TrailBlazer claimed $3,962,920 in Medicare Part B termination costs. The OIG determined that $2,666,455 of the costs were allowable, but $1,296,465 were not. This included $137,927 in unsupported costs and travel costs exceeding allowable rates. It also included $1,158,538 in potentially unallowable severance pay costs because TrailBlazer based severance on total employment rather than just Medicare work. TrailBlazer lacked adequate controls to ensure cost allowability under federal regulations.
Michael Reynolds has over 26 years of experience in various healthcare roles such as medical billing, coding, and claims processing. He currently teaches medical billing and coding courses and owns a medical claims consulting business. The presentation he will give provides an overview of healthcare compliance, including the key elements of an effective compliance program and laws related to fraud, waste, and abuse. It will discuss Medicare integrity programs, false claims acts, anti-kickback statutes, and Stark laws. Attendees will learn how to identify, prevent, and report suspected fraud, waste, and abuse. Case studies and a question period will also be included.
There are 3 ways that the LegalShield Commercial Drivers Legal Plan can help drivers and carriers:
1) Get the fine reduced.
2) Get the CSA or MVR Points reduced.
3) Get the violation dismissed.
How does that benefit the driver and carrier? The driver can maintain the privilege to drive. Earn an income. Insurance rates won't increase.
The Carrier Rating can stay high by getting a dismissal, points reduction, or fine reduction. Which, as you know, will keep your insurance premiums low.
If your Carrier rating is low, potential customers may look elsewhere when searching for a transportation company to move their freight
All of these things can affect the bottom line.
Let LegalShield help!
lburton33.wearelegalshield.com/commercial-drivers
- The document describes the benefits and exclusions of a legal plan for commercial drivers. Benefits include representation for moving violations, license reinstatement, property damage claims up to $2,000, personal injury claims up to $2,000, and other transportation related legal services at a 25% discount.
- Exclusions include pre-existing conditions, DUI/DWI charges, drug charges, hit and run incidents, acts committed during a crime. Fines and court costs are also excluded.
- Benefits take effect 11 days after enrollment and representation is provided by appointing a qualified attorney from the provider law firm's network.
Billing and Reimbursement for Surgical Assistants - How to startLuis F. Aragon
A basic guide of what you need to know if you are looking into going into private practice as a non-physician surgical assistant in regards to third party billing.
Understanding health insurance reimbursement for Surgical AssistantsLuis F. Aragon
This document discusses various topics related to billing for surgical assistants, including managed care models, consumer directed health plans, the life cycle of an insurance claim, common terms, and facts about billing patients. It addresses issues like billing or not billing patients, dealing with deductibles and coinsurance, and compliance with regulations from organizations like the AMA and OIG regarding waiving fees. The author recommends billing patients for deductibles and copays but not balance amounts, and being aware of regulations against routinely waiving fees.
Out of Network overview for Surgical AssistantsLuis F. Aragon
Being out of network means a provider does not have a contract with a patient's insurance carrier. There are risks to being out of network including delayed payments from insurance carriers and attempts by carriers to avoid or lower payments. Additionally, out of network providers require extensive training and education for staff and patients regarding the billing and payment process. Waiving co-payments or deductibles is considered insurance fraud by many medical organizations and regulators.
Michael Reynolds has over 26 years of experience in various healthcare roles such as medical billing, coding, and claims processing. He currently teaches medical billing and coding courses and owns a medical claims consulting business. The presentation he will give provides an overview of healthcare compliance, including the key elements of an effective compliance program and laws related to fraud, waste, and abuse. It will discuss Medicare integrity programs, false claims acts, anti-kickback statutes, and Stark laws. Attendees will learn how to identify, prevent, and report suspected fraud, waste, and abuse. Case studies and a question period will also be included.
There are 3 ways that the LegalShield Commercial Drivers Legal Plan can help drivers and carriers:
1) Get the fine reduced.
2) Get the CSA or MVR Points reduced.
3) Get the violation dismissed.
How does that benefit the driver and carrier? The driver can maintain the privilege to drive. Earn an income. Insurance rates won't increase.
The Carrier Rating can stay high by getting a dismissal, points reduction, or fine reduction. Which, as you know, will keep your insurance premiums low.
If your Carrier rating is low, potential customers may look elsewhere when searching for a transportation company to move their freight
All of these things can affect the bottom line.
Let LegalShield help!
lburton33.wearelegalshield.com/commercial-drivers
- The document describes the benefits and exclusions of a legal plan for commercial drivers. Benefits include representation for moving violations, license reinstatement, property damage claims up to $2,000, personal injury claims up to $2,000, and other transportation related legal services at a 25% discount.
- Exclusions include pre-existing conditions, DUI/DWI charges, drug charges, hit and run incidents, acts committed during a crime. Fines and court costs are also excluded.
- Benefits take effect 11 days after enrollment and representation is provided by appointing a qualified attorney from the provider law firm's network.
Billing and Reimbursement for Surgical Assistants - How to startLuis F. Aragon
A basic guide of what you need to know if you are looking into going into private practice as a non-physician surgical assistant in regards to third party billing.
Understanding health insurance reimbursement for Surgical AssistantsLuis F. Aragon
This document discusses various topics related to billing for surgical assistants, including managed care models, consumer directed health plans, the life cycle of an insurance claim, common terms, and facts about billing patients. It addresses issues like billing or not billing patients, dealing with deductibles and coinsurance, and compliance with regulations from organizations like the AMA and OIG regarding waiving fees. The author recommends billing patients for deductibles and copays but not balance amounts, and being aware of regulations against routinely waiving fees.
Out of Network overview for Surgical AssistantsLuis F. Aragon
Being out of network means a provider does not have a contract with a patient's insurance carrier. There are risks to being out of network including delayed payments from insurance carriers and attempts by carriers to avoid or lower payments. Additionally, out of network providers require extensive training and education for staff and patients regarding the billing and payment process. Waiving co-payments or deductibles is considered insurance fraud by many medical organizations and regulators.
Medical billing involves submitting bills to insurance companies in a standardized format for medical services provided by doctors to patients. The main parties involved are the patient, provider, billing office, and insurance company. The responsibilities of the billing office include properly coding bills, ensuring compliance with insurance rules, maintaining records, filing claims, and following up. Billing offices have various departments like coding, claims processing, and accounts receivable. There are two main types of insurance companies - federal programs like Medicare and Medicaid, and private commercial insurers like Aetna and Blue Cross Blue Shield.
This document discusses surgical assistants and their role. It outlines that surgical assistants can include physician assistants, nurse practitioners, registered nurses with additional training, and registered surgical assistants. It provides a brief history of how surgical assistants have evolved from physicians and residents to other licensed roles. It also lists several CAAHEP approved surgical assisting programs and discusses guidelines from organizations like the AMA and ACS regarding the qualifications and role of non-physician surgical assistants.
