(February 6, 2019) The Department of Health and Human Services (HHS), Office of Inspector General (OIG), didn’t skip a beat ringing in the new year. The OIG kept pursuing its goal of protecting the integrity of its federal health care programs and their respective patients. Several notable cases in which the OIG found inaccuracies or fraud are highlighted below:
(January 4, 2019). Oklahoma Assisted Living Facility Settles Case Involving an Excluded Individual.
An assisted living facility (ALF) in Owasso, Oklahoma agreed to pay the OIG more than $96,000. This action was taken due to the fact that the ALF improperly hired and excluded individual. Notably, the excluded individual was an “Admissions Specialist,” not a direct caregiver (such as a physician, nurse, medical assistant, etc.).This case aptly illustrates the importance of screening ALL employees, contractors, agents and vendors. As the OIG has previously noted, even volunteers must be screened.
(January 4, 2019). The State of Rhode Island Did Not Ensure Its Managed Care Organizations Complied with Requirements Prohibiting Medicaid Payments for Services Related to Provider-Preventable Conditions
Upon investigation, the OIG found that Rhode Island was not meeting certain requirements that had been set forth by the Federal and State government. Specifically, Rhode Island was not ensuring that its Medicaid managed-care organizations (MCO) prohibited Medicaid payments to providers for inpatient hospital services related to treating certain provider-preventable conditions (PPCs). For the audit period, OIG concluded that Rhode Island’s managed care organizations had paid providers around $4 million for almost 250 claims that all contained PPCs. As a result, the OIG made several recommendations to the state, three of which included:
“(1) work with the MCOs to determine the portion of the $4 million that was unallowable for claims containing PPCs and its impact on current and future capitation payment rates;
(2) include a clause in its managed-care contracts with the MCOs that would allow the State agency to recoup funds from the MCOs when contract provisions and Federal and State requirements are not met, thereby resulting in potential cost savings; and
(3) require the MCOs to implement internal controls to prohibit payments for inpatient hospital services related to treating PPCs, and other procedural recommendations.”[i]
Why should you care about this? It is important to keep in mind that the improper payments made by the state MCOs were being paid to providers for inpatient hospital services. In other words, enforcement rolls downhill. Providers that may be impacted by this report need to ensure that amounts paid by MCOs are, in fact, correct.
(January 10, 2019). State of Virginia Received Millions in Unallowable Bonus Payments
This past audit period, the State of Virginia received numerous bonus payments. However, in accordance with Federal requirements for CMS, some of these payments were in fact unallowable. The State of Virginia had overestimated its enrollments in its bonus requests for CMS from 2011-2013. This was due to inaccurate calculations which accounted for potential retroactive enrollment rather than their actual enrollment. Ultimately, the OIG has now recommended that the state pay back $13.8 million to CMS.
During the month of January, the OIG continued to take action against providers that have failed to perform their mandatory exclusion screening obligations. Frankly, the folks at Exclusion Screening have taken all of the guesswork out of these duties.
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Office of Inspector General. “Rhode Island Did Not Ensure Its Managed Care Organizations Complied With Requirements Prohibiting Medicaid Payments for Services Related to Provider-Preventable Conditions.”