Federal Reports

The New Jersey Office of the State Comptroller, Medicaid Fraud Division, did not always suspend Medicaid payments to providers with credible allegations of fraud in accordance with the Affordable Care Act. Of the 49 providers with credible allegations of fraud that we reviewed, the Medicaid Fraud Division suspended or had good cause not to suspend Medicaid payments to 36 providers. However, it did not initiate proceedings to suspend Medicaid payments to the remaining 13 providers.

Some contract supplies in Round 2 of the Durable Medical Equipment Competitive Bidding Program had not met all of the competitive bidding licensure requirements. Specifically, of the 146 suppliers covered in our audit, 69 suppliers met licensure requirements. However, 63 suppliers did not meet licensure requirements for some of the competitions for which they received a contract. Additionally, 14 suppliers need to be further researched by CMS and its contractors to determine if they met or had not met licensure requirements.

A former AmeriCorps member submitted fraudulent claims for childcare benefits after ending her service. The United States Attorney’s Office declined criminal prosecution, and CNCS recouped $1,047 from the former member.

Precision Health, Inc., (Precision), (located in Staten Island, New York) complied with certain Medicare Part B requirements for 88 of the 117 claims that we sampled. However, the remaining 29 claims did not comply with certain Medicare requirements. On the basis of our sample results, we estimated that Precision improperly claimed at least $332,000 in Medicare reimbursement for unallowable portable x-ray services

The payments that Medicare contractors made to providers in Jurisdiction E (American Samoa, California, Guam, Hawaii, Nevada, and Northern Mariana Islands) and Jurisdiction F (Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming) for hospital outpatient dental services generally did not comply with Medicare requirements. Of the 100 dental services in our stratified random sample, 79 did not comply with Medicare requirements. Using our sample results, we estimated that Medicare contractors improperly paid providers in Jurisdictions E and F at least $818,000 from January 1, 2013, through December 31, 2014.

From October 1, 2009, through September 30, 2012, the Washington State Health Care Authority (State agency) claimed $117,000 in unallowable Federal Medicaid reimbursement for dental services. The unallowable payments consisted of (1) duplicate payments, (2) payments for services that were provided more frequently than State regulations allowed, and (3) payments for certain services that required prior authorization but for which the State agency did not have a record of providing authorization.

Blockchain technology is a new way to transfer any kind of data or information in a fast, tracked, and secure manner without need for an intermediary. Major companies, such as Citibank and Australia Post, are beginning to research and experiment with this technology in order to provide new and more efficient services. The Postal Service could benefit from use of this technology – particularly regarding financial services, identity services, supply chain management, and device management – and should consider exploring and experimenting with it.

This report addresses the status of the Census Bureau’s (the Bureau’s) 2020 decennial program preparation and planning efforts. The Bureau maintains all known living quarters in the Master Address File (MAF). Each address in the MAF is linked to a geographic location in the Topologically Integrated Geographic Encoding and Referencing database (TIGER), to create the MAF/TIGER database (MTdb). Our audit objectives were to (1) assess the methods and costs of continuously updating the MTdb; (2) determine how efforts, such as the 2015 Address Validation Test, support the accuracy of the MAF; and (3) evaluate the preparation of the Local Update of Census Addresses (LUCA) program for the 2020 decennial census. This report focuses on risks identified for objective 1. A report on objectives 2 and 3 was released on February 23, 2016.

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The lack of internal guidance and implementation of controls puts the U.S. Chemical Safety and Hazard Investigation Board's (CSB) $11 million budget at risk.

States can prevent inappropriate payments, protect beneficiaries, and reduce time-consuming and expensive "pay and chase" activities by ensuring that providers that intend to engage in fraudulent or abusive activities are not allowed to enroll in Medicaid. For States to identify potentially fraudulent providers, as well as those that may be associated with excluded individuals or entities, providers must disclose accurate and timely information about their owners (i.e., individuals or corporations with a 5 percent or more ownership or controlling interest; agents; or managing employees). According to CMS, the highest incidence of regulatory noncompliance among State Medicaid programs is in their collection of ownership information from providers.

CMS can prevent inappropriate payments, protect beneficiaries, and reduce time-consuming and expensive "pay and chase" activities by ensuring that providers that intend to engage in fraudulent or abusive activities are not allowed to enroll in Medicare. For CMS to identify potentially fraudulent providers, as well as those that may be associated with excluded individuals or entities, providers must disclose accurate and timely information about their owners (i.e., individuals or corporations with a 5 percent or more ownership or controlling interest; agents; or managing employees).

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.

The University has created the KY College of Optometry and their inaugural class starts in August 2016. The new College will complement the University's existing medical school.

Sea View Health Care Services, Inc., (the Agency) (located in Charlotte Amalie, on the island of St. Thomas, U.S. Virgin Islands) did not comply with Medicare billing requirements for 95 of the 166 starts-of-care (122 of the 253 home health claims) reviewed. On the basis of our sample results, we estimated that the Agency received net overpayments of at least $184,000 for calendar years 2012 and 2013.

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This Newsletter provides a bimonthly summary of selected investigative accomplishments.

The Administration for Children and Families awarded $235.4 million in Disaster Relief Act funding to New York State for Social Services Block Grant (SSBG) activities, including social, health, and mental health services for individuals and for the repair, renovation, and rebuilding of health care, mental health, and childcare facilities.

The National Institutes of Health awarded $299,000 to Columbia University (Columbia) to replace research resources lost or damaged by Hurricane Sandy. Columbia claimed allowable Hurricane Sandy Disaster Relief Act costs for the period January 31, 2014, through February 28, 2015. Accordingly, this report does not contain recommendations.

Wesley Medical Center (the Hospital) (operating in Wichita, Kansas) complied with Medicare billing requirements for 208 of the 246 inpatient and outpatient claims we reviewed. However, the Hospital did not fully comply with Medicare billing requirements for the remaining 38 claims, resulting in overpayments of $182,000 for calendar years 2012 and 2013. Specifically, 27 inpatient claims had billing errors, resulting in overpayments of over $92,000, and 11 outpatient claims had billing errors, resulting in overpayments of over $89,000. 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.

The Department of Health and Human Services (HHS) OIG is the designated Federal agency that oversees State Medicaid Fraud Control Units (MFCUs or Units). This MFCU Fiscal Year (FY) 2016 Annual Report highlights statistical achievements from the investigations and prosecutions the 50 MFCUs conducted for FYs 2012 through 2016. The report also identifies beneficial practices noted in OIG onsite review reports.

The audit assessed the effectiveness and adequacy of management controls in place for refiles of IRS records at six FRCs: Atlanta, Dayton, Kansas City, Kingsridge, Lee’s Summit, and Lenexa.

The New York State Department of Health used the correct Federal medical assistance percentages when processing Medicaid claim adjustments for both public and private providers during the period October 2008 through June 2011. Accordingly, this report contains no recommendations.

CIGNA Government Services, LLC, a subsidiary of CIGNA Corporation, claimed unallowable postretirement benefit costs of $281,000 for Medicare reimbursement for fiscal years 2004 through 2012.

More than half of the Medicaid payments that the State agency made to providers for full vials of Herceptin were incorrect. Of the 381 line items reviewed, 203 (53 percent) were incorrect and included overpayments of about $1 million ($710,000 Federal share), or almost a third of total dollars reviewed. The 178 remaining line items were correct.

Federal Trade Commission’s Fiscal Year 2015 Compliance with the Improper Payments Elimination and Recovery Act of 2010 in the Fiscal Year 2015 Annual Financial Report, No. AR-16-01

As required by the IPIA, as amended, we reviewed PBGC's compliance with IPIA’s requirements. The Corporation has taken action to comply with all applicable requirements established in OMB Circular A-123, Appendix C. We concur with PBGC's assessment that payments to Benefit Payments and Premium Refunds were not susceptible to significant improper payments. In addition, we found areas of opportunity for PBGC to improve their payment recapture audit program.

We performed a required review of USDA’s FY 2015 AFR and accompanying information to determine whether the agency was compliant with improper payment requirements.

Wireless Program Management

Audit of NLRB's FOIA office and non-career official involvement in the FOIA process.

This report contains classified information that is exempt from disclosure under the Freedom of Information Act. To obtain further information, please contact the OIG Office of Counsel at OIGCounsel@oig.treas.gov, (202) 927-0650, or by mail at Office of Treasury Inspector General, 1500 Pennsylvania Avenue, Washington DC 20220.