claimsforteststripsand/orlancetsbyidentifyingdurablemedicalequipment(DME)
supplierswithahighvolumeofhighutilizationclaims,performingprepayment
reviewsofthosesuppliers,andreferringthemtotheOIGorCMSforfurtherreview
orinvestigationwhennecessary. Followingarethecontractornamesandaudit
reporttitlesandnumbersforourreviews.
NationalGovernmentServices,Inc. ReviewofMedicareClaimsforHomeBloodGlucoseTestStripsandLancetsDurableMedicalEquipmentMedicareAdministrative
ContractorforJurisdictionB.A090800044. FullReport
CIGNAGovernmentServices,LLCandPalmettoGovernmentBenefitsAdministrators,LLC. ReviewofMedicareClaimsforHomeBloodGlucoseTestStrips
andLancetsDurableMedicalEquipmentMedicareAdministrativeContractorfor
JurisdictionC.A090800045. FullReport
Spring2011|HHSOIGSemiannualReporttoCongress|I6
NoridianAdministrativeServices,LLC. ReviewofMedicareClaimsforHomeBloodGlucoseTestStripsandLancetsDurableMedicalEquipmentMedicareAdministrative
ContractorforJurisdictionD.A090800046. FullReport
http://oig.hhs.gov/oei/reports/oei-04-10-00130.pdfhttp://oig.hhs.gov/oei/reports/oei-04-10-00130.pdfhttp://oig.hhs.gov/oei/reports/oei-04-10-00130.pdfhttp://oig.hhs.gov/oei/reports/oei-04-10-00130.pdfhttp://oig.hhs.gov/oas/reports/region9/90800044.pdfhttp://oig.hhs.gov/oas/reports/region9/90800044.pdfhttp://oig.hhs.gov/oas/reports/region9/90800044.pdfhttp://oig.hhs.gov/oas/reports/region9/90800044.pdfhttp://oig.hhs.gov/oas/reports/region9/90800045.pdfhttp://oig.hhs.gov/oas/reports/region9/90800045.pdfhttp://oig.hhs.gov/oas/reports/region9/90800045.pdfhttp://oig.hhs.gov/oas/reports/region9/90800045.pdfhttp://oig.hhs.gov/oas/reports/region9/90800046.pdfhttp://oig.hhs.gov/oas/reports/region9/90800046.pdfhttp://oig.hhs.gov/oas/reports/region9/90800046.pdfhttp://oig.hhs.gov/oas/reports/region9/90800046.pdfhttp://oig.hhs.gov/oas/reports/region9/90800046.pdfhttp://oig.hhs.gov/oas/reports/region9/90800045.pdfhttp://oig.hhs.gov/oas/reports/region9/90800044.pdfhttp://oig.hhs.gov/oei/reports/oei-04-10-00130.pdf8/6/2019 Office of Inspector General Semiannual Report To Congress Spring 2011l
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PartI:MedicareReviews
PartBPrescriptionDrugs
Medicare > PartAandPartB > PartBPrescriptionDrugs > PaymentCalculations
Spring2011|HHSOIGSemiannualReporttoCongress|I7
MedicarePaymentsforNewlyAvailableGenericDrugsMedicareanditsbeneficiariescouldhavesavedanestimated$111millionhad
paymentamountsreflectedactualsalespricesduringtheinitialperiodinwhich
16genericdrugsbecameavailable.
Thepotentialsavingsaccountfor25percentoftotalexpendituresforthedrugs
duringthesameperiod.Wefoundthatduringtheperiodofinitialgeneric
availability,genericversionsofthesedrugswerebeingadministeredordispensed
tobeneficiaries,butMedicarewasstillpayingbrandprices.Manufacturersare
requiredtosubmitaveragesalesprice(ASP)datatoCMSwithin30daysafterthe
closeofeachquarter,andthosedataareusedtocalculatethepaymentamountsfor
thefollowing
quarter.
