Federal Reports

This report assesses the effectiveness of the company’s controls to mitigate the risk of fraud in its payments to non hospital facilities. We focused on claims the company paid to the top tenth percentile of non hospital facilities from 2014 through 2018.Just as with our previous work on medical claims, we found that the company is exposed to potential fraud in its medical claim payments and has not obtained a capability to proactively analyze its medical claim payments for potential fraud. Notably, Amtrak is self insured and pays for each medical claim as they are incurred from its operating budget.Among the medical claims of non-hospital facilities we reviewed, we identified 191 that exhibited billing patterns indicative of fraud. The company had not flagged the billing patterns of these facilities for further review. This has put at risk an estimated $57 million the company paid to these facilities between 2014 and 2018. To address the findings in our report, we recommend the company do the following:• Review claims paid to the 191 potentially fraudulent facilities and seek recovery of whatever portion of the $57 million in claims it determines were improper.• Implement proactive fraud detection procedures sooner, so that the company can stop fraudulent payments earlier. • Implement fraud awareness initiatives to enable plan members to better recognize and report potential fraud. • Gather information on fraud schemes and emerging fraud trends and use it to monitor its medical claim payments.

We undertook this study because of concerns that Medicare Advantage organizations (MAOs) may use chart reviews to increase risk adjusted payments inappropriately. Unsupported risk adjusted payments are a major driver of improper payments in the Medicare Advantage (MA) program, which provided coverage to 20 million beneficiaries in 2018 at a cost of $210 billion. CMS risk-adjusts payments using beneficiaries' diagnoses to pay higher capitated payments to MAOs for sicker beneficiaries?which may create financial incentives for MAOs to make beneficiaries appear as sick as possible. MAOs report these diagnoses via CMS's MA encounter data system based on services and chart reviews (i.e., MAO's reviews of a beneficiary's medical record to identify diagnoses that a provider did not submit or submitted in error). For a diagnosis to be eligible for risk adjustment, it must be documented in a medical record as a result of a face to face visit. Although CMS requires MAOs to identify chart reviews in the encounter data, CMS does not require MAOs to link these chart reviews to a specific service associated with the diagnoses. This may provide MAOs opportunities to circumvent CMS' face-to-face requirement and inflate risk adjusted payments inappropriately.

Due to the impact of first‑line supervisors on Postal Service operations, the OIG sought to gain an understanding of the structure, footprint within the organization, and investments made in first‑line supervisors. As such, key human capital and performance data related to first‑line supervisors was examined to assess patterns of historical performance, evaluate comparability across various categories, and identify relationships between first‑line supervisors and key performance metrics. This white paper provides the results of our assessment, including analyses of key operational, performance, and cost metrics that impact Postal Service operations.

During recent investigations into allegations of private companies (producers) accessing and producing unleased Federal minerals, we uncovered programmatic vulnerabilities that undermine the Bureau of Land Management’s (BLM’s) oversight of Federal mineral production and limit the U.S. Government’s ability to address mineral trespass violations.The BLM did not respond to producers’ proposed drilling plans and forced-pooling participation requests based on State forced-pooling statutes for proposed units containing unleased Federal minerals. Subsequently, the producers improperly proceeded with drilling operations and initiated production from the wells without first obtaining Federal leases, resulting in Federal mineral trespasses.Additionally, we learned that one BLM office waited years to refer mineral trespass matters to our office, and in a separate matter, U.S. Department of the Interior (DOI) personnel addressed trespass violations without a referral to our office.We make three recommendations to help the BLM avert future mineral trespass violations, improve compliance with the BLM’s mineral leasing process, and improve the Government’s ability to recover lost revenues that result from mineral trespass violations.