The document discusses the regulatory framework around healthcare ACOs, including three key laws: the Stark Law prohibiting physician self-referrals, the Federal Anti-Kickback Statute prohibiting payments to induce referrals, and the Civil Monetary Penalties Law prohibiting payments to limit care. It outlines exceptions and sanctions under these laws. It also discusses the False Claims Act which enables whistleblower suits for fraudulent claims and its role in cases involving regulatory violations.
This document provides an overview of the Stark Law, including:
- The Stark Law prohibits physician self-referrals of Medicare patients for designated health services if the physician has a financial relationship with the entity providing those services.
- It addresses questions about who enforces the law, why the law was created, what activities it prohibits, and differences between it, the Anti-Kickback Statute, and the False Claims Act.
- The document outlines penalties for Stark Law violations and lists 17 areas of compliance risk identified by the Office of Inspector General related to healthcare fraud and abuse.
This document compares the cost of employing surgical assistants at a facility versus contracting the services out. Employing one surgical assistant would cost the facility around $123,992 per year in salary and benefits. Contracting the assistant services out for a flat fee of $100,000 per year would save the facility 19.35% compared to employing one assistant. Employing two assistants would cost around $247,985 per year, while contracting would save 59.67%. For three employed assistants the cost would be around $371,978, with contracting saving 73.12% per year.
This document outlines the basic steps an independent RNFA needs to take to begin medical billing. The steps include: 1) applying for facility privileges, 2) obtaining a National Provider Identifier number, 3) deciding how to structure billing under an SSN, LLC, or corporation, 4) finding a surgeon to work with who will provide billing codes, 5) choosing a specialty with high reimbursement, 6) determining the surgeon's Medicare caseload, 7) checking states that allow RNFA reimbursement, 8) reviewing useful resources, and 9) optionally hiring NIFA for medical billing assistance.
A Q&A guide to workers' compensation law for employers in Georgia. This Q&A addresses Georgia laws requiring workers' compensation coverage, including the benefits process, penalties for an employer's failure to obtain workers' compensation coverage, and anti-retaliation provisions. Federal, local, or municipal law may impose additional or different requirements. Answers to questions can be compared across a number of jurisdictions (see Workers' Compensation Laws: State Q&A Tool)
This document discusses barriers, opportunities, and pitfalls related to implementing medical tourism into workers' compensation programs. It notes that average medical costs per lost-time workers' compensation claim have risen significantly in recent years. The main barriers include state regulations restricting out-of-state or foreign providers, outdated laws, and resistance from lawyers, politicians, and interest groups. However, it identifies opportunities related to cross-border programs with Mexico allowed in some states, expanding choice of physicians, and the growing option for employers to opt out of state workers' compensation programs, which could facilitate greater use of medical tourism.
A presentation on various frauds affecting the insurance industry along with cases emphasizing the need for forensic audit / accounting to uncover them and reduce losses
This document summarizes a presentation on healthcare compliance. It discusses how mandatory compliance requirements have increased in recent years through various laws and regulations. Specifically, the Affordable Care Act requires companies to have compliance programs with core elements in place by March 2013 or risk exclusion from federal healthcare programs. The presentation recommends that organizations conduct background checks on all employees, licensed and unlicensed, to various degrees to avoid noncompliance penalties that can include fines, damages, and exclusion from Medicare/Medicaid billing. It provides examples where lack of compliance oversight resulted in millions paid in penalties and kickbacks.
A comprehensive guide to the laws governing surrogacy arrangements in North Transatlantic (the UK, the USA, and Canada). DOI: 10.13140/RG.2.1.4485.2888
What you can do online at the social security administration websitemosmedicalreview
The SSA provides retirement and disability benefits, the latter granted based on a chart review, to applicants. Here is what you can do via SSA’s website.
Elucidates the governing laws (U.S., Canada, U.K), restrictions and extensions of the advance-directives (living wills) in obstetrics. DOI: 10.13140/RG.2.1.3671.4321
This document summarizes various fraud and abuse laws including the Federal False Claims Act, the Stark laws, and the Federal Anti-Kickback Statute. It provides an overview of these laws and regulations, details penalties for noncompliance, and discusses recent case law examples. The document also covers compliance issues and exceptions like the physician recruitment safe harbor.
Kelly Riddle of Kelmar Global shares tips for conducting insurance investigations.
To watch the webinar recording, visit: http://i-sight.com/webinar-investigating-insurance-fraud/
This document discusses the need for a citizen engagement platform, or "My Colorado" portal, to improve government services and reduce costs. It notes that current government customer management systems are outdated, inefficient, and costly to maintain. A national citizen engagement platform hosted in the cloud could share information across agencies and states, provide a single portal for citizens, offer standard applications, and save billions annually through economies of scale. The document proposes a prototype citizen-centric portal and asks for support to advance this initiative and pilot the "My CO" program in Colorado. The benefits cited include lower costs, increased citizen engagement, information sharing, scalability, and more efficient government services.
This document provides summaries of various WordPress websites, including details about their themes, customizations, plugins used, and developers. The websites showcase the full capabilities of WordPress, ranging from basic to fully customized themes and integrations. They cover industries like non-profits, arts, retail, and more.
Medical billing involves submitting bills to insurance companies in a standardized format for medical services provided by doctors to patients. The main parties involved are the patient, provider, billing office, and insurance company. The responsibilities of the billing office include properly coding bills, ensuring compliance with insurance rules, maintaining records, filing claims, and following up. Billing offices have various departments like coding, claims processing, and accounts receivable. There are two main types of insurance companies - federal programs like Medicare and Medicaid, and private commercial insurers like Aetna and Blue Cross Blue Shield.
This document discusses surgical assistants and their role. It outlines that surgical assistants can include physician assistants, nurse practitioners, registered nurses with additional training, and registered surgical assistants. It provides a brief history of how surgical assistants have evolved from physicians and residents to other licensed roles. It also lists several CAAHEP approved surgical assisting programs and discusses guidelines from organizations like the AMA and ACS regarding the qualifications and role of non-physician surgical assistants.
The document discusses the regulatory framework around healthcare ACOs, including three key laws: the Stark Law prohibiting physician self-referrals, the Federal Anti-Kickback Statute prohibiting payments to induce referrals, and the Civil Monetary Penalties Law prohibiting payments to limit care. It outlines exceptions and sanctions under these laws. It also discusses the False Claims Act which enables whistleblower suits for fraudulent claims and its role in cases involving regulatory violations.