As
aresult,
there
is
atwo
quarter
lag
between
the
point
at
whichdrugsalesoccurandwhenthepaymentamountsreflectthosesales. Thislag
isespeciallyproblematicwhennewlyavailablegenericdrugsenterthemarket
becausetheirASPsareoftensubstantiallylowerthantheirbrandcounterparts;
however,paymentamountsremainatthehigherbrandlevelfortwoquartersor
more.AccordingtotheFoodandDrugAdministration(FDA),26ofthe48brand
onlydrugswiththehighestPartBexpendituresin2008couldhavefirstgeneric
versionsapprovedinthenextseveralyears,meaningthatthevulnerabilityposedby
thetwoquarterlaglikelywillcontinuetogrow.
WerecommendedthatCMSworkwithCongresstorequiremanufacturersoffirst
genericsto
submit
monthly
ASP
data
during
the
period
of
initial
generic
availability.
ThiscouldsubstantiallyreducethetwoquarterlagandmakeMedicarepayment
amountsmorereflectiveofmarketprices. IfCMSfindsthistobeaneffectivemeans
foralleviatingthefinancialimpactofthetwoquarterlag,itcouldconsiderrequiring
monthlyASPsubmissionsforallPartBcovereddrugs. CMSdidnotconcurwith
ourrecommendation,citingpotentialproblemswithmanufacturerprice
submissionsandincreasedadministrativeburdensunderaproposedmonthlyASP
reportingrequirement.Wemaintainthatthesavingsfromareducedreimbursement
lagmayoutweighanyissuesinvolvedwithimplementingamonthlyASPreporting
system.MedicarePaymentsforNewlyAvailableGenericDrugs. OEI030900510.
Full
Report
http://oig.hhs.gov/oei/reports/oei-03-09-00510.pdfhttp://oig.hhs.gov/oei/reports/oei-03-09-00510.pdfhttp://oig.hhs.gov/oei/reports/oei-03-09-00510.pdfhttp://oig.hhs.gov/oei/reports/oei-03-09-00510.pdfhttp://oig.hhs.gov/oei/reports/oei-03-09-00510.pdf8/6/2019 Office of Inspector General Semiannual Report To Congress Spring 2011l
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PartI:MedicareReviews
Medicare > PartAandPartB > PartBPrescriptionDrugs > PaymentCalculations
ComparisonofAverageSalesPricesandAverageManufacturerPrices:ImpactonMedicareReimbursementofPartBPrescriptionDrugs
TheSocialSecurityAct,1847A(d),requiresOIGtocompareASPstoaverage
manufacturersprices
(AMP)
and
notify
the
Secretary
of
HHS
if
the
ASP
for
a
particulardrugexceedsthedrugsAMPbyathresholdof5percent. Ifthe5percent
thresholdismet,pursuanttosection1847A(d)(3)(A),theSecretarymaydisregardthe
ASPforthedrugwhensettingreimbursementandshallsubstitutethepayment
amountwiththelesserofeitherthewidelyavailablemarketpriceor103percentof
theAMP.AlthoughCMShasyettomakeanychangestoPartBdrugreimbursement
asaresultofthereviews,theagencypublishedaproposedruleat75Fed.Reg.
40040,40259(July13,2010)thatspecifiedcircumstancesunderwhichAMPbased
pricesubstitutionswouldoccur. However,theagencyoptednottofinalizetheprice
substitutionpolicyfromtheproposedrule. SomeofOIGspreviousreports
comparingASPs
and
AMPs
have
contained
recommendations,
which
we
continue
to
support.Wedidnotmakeadditionalrecommendationsinthereportsbelow.
FirstQuarter2010: ImpactonThirdQuarter2010.Weidentified38HCPCScodeswithASPthatexceededAMPbyatleast5percentinthefirstquarterof
2010. Ofthese,13hadcompleteAMPdata(i.e.,AMPdataforeverydrug
productthatCMSusedtoestablishreimbursementamounts). Ifreimbursement
amountsforall13codeswithcompleteAMPdatahadbeenbasedon103percent
oftheAMPsduringthethirdquarterof2010,weestimatethatMedicare
expenditureswouldhavebeenreducedbyabout$988,000inthatquarteralone.
