Federal Reports

This memorandum is Sensitive But Unclassified. To obtain further information, please contact the OIG Office of Counsel at OIGCounsel@oig.treas.gov, (202) 927-0650, or by mail at Office of Treasury Inspector General, 1500 Pennsylvania Avenue, Washington DC 20220.

The unclassified version of the SAR covers the period from October 1, 2019 through March 31, 2020, and reflects what the NSA OIG could release publicly about its work for that reporting period. The OIG issued 10 reports and oversight memoranda during the period, making 94 recommendations to assist the Agency in addressing the findings and deficiencies identified. NSA's management agreed with all OIG recommendations made during this period. The Director of the NSA and Congress received the classified version of the SAR in accordance with the IG Act.

OIG PEER REVIEW

Medicare payments may not be made for items or services that “are not reasonable andnecessary for the diagnosis or treatment of illness or injury or to improve the functioning of amalformed body member” (Social Security Act (the Act) § 1862(a)(1)(A)). In addition, the Actprecludes payment to any provider of services or other person without information necessaryto determine the amount due the provider (§ 1815(a)).Federal regulations state that the provider must furnish to the Medicare contractor sufficientinformation to determine whether payment is due and the amount of the payment (42 CFR§ 424.5(a)(6)).Claims must be filed on forms prescribed by CMS in accordance with CMS instructions (42 CFR§ 424.32(a)(1)). The Medicare Claims Processing Manual (the Manual) requires providers tocomplete claims accurately so that Medicare contractors may process them correctly andpromptly (Pub. No. 100-04, chapter 1, § 80.3.2.2). The Manual states that providers must useHCPCS codes for most outpatient services (chapter 23, § 20.3).3The Office of Inspector General (OIG) believes that this audit report constitutes credibleinformation of potential overpayments. Upon receiving credible information of potentialoverpayments, providers must exercise reasonable diligence to identify overpayments (i.e.,determine receipt of and quantify any overpayments) during a 6-year lookback period.Providers must report and return any identified overpayments by the later of (1) 60 days afteridentifying those overpayments or (2) the date that any corresponding cost report is due (ifapplicable). This is known as the 60-day rule.4The 6-year lookback period is not limited by OIG’s audit period or restrictions on theGovernment’s ability to reopen claims or cost reports. To report and return overpaymentsunder the 60-day rule, providers can request the reopening of initial claims determinations,submit amended cost reports, or use any other appropriate reporting process.

In 2010, Congress passed the Patient Protection and Affordable Care Act (ACA). The ACA established enhanced Federal reimbursement rates for services provided to nondisabled, low-income adults without dependent children (new adult group). The enhanced reimbursement rates established under the ACA have raised concerns about the possibility that States could improperly enroll individuals for Medicaid coverage in the new adult group and, as a consequence, the potential for improper payments.Our objective was to determine whether Colorado complied with Federal and State requirements when claiming Federal Medicaid reimbursement for Medicaid services provided to beneficiar