This document provides an overview of the Stark Law, including:
- The Stark Law prohibits physician self-referrals of Medicare patients for designated health services if the physician has a financial relationship with the entity providing those services.
- It addresses questions about who enforces the law, why the law was created, what activities it prohibits, and differences between it, the Anti-Kickback Statute, and the False Claims Act.
- The document outlines penalties for Stark Law violations and lists 17 areas of compliance risk identified by the Office of Inspector General related to healthcare fraud and abuse.
This document compares the cost of employing surgical assistants at a facility versus contracting the services out. Employing one surgical assistant would cost the facility around $123,992 per year in salary and benefits. Contracting the assistant services out for a flat fee of $100,000 per year would save the facility 19.35% compared to employing one assistant. Employing two assistants would cost around $247,985 per year, while contracting would save 59.67%. For three employed assistants the cost would be around $371,978, with contracting saving 73.12% per year.
This document outlines the basic steps an independent RNFA needs to take to begin medical billing. The steps include: 1) applying for facility privileges, 2) obtaining a National Provider Identifier number, 3) deciding how to structure billing under an SSN, LLC, or corporation, 4) finding a surgeon to work with who will provide billing codes, 5) choosing a specialty with high reimbursement, 6) determining the surgeon's Medicare caseload, 7) checking states that allow RNFA reimbursement, 8) reviewing useful resources, and 9) optionally hiring NIFA for medical billing assistance.
A Q&A guide to workers' compensation law for employers in Georgia. This Q&A addresses Georgia laws requiring workers' compensation coverage, including the benefits process, penalties for an employer's failure to obtain workers' compensation coverage, and anti-retaliation provisions. Federal, local, or municipal law may impose additional or different requirements. Answers to questions can be compared across a number of jurisdictions (see Workers' Compensation Laws: State Q&A Tool)
This document discusses barriers, opportunities, and pitfalls related to implementing medical tourism into workers' compensation programs. It notes that average medical costs per lost-time workers' compensation claim have risen significantly in recent years. The main barriers include state regulations restricting out-of-state or foreign providers, outdated laws, and resistance from lawyers, politicians, and interest groups. However, it identifies opportunities related to cross-border programs with Mexico allowed in some states, expanding choice of physicians, and the growing option for employers to opt out of state workers' compensation programs, which could facilitate greater use of medical tourism.
A presentation on various frauds affecting the insurance industry along with cases emphasizing the need for forensic audit / accounting to uncover them and reduce losses
This document summarizes a presentation on healthcare compliance. It discusses how mandatory compliance requirements have increased in recent years through various laws and regulations. Specifically, the Affordable Care Act requires companies to have compliance programs with core elements in place by March 2013 or risk exclusion from federal healthcare programs. The presentation recommends that organizations conduct background checks on all employees, licensed and unlicensed, to various degrees to avoid noncompliance penalties that can include fines, damages, and exclusion from Medicare/Medicaid billing. It provides examples where lack of compliance oversight resulted in millions paid in penalties and kickbacks.
A comprehensive guide to the laws governing surrogacy arrangements in North Transatlantic (the UK, the USA, and Canada). DOI: 10.13140/RG.2.1.4485.2888
What you can do online at the social security administration websitemosmedicalreview
The SSA provides retirement and disability benefits, the latter granted based on a chart review, to applicants. Here is what you can do via SSA’s website.
Elucidates the governing laws (U.S., Canada, U.K), restrictions and extensions of the advance-directives (living wills) in obstetrics. DOI: 10.13140/RG.2.1.3671.4321
This document summarizes various fraud and abuse laws including the Federal False Claims Act, the Stark laws, and the Federal Anti-Kickback Statute. It provides an overview of these laws and regulations, details penalties for noncompliance, and discusses recent case law examples. The document also covers compliance issues and exceptions like the physician recruitment safe harbor.
Kelly Riddle of Kelmar Global shares tips for conducting insurance investigations.
To watch the webinar recording, visit: http://i-sight.com/webinar-investigating-insurance-fraud/
This document discusses the need for a citizen engagement platform, or "My Colorado" portal, to improve government services and reduce costs. It notes that current government customer management systems are outdated, inefficient, and costly to maintain. A national citizen engagement platform hosted in the cloud could share information across agencies and states, provide a single portal for citizens, offer standard applications, and save billions annually through economies of scale. The document proposes a prototype citizen-centric portal and asks for support to advance this initiative and pilot the "My CO" program in Colorado. The benefits cited include lower costs, increased citizen engagement, information sharing, scalability, and more efficient government services.
This document provides summaries of various WordPress websites, including details about their themes, customizations, plugins used, and developers. The websites showcase the full capabilities of WordPress, ranging from basic to fully customized themes and integrations. They cover industries like non-profits, arts, retail, and more.
The acm is a patented credit card holder that keeps cards safe and organized. It holds up to six cards and dispenses them with a flick of the finger. Additional features include a removable money clip and interchangeable buttons. The acm comes in various colors and materials, and additional accessories like a leather case or dock are available. Users praise the acm for its uniqueness, quality, and usefulness in keeping their cards and cash organized while active in their daily lives.
El documento presenta la serie P5T de cilindros neumáticos compactos controlados de Parker. Incluye tablas con las características, fuerzas, calidad del aire requerida y datos principales de los cilindros. Ofrece información sobre amortiguación, detección, modelos, cojinetes y conexiones disponibles.
बेगुनाहों को सजा देने का तरिका इंसानियत को शर्मसार करता है
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नकली राष्ट्रवादियों ने बलि चढ़ा दी - रणधीर सिंह सुमन
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प्लीज मुझे पूजा नहीं, आमिना कहिए
Hello, my name is Joel Rojo, and it's my pleasure to introduce you to Guacamaya hot sauce. We're a mexican company focused on making great salsa with great ingredients and a unique taste.
We're really proud of who we are and how far we've come, but instead of boring you with it, just take a look, and if you want to contact us, the slide has our contact information, or gimme a shout at twitter.com/SalsaGuacamaya
El documento habla sobre la importancia de la privacidad y la seguridad en línea en la era digital. Explica que los usuarios deben tomar medidas para proteger su información personal en Internet, como usar contraseñas seguras y software antivirus actualizado. También enfatiza que las empresas deben implementar políticas claras sobre cómo protegen los datos de los clientes y ser transparentes en el uso y almacenamiento de información personal.
