Federal Register / Vol. 61, No. 117 / Monday, June 17, 1996 / Notices 30623

State and City Project period

ending date

Total Number of Grantees in the State of: CT ..................................................................................................................... 1

FL:.

MIAMI ........................................................................................................................................................................................ 10/31/96

TAMPA ...................................................................................................................................................................................... 03/31/97

Total Number of Grantees in the State of: FL ...................................................................................................................... 2

IN: INDIANAPOLIS .......................................................................................................................................................................... 05/31/97

Total Number of Grantees in the State of: IN ...................................................................................................................... 1

MI:

BATTLE CREEK ....................................................................................................................................................................... 10/31/96

DETROIT .................................................................................................................................................................................. 10/31/96

GRAND RAPIDS ...................................................................................................................................................................... 10/31/96

Total Number of Grantees in the State of: MI ...................................................................................................................... 3

MN:

ST. PAUL .................................................................................................................................................................................. 01/31/97

ST. PAUL .................................................................................................................................................................................. 01/31/97

Total number of Grantees in the State of: MN ..................................................................................................................... 2

NE: OMAHA 01/31/97

Total Number of Grantees in the State of: NE ..................................................................................................................... 1

NY: NEW YORK .............................................................................................................................................................................. 10/31/96

Total Number of Grantees in the State of: NY ..................................................................................................................... 1

OH:

COLUMBUS .............................................................................................................................................................................. 10/31/96

TOLEDO ................................................................................................................................................................................... 11/30/96

Total Number of Grantees in the State of: OH ..................................................................................................................... 2

SD: RAPID CITY .............................................................................................................................................................................. 01/31/97

Total Number of Grantees in the State of: SD ..................................................................................................................... 1

TX: LUBBOCK ................................................................................................................................................................................. 06/30/97

Total Number of Grantees in the State of: TX ..................................................................................................................... 1

WA: SPOKANE ................................................................................................................................................................................ 10/31/96

Total Number of Grantees in the State of: WA .................................................................................................................... 1

Total Number of Grantees .................................................................................................................................................... 17

[FR Doc. 96–15255 Filed 6–14–96; 8:45 am]

BILLING CODE 4160–15–U

Office of Inspector General

Publication of OIG Special Fraud Alert:

Fraud and Abuse in the Provision of

Services in Nursing Facilities

AGENCY: Office of Inspector General

(OIG), HHS.

ACTION: Notice.

SUMMARY: This Federal Register notice

sets forth a recently issued OIG Special

Fraud Alert concerning fraud and abuse

practices in the provision of medical

and other health services to residents of

nursing facilities. For the most part, OIG

Special Fraud Alerts address national

trends in health care fraud, including

potential violations of the Medicare

anti-kickback statute. This Special

Fraud Alert, issued directly to the

health care provider community and

now being reprinted in this issue of the

Federal Register, specifically identifies

and highlights some of the illegal

practices that the OIG has uncovered in

the provision of nursing facility

services.

FOR FURTHER INFORMATION CONTACT: Joel

J. Schaer, Office of Management and

Policy, (202) 619–0089.

SUPPLEMENTARY INFORMATION:

I. Background

The Office of Inspector General (OIG)

issues Special Fraud Alerts based on

information it obtains concerning

particular fraudulent and abusive

practices within the health care

industry. These Special Fraud Alerts

provide the OIG with a means of

notifying the industry that we have

become aware of certain abusive

practices which we plan to pursue and

prosecute, or bring civil and

administrative action, as appropriate.

The Alerts also serve as a powerful tool

to encourage industry compliance by

giving providers an opportunity to

examine their own practices.

The Special Fraud Alerts are intended

for extensive distribution directly to the

health care provider community, as well

as those charged with administering the

Medicare and Medicaid programs. On

December 19, 1994, the OIG published

in the Federal Register the texts of 5

previously-issued Special Fraud Alerts

(59 FR 65372), and indicated our

intention of publishing all future

Special Fraud Alerts in this same

manner as a regular part of our

dissemination of this information. Two

additional OIG Special Fraud Alerts

addressing home health fraud and fraud

and abuse provisions of medical

supplies in nursing facilities was

published in the Federal Register on

August 10, 1995 (60 FR 40847).

With regard to the provision of health

care services reimbursed by Medicare

and Medicaid to nursing facilities, this

newly-issued Special Fraud Alert

highlights such fraudulent practices as

(1) making claims for services not

rendered or not provided as claimed,

and (2) the submission of claims

falsified to circumvent coverage

limitations on medical specialties. A

reprint of this Special Fraud Alert

follows.