IfCMSsproposedpricesubstitutionpolicyhadbeenineffect,reimbursement
amountsfor
10
of
the
13
drugs
with
complete
AMP
data
would
have
been
reduced,resultinginestimatedsavingsof$840,000inthethirdquarterof2010.
WecouldnotcompareASPsandAMPsfor68HCPCScodesbecauseAMPdata
werenotsubmittedforanyofthenationaldrugcodes(NDC)thatCMSusedto
calculatereimbursement.Manufacturersfor23percentoftheseNDCshad
Medicaiddrugrebateagreementsandwerethereforegenerallyrequiredto
submitAMPs. OIGwillcontinuetoworkwithCMStoevaluateandpursue
appropriateactionsagainstthosemanufacturersthatfailtosubmitrequireddata.
ComparisonofFirstQuarter2010AverageSalesPricesandAverageManufacturer
Prices: ImpactonMedicareReimbursementforThirdQuarter2010. OEI031000440.
FullReport
Spring2011|HHSOIGSemiannualReporttoCongress|I8
SecondQuarter2010: ImpactonFourthQuarter2010.Weidentified25HCPCScodeswithASPsthatexceededAMPsbyatleast5percentinthesecondquarter
of2010. Ofthese,10hadcompleteAMPdata(i.e.,AMPdataforeverydrug
productthatCMSusedtoestablishreimbursementamounts). Ifreimbursement
amountsforall10codeswithcompleteAMPdatahadbeenbasedon103percent
oftheAMPsduringthefourthquarterof2010,weestimatethatMedicare
http://oig.hhs.gov/oei/reports/OEI-03-10-00440.pdfhttp://oig.hhs.gov/oei/reports/OEI-03-10-00440.pdfhttp://oig.hhs.gov/oei/reports/OEI-03-10-00440.pdfhttp://oig.hhs.gov/oei/reports/OEI-03-10-00440.pdfhttp://oig.hhs.gov/oei/reports/OEI-03-10-00440.pdf8/6/2019 Office of Inspector General Semiannual Report To Congress Spring 2011l
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PartI:MedicareReviews
expenditureswouldhavebeenreducedby$713,000inthatquarteralone.We
couldnotcompareASPsandAMPsfor54HCPCScodesbecauseAMPdatawere
notsubmittedforanyoftheNDCsthatCMSusedtocalculatereimbursement.
Manufacturersfor16percentoftheseNDCshadMedicaiddrugrebate
agreementsandwerethereforegenerallyrequiredtosubmitAMPs. OIGwill
continueto
work
with
CMS
to
evaluate
and
pursue
appropriate
actions
against
thosemanufacturersthatfailtosubmitrequireddata. ComparisonofSecond
Quarter2010AverageSalesPricesandAverageManufacturerPrices: Impacton
MedicareReimbursementforFourthQuarter2010. OEI031100030.
FullReport
Medicare > PartAandPartB > PartBPrescriptionDrugs > InhalationDrugs
QuestionableBillingforBrandNameInhalationDrugsMedicarepaymentstoSouthFloridasuppliersfortheinhalationdrugbudesonide
werereduced
by
almost
half
after
Medicare
implemented
autilization
edit
for
the
druginSeptember2008.However,thedecreaseswereoffsetbypaymentsforthe
inhalationdrugarformoterol(forwhichtherewasnoedit),whichthenmorethan
doubledwithin6months.MedicarepaidSouthFloridasuppliersforupto10times
moreunitsofarformoterolthanweredistributedforsaleinthegeographicarea.
Thesubstantialdifferencebetweenthesalesdataprovidedbyarformoterols
manufacturerandtheclaimsdataforSouthFloridasupplierssuggeststhatthese
supplierswerebillingfordrugsthatmaynothavebeenactuallypurchased.
