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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
Federal Reports
Report Date
Agency Reviewed / Investigated
Report Title
Type
Location
Department of the Interior
Investigation of Reprisal at the BIA Southern Plains Region
Tufts Medical Center (Tufts) (operating in Boston, Massachusetts) complied with Medicare billing requirements for 4 of the 18 inpatient and outpatient claims we reviewed. However, Tufts did not fully comply with Medicare billing requirements for the remaining 14 claims, resulting in overpayments of at least $118,000 for calendar years 2011 through 2014. These errors occurred primarily because Tufts staff (1) had inadequate education on inpatient level-of-care criteria and lacked documentation necessary to determine the appropriate level of service and (2) lacked the level of oversight and the coordination between departments to correctly report the device credits it received for warranted or recalled medical devices.
Palmetto Government Benefits Administrator, LLC, and TrailBlazer Health Enterprises, LLC, Understated Their Medicare Segments' Pension Assets as of January 1, 2005
Palmetto Government Benefits Administrator, LLC, understated its Medicare segment pension assets by $2.2 million and TrailBlazer Health Enterprises, LLC, understated its Medicare segment pension assets by $180,000 as of January 1, 2005. Both Palmetto and TrailBlazer were subsidiaries of Blue Cross Blue Shield of South Carolina during our audit period.
Palmetto Government Benefits Administrator, LLC, a subsidiary of Blue Cross Blue Shield South Carolina, claimed unallowable pension costs of $132,000 for Medicare reimbursement for fiscal years 2003 and 2004.
TrailBlazer Health Enterprises, LLC, a subsidiary of Blue Cross Blue Shield South Carolina, claimed unallowable pension costs of $341,000 for Medicare reimbursement for fiscal years 2003 and 2004.
Improper payments to healthcare providers constitute a significant vulnerability for Medicaid, costing an estimated $17.5 billion in fiscal year 2014. Automated claims processing safeguards called "edits" are critical program integrity tools that are available to State Medicaid agencies to prevent these improper payments. The Affordable Care Act required all States to implement the Medicaid National Correct Coding Initiative (NCCI) edits by October 1, 2010. The NCCI edits are designed to encourage providers to code correctly by automatically denying fee-for-service Medicaid payments for services that do not meet basic medical or billing standards.
