Federal Reports

The VA Office of Inspector General (OIG) initiated a healthcare inspection in spring 2018 after receiving allegations that former Pathology and Laboratory Medicine Service Chief Dr. Robert Levy misdiagnosed pathological specimens and altered quality management documents to conceal errors at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas. The inspection was completed after the OIG Office of Investigations conducted a criminal investigation. In January 2021, Dr. Levy was sentenced to 20 years in prison for manslaughter and mail fraud.The OIG substantiated the allegations. After a comprehensive, retrospective review of cases Dr. Levy interpreted over his 12-year tenure (almost 34,000 cases), clinical reviewers identified more than 3,000 diagnostic errors. The need for disclosures of errors causing serious injury was identified for 34 patients.As service chief of a specialty care department with only one other pathologist and chairperson of three pathology quality management committees, Dr. Levy had the opportunity to subvert the quality process. Facility leaders failed to recognize his manipulation of quality data. Dr. Levy admitted to long-term alcohol use. The OIG found that facility leaders missed opportunities to address signs of an impairment. The failure of facility leaders to promote a culture of accountability likely led to minimal reporting of Dr. Levy’s signs of impaired behaviors.The OIG made 10 recommendations to the Under Secretary for Health related to competency and pathology quality management processes, pathology reports, and the consulting process with external pathologists. The OIG also recommended the Office of General Counsel and the Office of Human Resources and Administration/Operations, Security & Preparedness be consulted about administrative actions for VHA leaders, as appropriate. Two recommendations focused on alcohol testing and management of impaired healthcare workers.Two recommendations to the Facility Director addressed peer references during reappraisal and evaluation of the facility’s psychological safety climate.

For a covered outpatient drug to be eligible for Federal reimbursement under the program, the drug’s manufacturer must enter into a rebate agreement that is administered by the CMS and pay quarterly rebates to the States. Manufacturers are required to submit a list to CMS of all covered outpatient drugs and to report each drug’s average manufacturer price and, where applicable, best price. On the basis of this information, CMS calculates a unit rebate amount for each drug and provides the information to the States each quarter. Section 1903(i)(10) of the Act prohibits Federal reimbursement for States that do not capture the information necessary for billing manufacturers for rebates as described in section 1927 of the Act. To bill for rebates, States capture drug utilization data that identifies, by NDC, the number of units of each drug for which the States reimbursed Medicaid providers and report the information to the manufacturers. The number of units is multiplied by the unit rebate amount to determine the actual rebate amount due from each manufacturer. States use two primary models to pay for Medicaid services: fee-for-service and managed care. In the managed-care model, States contract with MCOs to provide specific services to enrolled Medicaid beneficiaries, usually in return for a predetermined periodic payment known as a capitation payment. States pay MCOs for each covered individual regardless of whether the enrollee received services during the relevant time period. MCOs use the capitation payments to pay provider claims for these services. Capitation payments may cover outpatient drugs, which include both pharmacy and physician-administered drugs. To claim Federal reimbursement, States report capitation payments made to MCOs as MCO expenditures on the Form CMS-64. These expenditures are not identified by specific type of service (such as pharmacy or physician-administered drugs). When States receive drug rebates from manufacturers, the States must report the rebates as decreasing adjustments on the CMS-64 report. States report drug rebate accounts receivable data on the Medicaid Drug Rebate Schedule, which is part of the CMS-64 report. CMS reimburses States for the Federal share of Medicaid expenditures reported on the CMS-64 report.To collect rebates for drugs, States submit to the manufacturers the drug utilization data containing NDCs for the drugs. NDCs enable States to identify the drugs and their manufacturers and to facilitate the collection of rebates for the drugs. The DRA amended section 1927 of the Act to specifically address the collection of rebates on physician-administered drugs for all single-source and top-20 multiple-source drugs. Effective March 23, 2010, the Affordable Care Act (ACA) required manufacturers to pay rebates on covered outpatient drugs dispensed to MCO enrollees if the MCOs are responsible for coverage of such drugs. Before the enactment of the ACA, drugs dispensed by Medicaid MCOs were excluded from the rebate requirements. States typically require MCOs to submit to the State agency NDCs for covered outpatient drugs dispensed to eligible individuals. MCOs submit to the State agency provider claim information, including claim lines for covered outpatient drugs. This information includes drug utilization data, which States must include when billing manufacturers for rebates. The State agency, which is responsible for billing and collecting Medicaid drug rebates for both pharmacy and physician-administered drugs, contracted with Conduent State Healthcare, LLC (the contractor), during our audit period to manage its drug rebate program. However, during most of our audit period, the State agency conducted most of those duties. The State agency did not start billing manufacturers for rebates related to physician-administered drugs until 2013, at which time they began retroactively billing for claims back to 2010.