LOS NUEVOS VALORES DE LAS REDES SOCIALES Y COMO ÉSTOS AFECTAN LAS EMPRESAS Y...ana maria llopis
En los últimos cien años la vida media de las empresas se ha reducido significativamente. Las redes Sociales y los nuevos paradigmas de Internet, wikinomics, crowdsourcing y la innovación abierta abren nuevas rutas para los procesos de innovación en las empresas. Los valores de autenticidad, democratización, diversidad, accesibilidad, transparencia, colaboración colectiva de las redes sociales están enriqueciendo los procesos de innovación porque producen un entorno abierto más inteligente y más productivo y propicio a la creatividad a la generación de ideas y a resolver problemas inmediatos en el entorno de cambios permanentes e inestables en momentos de crisis. La innovación abierta es el ADN que las empresas necesitan redefinir para subsistir
MEDICAL ETHICS AND CONFLICT OF INTEREST IN SCIENTIFIC MEDICINEhome
SUMMARY
The Office of Technology Assessment (OTA) was perhaps the US government's last honest agency that critically reviewed the state of the nation's health care system. The purpose of the OTA was to provide Congress with objective and authoritative analysis of complex scientific and technical issues. In its final critical report, the OTA concluded: “There are no mechanisms in place to limit dissemination of technologies, regardless of their clinical value.”
Shortly after the OTA released a report that exposed how entrenched financial interests manipulate health care practice in the United States, Congress disbanded the OTA.
This is the professional profile of Marco de Groen. In this profile you can get to know me and see my latest and best work of the past 2 years. Hope you enjoy it.
This document summarizes an IMAB Tech Talk presentation about integrating technology to improve marketing and fundraising efforts. It discusses how organizations currently use different databases and systems that are not well integrated, making it difficult to get a full view of constituents and coordinate efforts. The presentation examines different levels of technology use from basic to complex and integrated. It provides a case study of an organization taking incremental steps to become more integrated by automating data syncing between its online and offline databases. Finally, it discusses the challenges a large, multi-location nonprofit faces in fully integrating its disparate systems and data into a single customer relationship management system over several years.
- TrailBlazer, a Medicare contractor, claimed $319 million in administrative costs from 2004-2008 to process Medicare claims.
- The OIG audited TrailBlazer's cost proposals to determine if the claimed costs were allowable under federal requirements.
- The OIG found that all administrative costs TrailBlazer claimed over the audit period were allowable, reasonable, and allocable according to federal regulations and the Medicare contract. The report contained no recommendations.
TrailBlazer claimed Medicare Part B administrative costs in accordance with Federal requirements. An audit of TrailBlazer's cost proposals for the period of October 2008 through March 2011 found that the $24,425,018 in claimed costs were reasonable, allowable, and allocable based on Federal Acquisition Regulation Part 31 and TrailBlazer's contract with CMS. The audit activities included reconciling cost proposals to accounting records, analytical tests, sampling expenses, and ensuring costs were allowable, allocable, and reasonable.
This document summarizes an audit conducted by the Office of Inspector General (OIG) regarding Texas' compliance with federal and state requirements for the Medicare buy-in program. The audit found that Texas did not always comply with eligibility determination and documentation requirements, resulting in a small number of ineligible payments. It also found that Texas did not periodically review the eligibility of individuals enrolled through the Social Security Administration to ensure their continued eligibility as required. The OIG recommends Texas improve its eligibility policies and procedures and conduct periodic eligibility reviews of all individuals enrolled in the buy-in program.
This audit report examines whether acute-care hospitals in Texas reconciled Medicaid credit balances and refunded overpayments to the state agency. The audit found that one hospital always reconciled accounts and refunded overpayments, but seven other hospitals sampled did not always do so. These seven hospitals had $30,057 in overpayments across 81 patient accounts sampled. Extrapolating this overpayment rate, auditors estimated the state agency could recover $15.3 million in additional overpayments from hospitals. The report recommends the state agency refund identified overpayments, enhance efforts to ensure hospitals reconcile accounts and refund overpayments within a specified time period. The state agency agreed with the recommendations.
The Colorado Health Benefit Exchange is applying for a cooperative agreement from the Department of Health and Human Services to establish a state-operated health insurance exchange. Colorado has already conducted research on its uninsured population and insurance market and engaged stakeholders. If funded, Colorado will refine its exchange vision and goals, secure staff and experts, develop a 3-year business plan, and begin establishing IT systems to receive certification by 2013 and be self-sustaining by 2015.
Frequently asked questions about Obamacareexchangeenvoy
The document summarizes key provisions of the Affordable Care Act (ACA) related to health insurance exchanges, the individual mandate, employer penalties, and dependent coverage requirements. It explains that the ACA requires states to establish health insurance exchanges by 2014 to offer qualified health plans. It also outlines the individual mandate requiring most individuals to have minimum essential health coverage beginning in 2014, and penalties for employers not offering coverage. The ACA extends dependent coverage to age 26.
The document discusses compliance and accounts receivable risk areas for skilled nursing facilities. It identifies five main risk areas for bad debt and lost revenue: bad debt, compliance issues, inefficiencies and waste, cash flow problems, and theft. It also provides tips for minimizing these risks through best practices in admissions, compliance processes, personnel management, billing and collection standards, and oversight and monitoring.
The Oregon Medical Association's 2015 Legislative Report summarizes key bills addressed by the Oregon legislature during the 2015 session that were of importance to physicians and healthcare in Oregon. Some highlights include:
- Bills passed to provide physicians timely notice from insurers about patients' premium payment status and increase transparency around virtual credit card payments from insurers.
- A bill addressing healthcare provider incentive programs for underserved areas passed but with reductions in funding for a related study and potential sunsetting of programs.
- Legislation passed requiring individual schools and daycares to post immunization rates to improve parents' access to information.
- The report outlines other bills that passed and failed relating to issues like rural healthcare access, insurance
This document defines various health insurance terms used in the Affordable Care Act and Washington state programs. It provides definitions for over 50 terms related to health plans, coverage, costs, eligibility and other key concepts. The document is intended to help consumers understand and navigate their health insurance options.
Corrected OIG Final Report OEI-05-09-00070 -- 03-01-2010Erica Fleischer
This report from the Office of Inspector General summarizes its findings from an investigation of sales agent marketing practices for Medicare Advantage plans. The investigation found that 5 of 6 selected health plan sponsors had compensation practices that could incentivize signing up beneficiaries into inappropriate plans. It also found that 5 of the 6 sponsors used unqualified sales agents who were either not licensed or had not passed required training. Additionally, the number and types of beneficiary complaints about sales agent marketing did not change after new regulations were implemented. The report recommends that CMS take actions regarding plan sponsors' noncompliance and improve its oversight of sales agent marketing.
State innovation and medicare expansion waivers employer considerationsDebera Salam, CPP
How will the state response to the Affordable Care Act affect employers? In this special report, we explain how state innovation and Medicare expansion waivers will impact businesses now and in the future.