WerecommendedthatCMS(1)requireDMEcontractorstoimplementutilization
edits
in
high
fraud
areas
as
soon
as
Medicare
begins
paying
for
a
brand
name
drug,
(2)monitorutilizationchangesamongbrandnameinhalationdrugs,(3)strengthen
initialclaimreviewprocessestofocusonpreventionofimproperpayments,and
(4)performsitevisitsandrequestdocumentationtosupportbudesonideand
arformoterolbillingsfromtheSouthFloridasuppliersthatwewillreferforfurther
review. CMSconcurredwithourrecommendations;however,theconcurrencewith
ourfirstrecommendationincludedthecaveatthatcertainprocedures,suchas
developingandissuingalocalcoveragedetermination,wouldneedtobefollowed
beforeimplementingedits. QuestionableBillingforBrandNameInhalationDrugsin
SouthFlorida. OEI030900530. FullReport
Medicare > PartAandPartB > PartBPrescriptionDrugs >HospitalBasedOutpatientPrescription
Drugs
Spring2011|HHSOIGSemiannualReporttoCongress|I9
PaymentforDrugsundertheHospitalOutpatientProspectivePaymentSystem
WefoundthatMedicarepaymentswere31percenthigherthanacquisitioncosts
amongrespondinghospitalsthatparticipateinthePublicHealthServiceActsection
http://oig.hhs.gov/oei/reports/oei-03-09-00530.pdfhttp://oig.hhs.gov/oei/reports/oei-03-09-00530.pdfhttp://oig.hhs.gov/oei/reports/oei-03-09-00530.pdfhttp://oig.hhs.gov/oei/reports/oei-03-09-00530.pdfhttp://oig.hhs.gov/oei/reports/oei-03-09-00530.pdf8/6/2019 Office of Inspector General Semiannual Report To Congress Spring 2011l
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PartI:MedicareReviews
340Bdrugpricingprogram(340BProgram)and1percenthigherthanacquisition
costsamongrespondingnon340Bhospitalsforselectedseparatelypayabledrugs.
The340BProgram,whichisoverseenbytheHealthResourcesandServices
Administration(HRSA),wascreatedtoassistentitiesthatprovideservicesto
disproportionatelylowincome,uninsured,andunderinsuredpopulationsandallow
themtopurchasedrugsatreducedprices. Underthe340BProgram,pharmaceutical
manufacturersagreetochargeatorbelowstatutorilydefinedprices,knownasthe
340Bceilingprices,forcertainsalestocertaincoveredentities.
ThehospitalOutpatientProspectivePaymentSystem(OPPS)wasimplementedto
payhospitalsforPartBoutpatientservicesincluding,butnotlimitedto,certain
PartBcovereddrugs. TheOPPSpaymentfordrugsisgenerallydividedintotwo
categories:separatelypayabledrugsandpackageddrugs. Formorethanhalfofthe
selecteddrugs,Medicarepaymentsexceedednon340Bhospitalacquisitioncosts.
Fortheremainingdrugs,Medicarepaymentswerebelowaveragenon340B
acquisition
costs
by
between
0.6
and
11
percent.
This
report
did
not
contain
recommendations. PaymentforDrugsUndertheHospitalOutpatientProspective
PaymentSystem. OEI030900420. FullReport
MedicarePartAandPartBAdministration
Medicare > PartAandPartB > Administration > ProgramIntegrity > PaymentSuspensions
Spring2011|HHSOIGSemiannualReporttoCongress|I10
UseofPaymentSuspensionstoPreventInappropriateMedicarePaymentsWefoundthatCMSusedpaymentsuspensionsin2007and2008almostexclusively
asatool
to
fight
fraud,
though
the
sanction
is
available
in
overpayment
circumstancesshortoffraud,andthatCMSsguidanceonpaymentsuspensionsto
itscontractorshasincompleteorinconsistentrequirements. Inparticular,guidance
lacksspecificityintermsofthetypesofinformationthatitscontractorsshould
submitwitharequestforasuspension,aswellasindescribingthecircumstancesin
whichanextensionispermitted.