Lamont Brown, of Brooklyn, New York, was sentenced in U.S. District Court, Eastern District of New York, on June 2, 2021, to a prison term of time served, probation for 36-months and was ordered to pay restitution of $97,210 to Amtrak. Brown previously pleaded guilty to conspiracy to commit wire fraud for his involvement in an Amtrak eVoucher scheme. Our investigation found that Brown and his co-conspirators used stolen credit card information to make unauthorized purchases of Amtrak tickets, canceled or exchanged those tickets for eVouchers, and then sold the fraudulently obtained eVouchers on the internet.

To determine whether the Social Security Administration’s (SSA) responses to the end of Fiscal Year (FY) 2019 Chief Information Officer (CIO) Federal Information Security Modernization Act of 2014 (FISMA) metrics were reliable.

What We Looked AtTo support its mission to provide the safest, most efficient airspace system in the world, the Federal Aviation Administration (FAA) seeks to procure state-of-the-art systems, high-quality goods, and first-rate services. In 2017, for example, the Agency made over $4 billion worth of purchases—of which a range of $87 million to an estimated $1.7 billion could be subject to the Buy American Act (BAA) and the FAA-specific Buy American Preference provisions (BAP). In response to a congressional request, we initiated this audit to assess FAA’s policies and procedures for awarding and administering contracts in accordance with domestic content laws. Specifically, we evaluated FAA’s policies and procedures for (1) implementing Buy American requirements and (2) overseeing Buy American compliance. What We FoundFAA’s Acquisition Management System requires Buy American–applicable contracts to include specific clauses that direct vendors to certify the origins of goods or products and contracting officers (CO) to fully understand BAA and BAP requirements. However, we found Buy American–applicable contracts where COs had omitted or improperly applied the required clauses, lacked vendor certifications, or did not fulfill contract filing requirements—due to a lack of BAA- and BAP-specific guidance and training. As a result, we estimate that FAA may have put up to $127 million in Federal funds at risk due to contracts missing required vendor certifications. In addition, while Federal policy directed agencies to monitor, enforce, and comply with the Buy American Laws, FAA does not require its staff to assess and report on compliance, although it has tools available for this purpose. The Agency also lacks effective processes for recording “place of manufacture data” or for tracking usage of BAP waivers. As a result, FAA cannot be certain that it is meeting the intent of the Buy American Laws—to purchase American-made materials and goods to strengthen our economic and national security. Our RecommendationsWe made eight recommendations to improve FAA’s compliance and oversight for contracts subject to domestic content laws. FAA concurred with all eight recommendations, which we consider resolved but open pending completion of the planned actions.

We audited the Harris County Hurricane Harvey Community Development Block Grant Disaster Recovery (CDBG-DR) program. We initiated this audit as part of our commitment to helping the U.S. Department of Housing and Urban Development (HUD) address its top management challenges and to support HUD’s strategic objective to support effectiveness and accountability in long-term disaster recovery. Further, Congress has expressed strong interest in HUD’s disaster programs.Our objective was to assess the efficiency and effectiveness of Harris County’s Hurricane Harvey CDBG-DR program and whether the program was assisting disaster participants in a timely manner; specifically, to examine the status of its HUD-approved activities and challenges, if any, in implementing the activities.We found that Harris County had not efficiently or effectively operated its Hurricane Harvey CDBG-DR program. Specifically, 3 years after Hurricane Harvey, Harris County had assisted only 112 of 4,513 planned program participants and had spent less than 1 percent of its grant funds. Harris County’s challenges included an inability to effectively assist applicants and inefficiencies in its reimbursement program. These conditions occurred because Harris County was overwhelmed by the number of programs it intended to operate and its staff did not respond effectively to Texas General Land Office (Texas GLO) guidance and training. As a result, the Texas GLO reduced the number of Harris County’s programs and assumed control of $338.7 million (27 percent) of its $1.2 billion Hurricane Harvey grant suballocation.We recommend that the Director of the Office of Block Grant Assistance require the Texas GLO to (1) provide its plan to continuously monitor Harris County’s pace and performance in its remaining program and take appropriate action to ensure that program goals are met; (2) set performance and financial milestones for all programs and activities funded under Harris County’s subrecipient agreement; (3) monitor Harris County’s capacity to manage its funds and address duplicative, inefficient, and cost-prohibitive processes or positions; and, (4) review Harris County’s priorities for providing assistance to program participants. Implementation of these recommendations would include determining whether additional activities need to be combined or eliminated and repurposing additional grant funds if necessary.