From: HHS Office of Inspector General <donotreply@subscriptions.hhs.gov>
Date: Fri, Jul 11, 2014 at 9:03 AM
Subject: OIG posts 2 federal register notices, 3 reports and news about enforcement actions - 7/11
To: iammejtm@gmail.com
Good afternoon from Washington, DC. Today OIG posts 2 Federal Register Notices – including a Special Fraud Alert, 3 reports, and news about enforcement actions. As always, you can use the links provided to go directly to the new material.
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Solicitation of Information and Recommendations for Revising OIG's Non-Binding Criteria for Implementing Permissive Exclusion Authority Under Section 1128(b)(7) of the Social Security Act http://go.usa.gov/XdRx This Federal Register notice informs the public that OIG: (1) Is considering revising the Non-Binding Criteria for Implementing Permissive Exclusion Authority Under Section 1128(b)(7) of the Social Security Act (62 FR 67392, December 24, 1997), and (2) is soliciting input from the public for OIG to consider in developing the revised criteria.
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Special Fraud Alert: Laboratory Payments to Referring Physicians http://go.usa.gov/XdRH
This Special Fraud Alert addresses compensation paid by laboratories to referring physicians and physician group practices (collectively, physicians) for blood specimen collection, processing, and packaging, and for submitting patient data to a registry or database.
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Louisiana Received More Than $7.1 Million in Unallowable Bonus Payments (A-04-14-08029) http://go.usa.gov/XdnP
Under the Children's Health Insurance Program Reauthorization Act of 2009, Congress appropriated $3.225 billion for qualifying States to receive performance bonus payments (bonus payments) for Federal fiscal years (FYs) 2009 through 2013 to offset the costs of increased enrollment of children in Medicaid.
We found that the bonus payments that Louisiana received for the audit period were not allowable in accordance with Federal requirements. Most of the data used in Louisiana's bonus payment calculations was in accordance with Federal requirements. However, the State agency overstated its FYs 2009 through 2011 current enrollment in its bonus requests to CMS because it included individuals who did not qualify because of their basis-of-eligibility code. As a result, CMS overpaid Louisiana $7.1 million in bonus payments.
We recommended that the State agency refund $7.1 million to the Federal Government and ensure that future requests for CHIPRA bonus payments include only qualifying children to comply with Federal requirements.
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Virginia Improperly Claimed Federal Reimbursement for Most Reviewed Medicaid Payments to Piedmont Geriatric Hospital (A-05-12-00056) http://go.usa.gov/XdQC
Virginia's Department of Medical Assistance Services (State Medicaid agency) claimed $39.4 million in Federal reimbursement for Medicaid payments to Piedmont Geriatric Hospital (Piedmont), an institution for mental diseases (IMD), for inpatient services it provided to patients aged 65 or older on dates during the audit period January 1, 2006, through December 31, 2010. Of that amount, $36.9 million was not claimed in accordance with Federal requirements for such services.
For States to claim Federal reimbursement for their Medicaid payments for inpatient hospital services provided to patients aged 65 or older in IMDs, those services must meet the Federal definition of such services. This definition requires the provider to demonstrate compliance with the basic Medicare Conditions of Participation (CoP) generally applicable to all hospitals and two special Medicare CoP applicable to IMDs providing such services.
Piedmont did not demonstrate compliance with the special Medicare CoP at any time during the audit period; however, for several months during that period (the regulatory gap period), CMS inadvertently changed some applicable regulations. Of the $39.4 million in Federal reimbursement claimed by the State Medicaid agency during the audit period, $36.9 million was for unallowable claims with dates of service outside the regulatory gap period. We have not provided an opinion on the allowability of the remaining $2.5 million, which was for claims with dates of service during the regulatory gap period. The State Medicaid agency made these improper claims because it believed that Piedmont had met all requirements to be eligible for Medicaid payments for the inpatient hospital services it provided to patients aged 65 or older.
We recommended that the State Medicaid agency:
(1) Refund $36.9 million to the Federal Government,
(2) Work with CMS to determine whether the State Medicaid agency should refund an additional $2.5 million to the Federal Government, and
(3) Ensure that it claims Federal reimbursement for Medicaid payments for inpatient hospital services provided to patients aged 65 or older in IMDs only if those IMDs can demonstrate compliance with the special Medicare CoP.
