Federal Reports

From January 1, 2015, through March 31, 2017 (audit period), Pacific Medical, Inc., which is located in Tracy, California, did not always comply with Medicare requirements when billing for selected orthotic braces (i.e., back, knee, and ankle-foot braces). For 89 of the 100 sampled claims, Pacific Medical complied with the requirements. However, for the remaining 11 claims, it did not comply with the requirements. Specifically, Pacific Medical billed for orthotic braces that were not medically necessary for nine claims and could not provide medical records for two claims.

Nearly all Medicare Part B payments to a chiropractor in Queens, New York, did not comply with Medicare requirements. Specifically, 95 of 100 sample claims for which the chiropractor received Medicare Part B reimbursement did not comply with Medicare requirements. These improper payments occurred because the chiropractor did not have any policies and procedures to ensure that chiropractic services provided to Medicare beneficiaries were medically necessary and sufficiently documented.

Atlantis Health Care Group of Puerto Rico, Inc., claimed dialysis services that did not comply with Medicare requirements during all 100 beneficiary-months that we sampled. (A beneficiary-month was defined as all dialysis services provided to a Medicare beneficiary during 1 calendar month.) For example, Atlantis claimed reimbursement for dialysis services for which (1) beneficiaries' medical information was not adequately supported, (2) plans of care or comprehensive assessments did not comply with Medicare requirements, and (3) physicians' orders did not meet Medicare requirements.

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the VA New Jersey Health Care System. The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances Inspection Program; Mental Health: Posttraumatic Stress Disorder Care; Long-term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-up; and High-risk Processes: Central Line-associated Bloodstream Infections. The Facility leaders have worked together as a team since February 28, 2017. The OIG noted that Facility leaders appeared actively engaged with employees and patients. Organizational leaders support efforts related to patient safety, quality care, and other positive outcomes (such as initiating processes and plans to maintain positive perceptions of the Facility through active stakeholder engagement). However, the presence of organizational risk factors, as evidenced by sentinel events, disclosures, and Patient Safety Indicator data, may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and continuously monitored. Although the leadership team was knowledgeable about selected SAIL metrics, the leaders should take actions to improve care and performance of poorly performing Quality of Care and Efficiency metrics that are likely contributing to the Facility’s drop from its previous “3-Star” rating to the current “2-Star” rating. The OIG noted findings in three of the clinical operations reviewed and issued six recommendations that are attributable to the Director, Chief of Staff, and Associate Director–Lyons Campus. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes (2) Environment of Care • Medical equipment storage • Documentation of response time during panic alarm testing (3) Medication Management: Controlled Substances Inspection Program • Correction of Annual Physical Security Survey deficiencies

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Marion VA Medical Center. The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances Inspection Program; Mental Health: Posttraumatic Stress Disorder Care; Long-term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-up; and High-risk Processes: Central Line-associated Bloodstream Infections. Apart from the Director, the Facility had a relatively new leadership team. The OIG noted that Facility leaders were actively taking measures to improve employee engagement and satisfaction scores and seemed committed to creating and sustaining positive change. Patients were generally satisfied with the leadership and care provided, and Facility leaders appeared to be actively engaged with improvement activities to enhance patient experiences. The OIG reviewed accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results and did not identify any substantial organizational risk factors. The leadership team should continue to take actions to improve care and performance of selected Quality of Care and Efficiency metrics that are likely contributing to the current “2-Star” rating. The OIG noted findings in four of the clinical operations reviewed and issued six recommendations that are attributable to the Director, Chief of Staff, Associate Director for Patient Care Services, and Associate Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Ongoing Professional Practice Evaluation process (2) Environment of Care • Panic alarm testing and follow-up • Annual Emergency Operations Plan review (3) Controlled Substances Inspection Program • Annual physical security survey • Verification of drugs held for destruction (4) Central Line-associated Bloodstream Infections • Staff education