Federal Reports

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OIG conducted a healthcare inspection to assess allegations made regarding patient flow and quality of care in the Emergency Department (ED) at the Baltimore VA Medical Center (facility), part of the VA Maryland Health Care System (system). We substantiated patients remained in the ED for more than 4 hours while waiting for an inpatient bed, and found the median ED length of stay (LOS) for admitted patients, the delay in inpatient admission, and the percentage of patients boarded exceeded Veterans Health Administration (VHA) targets and thresholds during the period October 2013–December 2016. We did not identify patients who were clinically impacted by delays. We found that the accuracy of the ED metrics could be compromised when a provider encountered challenges using Emergency Department Integration Software (EDIS). We found that system policy did not include the maximum number of ED boarders as required by VHA. We found that staff failed to consistently utilize the Bed Management Solution software. We also found that Environmental Management Services staff schedules and cleaning processes were inadequate to support the patient flow process. We found that Patient Flow Committee members did not take adequate action to improve patient flow. We substantiated the system’s capping practice may limit the number of patients the admitting teams can treat and that facility managers had not established alternative processes to improve patient flow. Although we substantiated that on a day in 2015, ED patients waited extended times, we found no reports of adverse patient events. We substantiated that inpatient nurses were sometimes unavailable to receive the handoff report from ED nurses. We substantiated that the ED administrative support staffing level was not compliant with the VHA requirement. Further, we found that the lack of timely after-hours coverage of computerized tomography scan services contributed to the extended LOS for some ED patients. We made 11 recommendations.

In December 2016, OIG evaluated the Louisville VA Regional Office (VARO) to determine how well Veterans Service Center (VSC) staff processed disability claims, how timely and accurately they processed proposed rating reductions, how accurately they input claims-related information, and how well VARO staff responded to special controlled correspondence. Staff did not consistently process one of the two types of disability claims we reviewed. OIG reviewed 30 veterans’ traumatic brain injury claims and found staff accurately processed all 30 claims. OIG reviewed 30 special monthly compensation (SMC) benefits claims and found that a Rating Quality Review Specialist and Rating Veterans Service Representatives incorrectly processed 11 claims due to ineffective training and weaknesses in the VSC’s second signature review process. Overall, VSC staff incorrectly processed 11 of the 60 disability claims OIG reviewed—resulting in 160 improper payments to 9 veterans totaling approximately $146,000. OIG reviewed 30 rating reductions cases and found that staff delayed 13 cases because staff placed higher priority on other workloads. This resulted in 128 improper monthly payments, representing approximately $140,000 in overpayments. OIG reviewed 30 newly established claims and found staff did not correctly input claim and claimant information into the electronic systems for 14 claims generally because staff were unaware of Veteran Benefits Administration policies. The VARO did not process any special controlled correspondence within the scope of our inspection. Therefore, we were unable to assess VARO staff’s effectiveness in this area. OIG recommended the Louisville VARO Director develop a plan to monitor the effectiveness of training, strengthen oversight, and assess the accuracy of secondary reviews involving higher-level SMC; ensure oversight of proposed rating reduction cases; and provide training for claims establishment procedures. The VARO Director concurred with our recommendations; planned corrective actions are responsive.

Our objective was to review the accuracy and completeness of the Commission’s reporting, as well as agency performance in reducing and recapturing improper payments, if applicable. Overall, we found that the Denali Commission met the applicable OMB criteria for compliance with IPIA, as amended, for FY 2016.

Medicare Part B provides for the coverage of outpatient therapy services, including occupational, physical, and speech therapy. Previous OIG reports identified unallowable claims for these services. Fox Rehabilitation (Fox), headquartered in New Jersey, was among the largest providers of outpatient therapy services in the country. Our objective was to determine whether claims for outpatient therapy services provided in New Jersey and submitted for Medicare reimbursement by Fox complied with Medicare requirements.

Accredo Health Group, Inc. (which is located in Memphis, Tennessee, and has pharmacies across the United States) complied with Medicare requirements when billing for inhalation drugs. Specifically, all 100 claim lines in our sample complied with the requirements. Consequently, this report has no recommendations.