II. Special Fraud Alert: Fraud and

Abuse in the Provision of Services in

Nursing Facilities (May 1996)

The Office of Inspector General (OIG)

was established at the Department of

Health and Human Services by Congress

in 1976 to identify and eliminate fraud,

waste and abuse in Health and Human

Services programs and to promote

efficiency and economy in departmental

operations. The OIG carries out this

mission through a nationwide program

of audits, investigations and

inspections.
30624 Federal Register / Vol. 61, No. 117 / Monday, June 17, 1996 / Notices

To help reduce fraud and abuse in the

Medicare and Medicaid programs, the

OIG actively investigates schemes to

fraudulently obtain money from these

programs and, when appropriate, issues

Special Fraud Alerts which identify

segments of the health care industry that

are particularly vulnerable to abuse.

This Special Fraud Alert focuses on the

provision of medical and other health

care services to residents of nursing

facilities and identifies some of the

illegal practices that the OIG has

uncovered.

How Nursing Facility Benefits Are

Reimbursed

There were 17,000 nursing facilities

in the United States, as of June 1995. An

OIG study reported that in 1992,

Medicare payments to nursing facilities

included Part B payments of $2.7 billion

and Part A payments of $3.1 billion for

covered stays in nursing facilities. When

the Federal share of the $24 billion

spent by Medicaid is factored in, the

Federal cost of nursing care reached a

total of approximately $20 billion.

Many nursing facilities receive

reimbursement from both Medicare and

Medicaid for care and services provided

to eligible residents. Under Medicare

Part A, skilled nursing facility services

are paid on the basis of cost for covered

stays of a limited length. Nursing

facility residents may be concurrently

eligible for benefits under Medicare Part

B. For Medicaid-eligible residents,

extended nursing facility stays may be

reimbursed by state-administered

programs financed in part by Medicaid.

Nursing facilities and their residents

have become common targets for

fraudulent schemes. Nursing facilities

represent convenient resident ‘‘pools’’

and make it lucrative for unscrupulous

persons to carry out fraudulent schemes.

The OIG has become aware of a number

of fraudulent arrangements by which

health care providers, including medical

professionals, inappropriately bill

Medicare and Medicaid for the

provision of unnecessary services and

services which were not provided at all.

Sometimes, nursing facility

management and staff also are involved

in these schemes.

False or Fraudulent Claims Relating to

the Provision of Health Care Services

The government may prosecute

persons who submit or cause the

submission of false or fraudulent claims

to the Medicare or Medicaid program.

Examples of false or fraudulent claims

include claims for items that were never

provided or were not provided as

claimed, and claims for services which

a person knows are not medically

necessary.

Submitting or causing false claims to

be submitted to Medicare or Medicaid

may subject the individual or entity to

criminal prosecution, civil penalties

including treble damages, and exclusion

from participation in the Medicare and

Medicaid programs. The OIG has

uncovered the following types of

fraudulent transactions related to the

provision of health care services to

residents of nursing facilities

reimbursed by Medicare and Medicaid:

Claims for Services Not Rendered or Not

Provided as Claimed

Common schemes entail falsifying

bills and medical records to

misrepresent the services, or extent of

services, provided at nursing facilities.

Some examples follow:

• One physician improperly billed

$350,000 over a 2-year period for

comprehensive physical examinations

of residents without ever seeing a single

resident. The physician went so far as

to falsify medical records to indicate

that nonexistent services were rendered.

• A psychotherapist working in

nursing facilities manipulated Medicare

billing codes to charge for 3 hours of

therapy for each resident when, in fact,

he spent only a few minutes with each

resident. In a nursing facility, 3 hours of

psychotherapy is highly unusual and

often clinically inappropriate.

• An investigation of a speech

specialist uncovered documentation

showing that he overstated the time

spent on each session claimed. Claims

analysis showed that the speech

specialist actually claimed to spend 20

hours with residents every day, far more

time than possible. Further investigation

revealed that some residents had never

met the specialist, and some were dead

at the time when the specialist claimed

to have provided speech services to

them.

• A company providing mobile X-ray

services made visits to nursing facilities,

and billed for taking two X-rays when

only one was actually taken. The case

also presented serious concerns about

quality of care when the investigation

revealed that company personnel were

not certified to take X-rays.

Claims Falsified To Circumvent

Coverage Limitations on Medical

Specialties

Practitioners of medical specialties

have been found to misrepresent the

nature of services provided to Medicare

and Medicaid beneficiaries because the

Federally funded programs have

stringent coverage limitations for some

specialties, including podiatry,

audiology, and optometry. For instance:

• The OIG has learned about

podiatrists whose entire practices

consisted of visits to nursing facilities.

