Federal Reports

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This Newsletter provides a bimonthly summary of selected investigative accomplishments.

Medicare hospice care is intended to help terminally ill beneficiaries continue life with minimal disruptions and to support beneficiaries' families and other caregivers. Two key requirements of the Medicare hospice benefit are for the beneficiary to sign an election statement and for a physician to certify the beneficiary as terminally ill. Together, the election statement and certification of terminal illness provide critical safeguards to ensure that the beneficiary understands the hospice benefit and that the physician is involved in determining whether the beneficiary is appropriate for hospice care. However, previous OIG work has raised concerns that some election statements used by hospices are misleading and that physicians are sometimes not involved in care planning and may rarely see beneficiaries. Also, OIG has investigated numerous cases in which hospices submitted fraudulent claims for patients who were not appropriate for hospice care. This report assesses both hospice election statements and certifications of terminal illness.

The Washington State Health Care Authority (State agency) claimed Federal Medicaid reimbursement for inpatient hospital services related to treating certain provider-preventable conditions (PPCs). For the period July 1, 2012, through December 31, 2013, we identified 463 claims totaling $18.3 million ($10.8 million Federal share) that contained PPCs and (1) a present-on-admission indicator code (POA code) indicating that the condition was not present on admission, (2) a POA code indicating that the documentation in the patient's medical record was insufficient to determine whether the condition was present on admission, or (3) no POA code.

From July 1, 2012, through June 30, 2014, the Idaho Department of Health and Welfare claimed $4.3 million in Federal Medicaid reimbursement for inpatient hospital services related to certain provider-preventable conditions, some portion of which was unallowable.

In March 2016, the Nuclear Regulatory Commission (NRC) issued a Chilled Work Environment Letter for Watts Bar Nuclear Plant. The NRC concluded a chilled work environment existed in the Operations Department because of a perception that operators were not free to raise safety concerns using all available avenues without fear of retaliation. According to the NRC Policy Statement for Nuclear Employees Raising Safety Concerns Without Fear of Retaliation, "A reluctance on the part of employees to raise concerns is detrimental to nuclear safety." The Nuclear Oversight group, through the Quality Assurance (QA) function, should provide reasonable assurance that plant safety functions are performed in a satisfactory manner. Additionally, Nuclear Oversight's Employee Concerns Program (ECP) is charged with providing an independent avenue for employees to raise concerns. With these key roles, it is crucial that employees in Nuclear Oversight feel free to raise concerns without fear of retaliation. The OIG found the work environment for Nuclear Oversight is not always conducive to raising concerns without fear of retaliation. Most QA employees felt free to raise concerns or problems without fear of retaliation; however, one QA employee informed us that although they would report a nuclear quality problem or concern, they would not report these problems or concerns to their management. While most QA employees felt free to raise concerns or problems, most ECP employees did not without fear of retaliation. Our interviews with QA and ECP personnel identified issues that could be impacting employees' willingness to report concerns, including (1) distrust of management, (2) past concerns being overridden or ignored, (3) work being influenced, and (4) QA rotational positions.