This letter supports a demonstration grant application from HL Consulting and JH Cohn, LLP to test procedural changes and innovative technology for hospital reimbursements through Medicaid. The goal is to save state and federal budgets. The letter proposes using objective, data-driven procedures for cost report audits and implementing technologies already used for Medicare that have not been applied to Medicaid cost reporting. This could benefit and serve recipients of long-term healthcare programs while reforming healthcare reimbursement regulations.
Department of Health and Human Services OFFICE OF INSPECsimisterchristen
Department of Health and Human Services
OFFICE OF
INSPECTOR GENERAL
June 2001
OEI-02-00-00290
Medicare Coverage of Non-Physician
Practitioner Services
OFFICE OF INSPECTOR GENERAL
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to
protect the integrity of the Department of Health and Human Services programs as well as the
health and welfare of beneficiaries served by them. This statutory mission is carried out through
a nationwide program of audits, investigations, inspections, sanctions, and fraud alerts. The
Inspector General informs the Secretary of program and management problems and recommends
legislative, regulatory, and operational approaches to correct them.
Office of Evaluation and Inspections
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of
Inspector General. It conducts short-term management and program evaluations (called
inspections) that focus on issues of concern to the Department, the Congress, and the public.
The inspection reports provide findings and recommendations on the efficiency, vulnerability,
and effectiveness of departmental programs.
OEI's New York Regional Office prepared this report under the direction of John I. Molnar,
Regional Inspector General and Renee C. Dunn, Deputy Regional Inspector General. Principal
OEI staff included:
REGION HEADQUARTERS
Nancy Harrison, Project Leader Jennifer Antico, Program Specialist
Natasha Besch Tricia Davis, Program Specialist
Vincent Greiber Brian Ritchie, Technical Support Staff
Christi Macrina
To obtain copies of this report, please call the New York Regional Office at 212-264-2000.
Reports are also available on the World Wide Web at our home pate address:
http://www.hhs.gov/oig/oei
Department of Health and Human Services
OFFICE OF
INSPECTOR GENERAL
June 2001
OEI-02-00-00290
Medicare Coverage of Non-Physician
Practitioner Services
E X E C U T I V E S U M M A R Y
PURPOSE
To describe the scope of services nurse practitioners, clinical nurse specialists, and
physician assistants provide to Medicare beneficiaries, and to identify any potential
vulnerabilities that may have emerged since the Balanced Budget Act of 1997.
BACKGROUND
Nurse practitioners, clinical nurse specialists, and physician assistants are health care
providers who practice either in collaboration with or under the supervision of a
physician. We refer to them as non-physician practitioners. States are responsible for
licensing and for setting the scopes of practice for all three specialties. Services provided
by them can be reimbursed by Medicare Part B.
The Balanced Budget Act of 1997 (BBA97) modified the way the Medicare program
pays for their services. Prior to January 1, 1998, their services were reimbursed by
Medicare only in rural areas and certain health care settings. Payments are now allowed
in all geographic areas and health care settings ...
AGRI-SERVICES AGENCY provides workers' compensation coverage through alternative risk transfer programs due to traditional carriers exiting the market and increasing costs. Coverage is state regulated and benefits differ by state. The key objectives of workers' compensation are to provide reasonable benefits regardless of fault, be the sole remedy for occupational injury, and relieve public institutions of costs while encouraging workplace safety. Injured employees receive medical, disability, rehabilitation and death benefits. Agrisurance and EMPACT are the two programs offered, each with underwriting guidelines and binding/payment options. Claims are managed by PMA Management Corp. through experienced professionals and cost control programs.
U S Supreme Court Upholds The Affordable Care Act1charles_3us
The U.S. Supreme Court upheld the constitutionality of the Affordable Care Act, including the individual mandate requiring Americans to obtain health insurance. The Court ruled the mandate is valid under Congress's taxing authority. However, it placed some limitations on the Medicaid expansion. Employers and health plans must continue complying with ACA provisions such as reporting requirements, limits on flexible spending accounts, and minimum loss ratios for insurers. Additional reforms take effect in 2014, including the employer mandate and health insurance exchanges.
The health care reform law calls for the creation of state-based insurance Exchanges. This Legislative Brief provides an overview of state progress toward creating the Exchanges and the role of entities typically involved with the insurance placement process (such as brokers and agents) under the Exchanges. It also discusses the emergence of private health insurance Exchanges.
The document discusses compliance requirements for healthcare providers, including Medicaid compliance programs mandated by New York state and the Affordable Care Act. It notes that compliance includes reporting any issues related to patient care, operations, procedures, non-compliance, fraud, waste or abuse. The document also summarizes elements of an effective compliance program and defines fraud, waste and abuse. Key compliance laws and regulations are also outlined such as the anti-kickback statute and HIPAA privacy and security rules.
The UPIC program aims to simplify and strengthen Medicaid integrity by replacing Zone Program Integrity Contractors with United Program Integrity Contractors to conduct unified audits across Medicare, Medicaid, and other federal health programs; UPICs will focus on identifying fraudulent providers, strengthening oversight of state financial policies, and collaborating between federal and state agencies to combat fraud, waste, and abuse. Providers can expect increased scrutiny of billing practices and medical records from UPIC audits starting in 2018.
“Regulatory Compliance Enforcement Update: Getting Results from the Guidance” PYA, P.C.
PYA Principal and Chief Compliance Officer Shannon Sumner and Consulting Senior Manager Susan Thomas presented “Regulatory Compliance Enforcement Update: Getting Results from the Guidance” at the virtual 2020 Montana Healthcare Conference. They reviewed the sources of regulatory enforcement and investigation information—guidelines, statutory updates, best practices, settlements, case studies, etc.—available to healthcare organizations. They will also discuss how to interpret and implement the guidance in order to strengthen the compliance function and protect the organization. The presentation covered:
Compliance regulatory requirements for healthcare organizations.
Guidance available for consideration in organizational compliance programs.
Internal and external reporting to ensure regulatory requirements are met.
Best practices for implementation of guidance.
Case studies for illustration of guidance implementation.
Health Reform - Additional IRS Approaches to the Cadillac Tax; Transitional R...CBIZ, Inc.
Guidance on:
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2. Transitional Reinsurance Fee Process for 2015 Benefit Year. In preparation for reporting and paying the transitional reinsurance fees for the 2015 benefit year, the Centers for Medicare and Medicaid services released an overview of the process and procedures
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4. Applicability of ACA’s Employer Shared Responsibility Provisions. On July 31, 2015, President Obama signed the Surface Transportation and Veterans Health Care Choice Improvement Act of 2015 (H.R. 3236); now Public Law 114-41). This law provides that for purposes of determining whether an employer is an applicable large employer with regard to employee enrollment in minimum essential health coverage under an eligible employer sponsored plan, individuals covered for medical care under TRICARE or the Veterans Administration are not counted. In addition, a recent lawsuit challenged the applicability of the ACA’s employer shared responsibility mandate to a Native American tribe.
