Federal Reports

EAC OIG, through an interagency agreement with the U.S. Postal Service OIG, conducted this audit to determine whether EAC's decision-making controls were properly designed, placed in operation, and operating effectively to provide reasonable assurance that key EAC decision-making policies met their objectives.

Kentucky did not always determine Medicaid eligibility in accordance with Federal and State requirements. For our sample of 120 beneficiaries, Kentucky correctly determined eligibility for 113 beneficiaries, but it did not meet Federal and State requirements for eligibility determinations of 7 beneficiaries. Specifically, Kentucky did not always maintain documentation supporting that it electronically or manually verified citizenship. In addition, although it did not violate an eligibility requirement, Kentucky did not perform or did not maintain documentation that it had performed identity-proofing for 13 beneficiaries in accordance with Federal requirements. The Federal identity-proofing requirements are intended to reduce the potential for identity theft.

OIG conducted a healthcare inspection in response to allegations from anonymous complainant(s) regarding the quality of care provided by a thoracic surgeon at the Bay Pines VA Healthcare System (system), Bay Pines, FL. We did not substantiate that the thoracic surgeon was incompetent. However, we identified a deficiency in the system’s process for evaluating surgeons’ competency. Contrary to VA policy, the criteria used in focused professional practice evaluations (FPPE) were not privilege-specific and inadequate to fully assess a provider’s skills. An August 2016 Deputy Under Secretary for Health for Operations and Management memorandum specified that as of August 2017, a provider with similar training and privileges should conduct ongoing professional practice evaluations (OPPE). The surgeon’s OPPE that we reviewed had been completed prior to the August 2016 DUSHOM memorandum and was done by an administrative psychiatrist.We did not substantiate that the surgeon had a high rate of complications. We did not identify specific quality of care concerns in the surgeon’s mortality cases we reviewed. The anonymous complainant(s) provided nine specific patient cases. We consulted with a thoracic surgeon who did not identify quality of care concerns for the nine patients. We also identified six deaths occurring within 30 days of a thoracic surgical procedure. We did not identify quality of care concerns with these cases. We substantiated that the thoracic surgeon requested the critical care team not care for his patients related to disagreements about fluid management. We determined that he had the authority to do so under the system’s policy.We could not substantiate that surgeons left the system because of quality of care concerns related to the thoracic surgeon, or that the Chief of Staff and/or System Director were aware of concerns regarding the thoracic surgeon’s competence yet failed to address them. We made two recommendations.