Federal Reports

OMB Circular A-136, Financial Reporting Requirements, requires that the Inspector General provide the agency head with a summary of the top management and performance challenges facing the agency. After careful analysis, it is our assessment that the areas of financial management, human capital, information technology, and grantee accountability represent the top management and performance challenges for NEA.

The Patient Protection and Affordable Care Act (ACA) established standards for the amount of premium revenue that certain commercial health insurers and Medicare Advantage plans can spend on costs other than healthcare-related expenses. These standards are known as the medical loss ratio (MLR). Insurers that do not meet these standards must pay rebates to their enrollees or the Department of Health and Human Services. Although the MLR standards do not apply to Medicaid spending, some States have applied similar standards to their contracts with Medicaid managed care organizations. The Federal Government is entitled to the Federal share of the net amount recovered by a State with respect to its Medicaid program.

Boca Raton Regional Hospital, Inc. (the Hospital), located in Florida, complied with Medicare billing requirements for 161 of the 211 inpatient and outpatient claims we reviewed. However, the Hospital did not fully comply with Medicare billing requirements for the remaining 50 claims, resulting in overpayments of $514,000 for the audit period. The outpatient claims selected for review did not contain errors. These errors occurred primarily because the Hospital did not have adequate controls to prevent the incorrect billing of Medicare claims within the selected risk areas that contained errors. On the basis of our sample results, we estimated that the Hospital received at least $2.6 million in overpayments from Medicare.