Similar to A-06-13-00017- TB Part B Termination (20)
Health Reform - Additional IRS Approaches to the Cadillac Tax; Transitional R...
A-06-13-00017- TB Part B Termination
1. Department of Health and Human Services
OFFICE OF
INSPECTOR GENERAL
TRAILBLAZER HEALTH ENTERPRISES,
LLC, CLAIMED UNALLOWABLE
MEDICARE PART B TERMINATION COSTS
Gloria L. Jarmon
Deputy Inspector General
for Audit Services
October 2014
A-06-13-00017
Inquiries about this report may be addressed to the Office of Public Affairs at
Public.Affairs@oig.hhs.gov.
2. Office of Inspector General
http://oig.hhs.gov
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, is
to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the
health and welfare of beneficiaries served by those programs. This statutory mission is carried out
through a nationwide network of audits, investigations, and inspections conducted by the following
operating components:
Office of Audit Services
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting audits with
its own audit resources or by overseeing audit work done by others. Audits examine the performance of
HHS programs and/or its grantees and contractors in carrying out their respective responsibilities and are
intended to provide independent assessments of HHS programs and operations. These assessments help
reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS.
Office of Evaluation and Inspections
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress,
and the public with timely, useful, and reliable information on significant issues. These evaluations focus
on preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness of
departmental programs. To promote impact, OEI reports also present practical recommendations for
improving program operations.
Office of Investigations
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of fraud and
misconduct related to HHS programs, operations, and beneficiaries. With investigators working in all 50
States and the District of Columbia, OI utilizes its resources by actively coordinating with the Department
of Justice and other Federal, State, and local law enforcement authorities. The investigative efforts of OI
often lead to criminal convictions, administrative sanctions, and/or civil monetary penalties.
Office of Counsel to the Inspector General
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering
advice and opinions on HHS programs and operations and providing all legal support for OIG’s internal
operations. OCIG represents OIG in all civil and administrative fraud and abuse cases involving HHS
programs, including False Claims Act, program exclusion, and civil monetary penalty cases. In
connection with these cases, OCIG also negotiates and monitors corporate integrity agreements. OCIG
renders advisory opinions, issues compliance program guidance, publishes fraud alerts, and provides
other guidance to the health care industry concerning the anti-kickback statute and other OIG enforcement
authorities.
3. Notices
THIS REPORT IS AVAILABLE TO THE PUBLIC
at http://oig.hhs.gov
Section 8M of the Inspector General Act, 5 U.S.C. App., requires
that OIG post its publicly available reports on the OIG Web site.
OFFICE OF AUDIT SERVICES FINDINGS AND OPINIONS
The designation of financial or management practices as
questionable, a recommendation for the disallowance of costs
incurred or claimed, and any other conclusions and
recommendations in this report represent the findings and
opinions of OAS. Authorized officials of the HHS operating
divisions will make final determination on these matters.
4. TrailBlazer Medicare Part B Termination Costs (A-06-13-00017) i
EXECUTIVE SUMMARY
WHY WE DID THIS REVIEW
The Centers for Medicare & Medicaid Services (CMS) administers the Medicare program
through contracts with private organizations that process and pay Medicare claims. These
contracts with CMS provide for the reimbursement of allowable contract termination costs.
CMS terminated its Medicare Part B contract with TrailBlazer Health Enterprises, LLC
(TrailBlazer). CMS requested that we audit the Medicare Part B termination costs that
TrailBlazer claimed for reimbursement.
The objective of this review was to determine whether TrailBlazer’s claims for Medicare Part B
termination costs were reasonable, allocable, and otherwise allowable in accordance with part 31
of the Federal Acquisition Regulation (FAR) and its Medicare Part B contract.
BACKGROUND
Title XVIII of the Social Security Act established the Medicare program, which provides health
insurance coverage to people aged 65 and over, people with disabilities, and people with end-
stage renal disease. CMS administers the Medicare program through contractors, including
Part B carriers that process and pay Medicare claims. Contracts between CMS and the Medicare
contractors define the functions to be performed and provide for the reimbursement of allowable
administrative costs incurred in the processing of Medicare claims and allowable termination
costs when CMS terminates a contract. In claiming costs, contractors must comply with the
Medicare contract and follow cost reimbursement principles contained in the FAR.
CMS contracted with TrailBlazer to serve as the Medicare Part B carrier responsible for
processing claims for Virginia, Maryland, Delaware, and the District of Columbia. Beginning
June 2006, CMS started replacing Medicare Part B carriers with entities called Medicare
Administrative Contractors (MACs). CMS did not award TrailBlazer a MAC contract and
terminated TrailBlazer’s Medicare Part B contract for Maryland, Delaware, and the District of
Columbia effective July 15, 2008, and for Virginia effective March 21, 2011.
TrailBlazer, formerly headquartered in Dallas, Texas, was a wholly owned subsidiary of
BlueCross BlueShield of South Carolina (BlueCross). BlueCross provided certain management
and other operational support services for TrailBlazer, including accounting, human resources,
legal, and general corporate administration. Because TrailBlazer is no longer in business, we are
addressing the report findings and recommendations to BlueCross.
TrailBlazer claimed $137,927 in Medicare Part B termination costs that did not comply with
Federal regulations and applicable guidelines and claimed $1,158,538 in potentially unallowable
termination costs for severance pay.
5. TrailBlazer Medicare Part B Termination Costs (A-06-13-00017) ii
WHAT WE FOUND
Of the $3,962,920 in Medicare Part B termination costs that we reviewed, $2,666,455 was
reasonable, allocable, and otherwise allowable in accordance with part 31 of the FAR and the
Medicare contract. The remaining $1,296,465 consisted of $137,927 in unsupported costs and
travel costs in excess of the allowable per diem rates and $1,158,538 in potentially unallowable
termination costs for severance pay.
TrailBlazer claimed these unsupported costs and travel costs in excess of allowable per diem
rates because it did not have adequate internal control procedures to ensure that it claimed costs
in accordance with the regulations set forth in the FAR and the Medicare contract.
WHAT WE RECOMMEND
We recommend that BlueCross:
• refund to the Federal Government $137,927 for unsupported costs and travel costs and
• work with CMS to determine the allowability of $1,158,538 in termination costs for
severance pay that we set aside and refund to the Federal Government any amount
determined to be unallowable.
BLUECROSS BLUESHIELD OF SOUTH CAROLINA COMMENTS
In its comments on our draft report, BlueCross concurred with our recommendations.
