Kusserow on Compliance: HHS OIG reports on identified improper payments

In its Semi-Annual Report for 2017, the OIG announced that improper payments reported in the HHS financial statements have demonstrated a steady increase over the last several years. In FY 2016, HHS reported estimated improper payments of more than $96 billion. During the first half of 2017, the OIG issued a number audits that identified improper payments for a variety of reasons.

Eligibility Determinations

  1. Express Lane Eligibility. Under the express lane eligibility option, which allows States to expedite and simplify enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) by relying on findings from other agencies’ eligibility determinations, the OIG estimated that improper Medicaid payments on behalf of potentially ineligible beneficiaries totaled $284.1 million. CHIP payments for potentially ineligible beneficiaries totaled $10.6
  2. Payments after death. Medicare and Medicaid continued to make improper payments on behalf of beneficiaries who are deceased. During this reporting period, the OIG found that Florida did not always stop making capitation payments to Medicaid managed care organizations (MCOs) after a beneficiary’s death, resulting in more than $26 million in
  3. Incarcerated beneficiaries. The OIG continued its work reviewing inappropriate payments for incarcerated beneficiaries, recently reporting that CMS has not taken steps to recoup $34 million in potentially improper payments made on behalf of incarcerated

Improper Payments for Medical Devices and Services

  1. Chiropractic Services. Based on the OIG’s sample results, the agency estimated that $358.8 million (82 percent) of $438.1 million paid by Medicare for chiropractic services was
  2. Room and Board Costs Associated with HCBS Waiver Program Payments. State Agencies claimed at least $176 million in unallowable Medicaid reimbursements for services under the HCBS waiver
  3. Cochlear Devices. Medicare spent $2.7 million inappropriately for cochlear devices (hearing aid devices) that were replaced without cost to the hospital or

The OIG also reported that it has a body of work looking at situations where providers billed for goods and services at higher rates than allowed by program regulations. In this reporting period, the OIG looked at how a hospital’s reporting of inaccurate wage data affected Medicare payments for hospital services.

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2017 Strategic Management Services, LLC. Published with permission.

Medicaid’s role in low income individuals access to mental health services

Medicaid plays a significant role in providing treatment for low income individuals with mental health conditions. Medicaid recipients usage of mental health services “is comparable to and sometimes greater” than usage among privately insured individuals, according to a Kaiser Family Foundation (KFF) analysis. In 2015, Medicaid covered 22 percent of nonelderly adults with mental illness and 26 percent of nonelderly adults with serious mental illness. KFF found that Medicaid coverage of mental health services is often more comprehensive than private insurance coverage.

Analysis Findings

The analysis (1) describes individuals with mental health conditions, and (2) compares the mental health needs and the receipt of services among individuals without insurance, with Medicaid, and with private insurance. KFF provided the following findings:

  • Characteristics of nonelderly adults with mental illness. Twenty percent of nonelderly adults have a mental illness. They are predominantly white, female, and under 50. Five percent have a serious mental illness. Most are employed (63 percent), but 4 in ten have low incomes and 22 percent are below poverty. In addition, nonelderly adults with mental illness often have co-morbid conditions.
  • Utilization of mental health services. Most nonelderly adults with mental illness have either Medicaid or private insurance. Those with Medicaid are more likely to receive treatment than those with private insurance or without insurance. In addition, the receipt of psychiatric medication is more common among those individuals covered by Medicaid.

The role of Medicaid expansion

The Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148) and the Health Care and Education Reconciliation Act of 2010 (HCERA) (P.L. 111-152), (together referred to as the Affordable Care Act (ACA)) expanded Medicaid coverage to millions of low-income Americans. Sections 2001 and 2002 of the PPACA as amended by 1004 and 1201 of HCERA enabled many low-income individuals with mental health conditions to obtain coverage and access treatment through state Medicaid programs that choose to expand.

KFF pointed out that the American Health Care Act of 2017 (AHCA) (H.R. 1628), introduced by Republicans and passed by the House of Representatives on May 4, 2017 would limit enhanced federal support for the expansion population. The Congressional Budget Office projected that the reduction in federal funds would result in a cut of $834 billion over 10 years. “A reduction in federal funds of this magnitude would likely cause states to decrease Medicaid payment rates, covered services, and/or eligibility, limiting states’ ability to reach people with mental health conditions,” KFF said.

Kusserow on Compliance: Summary of OIG fraud and abuse actions first half of 2017

The HHS OIG issued their Semi-Annual report for first half of fiscal year (FY) 2017 and summarized key accomplishments, significant problems, abuses, deficiencies, and investigative outcomes relating to the administration of HHS programs and operations that were disclosed during the reporting period. The following summarizes reported statistical accomplishments.

Criminal Actions (468). OIG reported 468 criminal actions against individuals or entities that engaged in crimes against HHS programs and 461 civil actions, which include false claims and unjust-enrichment lawsuits filed in Federal district court, civil monetary penalties (CMP) settlements, and administrative recoveries related to provider self-disclosure matters.  During the first half of FY 2017, OIG reported expected investigative recoveries of over $2.04 billion.

Health Care Strike Force (152 Criminal Actions). The Health Care Fraud Strike Force teams brought charges against 45 individuals or entities, 152 criminal actions, and $267 million in recoveries through investigations.

