Evaluation of the effectiveness of the Operation Restore Trust demonstration : appendixes to the final report

184 Pages·1997·9.2 MB·English

by  United States. Health Care Financing Administration

.
Evaluation ofthe
Effectivenessof
the Operation
Abt Restore Trust
Demonstration
AbtAssociatesInc.
Contract No.
500-92-0014
55WheelerStreet
Cambridge,Massachusetts
02138-1168 Appendixes to
617492-7100telephone the Final Report
617492-5219/flfw«/Vf
Appendix1:ORTRegions&.
ComparisonSlates
HampdenSquare,Suite500 Appendix2:Administration
4800MontgomeryLane onAging
Bethesda,Maryland Appendix3:ContractorCase
20814-5541 Studies
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December 22, 1997
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Table of Contents
Appendix1: ReviewoftheORTRegionsandComparisonStates 1-]
1.1 O1.v1e.1rviewThoefEAcmtpihvaitsiiessoinntChoellOaRboTraSttiaotnes I1-.]3
1.1.2 ORTActivitiesRelatedtoHomeHealthAgencies 1-9
1.1.3 ORTActivitiesRelatedtoSkilledNursingFacilities 1-13
1.1.4 ORTActivitiesRelatedtoDurableMedicalEquipment 1-15
1.1.5 ORTActivitiesRelatedtoHospices 1-17
1.1.6 OEIStudies 1.19
1.1.7 PolicyInitiatives 1-21
1.2 California 1.25
1.2.1 Overview ].25
1.2.2 ReviewofHomeHealthProjects 1-28
1.2.3 Ollnvestigations 1-38
1.2.4 NursingFacilitiesProjects 1-40
1.2.5 HCFADataAnalysisandWorkwiththePartBCarrier 1-42
1.2.6 OutreachProjects 1-44
1.2.7 DMEOversightandCoordinationActivities 1-46
1.2.8 TheOIGHotline 1-47
1.3 Florida |.48
1.3.1 Overview |.48
1.3.2 ExpandedAuditsofHomeHealthAgencies 1-49
1.3.3 ReviewsofSkilledNursingFacilities i-51
1.3.4 HHAStudies 1-51
1.3.5 PolicyChangesConcerningDMEProviderNumbers 1-53
1.3.6 OutreachActivities I.54
1.3.7 InvestigationofSt.John'sHomeHealthAgency 1-55
1.3.8 IndependentPhysiologicalLaboratones 1-55
1.3.9 DMEInvestigations 1-56
1.3.10 The"MedicallyUnbelievable"Screen 1-56
1.3.!I PolicyChangeRelatedtoCompoundingof.Medications 1-57
1.3.12 OtherActivities I.57
1.4 Illinois 1.58
14.1 Overview I.58
1.4.2 OIGORTProjects 1-59
1.4.3 OtherORTProjects/InitiativesoftheOIG 1-64
1.4.4 HCFAORTActivities 1-65
1.4.5 AdministrationonAging(AoA)ChicagoROORTProjects 1-69
1.5 New^'ork 1-71
15.1 Overview I.7I
1.5.2 SharingofDataonDurableMedicalEquipmentClaims 1-72
1.5.3 ClaimsforPortablyX-RayServices 1-73
1.5.4 InvestigationsofDMESuppliersandOtherProviders 1-73
1.5.5 TrainingoftheAgingNetwork 1-74
1.5.6 SurveysofSkilledNursingFacilities 1-75
1.5.7 AuditofHomeHealthAgencyCostReport 1-76
1.5.8 AnalysisofMedicaidClaimsforServicestoNursingHomeResidents 1-77
1.5.9 MentalHealthServicesinNursingFacilities i-78
1.5.10 CarePlanOversight 1-79
1.5.11 SurveysofHomeHealthAgencies 1-80
1.5.12 AuditsofHomeHealthAgencies 1-80
1.5.13 StudyofDischargePlanning 1-81
1.6 Texas 1-81
1.6.1 Overview 1-81
1.6.2 01InitiativesinTexas 1-82
1.6.3 OEIProjectsinTexas 1-84
1.6.4 OASProjectsinTexas 1-89
1.6.5 HCFAProjects/InitiativesinTexas 1-92
1.6.6 AdministrationonAging(AoA)Projects/ActivitiesinTexas 1-97
1.7 Boston 1-100
1.7.1 Overview 1-100
1.7.2 MajorFindings 1-100
1.7.3 SpecificFindingsattheAgency/ComponentLevel 1-103
1.8 Philadelphia 1-105
1.8.1 Overview 1-105
1.8.2 MajorFindings 1-106
1.8.3 SpecificFindingsattheAgency/ComponentLevel 1-107
Appendi.x2: OutreachtotheAgingNetworkandtoBeneficiaries 2-1
