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OIG Posts HEAT PCT Videos / OIG Reports / State Enforcement Actions


Today OIG posts a new video and an audio podcast, “Tips for Implementing an Effective Compliance Program,” the seventh of 11 HEAT Provider Compliance Training video and audio presentations on top health care compliance topics.

This video and audio podcast describes six steps to implement and operate an effective compliance program in a health care entity. These steps cover

  1. Culture of compliance,
  2. Useful policies,
  3. Appropriate training,
  4. Effective communication,
  5. Corrective action plans, and
  6. Regular risk-based auditing.

You can view the PCT videos and an introductory video by the Inspector General, and listen to the podcasts at

PCT videos and audio podcasts will continue to be released at the beginning of each week over a 3-month period.

Add the New Compliance Training widget to your website or Facebook page! The Compliance Training widget, a sleek graphical image containing a hyperlink, can be posted to non-OIG Web sites, allow visitors easy access to OIG’s Provider Compliance Training materials. See

Also, OIG tweets about these videos and audio podcasts using the hashtag #OIGcompliance, which Twitter users are encouraged to include when tweeting about the presentations:

You can see the news release unveiling this series of videos and audio podcasts at

Review of Controls at SilverScript Insurance Company to Ensure Adherence to Formularies (A-07-11-06029)

Our review of SilverScript Insurance Company (SSIC), a Medicare Part D sponsor, found that SSIC's claims for prescription drug event data generally complied with Federal requirements regarding drugs that are provided to beneficiaries but that are not included in a sponsor's Part D plan formulary (non-formulary drugs). Based on our review of 100 claims, 1 claim was unallowable because the prescription was filled outside the allowable transition fill period. Because this is below the threshold of six errors needed for a statistical projection, we have no findings.

The Part D program allows Part D plan sponsors to choose whether or not they will use a formulary to administer their Part D plans. Sponsors that use a formulary must comply with certain statutory and regulatory requirements governing formulary operation. In certain circumstances, sponsors that use a formulary can submit claims for non-formulary drugs for Part D coverage. If these circumstances are not met, the Part D program does not permit reimbursement for these non-formulary drugs.

This report has no recommendations.

Review of Oklahoma Collections for the Medical Assistance Program for Calendar Years 2004 through 2009 (A-06-10-00057)

From January 1, 2004, through December 31, 2009, the State agency did not accurately report all of the collections on the CMS-64 reports. The State agency reported collections of $714.2 million ($492.2 million Federal share) but should have reported $729.6 million ($507 million Federal share). The State agency did not report collections of $15.4 million ($10.9 million Federal share) and underreported the Federal share of collections by $3.9 million.

Additionally, we set aside $435,000 in adjusted claims that the State agency could not support.

We recommended that the State agency

(1) Refund to the Federal Government $14.8 million;

(2) Work with CMS to determine what portion of the $435,000 in unsupported adjusted claims should be used to decrease medical assistance expenditures;

(3) Ensure that records supporting collections reported on the CMS-64 report are maintained and readily available; and

(4) Establish review procedures to ensure that collections are correctly compiled, assigned, and reported on the CMS-64 report.

The State agency agreed with three of the four recommendations but disagreed with our recommendation to work with CMS to determine what portion of the $435,000 in unsupported adjusted claims should be used to decrease medical assistance expenditures.

Review of Resident Data Reported in the Intern and Resident Information System for Medicare Cost Reports Submitted to Highmark Medicare Services, Inc. (A-02-09-01019)

Hospitals in Medicare Administrative Contractor (MAC) Jurisdiction 12 did not always claim Medicare graduate medical education (GME) reimbursement for residents in accordance with Federal requirements. Medicare makes two types of payments to teaching hospitals to support GME programs for physicians and other practitioners. Direct GME payments are Medicare's share of the direct costs of training interns and residents. Indirect GME payments cover the additional operating costs that teaching hospitals incur in treating inpatients.

We found that 66 hospitals overstated direct and/or indirect full-time equivalent (FTE) counts on cost reports covering fiscal years (FY) 2006 and 2007. As a result, 50 of those 66 hospitals received excess Medicare GME reimbursement totaling $1.9 million for residents who were claimed by more than 1 hospital for the same period and counted in the Intern and Resident Information System (IRIS) as more than 1 FTE. For the remaining 16 hospitals, the FTE overstatements did not have an effect on the hospitals' Medicare GME reimbursement.

The overstated FTE counts and excess reimbursement occurred because there was no Federal requirement for Highmark to review IRIS data that hospitals in MAC Jurisdiction 12 submitted to detect whether a resident had overlapping rotational assignments at more than one hospital. As a result, Highmark did not have procedures to adequately ensure that no resident was counted as more than one FTE in the calculation of Medicare GME payments.

We recommended that Highmark

(1) Recover $1.9 million in excess Medicare GME reimbursement paid to 50 hospitals in MAC Jurisdiction 12,

(2) Adjust the direct and indirect FTE counts claimed on the Medicare cost reports covering FYs 2006 and 2007 for each of the hospitals that did not always claim Medicare GME reimbursement in accordance with Federal requirements,

(3) Consider developing procedures to ensure that no resident is counted as more than 1 FTE in the calculation of Medicare GME payments, and

(4) Consider identifying and recovering any additional overpayments made to hospitals in MAC Jurisdiction 12 for residents whose FTE count exceeded 1 on Medicare cost reports submitted after FY 2007.

Highmark generally concurred with our first and second recommendations, partially concurred with our fourth recommendation, and disagreed with our third recommendation.

State Enforcement Actions Updated

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