From: HHS Office of Inspector General <donotreply@subscriptions.hhs.gov>
Date: Fri, Jul 25, 2014 at 6:31 AM
Subject: OIG posts 3 reports and news about enforcement actions - 7/25
To: iammejtm@gmail.com
Good morning from Washington, DC. Today OIG posts 3 reports and news about enforcement actions. As always, you can use the links provided to go directly to the new material.
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The Medicare Contractor for Jurisdiction 14 Overpaid Providers for Selected Outpatient Drugs (A-01-13-00504) http://go.usa.gov/5vbC
Payments that the Medicare contractor for Jurisdiction 14 made to providers for 295 of the 779 line items for outpatient drugs we reviewed were not correct. These incorrect payments resulted in overpayments of $1.3 million and underpayments of $5,000 that the providers had not identified, refunded, or adjusted by the beginning of our audit. Before our fieldwork, providers refunded $206,000 of overpayments for another 53 line items. The remaining 431 line items were correct.
For the 290 incorrect line items with overpayments of $1.3 million that had not been refunded, providers reported incorrect units of service, did not provide supporting documentation, used incorrect HCPCS codes, reported a combination of incorrect units of service and incorrect HCPCS codes, billed separately for an outpatient drug for which payment was packaged with the primary service, and billed for a noncovered use of a drug. For the five incorrect line items with underpayments of $5,000 that had not been adjusted, we notified the providers of the underpayments so that they could submit adjustment claims.
Providers attributed the incorrect billings to clerical errors and to provider billing systems that could not prevent or detect the incorrect billing of outpatient drug services. The Medicare contractor overpaid these providers because there were insufficient edits in place to prevent or detect overpayments.
We recommend that National Government Services, Inc. (NGS), the Medicare contractor: (1) Recover the $1.3 million in identified overpayments, (2) Verify the payment of $5,000 in identified underpayments, and (3) Use the results of this audit in its ongoing provider education activities.
NGS stated that it would review the line items paid in error to adjust and recover any overpayments and verify the underpayments. NGS said that it had conducted educational sessions with providers and that it would enhance its educational materials as needed based on the results of this review.
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Medicare Compliance Review of Good Samaritan Hospital for Calendar Years 2010 and 2011 (A-09-13-02008) http://go.usa.gov/5vjA
Good Samaritan Hospital (the Hospital), located in Los Angeles, California, complied with Medicare billing requirements for 48 of the 132 inpatient and outpatient claims we reviewed. However, the Hospital did not fully comply with Medicare billing requirements for the remaining 84 claims, resulting in overpayments of $904,000 for calendar years 2010 and 2011. These overpayments occurred primarily because the Hospital did not have adequate controls to prevent the incorrect billing of Medicare claims within the selected risk areas that contained errors.
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The Medicare Contractor for Jurisdiction 13 Overpaid Providers for Selected Outpatient Drugs (A-02-13-01011) http://go.usa.gov/5vbW
Payments that the Medicare contractor for Jurisdiction 13 made to providers for 667 of the 1,138 line items for outpatient drugs we reviewed were not correct. These incorrect payments resulted in overpayments of $2.7 million and underpayments of $1,700 that the providers had not identified, refunded, or adjusted by the beginning of our audit. Before our fieldwork, providers had refunded $127,000 of overpayments for another 30 line items. The remaining 441 line items were correct.
For the 665 incorrect line items with overpayments of $2.7 million that had not been refunded, providers reported incorrect units of service, did not provide supporting documentation, reported a combination of incorrect units of service and incorrect HCPCS codes, used incorrect HCPCS codes, and billed for noncovered use of a drug. For the two incorrect line items with underpayments of $1,700 that had not been adjusted, we notified the providers of the underpayments so that they could decide whether to submit adjustment claims. One provider also identified 13 additional line items that we did not review that resulted in overpayments of $27,000.
Providers attributed the incorrect billings to clerical errors and to provider billing systems that could not prevent or detect the incorrect billing of outpatient drug services. The Medicare contractor overpaid these providers because there were insufficient edits in place to prevent or detect the overpayments.
We recommend that National Government Services (NGS), the Medicare contractor for Jurisdiction 13:
(1) Recover the $2.7 million in identified overpayments,
(2) Verify the payment of $1,700 in identified underpayments,
(3) Verify the recovery of $27,000 in additional provider-identified overpayments, and
(4) Use the results of this audit in its ongoing provider education activities.
NGS agreed with our first, second, and fourth recommendations and described actions that it planned to take to address these recommendations. Regarding our third recommendation, NGS asked us for specific claims information, which we provided.
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July 24, 2014; Office of Inspector General; U.S. Department of Health and Human Services Tennessee Senior Living Community Chain Settles Case Involving Allegations of Employing Excluded Individuals http://go.usa.gov/5vTz
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July 24, 2014; U.S. Attorney; Eastern District of Texas Texas Doctor Convicted of Health Care Fraud Violations http://go.usa.gov/9SrT
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July 24, 2014; U.S. Attorney; Eastern District of Virginia Hacker Charged with Breaching Multiple Government Computers and Stealing Thousands of Employee and Financial Records http://go.usa.gov/9SrT
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July 24, 2014; U.S. Attorney; District of South Dakota Four Individuals Sentenced In Federal Program Fraud Case http://go.usa.gov/9SrT
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July 24, 2014; U.S. Attorney; Southern District of Illinois U.S. Seniors Deceived by Foreign Scammers in Medicare Hoax http://go.usa.gov/9SrT
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July 24, 2014; U.S. Attorney; Southern District of Florida Palm Beach County Brothers and Company Sentenced in $4 million "Cash Back" Food Stamp Fraud Scheme http://go.usa.gov/9SrT
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State Enforcement Actions Updated http://go.usa.gov/9Srm
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That's all we have for today. If we can be of any further assistance, please send an Email to public.affairs@oig.hhs.gov
I hope your week has gone well and you are able to enjoy the upcoming weekend.
Marc Wolfson – Office of External Affairs
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Jeremy Tobias Matthews
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