2.0 Overview 2-1
2.1 BroadeningtheResponsibilityforAnti-FraudEfforts 2-1
2.2 TrainingtheAgingNetwork 2-3
2.3 OutreachtotheBeneficiar>Community 2-5
Appendix3: ContractorCaseStudies 3-1
3.0 Overview 3-1
3.1 MethodologyofContractorCaseStudies 3-1
3.LI FirstWaveMethodology 3-1
3.1.2SecondWaveCaseStudyMethodology 3-4
3.2 FindingsFromtheFirstWaveofCaseStudies 3-5
3.2.1 Cross-ContractorResponsestoGeneralQuestionsAboutORTand
ManagementSystems 3-5
3.2.2ORT-RelatedProjects/ActivitiesofContractors 3-7
3.3 FindingsFromSecondWave—CaseStudies 3-12
3.3.1 SanFranciscoRegion TransainericaOccidentalLifeInsurance
Company(TOLIC) 3-12
3.3.2DallasRegion—BlueCrossandBlueShieldofTe.\as(BCBSTX) 3-22
3.3.3Conclusion -'"-8
3.4 AnalysisofContractorCaseRecordDatafromHCFA'sFraudInvestigation
Database(FID) ^-^^
3.4.1 Introduction -'"-3'
3.4.2AnalysisofSummary-LevelFIDData 3-33
3.4.3Conclusion 3-45
Appendix4: TheInteractionofOperationRestoreTrustandtheDepartmentofJustice 4-1
4.1 Overview
4.2 TheRolesoftheTwoDepartments -^-1
4.2.1 Investigations
4.2.2 ThePursuitofSanctions
4.3 ChangesinHealthCareFraudInvestigationinRecent^ears 4-2
4.4 ChangesintheU.S.Attorney'sOfficesinRecent'lears -1-3
Appendix 1
Review ofthe ORT Regions and Comparison States
1.1 OverviewofActivitiesintheORTStates
Operation Restore Trust was a national program designed to give the five demonstration states
considerableleewayinhowtheyundertookORTactivities. Accordingly,ORTactivitieshavemany
sdiemsiclrairbietitehseaancdtivmiatineysidnifefaecrhencsteast,e,wfhoilclhowaerdebthyeasduibsjceucstsoifonthoifstsheectdiiofnf.ereInncethsebfeotlwleoewnintgheseOctRiTonss,tawtees
andtwoDepartmentofHealthandHumanServicesregionalofficesthatwerenotaffectedbyOperation
RestoreTrust.
Exhibit1-1isanattempttocategonzethemyriadactivitiesthattookplaceovertwoyearsinthefiveORT
states.Itisanover-generalization,tobesure,butitisdesignedtohighlightthedifferencesandsimilanties
intheORTactivities. Italsoisanattempttoputtheseactivitiesinperspective. Eachactivityis
categorizedas"smaller,""medium"or"largef'onthreecriteria:
• ORTinfluence. AlmostalltheactivitiesshowninthetablewerecarriedoutbeforeORT
beganandarestillbeingcarriedoutnowthatORTisover. Forsomeactivities,however.
ORTmadeamajordifferenceinhowtheywerecarriedoutwhileforotheractivitiestheeffect
ofORTwasminimal.
• Requiredresources. SomeORTactivitiesrequiredamajorcommitmentofresources,by
whichwemeannotonlythe"ORTbudget"butalsothetimeofpersonnelfromfederaland
stateagenciesandMedicarecontractors. Thetotalresourcecostofsomeoftheactivities,
suchastheHHAaudits,wascertainlyinthehundredsofthousandsofdollars,andpossibly
more.
• Likelyimpact. TheimpactofmanyORTactivitieswasverydifficulttoquantify,butthis
cnterionwasdesignedtogiveatleastsomeindicationoftheimpacttheactivityappearedto
have.
Iatbsmoulsuttebteeremmsp.haRsatihzeerd,tthhaetytahreetienrtmesnd"esdmatlolienrd,i"ca"tmeetdoituhme"reaandder"ulnafragmeirl"isarhowuiltdhnOoRtTbewhinattertphreetmeadjoirn
initiativesofthedemonstrationwere,andwhichoftheseinitiativesweremostaffectedbythepnnciples
ofOperationRestoreTrust.
Wis.ethbeeggionalthtihsatapvpaernidoiusxobrygdainsiczuastsiionngstshheoOulRdTwoprriknctiopgleetthheartmwoarsemcolsotseilmyp.orWtaentthaetnthseurmemgaironiazleltevheel,OtRhaTt
states'activitiesineachoftheORTfocusareas.