The State Medicaid agency did not concur with our first and second recommendations and did not comment on our third recommendation.
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Virginia Improperly Claimed Federal Reimbursement for Most Reviewed Medicaid Payments to Catawba Hospital (A-05-12-00055) http://go.usa.gov/XdQR
Virginia's Department of Medical Assistance Services (State Medicaid agency) claimed $18.6 million in Federal reimbursement for Medicaid payments to Catawba Hospital (Catawba), an institution for mental diseases (IMD), for inpatient services it provided to patients aged 65 or older on dates during the audit period January 1, 2006, through December 31, 2010. Of that amount, $17.4 million was not claimed in accordance with Federal requirements for such services.
For States to claim Federal reimbursement for their Medicaid payments for inpatient hospital services provided to patients aged 65 or older in IMDs, those services must meet the Federal definition of such services. This definition requires the provider to demonstrate compliance with the basic Medicare Conditions of Participation (CoP) generally applicable to all hospitals and two special Medicare CoP applicable to IMDs providing such services.
Catawba did not demonstrate compliance with the special Medicare CoP at any time during the audit period; however, for several months during that period (the regulatory gap period), CMS inadvertently changed some applicable regulations. Of the $18.6 million in Federal reimbursement claimed by the State Medicaid agency during the audit period, $17.4 million was for unallowable claims with dates of service outside the regulatory gap period. We have not provided an opinion on the allowability of the remaining $1.2 million, which was for claims with dates of service during the regulatory gap period. The State Medicaid agency made these improper claims because it believed that Catawba had met all requirements to be eligible for Medicaid payments for the inpatient hospital services it provided to patients aged 65 or older.
We recommended that the State Medicaid agency:
(1) Refund $17.4 million to the Federal Government,
(2) Work with CMS to determine whether the State Medicaid agency should refund an additional $1.2 million to the Federal Government,
(3) Identify and refund the Federal share of any additional Medicaid payments to Catawba for inpatient hospital services it provided to patients aged 65 or older on dates after the audit period if neither the State Medicaid agency nor Catawba can demonstrate Catawba's compliance with Federal requirements for those services, and
(4) Ensure that it claims Federal reimbursement for Medicaid payments for inpatient hospital services provided to patients aged 65 or older in IMDs only if those IMDs can demonstrate compliance with the special Medicare CoP.
The State Medicaid agency did not concur with our first and second recommendations and did not comment on our third and fourth recommendations.
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Civil Monetary Penalty Case Narratives Updated
False and Fraudulent Claims http://go.usa.gov/XdNQ
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July 11, 2014; Office of Inspector General; U.S. Department of Health and Human Services Utah Health Care System Settles Case Involving Allegations of Employing Excluded Individuals http://go.usa.gov/XdQF
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July 11, 2014; Office of Inspector General; U.S. Department of Health and Human Services Kentucky Long Term Care Organization Settles Case Involving Allegations of Employing An Excluded Individual http://go.usa.gov/XdQF
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July 10, 2014; U.S. Department of Justice Four Patient Recruiters Plead Guilty in Miami to Roles in $20 Million Health Care Fraud Scheme http://go.usa.gov/9SrT
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July 10, 2014; U.S. Attorney; Eastern District of Pennsylvania Child Care Center Owner Pleads Guilty to Fraud http://go.usa.gov/9SrT
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July 10, 2014; U.S. Attorney; Northern District of New York Watertown Area Hospital Settles Health Care Lawsuit http://go.usa.gov/9SrT
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July 10, 2014; U.S. Attorney; District of Nevada Former Chief Operating Officer of Nevada Endoscopy Center Pleads Guilty To Medicare/Medicaid Fraud Billing Scheme http://go.usa.gov/9SrT
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State Enforcement Actions Updated http://go.usa.gov/9Srm
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That's all we have for today. If we can be of any further assistance, please send an Email to public.affairs@oig.hhs.gov
I hope you have had a good week and are able to enjoy the upcoming weekend.
Marc Wolfson – Office of External Affairs
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Jeremy Tobias Matthews