6. TrailBlazer Medicare Part B Termination Costs (A-06-13-00017) iii
TABLE OF CONTENTS
INTRODUCTION ..........................................................................................................................1
Why We Did This Review..................................................................................................1
Objective.............................................................................................................................1
Background.........................................................................................................................1
How We Conducted This Review.......................................................................................2
FINDINGS......................................................................................................................................2
TrailBlazer Claimed Unallowable Costs ............................................................................2
TrailBlazer Claimed Unsupported Costs ................................................................2
TrailBlazer Claimed Travel Costs That Exceeded Allowable Per Diem Rates......3
Lack of Adequate Internal Controls........................................................................3
TrailBlazer Claimed Potentially Unallowable Severance Costs.........................................3
RECOMMENDATIONS................................................................................................................4
BLUECROSS BLUESHIELD OF SOUTH CAROLINA COMMENTS......................................4
APPENDIXES
A: Audit Scope and Methodology .....................................................................................5
B: BlueCross BlueShield of South Carolina Comments ...................................................6
7. TrailBlazer Medicare Part B Termination Costs (A-06-13-00017) 1
INTRODUCTION
WHY WE DID THIS REVIEW
The Centers for Medicare & Medicaid Services (CMS) administers the Medicare program
through contracts with private organizations that process and pay Medicare claims. These
contracts with CMS provide for the reimbursement of allowable contract termination costs.
CMS terminated its Medicare Part B contract with TrailBlazer Health Enterprises, LLC
(TrailBlazer). CMS requested that we audit the Medicare Part B termination costs that
TrailBlazer claimed for reimbursement.
OBJECTIVE
Our objective was to determine whether TrailBlazer’s claims for Medicare Part B termination
costs were reasonable, allocable, and otherwise allowable in accordance with part 31 of the
Federal Acquisition Regulation (FAR)1
and its Medicare Part B contract.
BACKGROUND
Title XVIII of the Social Security Act established the Medicare program, which provides health
insurance coverage to people aged 65 and over, people with disabilities, and people with end-
stage renal disease. CMS administers the Medicare program through contractors, including
Part B carriers that process and pay Medicare claims. Contracts between CMS and the Medicare
contractors define the functions to be performed and provide for the reimbursement of allowable
administrative costs incurred in the processing of Medicare claims and allowable termination
costs when CMS terminates a contract. In claiming costs, contractors must comply with the
Medicare contract and follow cost reimbursement principles contained in the FAR.
CMS contracted with TrailBlazer to serve as the Medicare Part B carrier responsible for
processing claims for Virginia, Maryland, Delaware, and the District of Columbia. Beginning
June 2006, CMS started replacing Medicare Part B carriers with new contract entities called
Medicare Administrative Contractors (MACs).2
CMS did not award TrailBlazer a MAC
contract and terminated TrailBlazer’s Medicare Part B contract for Maryland, Delaware, and the
District of Columbia effective July 15, 2008, and for Virginia effective March 21, 2011.3
TrailBlazer, formerly headquartered in Dallas, Texas, was a wholly owned subsidiary of
BlueCross BlueShield of South Carolina (BlueCross). BlueCross provided certain management
and other operational support services for TrailBlazer, including accounting, human resources,
1
48 CFR, part 31, Contract Cost Principles and Procedures.
2
Section 911 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, P.L. No. 108-173.
3
TrailBlazer also processed claims for Texas. CMS terminated TrailBlazer’s Medicare Part B carrier contract for
Texas effective June 13, 2008, and requested that we audit termination costs that TrailBlazer claimed for its Part B
carrier contract for Virginia, Maryland, Delaware, and the District of Columbia, but not Texas.
8. TrailBlazer Medicare Part B Termination Costs (A-06-13-00017) 2
legal, and general corporate administration. Because TrailBlazer is no longer in business, we are
addressing the report findings and recommendations to BlueCross.
HOW WE CONDUCTED THIS REVIEW
Our review covered $3,962,920 in Medicare Part B termination costs that TrailBlazer claimed
from July 2008 through March 2012. TrailBlazer claimed costs for building lease termination,
asset disposal, severance pay, personnel, termination of service and maintenance contracts, and
other miscellaneous costs. We determined the allowability of the termination costs that
TrailBlazer claimed by tracing claimed cost items to supporting documentation and reviewed
TrailBlazer’s severance costs to ensure that TrailBlazer claimed severance only for employees
eligible under the contract.
We conducted this performance audit in accordance with generally accepted government
auditing standards. Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions
based on our audit objectives. We believe that the evidence obtained provides a reasonable basis
for our findings and conclusions based on our audit objectives.
See Appendix A for the details of our audit scope and methodology.
FINDINGS
Of the $3,962,920 in Medicare Part B termination costs that we reviewed, $2,666,455 was
reasonable, allocable, and otherwise allowable in accordance with part 31 of the FAR and the
Medicare contract. The remaining $1,296,465 consisted of $137,927 in unsupported costs and
travel costs in excess of the allowable per diem rates and $1,158,538 in potentially unallowable
termination costs for severance pay.
TrailBlazer claimed the unsupported costs and travel costs in excess of allowable per diem rates
because it did not have adequate internal control procedures to ensure that it claimed costs in
accordance with the regulations set forth in the FAR and with the terms of the Medicare contract.
TRAILBLAZER CLAIMED UNALLOWABLE COSTS
TrailBlazer Claimed Unsupported Costs
A contractor is responsible for accounting for costs appropriately and for maintaining records,
including supporting documentation, adequate to demonstrate that costs claimed have been
incurred, are allocable to the contract, and comply with applicable cost principles in the
FAR 31.2 and in agency supplements (FAR 31.201-2(d)). The contracting officer may disallow
all or part of a claimed cost that is inadequately supported.
In addition, the contract between TrailBlazer and CMS required the contractor to maintain
records and provide such access to them as the Secretary of Health and Human Services finds
9. TrailBlazer Medicare Part B Termination Costs (A-06-13-00017) 3
necessary to assure the correctness and verification of the information necessary for the
administration of the contract.4
TrailBlazer could not provide documentation to support $137,820 in costs claimed for asset
disposal, moving and rearranging, termination of service and maintenance contracts, personnel,
and other miscellaneous items.
TrailBlazer Claimed Travel Costs That Exceeded Allowable Per Diem Rates
Costs incurred by contractor personnel on official company business are allowable, subject to
certain limitations. Costs incurred for lodging, meals, and incidental expenses are considered to
be reasonable and allowable only to the extent that they do not exceed the maximum per diem
rates in effect at the time of travel, as set forth in the Federal Travel Regulations for travel in the
contiguous United States (FAR 31.205-46(a)(2)(i)).