State Medicaid Fraud Control Units (MFCUs) (1,564 Criminal Actions).  The OIG has oversight responsibility for MFCUs and administers grants that provide federal funding for their operations. There are 50 MFCUs (in 49 States and the District of Columbia) totaled almost $259 million. The MFCUs employed 1,965 individuals. MFCUs reported 18,730 investigations, of which 15,509 were related to Medicaid fraud and 3,221 were related to patient abuse and neglect, including misappropriation of patients’ private funds. The cases resulted in criminal charges or indictments involving 1,721 individuals, including 1,249 for fraud and 472 for patient abuse and neglect. In total, 1,564 convictions were reported in FY 2016, of which 1,160 were related to Medicaid fraud and 404 were related to patient abuse and neglect. Civil judgments and settlements for FY 2016 totaled 998, and monetary recoveries in civil cases totaled over $1.5 billion. During this reporting period, OIG special agents partnered with MFCUs in conducting joint investigations on 714 criminal cases.

Program Exclusions (1,422). During this semiannual reporting period, OIG excluded 1,422 individuals and entities from Medicare, Medicaid, and other federal health care programs. Most of the exclusions resulted from convictions for crimes relating to Medicare or Medicaid, for patient abuse or neglect, or as a result of license revocation. OIG is also responsible for reinstating providers who apply and have met the requirements of their exclusions.

Sanction Authorities and Other Administrative Actions (1,504).  OIG sanctions include the exclusion of individuals and entities from federal health care programs and the imposition of CMPs for submitting false and fraudulent claims to a federal health care program or for violating the Anti-kickback statute, the Stark law, or the Emergency Medical Treatment and Labor Act (EMTALA), also known as the patient dumping statute. During this semiannual reporting period, OIG imposed 1,504 administrative sanctions in the form of program exclusions or administrative actions for alleged fraud or abuse or other activities that posed a risk to federal health care programs and their beneficiaries.

Civil Monetary Penalties Law (CMPL) ($26 million0. The CMPL authorizes OIG to impose administrative penalties on and assessments against a person who, among other things, submits, or causes to be submitted, claims to a federal health care program that the person knows, or should know, are false or fraudulent. In addition to administrative penalties and assessments, OIG can also exclude individuals for engaging in conduct prohibited by the CMPL. During this semiannual reporting period, OIG concluded cases involving more than $26.3 million in CMPs and assessments.

Self-Disclosure Programs ($23 million). Health care providers, suppliers, or other individuals or entities subject to CMPs can apply for acceptance into the Provider Self-Disclosure Protocol, a program created in 1998, to voluntarily disclose self-discovered evidence of potential fraud. During this semiannual reporting period, self-disclosure cases resulted in more than $23 million in HHS receivables.

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2017 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: OIG issues detailed report on state Medicaid Fraud Control Units

1,564 Criminal Convictions

1,000 Civil Settlements

Almost $2 billion in recoveries

The OIG Office of Evaluation and Inspection (OEI) issued a more detailed analysis of statistical results from the State Medicaid Fraud Control Units (MFCUs) for 2016. The OIG is the designated Federal agency that oversees them and has been instrumental in establishing the Units.  As Inspector General, I worked to establish a number of these MFCUs that currently operate in 49 States and the District of Columbia (States). Once established the OIG administers a grant to each of the units that provides 75 percent of their funding and set performance standards, reviews each state’s program, provides technical assistance identify best practices, and collect and analyze statistics. The mission of MFCUs is to investigate and prosecute, under State law, Medicaid provider fraud and patient abuse or neglect. In FY 2016, the OIG reported 1,564 convictions, over one-third of which involved personal care services attendants. The OIG reported nearly 1,000 civil settlements and judgments, with settlements with pharmaceutical manufacturers making up almost half of settlements; along with almost $1.9 billion in criminal and civil recoveries. The OIG works often with the MFCUs and in 2016 the OIG Medicaid cases resulted in 312 indictments, 348 criminal actions, and 222 civil actions. These Medicaid cases—some of which also involved Medicare—resulted in almost $3 billion dollars in expected recoveries. However, in most cases the MFCUs work their own cases without assistance from other agencies.

It is noteworthy that current funding for Medicaid fraud control is at a higher level than for the federally funded and administered Medicare program. Medicaid annual expenditures exceed $500 billion dollars and funding for the MFCUs was also at a high level of $258,698,147 in 2016.  The staffing level of investigators, auditors, and attorneys was 1,965. Those entities investigated 15,505 fraud cases and another 3,221 abuse and neglect cases. The largest category of convictions involved personal care services (PCS) (35 percent). Nursing care came in second (11 percent) and involved of licensed practical nurses (LPN), registered nurses (RN), physician assistants (PA), or nurse practitioners (NP). Convictions of nurse-aides represented the third largest category (10 percent).

In this report, the OIG provided a detailed breakdown of the types of cases and trending data. Statistical results by state are included in the OIG Report.  Comparison of results to the prior year can be made by referring to the OIG issued report for 2015 that noted MFCUs achieving 1,553 convictions, 731 civil settlements and judgments, and $744 million in criminal and civil recoveries.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on
Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2017 Strategic Management Services, LLC. Published with permission.