Federal Reports

The OIG conducted this healthcare inspection after receiving information from the facility that an audiologist had provided poor care and billed for unrendered services. The inspection focused on actions the Audiology Supervisor, Service Chief, and Chief of Staff (audiology leaders) took in response to the audiologist’s poor clinical care. A facility fact-finding review revealed the audiologist provided poor care to eight of 43 patients reviewed, including misinforming patients who needed hearing aids that hearing aids were not needed.Although the audiology leaders reported the fact-finding results to the OIG, they failed to evaluate whether patients needed clinical follow-up; determine whether additional patients were affected by the audiologist’s poor care; evaluate whether clinical disclosures were required for the affected patients; and communicate the fact-finding results to the Facility Director, who was therefore unable to initiate the process to determine the necessity of a large scale disclosure.The instances of poor care were also not reported to the Patient Safety Manager who was, as a result, unable to assess the adverse events to determine if patient safety interventions were indicated.The OIG also found that performance monitoring of facility audiologists was not conducted as required. Annual competency assessments and annual performance appraisals were not consistently completed and did not contain adequate performance standards.Audiology leaders failed to consider whether the audiologist’s actions warranted a report to the state licensing board due to a lack of understanding of the requirements for reporting and, therefore, the Facility Director was not informed of the need to initiate a state licensing board review.The OIG made 10 recommendations to the Facility Director related to ensuring patients affected by poor audiology care receive follow-up and disclosures as appropriate, overseeing audiologists, and ensuring audiology leaders’ compliance with policies regarding disclosure, adverse event reporting, and state licensing board reporting.

The purpose of the VA Fiduciary Program is to protect beneficiaries who are unable to manage their VA benefits as a result of injury, disease, advanced age, or because they are under age 18. The Veterans Benefits Administration’s (VBA) Pension and Fiduciary Service administers the program through six fiduciary offices called “hubs.” The OIG examined whether program staff properly addressed allegations of benefit payments being misused and then reimbursed beneficiaries as required.Program staff initiated inquiries into approximately 12,000 allegations of misuse from January 1, 2018, through September 30, 2019. The OIG team assessed staff actions for 40 misuse determinations and did not find systemic issues. However, the team found instances of significant wait times for program staff to determine misuse and negligence and to reimburse misused funds. For example, one beneficiary waited 19 months after an initial determination of misuse before staff completed a negligence determination.VA then reimbursed the beneficiary over $20,000 in misused funds. Another beneficiary waited 14 months after the misuse determination before staff reimbursed approximately $5,800. VBA should consider whether the average number of days taken to complete each type of misuse action is acceptable to meet oversight responsibilities and fulfill the stated mission of protecting vulnerable veterans and other beneficiaries.The team also found that VBA did not adequately monitor all follow-up actions on reported misuse. VBA was unaware of unprocessed negligence determinations from 2016 and 2017 that the team identified. Additionally, the team examined the workload management plans and systematic analysis of operations for the two fiduciary hubs visited, but none of the documents discussed or identified pending reimbursements.The OIG made two recommendations to VBA to ensure prompt completion of determinations and reimbursements after December 31, 2017.

Our objective was to determine to determine whether Social Security Administration (SSA) staff used updated values of all resources when they completed redeterminations to determine whether recipients remained eligible for Supplemental Security Income (SSI) payments.

Our objective was to report internal control weaknesses, noncompliance issues, and unallowable costs identified in the single audit to the Social Security Administration (SSA) for resolution.

To ensure that hospice care does not exceed the cost of conventional care at the end of life, there are two annual limits (called caps) to payments made to hospices. Hospices that receive claim payments exceeding the cap amounts must repay the difference (overpayment) to Medicare. The Centers for Medicare & Medicaid Services (CMS) contracts with four Medicare administrative contractors (MACs) to calculate cap amounts and recover associated overpayments. We selected Palmetto GBA, LLC (Palmetto), one of the four MACs, for our audit because it had the highest number of hospices in its jurisdiction during our audit period of cap year 2017. OIG has not performed previous work related to the hospice caps. When a beneficiary receives hospice services in more than one cap year, the beneficiary count is allocated to each cap year based on the percentage of total hospice days that occurred in each cap year. For the second cap year, Palmetto must adjust the previous year’s (i.e., the first cap year that hospice service was provided) cap calculation if the beneficiary count has changed. If a beneficiary continues to receive hospice care into a third cap year, Palmetto must adjust the cap calculations again for both previous cap years so that each beneficiary is counted only one time for his or her total hospice days. The process of redetermining the cap calculations based on the change in beneficiary counts for previous years is referred to as a “lookback.” Palmetto calculates each hospice’s aggregate cap amount for a specific cap year a total of four times, consisting of the initial cap calculation year and three lookback years. For example, the initial cap calculation for 2014 was performed after the 2014 cap year had ended. For cap year 2015, Palmetto performed a lookback of 2014. For cap year 2016, Palmetto performed lookbacks of 2015 and 2014. For cap year 2017, Palmetto performed lookbacks of 2016, 2015, and 2014. After the third lookback, Palmetto will not review the cap calculation for the initial cap year again. As a result, the 2017 cap calculation was the final lookback at 2014. A hospice is expected to repay cap overpayments promptly. If a hospice cannot repay a cap overpayment immediately, it may submit an Extended Repayment Schedule (ERS) request to Palmetto. If approved, a hospice may receive up to 60 months to repay an overpayment. Palmetto may approve ERS requests up to 36 months, but CMS must approve ERS requests for 37 to 60 months. If a hospice does not make ERS payments, Palmetto classifies the debt as currently not collectible and refers the debt to the Department of the Treasury. According to CMS, debt that is currently not collectible is unlikely to be collected.