TrailBlazer claimed $107 in travel costs that exceeded the allowable per diem rates.5
The
individual traveled to Baltimore, Maryland, for four nights and stayed in a hotel with a nightly
rate that exceeded the allowable per diem rate. In addition, the individual’s meals and incidental
expenses exceeded the allowable per diem amount for the trip.
Lack of Adequate Internal Controls
TrailBlazer claimed the unsupported costs and travel costs in excess of allowable per diem rates
because it did not have adequate internal control procedures to ensure that it claimed costs in
accordance with the regulations for determining the allowability of contract costs set forth in the
FAR and the Medicare contract.
TRAILBLAZER CLAIMED POTENTIALLY UNALLOWABLE SEVERANCE COSTS
A cost is allocable if it is assignable or chargeable to one or more cost objectives on the basis of
relative benefits received or other equitable relationship. Subject to the foregoing, a cost is
allocable to the Government contract if it is incurred specifically for the contract or benefits both
the contract and other work but can be distributed to them in reasonable proportion to the
benefits received, or is necessary to the overall operation of the business, although a direct
relationship to any particular cost objective cannot be shown (FAR 31.201-4).
For “abnormal” or “mass” severance pay, as opposed to “normal turnover” severance payments,
the FAR provides that the Government will participate “to the extent of its fair share”
(FAR 31.205-6(g)(5)).
Moreover, a contractor is responsible for accounting for costs appropriately and for maintaining
records, including supporting documentation, adequate to demonstrate that costs claimed have
been incurred, are allocable to the contract, and comply with applicable cost principles in
4
Section I, Article II, Functions to be Performed by the Carrier, paragraph H.
5
TrailBlazer stated that it was their intent to comply with the per diem rates.
10. TrailBlazer Medicare Part B Termination Costs (A-06-13-00017) 4
FAR 31.2 and in agency supplements (FAR 31.201-2(d)). The contracting officer may disallow
all or part of a claimed cost that is inadequately supported.
Finally, TrailBlazer’s contract states that “[a]ll direct and indirect costs which relate to the
contractor’s non-Medicare business and do not contribute to the Medicare agreement/contract”
are unallowable (Appendix B, § XV, paragraph A).
TrailBlazer claimed $1,158,538 in reimbursement for employee severance costs. TrailBlazer
based its claim for severance reimbursement for all employees on the total years of their service
with TrailBlazer. However, some of these employees worked for TrailBlazer’s private lines of
business as well as Medicare. This method provided an inequitable allocation of costs to
Medicare.
TrailBlazer should have based the severance costs charged to Medicare only on those years that
the employees worked on TrailBlazer’s Medicare line of business. The remainder of the
employees’ severance costs should have been charged to TrailBlazer’s private lines of business,
as appropriate. However, TrailBlazer’s accounting system was unable to calculate the years of
service an employee worked on TrailBlazer’s private lines of business. As a result, we are
setting aside $1,158,538 for CMS to determine whether it was allowable.
RECOMMENDATIONS
We recommend that BlueCross:
• refund to the Federal Government $137,927 for unsupported costs and travel costs and
• work with CMS to determine the allowability of $1,158,538 in termination costs for
severance pay that we set aside and refund to the Federal Government any amount
determined to be unallowable.
BLUECROSS BLUESHIELD OF SOUTH CAROLINA COMMENTS
In its comments on our draft report, BlueCross concurred with our recommendations.
BlueCross’s comments are included in their entirety as Appendix B.
11. TrailBlazer Medicare Part B Termination Costs (A-06-13-00017) 5
APPENDIX A: AUDIT SCOPE AND METHODOLOGY
SCOPE
Our review covered $3,962,920 in Medicare Part B termination costs that TrailBlazer claimed
from July 2008 through March 2012. TrailBlazer claimed costs for building lease termination,
asset disposal, severance pay, personnel, termination of service and maintenance contracts, and
other miscellaneous costs.
Our objective did not require us to review TrailBlazer’s overall internal control structure. We
limited our review to obtaining an understanding of TrailBlazer’s procedures for identifying and
reporting cost claims to CMS.
We conducted our audit work from May 2013 through February 2014.
METHODOLOGY
To accomplish our objective, we:
• reviewed applicable Medicare laws, regulations, and guidelines, including part 31 of the
FAR and the Medicare contract provisions;
• reviewed TrailBlazer’s policies and procedures, including its severance policy;
• interviewed TrailBlazer officials to obtain an understanding of how TrailBlazer claimed
termination costs;
• determined the allowability of the termination costs that TrailBlazer claimed for the
building lease termination, asset disposal, personnel, termination of service and
maintenance contracts, and other miscellaneous costs by tracing claimed cost items to
supporting documentation, including invoices, accounting reports, and payroll records;
• reviewed TrailBlazer’s severance costs to ensure that TrailBlazer claimed severance only
for employees eligible under the contract; and
• discussed the results of our audit with BlueCross officials.
We conducted this performance audit in accordance with generally accepted government
auditing standards. Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions
based on our audit objectives. We believe that the evidence obtained provides a reasonable basis
for our findings and conclusions based on our audit objectives.
12. APPENDIX B: BLUECROSS BLUESHIELD OF SOUTH CAROLINA COMMENTS
~0
PALMETTO GSA.
PO BOX 100134 I COlUMBIA, sc 29202-3134 I PAlMETTOGBA.COM I ISO 9001 A CELERIAN GROUP COMPANY
JOE WRIGHT
Vke Pro•ident endCFO
August 20, 2014
Ms. Patricia Wheeler
Regional Inspector General
For Audit Services
Centers for Medicare and Medicaid Setvices
I tOO Commerce Street, Room 632
Dallas, Texas 75242
RE: Audit Rep0l1 Number: A-06-13-00017
Dear Ms. Wheeler:
We are responding to the draft report dated July 22, 2014 entitled "TrailBlazer Health
Enterprises, LLC, Claimed Unallowable Medicare Part 8 Tem1ination Costs" for the FY July
2008 thru March 2012.
'TI1e audit contained the following recommendations with which we concur on behalf of
TrailBlazer Enterprises, LLC:
• Refund to the Federal Govemmenl $137,927 ofunsupported costs and travel costs and
• Work with CMS to determine the allowability of $1,158,538 in tem1ination costs for
severance pay that was set aside and refund to the Federal Govemment any amount
detennined to be unallowable.
If you have any questions, please !'eel free to contact me at 803-763-5544.
Sincerely,
/s/
cc: Bmce Hughes, BCBSSC
Louis McElveen, BCBSSC
Mark Wimple, OIG
TrailBlazer Medicare Part B Terminaiion Costs (A-06-13-00017) 6