Federal Reports

The Centers for Medicare & Medicaid Services administers the Medicare program, which includes coverage for hospital outpatient services under Part B. Under the outpatient prospective payment system, Medicare pays for hospital outpatient services on a rate-per-service basis that varies according to the assigned ambulatory payment classification. Healthcare Common Procedure Coding System codes and descriptors are used to identify and group the services within each ambulatory payment classification group. Outpatient prospective payment system provides outlier payments to hospitals to help mitigate the financial risk associated with high-cost and complex procedures, when a very costly service could present a hospital with significant financial loss. A service or group of services becomes eligible for outlier payments when the cost of the service or group of services estimated using the hospital’s most recent overall cost-to-charge ratio separately exceeds each relevant threshold. Medicare payments may not be made for items or services that “are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” Providers must furnish to the Medicare contractor sufficient information to determine whether payment is due and the amount of the payment. Upon receiving credible information of potential overpayments, providers must exercise reasonable diligence to identify overpayments (i.e., determine receipt of and quantify any overpayments) during a 6-year lookback period. Providers must report and return any identified overpayments by the later of (1) 60 days after identifying those overpayments or (2) the date that any corresponding cost report is due (if applicable). This is known as the 60-day rule. The 6-year lookback period is not limited by Office of Inspector General’s audit period or restrictions on the Government’s ability to reopen claims or cost reports. To report and return overpayments under the 60-day rule, providers can request the reopening of initial claims determinations, submit amended cost reports, or use any other appropriate reporting process. Each facility should have an established charge structure which is applied uniformly to each patient as services are furnished to the patient and which is reasonably and consistently related to the cost of providing the services. While the Medicare program cannot dictate to a provider what its charges or charge structure may be, the program may determine whether or not the charges are allowable for use in apportioning costs under the program. To promote correct coding by providers and to prevent Medicare payments for improperly coded services, Centers for Medicare & Medicaid Services developed the National Correct Coding Initiative. Medicare Administrative Contractors implemented National Correct Coding Initiative edits within their claim processing systems for dates of service on or after January 1, 1996. The National Correct Coding Initiative edits include procedure-to-procedure edits that define pairs of Healthcare Common Procedure Coding System codes and current procedural terminology codes (i.e., code pairs) that generally should not be reported together for the same beneficiary on the same date of service. Baylor Scott & White-College Station is a 142-bed acute care hospital, located in College Station, Texas. The hospital originally opened in 2013 and subsequently in 2013 merged with Baylor Health Care System.

The Office of the Inspector General conducted a review of the Watts Bar Nuclear Plant (WBN) Chemistry/Environmental (Chemistry) organization to identify factors that could impact WBN Chemistry’s organizational effectiveness. Our report identified behavioral risks that could have a negative impact on WBN Chemistry’s effectiveness, including those related to (1) interactions with certain management and (2) relationships between employees. We also identified operational risks that could hinder WBN Chemistry’s ability to execute its responsibilities and support Nuclear’s vision and core principles. These risks were comprised of (1) perceptions of inadequate qualified and/or experienced technicians and turnover in Nuclear Chemistry and (2) concerns with the technician training program. In addition, based on feedback received from other WBN organizations, we corroborated concerns about WBN Chemistry’s staffing and personnel knowledge.

We audited Mid America Mortgage’s, dba 1st Tribal Lending’s, Section 184 Indian Home Loan Guarantee program based on a previous U.S. Department of Housing and Urban Development (HUD), Office of Inspector General, audit and corrective action verification of the Section 184 program, which determined that HUD lacked proper oversight of the program and lenders did not always underwrite loans in accordance with HUD’s requirements. The lender was selected because it is the largest Section 184 program lender. Our audit objective was to determine whether the lender underwrote Section 184 loans in accordance with HUD’s requirements.The lender did not always follow HUD’s Section 184 program requirements. Specifically, it did not always (1) underwrite Section 184 loans in accordance with program requirements and (2) follow HUD’s quality control requirements when reviewing loan files. This condition occurred because the lender did not always exercise due diligence when underwriting loans and did not strictly follow HUD’s underwriting and quality control requirements. As a result, there was an increased risk to the Section 184 program and HUD’s Loan Guarantee Fund. There were 11 loans with material underwriting deficiencies and we recommend indemnification for 7 of these loans. The seven loans had a total unpaid mortgage balance of $1.3 million with an estimated potential loss to HUD of $607,598.We recommend that the Deputy Assistant Secretary for Native American Programs (1) request indemnification for 7 of the 11 loans that had material underwriting deficiencies and had an unpaid mortgage balance of $1.3 million with an estimated potential loss to HUD of $607,598, (2) require the lender to develop and implement enhanced policies and procedures to ensure electronic signatures from borrowers are properly supported, and (3) require the lender to fully implement its quality control plan with respect to reverifications and provide HUD with periodic reports for 12 months to ensure that its quality control reviews are conducted in accordance with the 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.Our objective was to determine whether Hawaii’s monitoring of child care providers ensured provider compliance with State requirements related to criminal background checks established under the CCDBG Act.

The Federal Emergency Management Agency (FEMA) is not adequately managing severe repetitive loss (SRL) properties covered by the National Flood Insurance Program (NFIP). FEMA has not established an effective program to reduce or eliminate damage to SRL properties and disruption to life caused by the repeated flooding. Primarily, FEMA does not have reliable, accurate information about SRL properties. Secondly, FEMA’s Flood Mitigation Assistance (FMA) program, which aims to mitigate flood damage for NFIP policyholders, provides neither equitable nor timely relief for SRL applicants. We made three recommendations to FEMA to ensure the accuracy of the SRL list, as well as equitable and timely distribution of mitigation funding, and promoting the use of National Flood Insurance Program (NFIP) Increased Cost of Compliance coverage. FEMA concurred with all three of the recommendations