AbtAssociatesInc. Appendix1: ReviewoftheORTRegionsandComparisonStates 1-1
)
EKhlbl!1-1
SummaryofActivitiesunderOperationRestoreTrust
Notes
1Categnn/ationsabouttfierelativedegreeo(hkelyimpact,requiredresourcesandORTinfluenceareallapproximateandrelativeonlytootherORTactivities
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AbtAssociatesInc. Appendix1: ReviewoftheORTRegionsandComparisonStates 1-2
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AbtAssociatesInc. Appendix1: ReviewoftheORTRegionsandComparisonStates 1-2a
1.1.1 TheEmphasisonCollaboration
CouldOperationRestoreTrustmakedifferentagenciesworkmorecloselytogether'^ Andwouldcloser
collaborationmakeeffortstoreducefraudandabusemoreeffective? Theanswerstobothquestionsare
affirmative,butconsiderableroomremainsforimprovement.
TheChallengeofCollaboration
OperationRestoreTrustwasintendedtoimprovecollaborationamongthemanyorganizationsthathave
someresponsibilityforcontrolofMedicareandMedicaidfraudandabuse. IneachORTstatetherewere
probably 15 to20differentorganizationswithsubstantial involvement. Exhibit 1-2 showsthese
organiza—tionsandsomeoftherelationshipsbetweenthem. ThoughtherewerethreeformalORT
partners the Office of—Inspector General, the Health Care Financing Administration and the
OAIndIsmGpien—citsittohrneast—iOofnafrioecnesoAogdfiifnIfgenrsepneitcnttiphorantasct,thiectyeheatrheeOfanfluimmcobesetortfhwraAeseudscieltpoasreSaretrtevoiascgeeevnsecnia.ensTd.heUtnhttehirleOefAfumigacuiesntocf1o9mE9pv7oa,nleueaanctthisoHnoCfaFtnhAde
regionalofficewasalsodividedintoDivisionsofMedicare,MedicaidandHealthStandardsandQuality.
ThelinesbetweenthedivisionswerenotassharplydefinedasatOIG.butthedivisionsneverthelesshad
differentroles.
AcceptingforthemomentthattherewerereallysevenformalORT"partners,"Exhibit1-2alsoshowsthe
relationshipeachhadwith""outside"agencies. Ineachregion,theHCFADivisionofMedicarewas
responsibleforoversightofthecontractorswhooperatedtheprogramonaday-to-daybasis. TheHCFA
DivisionofMedicaidworkedmostcloselywiththestateMedicaidagency,buteachstate'sMedicaidfiscal
agent(whichperformstheclaims-payingrole)anditsMedicaidfraudcontrolunitalsohadresponsibility
forfraudandabuse. TheHCFADivisionofHealthStandardsandQualityworkedmostcloselywiththe
statesurveyagency,togethertheydidinspections("surveys")ofnursinghomes,homehealthagenciesand
hospiceprogramsforadherencetofederalqualityguidelines. Similarly,theAdministrationonAging
workedwiththestateunitonaginganditslocalcounterparts,especiallythestatelong-termcare
ombudsmen. TheOIGOfficeofInvestigationshadrelationshipswithtwocomponentsoftheDepanment
ofJustice:itand/ortheFederalBureauofInvestigationpursuedcases,whichwereprosecutedbytheU.S.
Attorney"sOffice. TheOIGofficesofAuditServicesandEvaluationandInspectionsdidnotroutinely
workwithspecificoutsideorganizations.
Inaddition,therewerevanousotherorganizationsthatworkedonMedicareandMedicaidfraudbutare
leftoutoftheexhibit. Peerrevieworganizations(PROs)reviewedthemedicalnecessityofMedicare
services,thoughusuallynotwithafocusonfraud. InspectorsGeneralwithresponsibilityforotherfederal
healthprograms(e.g.,militarvandveterans"healthcare)weresometimesinvolved,aswerestateandlocal
policeagenciesandstate.AttorneysGeneral. Butthemain"players"inMedicareandMedicaidfraud
controlatthestalelevelwereasshowninExhibit1-2.