Afterwecollecteddataforthisevaluation,theAffordableCareActestablishednew
provisionsforpaymentsuspensions. TheAffordableCareActstatesthata
providerspaymentsmaybesuspendedbasedonacredibleallegationoffraud,
unlessthereisgoodcausenottosuspendsuchpayments. Thestatutealsorequires
CMSto
consult
with
OIG
in
determining
whether
acredible
allegation
of
fraud
exists. OnSeptember23,2010,CMSissuedproposedregulationsat75Fed.Reg.
58204,58239(Sept.23,2010)fortheseprovisions. Infinalizingtheregulationsand
developingrelatedguidance,CMScouldalsoaddresstheinconsistenciesthatthis
reportidentified. Thereportdidnotcontainrecommendations. TheUseofPayment
SuspensionsToPreventInappropriateMedicarePayments. OEI010900180. FullReport
http://oig.hhs.gov/oei/reports/oei-03-09-00420.pdfhttp://oig.hhs.gov/oei/reports/oei-03-09-00420.pdfhttp://oig.hhs.gov/oei/reports/oei-03-09-00420.pdfhttp://oig.hhs.gov/oei/reports/oei-03-09-00420.pdfhttp://oig.hhs.gov/oei/reports/oei-01-09-00180.pdfhttp://oig.hhs.gov/oei/reports/oei-01-09-00180.pdfhttp://oig.hhs.gov/oei/reports/oei-01-09-00180.pdfhttp://oig.hhs.gov/oei/reports/oei-01-09-00180.pdfhttp://oig.hhs.gov/oei/reports/oei-01-09-00180.pdfhttp://oig.hhs.gov/oei/reports/oei-03-09-00420.pdf8/6/2019 Office of Inspector General Semiannual Report To Congress Spring 2011l
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PartI:MedicareReviews
Medicare > PartAandPartB > Administration > ProgramIntegrity
MedicareandMedicaidFraudandAbuseTraininginMedicalEducationDespitelackofaFederalrequirement,44percentofmedicalschoolsand68percent
ofinstitutionsofferingresidencyandfellowshipprogramsreportedproviding
instructionto
students
and
participants
on
compliance
with
Medicare
and
Medicaid
fraudandabuselawsin2010.
Almostallthemedicalschoolsandinstitutionsofferingresidencyandfellowship
programsthatwereviewedexpressedinterestinreceivingOIGprovided
instructionalmaterialsrelatingtoMedicareandMedicaidfraudandabuse.Most
respondentsexpressedinterestspecificallyinmoreinformationaboutthecivilFalse
ClaimsAct(FCA),theantikickbackstatute,andthephysicianselfreferralstatute.
Accordingly,OIGdecidedto(1)prepareeducationalmaterialsappropriatefor
medicalschoolsandinstitutionsofferingresidencyandfellowshipprograms,
(2)
distribute
the
materials
to
those
medical
schools
and
institutions
that
sponsor
residencyandfellowshipprograms,and(3)seekfeedbackfromthemedicalschools
andinstitutionsofferingresidencyandfellowshipprogramsonwaystoimprovethe
materials.MedicareandMedicaidFraudandAbuseTraininginMedicalEducation.
OEI011000140. FullReport
Medicare > PartAandPartB > Administration > QualityImprovementOrganizations
Spring2011|HHSOIGSemiannualReporttoCongress|I11
QualityImprovementOrganizationsFinalResponsestoBeneficiaryComplaints
Ourreview
covering
August
1,
2008,
through
December
31,
2009,
showed
that
most
QualityImprovementOrganizations(QIO)responsestobeneficiarycomplaintsare
meetingapplicablestandardsandCMSsadditionalcriteriathatapplywhenthe
involvedpractitionersprovideconsentfordisclosure.
