Federal Reports

To bill for items and services provided to beneficiaries, providers must enroll, and periodically revalidate this enrollment, in Medicaid. Effective provider enrollment screening is an important tool in preventing Medicaid fraud. To protect Medicaid against ineligible and fraudulent providers, the Affordable Care Act requires States to screen Medicaid providers according to their risk for fraud, waste, and abuse using enhanced screening procedures. These can include fingerprint-based criminal background checks and site visits. To help States meet the demands of applying enhanced screening to all new and existing providers, the Centers for Medicare & Medicaid Services (CMS) allows States to substitute Medicare or other State Medicaid agency or Children's Health Insurance Program screening results for their own. Ensuring that States screen all providers in accordance with the new requirements is vital to protecting Medicaid, especially as it grows to serve more beneficiaries.

The Centers for Disease Control and Prevention (CDC) did not award President's Emergency Plan for AIDS Relief (PEPFAR) funds for fiscal year 2013 in compliance with Department of Health and Human Services (HHS) and internal policies. For all 30 Funding Opportunity Announcements (FOAs) in our judgmental sample, CDC did not comply with 1 or more HHS or internal policies in some awards.

Huntsville Hospital (the Hospital) (operating in Huntsville, Alabama) complied with Medicare billing requirements for 178 of the 277 inpatient and outpatient claims we reviewed. However, the Hospital did not fully comply with Medicare billing requirements for the remaining 99 claims, resulting in net overpayments of $24,000 for the audit period. Specifically, 7 inpatient claims had billing errors, resulting in net overpayments of $18,000, and 92 outpatient claims had billing errors, resulting in overpayments of $6,000. 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 overpayments of at least $203,000 for the audit period.