Inmanvsituations,therewasnoneedforcooperationbetweentheseorganizations,oriftherewasthen
itwasbetweenanorganizationandoneofits"neighbors"inExhibit1-2. Butwhenbroadercollaboration
wasnecessary,achievingitrequiredanumberofobstaclestobeovercome. Theseobstaclesmatteredto
agreaterorlesserdegreedependingonthestate,thepersonalitiesandwhatever
AbtAssociatesInc. Appendix1: ReviewoftheORTRegionsandComparisonStates 1-3
Exhibit1-2
OrganizationsResponsibleforFraudandAbuseControl
/
DoJ:UnitedStates
OIG:Officeof OIG:Officeof Attorney'sOffice
Evaluation&Inspections AuditServices
Stateoffice
onaging
DoJ:FederalBureau
OIG:Officeof ofInvestigation
Investigations
Administration
onAging
HCFA:Divisionof HCFA:Division
HealthStandards&Quality ofMedicare Fiscalintermediary
(nursinghomeclaims)
State HCFA:Division Regionalhomehealth
surveyagency ofMedicaid intermediary(RHHI)
Durablemedicalequipment
StateMedicaidagency regionalcarrier(DMERC)
Medicaidfraud Medicaidfiscalagent Carrier
controlunit (i.e.,contractor) (PartBclaims)
AbtAssociatesInc Appendix1: ReviewoftheORTRegionsandComparisonStates 1-4
theproblemathandwas. Manyobstacleswereunavoidable,butanyeffortstoincreasecollaborationstill
hadtosteparoundthem.
• ThedifferencesamongOIGoffices. ThelinesbetweenOIG'sthreemaincomponentsare
sharplydefined,whichreflectstheirdifferentmissions,thedifferenttypesofpeoplewhostaff
them,thelackofstaffmovementbetweenthemandthefactthatthatnosingleOIGofficial
isinchargeofallOIGpersonnelwithinaregion.
• StrainedformalitybetweentheOIGandHCFA. Inanydepartment,theOfficeofInspector
Generalisnotsupposedtohavearelaxedrelationshipwiththerestofthedepartment,andit
rarelydoes. TheHealthandHumanServicesOIGpursuesfraudbyindividualproviders,
wbehliicehvesHCHFCAFAwelccooumleds.doBuatbtehteterOIjGob—rolaenadlseovienncloundesocpcoaisnitoinngtooutpraorbeeasiinntowhHiCchFAit
managementpractices. EveryOIGsemi-annualreporthasapotentiallyembarrassinglistof
recommendationsthatHCFAhasnotimplemented. BeforeORT,theprevailingattitude
amongHCFAofficialsabouttheOIGwas(slightlyparaphrased),"Ohoh,heretheycome,"
asoneofficialputit. Meanwhile,manyOIGpersonnelthoughtHCFAwasn'tinterestedin
reducingfraudandthereforedidnotroutinelyconsultwithHCFAofficials. "Believeitor
not,"one01officialtoldus,"beforeORTwenevertalkedtoHCFA. BeforeORT,wenever
sharedwithearnersthenamesofcompaniesthatwewereinvestigating."
• Differencesinphysicallocation. Geographicdispersoninevitablymeansthatworking
relationshipsdonotarisenaturally. HCFA.OEIandAoAstaffareconcentratedinthe
regionaloffices,locatedfortheORTstatesinAtlanta(forFlorida).Chicago.Dallas.New
YorkCityandSanFrancisco. OASand01alsohavestaffoutsidetheregionaloffices,but
theytendnottobeinthesamecities. InOctober1996.forexample.OAShad61peoplein
thefivestatecapitalswhile01hadjustsix. IncitiessuchasBuffalo.Clearwater.Houston.
OrlandoandSanDiego,however,OIhadofficesbutOASdidnot.(SeeExhibit10-6.)Other
organizationswithresponsibilityforfraudcontrolaresimilarlydispersed. Thevariousstate
agenciesarebasedinthestatecapitals,noneofwhicharealsothelocationsofthefederal
regionaloffices. TheMedicarecontractorsarealsoindifferentcitiesandsometimesdifferent
timezones;someclaimsfromCaliforniahomehealthagencies,forexample,werepaidby
BlueCrossofIowa.
• Differentbackgroundsofpersonnel. Allofusareshapedb\oureducationandourwork
experience,andthesefactorscouldbequitedifferentamongthedifferentorganizations. This
is especially true in OIG, where OAS. 01 and OEI can be described without much
exaggerationastheaccountants,thepoliceandtheprofessors. Consequently,thereislittle
movementofstaffbetweenthethreecomponents. PersonnelintheHCFADivisionsof
.MedicareandMedicaidareoftendesignatedas"healthinsurancespecialists"andtendto
comefromavanetyofbackgrounds;thereisconsequentlymoreinterchangebetweenthetwo
divisionsthanbetweentheOIGcomponents. HCFADivisionofHealthStandardsand
QualitypersonnelwereamongtheveryfewpeopleinORTwhohadclinicalbackgrounds;
manywerenurses.
• Tensionsbetweenstateagencies. Thecommentsmadeaboveaboutfederalagenciesalso
appliedinsomecasestostateagencies. TheMedicaidfraudcontrolunitsareseparatefrom
AbtAssociatesInc. Appendix1: ReviewoftheORTRegionsandComparisonStates 1-5