CMScontractswithQIOs,which,amongotherresponsibilities,reviewwritten
complaintsfromMedicarebeneficiariesaboutthequalityofcarethebeneficiaries
receivedand,attheconclusionofsuchreviews,sendtothebeneficiariesfinal
responsessummarizingthefindingsofthereviews.Wefoundthatofthe120QIO
finalresponsestoMedicarebeneficiariescomplaintsthatwereviewedindetail,
116metrequirements.However,wefoundthatQIOsdonotobtainconsentfor
disclosurefrom
almost
half
of
the
practitioners
involved.
Medicare
regulations
allowpractitionerstorefusetogiveconsenttotheQIOsreleaseofinformationin
finalreportsthatidentifythem.Wemadenorecommendationsbasedonthis
review. QualityImprovementOrganizationsFinalResponsestoBeneficiaryComplaints.
OEI010900620. FullReport
http://oig.hhs.gov/oei/reports/OEI-01-10-00140.pdfhttp://oig.hhs.gov/oei/reports/OEI-01-10-00140.pdfhttp://oig.hhs.gov/oei/reports/OEI-01-10-00140.pdfhttp://oig.hhs.gov/oei/reports/OEI-01-10-00140.pdfhttp://oig.hhs.gov/oei/reports/oei-01-09-00620.pdfhttp://oig.hhs.gov/oei/reports/oei-01-09-00620.pdfhttp://oig.hhs.gov/oei/reports/oei-01-09-00620.pdfhttp://oig.hhs.gov/oei/reports/oei-01-09-00620.pdfhttp://oig.hhs.gov/oei/reports/oei-01-09-00620.pdfhttp://oig.hhs.gov/oei/reports/OEI-01-10-00140.pdf8/6/2019 Office of Inspector General Semiannual Report To Congress Spring 2011l
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PartI:MedicareReviews
Medicare > PartAandPartB > Administration > ProgramInegrity > ErrorProneProviders
UseofMedicareFeeforServiceErrorRateDataToIdentifyandFocusonErrorProneProviders
AlthoughMedicarepaymentcontractorsdevelopedcorrectiveactionsbasedon
availableerror
rate
data,
they
typically
did
not
focus
on
error
prone
providers
for
reviewandcorrectiveaction.
UsingthereportederrorratedatafromtheHospitalPaymentMonitoringProgram
andtheComprehensiveErrorRateTesting(CERT)programforfiscalyears(FY)2005
through2008,weidentified740errorproneproviders. Theseprovidersaccounted
forasignificantportionofthetotaldollarsinerrorinthesampledyears. Focusing
onerrorproneprovidersforcorrectiveactionandrepaymentofimproperpayments
couldimprovetheeffectivenessofCMSseffortstoreduceimproperpayments.
WerecommendedthatCMS(1)useavailableerrorratedatatoidentifyerrorprone
providers,(2)
require
error
prone
providers
to
identify
the
root
causes
of
claim
errorsandtodevelopandimplementcorrectiveactionplans,(3)monitorprovider
specificcorrectiveactionplans,and(4)shareerrorratedatawithitscontractorsto
assistinidentifyingimproperpayments. CMSconcurredwithour
recommendations. CentersforMedicare&MedicaidServicesUseofMedicareFeefor
ServiceErrorRateDataToIdentifyandFocusonErrorProneProviders.
A050800080. FullReport
Medicare > PartAandPartB > Administration > ProgramIntegrity >Hotline
ComplaintsReceivedThroughthe1800HHSTIPSHotlineOurreviewrevealedthatasofMarch2010,CMShadresolvedorclosed
administratively88percentofthecomplaintsitreceivedduringthefirst6monthsof
2008fromthe1800HHSTIPShotline. CMSandcontractorstaffreportedtheneed
forwrittenguidanceforprocessinghotlinecomplaints.
WerecommendedthatCMS(1)issuewrittenguidancetoitsownstaffand
contractorstaffforprocessinghotlinecomplaintsand(2)upgradeitsinformation
systemforprocessingcomplaints. CMSconcurredwithourrecommendations.
CMSsProcessingofComplaintsReceivedThroughthe1800HHSTIPSHotline.
OEI070900020. FullReport
Medicare > PartAandPartB > Administration > ProgramIntegrity > In
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