Federal Reports

Under the prospective payment system (PPS), Medicare pays home health agencies (HHAs) for each 60 day episode of care that beneficiary receives, called a payment episode. During our audit period, if an HHA provided four or fewer visits in a payment episode, Medicare paid the HHA a standardized per-visit payment. Claims for these types of payments are called Low Utilization Payment Adjustment (LUPA) claims. Once a fifth visit was provided during the payment episode (i.e., above the LUPA threshold), Medicare paid an amount for the services provided that was, in general, substantially higher than the per-visit payment amount. Because of the large payment increase starting with the fifth visit, HHAs have an incentive to improperly bill claims with visits slightly above the LUPA threshold.

In 2017, HHS declared the opioid epidemic in the United States a public health emergency. The misuse of and addiction to opioids-including prescription pain relievers, heroin, and synthetic opioids such as fentanyl-is a serious national crisis that affects public health as well as social and economic welfare. In 2018 alone, there were more than 46,000 opioid-related overdose deaths in the United States. As part of its efforts to combat the opioid crisis, the Health Resources and Services Administration (HRSA) awarded $200.5 million in Access Increases in Mental Health and Substance Abuse Services (AIMS) grants to health centers nation-wide. OIG audited HRSA's oversight of AIMS supplemental grant funding as part of our oversight on the integrity and proper stewardship of Federal funds used to combat the opioid crisis.

For a covered outpatient drug to be eligible for Federal reimbursement under the Medicaid program's drug rebate requirements, manufacturers must pay rebates to the States for the drugs. However, previous OIG audits found that States did not always bill and collect all rebates due for drugs administered by physicians.

Medicare paid approximately $2.2 billion for psychotherapy services provided to Medicare beneficiaries nationwide during calendar years 2017 and 2018. Prior OIG audits and reviews found that Medicare had made millions of dollars in improper payments for mental health services, including psychotherapy services. Using data analysis techniques, we identified On-Site Psychological Services, P.C. (On-Site), at risk for noncompliance with Medicare billing requirements.

The Child Care and Development Block Grant Act (CCDBG Act) of 2014 added new requirements for States that receive funding from the Child Care and Development Fund (CCDF) to conduct comprehensive criminal background checks on staff members and prospective staff members of child care providers every 5 years. Criminal background check requirements apply to any staff member who is employed by a child care provider for compensation or whose activities involve the care or supervision of children or unsupervised access to children.

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