Non-covered routine care is provided,

e.g., toenail clipping, but Medicare is

billed for covered services which were

not provided or needed. In one case, an

investigator discovered suspicious

billing for foot care when it was

reported that a podiatrist was

performing an excessive number of

toenail removals, a service that is

covered but not frequently or routinely

needed. This podiatrist billed Medicare

as much as $100,000 in 1 year for

toenail removals. Investigators

discovered one resident for whom bills

were submitted claiming a total of 11

toenail removals.

• An optometrist claimed

reimbursement for covered eye care

consultations when he, in fact,

performed routine exams and other noncovered services. His billing history

indicated that he claimed to have

performed as many as 25 consultations

in one day at a nursing home. This is

an unreasonably high number, given the

nature of a Medicare-covered

consultation.

• An audiologist made arrangements

with a nursing facility and affiliated

physicians to get orders for hearing

exams that were not medically

necessary. The audiologist used this

access to residents exclusively to market

hearing aids. In this case, the facility

and physicians, in addition to the

audiologist, could be held liable for

false or fraudulent claims if they acted

with knowledge of the claims for

unnecessary service.

What To Look For in the Provision of

Services to Nursing Facilities

The following situations may suggest

fraudulent or abusive activities:

• ‘‘Gang visits’’ by one or more

medical professionals where large

numbers of residents are seen in a single

day. The practitioner may be providing

medically unnecessary services, or the

level of service provided may not be of

a sufficient duration or scope consistent

with the service billed to Medicare or

Medicaid.

• Frequent and recurring ‘‘routine

visits’’ by the same medical

professional. Seeing residents too often

may indicate that the provider is billing

for services that are not medically

necessary.

• Unusually active presence in

nursing facilities by health care

practitioners who are given or request

unlimited access to resident medical

records. These individuals may be
Federal Register / Vol. 61, No. 117 / Monday, June 17, 1996 / Notices 30625

collecting information used in the

submission of false claims.

• Questionable documentation for

medical necessity of professional

services. Practitioners who are billing

inappropriately may also enter, or fail to

enter, important information on medical

charts.

What To Do if You Have Information

About Fraud and Abuse Against the

Medicare and Medicaid Programs

If you have information about the

types of activities described above,

contact any of the field offices of the

Office of Investigations of the Office of

Inspector General, U.S. Department of

Health and Human Services, at the

following locations:

Field offices States served Telephone

Boston ...................................................................................... MA, VT, NH, ME RI, CT ......................................................... 617–565–2660

New York .................................................................................. NY, NJ, PR, VI ........................................................................ 212–264–1691

Philadelphia .............................................................................. PA, MD, DE, WV, VA .............................................................. 215–596–6796

Atlanta ...................................................................................... GA, KY, NC, SC, FL, TN, AL, MS (No. District) ..................... 404–331–2131

Chicago .................................................................................... IL, MN, WI, MI, IN, OH, IA, MO .............................................. 312–353–2740

Dallas ....................................................................................... TX, NM, OK, AR, LA, MS (So. District), CO, UT, WY, MT,

ND, SD, NE, KS.

214–767–8406

Los Angeles ............................................................................. AZ, NV (Clark Co.), So. CA .................................................... 714–246–8302

San Francisco .......................................................................... No. CA, NV, AK, HI, OR, ID, WA ........................................... 415–437–7960

Washington, DC ....................................................................... DC and Metropolitan areas of VA & MD ................................ 202–619–1900

To Report Suspected Fraud, Call or

Write

1–800–HHS-TIPS, Department of

Health and Human Services, Office of

Inspector General, P.O. Box 23489,

L’Enfant Plaza Station, Washington,

D.C. 20026–3489.

Dated: May 29, 1996.

June Gibbs Brown,

Inspector General.

[FR Doc. 96–15269 Filed 6–14–96; 8:45 am]

BILLING CODE 4150–04–P

National Institutes of Health

National Institute of Mental Health;

Notice of Closed Meetings

Pursuant to Section 10(d) of the

Federal Advisory Committee Act, as

amended (5 U.S.C. Appendix 2), notice

is hereby given of the following

meetings of the National Institute of

Mental Health Special Emphasis Panel:

Agenda/Purpose: To review and evaluate

grant applications.

Committee Name: National Institute of

Mental Health Special Emphasis Panel.

Date: June 26, 1996.

Time: 1 p.m.

Place: Parklawn Building, Room 9C–26,

5600 Fishers Lane, