Federal Reports

Why OIG Did This AuditThe Medicare hospice benefit allows providers to claim Medicare reimbursement for hospice services provided to individuals with a life expectancy of 6 months or less who have elected hospice care. Previous OIG audits and evaluations found that Medicare inappropriately paid for hospice services that did not meet certain Medicare requirements.How OIG Did This AuditOur audit covered 6,142 claims for which Mission (located in San Mateo, California) received Medicare reimbursement of about $37 million for hospice services provided from October 1, 2015, through September 30, 2017. We reviewed a random sample of 100 claims. We evaluated compliance with selected Medicare billing requirements and submitted these sampled claims and the associated medical records to an independent medical review contractor to determine whether the services met coverage, medical necessity, and coding requirements.

A Clerk based in Bear, Delaware, was terminated on July 8, 2021, for failing to report his December 2020 arrest for drug-related charges. Company policy requires employees to notify the company as soon as practicable after an arrest, or within 48 hours after being released from incarceration. The employee’s disclosure occurred nearly six months later, and only after he was formally asked about the arrest during the course of our investigation.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations that Community Care consults were completed in June 2018 without scanning and attaching available clinical results to patients’ Veterans Health Administration (VHA) electronic health records (EHR). By completing these consults, view alerts were triggered but consult results were not available for review by ordering providers at the New Mexico VA Health Care System (facility). Additionally, it was alleged that Veterans Integrated Service Network 22 and facility leaders were aware of this practice and did not act..The OIG substantiated that in June 2018, Community Care nurses were completing consults without scanning and attaching clinical documentation to patients’ EHRs. Providers who received incorrect view alerts developed work-arounds to obtain information necessary to care for patients, and the OIG did not identify adverse clinical outcomes associated with the false view alerts for the patients reviewed.The OIG determined that Community Care nurses lacked a comprehensive orientation and training program. The Chief of Community Care did not verify adherence to consult-related VHA requirements or conduct regular reviews and improvements for departmental performance deficiencies. Additionally, Community Care performance monitoring addressed consult processes prior to patients receiving care but did not address the consult completion process or identify non-compliance with VHA policy prior to 2019.The OIG made five recommendations to the Facility Director related to the Community Care consult completion process, nursing competencies and training, Consult and Access Management Steering Committee oversight and monitoring, facility leaders’ oversight, and Community Care organizational structure and leaders’ expertise.

The OIG examined whether VA medical centers have adequate controls for, and provide sufficient oversight of, payments to affiliated nonprofit corporations. Under Intergovernmental Personnel Act agreements, VA reimburses nonprofit corporations for all or part of the salaries and associated costs for employees working on mutually beneficial research, education, and training activities.The OIG previously evaluated complaints involving nonprofit corporations affiliated with five VA medical centers. For this audit, the team added two medical centers in Albuquerque, New Mexico, and Palo Alto, California.The OIG estimated that the Albuquerque and Palo Alto medical centers made about $17.9 million in improper payments to affiliated nonprofit corporations. The reason for improper payments was the same for all seven VA medical centers reviewed. Specifically, procedures for approving invoices did not satisfy VA policy requirements because they did not require verification that the services were provided. The audit team also noted an absence of required periodic reviews by VA supervisors of approved invoices at all seven medical centers. Furthermore, triennial reviews by VA’s Nonprofit Program Office did not identify that the lack of evidence that services were provided was a problem.The OIG made three national recommendations. These included recommending that the assistant under secretary for health for discovery, education and affiliate networks establish procedures to ensure that (1) designated medical center staff verify that services invoiced by affiliated nonprofit corporations were provided before approving payment, and (2) Research and Development Budget Office supervisors conduct periodic reviews of invoices from VA affiliated nonprofit corporations that staff authorized for payment. The OIG also recommended that (3) the program office director add a step to the triennial review procedures to verify that nonprofits include evidence of providing services when they submit invoices to VA.