| Good morning to all from Washington, DC. Today OIG posts three 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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Spotlight On ... Bad Bargains for Federal Health Programs http://go.usa.gov/jPZA In a time of budget-cutting and fiscal crises, it's more important than ever to be sure that Federal money is put to good use. Yet according to a 2012 Institute of Medicine report, 30% of all U.S. health spending is wasted.
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The Centers for Medicare & Medicaid Services Awarded Consumer Operated and Oriented Plan Program Loans in Accordance With Federal Requirements, and Continued Oversight Is Needed (A-05-12-00043) http://go.usa.gov/jPZJ
Starting in 2013, individuals and small businesses will be able to enroll in private health insurance plans through State-based competitive marketplaces called Affordable Insurance Exchanges (marketplaces). To expand the number of health plans available in the marketplaces, the Patient Protection and Affordable Care Act (ACA) established the Consumer Operated and Oriented Plan (CO-OP) program and provided $6 billion in funding for the program. The ACA directed the Secretary of Health and Human Services to provide loans to help establish new consumer-governed, nonprofit health insurance issuers, referred to as CO-OPs, in every State.
We found that CMS awarded CO-OP loans to applicants in accordance with Federal requirements. However, we identified factors that may affect the CO-OP program. Specifically, we found that CO-OPs reported limited private support, and many CO-OPs’ budgeted startup expenditures exceeded available funding.
Private support is one of the three selection factors that the ACA specifies will have priority in the selection process; however, we saw little evidence of private monetary support in any of the 16 applications we reviewed. Additionally, 11 of 16 CO-OPs reported estimated startup expenditures in their applications that exceeded the total startup funding ultimately provided by CMS. There is a risk that CO OPs could exhaust all startup loan funding before they are fully operational or before they earn sufficient operating income to be self-supporting. This may affect the CO-OP program in the long term.
We recommended that CMS monitor (1) CO-OPs to ensure startup funds are not exhausted before the CO-OPs become fully operational and (2) CO-OPs’ solicitation of additional private monetary support. CMS concurred with our recommendations.
We issued a related report (OEI-01-12-00290) on July 17, 2013, that addresses CMS’s early implementation of the Consumer Operated and Oriented Plan loan program.
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The Southern African Catholic Bishops’ Conference AIDS Office Generally Managed President’s Emergency Plan for AIDS Relief Funds and Met Program Goals in Accordance With Award Requirements (A-05-12-00023) http://go.usa.gov/jPBY
Through its Global HIV/AIDS Program, CDC implemented the President's Emergency Plan for AIDS Relief (PEPFAR), working with ministries of health and other in-country partners to combat HIV/AIDS by strengthening health systems and building sustainable HIV/AIDS programs in more than 75 countries. Through a 5-year cooperative agreement, CDC awarded PEPFAR funds totaling $13 million to the Southern African Catholic Bishops’ Conference AIDS Office (SACBC) for the budget period June 1, 2009, through May 31, 2010.
SACBC generally managed PEPFAR funds and met program goals in accordance with award requirements. With respect to financial management, of the 33 financial transactions totaling $460,000 that we tested, 25 transactions totaling $442,000 were allowable, 6 transactions totaling $16,000 were unallowable, and 2 travel-related transactions totaling $3,000 were set aside because we were unable to determine whether the transactions were allowable. In addition, SACBC used $25,000 of PEPFAR funds to pay potentially unallowable value-added taxes (VAT) on purchases and did not submit the results of an annual financial audit to HHS’s National External Audit Review Center (NEAR) as required by the notice of award (NOA).
Our program management review found that, of the 32 accomplishments sampled from the annual progress report, 2 accomplishments were only partially met. The remaining 30 accomplishments were adequately supported. However, SACBC did not address two of the program goals from its application in the progress report, and the progress report was not submitted on time.
We recommended that SACBC (1) refund to CDC $16,000 of unallowable expenditures;
(2) work with CDC to determine the allowability of the $3,000 related to potentially unallowable travel expenses; (3) work with CDC to resolve whether the $25,000 of VAT was an allowable expenditure under the cooperative agreement; (4) develop and implement policies and procedures to ensure that expenditures reported under the cooperative agreement are allowable and that it maintains adequate supporting documentation; (5) develop and implement policies and procedures covering the overall process of collecting, verifying, summarizing, recording, and reporting performance information related to the cooperative agreement and the timely submission of the progress report to CDC; and (6) submit annual audit reports to NEAR in accordance with the NOA. SACBC generally concurred with our recommendations and described actions it has taken to address them.
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Medicare Compliance Review of Community Medical Center for Calendar Years 2010 and 2011 (A-07-12-01119) http://go.usa.gov/jPBw
Community Medical Center (Community) (operating in Montana) did not comply with Medicare billing requirements for all 57 of the outpatient claims with Lupron injections that we reviewed, resulting in overpayments totaling $158,000 for calendar years 2010 and 2011. Overpayments occurred primarily because Community did not have adequate controls to prevent incorrect billing of Medicare outpatient claims with Lupron injections.
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Wednesday, July 31, 2013; U.S. Attorney, District of Columbia
Former CEO/Owner of Home Health Care Provider Sentenced To Prison For Falsifying Records Involving a Federal Audit http://go.usa.gov/jPWd
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State Enforcement Actions Updated http://go.usa.gov/jPZ3
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