Federal Reports

A procurement manager was terminated from employment on May 21, 2021, after our investigation found she violated Amtrak policies by repeatedly mischaracterizing the relationship with and misrepresenting actions by our office to intimidate and coerce Amtrak employees and vendors from taking certain actions or into conducting certain actions on multiple occasions. Although the employee admitted to her misconduct, she was also evasive and provided inconsistent responses to our agents during her interview with us.

Under the Medicare Advantage (MA) program, the Centers for Medicare & Medicaid Services (CMS) makes monthly payments to MA organizations based in part on the characteristics of the enrollees being covered. Using a system of risk adjustment, CMS pays MA organizations the anticipated cost of providing Medicare benefits to a given enrollee, depending on such risk factors as the age, sex, and health status of that individual. Accordingly, MA organizations are paid more for providing benefits to enrollees with diagnoses associated with more intensive use of health care resources relative to healthier enrollees, who would be expected to require fewer health care resources. To determine the health status of enrollees, CMS relies on MA organizations to collect diagnosis codes from their providers and submit these codes to CMS. We are auditing MA organizations because some diagnoses are at higher risk for being miscoded, which may result in overpayments from CMS.This audit is part of a series of audits in which we are reviewing the accuracy of diagnosis codes that MA organizations submitted to CMS. Using data mining techniques and considering discussions with medical professionals, we identified diagnoses that were at higher risk for being miscoded and consolidated those diagnoses into specific groups. (For example, we consolidated 28 major depressive disorder diagnoses into 1 group.) This audit covered Anthem Community Insurance Company, Inc. (Anthem), for contract number H3655 and focused on seven groups of high-risk diagnosis codes. Our objective was to determine whether selected diagnosis codes that Anthem submitted to CMS for use in CMS’s risk adjustment program complied with Federal requirements.

As part of our annual audit plan, we audited costs billed to the Tennessee Valley Authority (TVA) by Stantec Consulting Services, Inc. (Stantec) to provide coal combustion residual engineering services under Contract No. 13051. The contract provided for TVA to compensate Stantec for work on either a cost reimbursable, time and material (T&M), unit rate, or fixed price basis. Our audit objectives were to determine if (1) costs were billed in accordance with the terms and conditions of the contract and <br> (2) tasks were issued using the most cost efficient pricing methodology. Our audit scope included about $55.3 million in costs billed to TVA from January 5, 2018, through February 29, 2020, of which over 99.9 percent was billed using T&M compensation terms. In summary, we determined:Stantec overbilled TVA $93,916, including (1) $73,099 for mileage rates not specified in the contract and (2) $20,817 for ineligible travel costs.The use of T&M terms on projects caused TVA to pay at least $1.65 million more than it would have if cost reimbursable payment terms had been used for those projects. Additionally, if TVA utilized cost reimbursable pricing for the remaining contract spend, they could potentially avoid $1.01 million in future costs.(Summary Only)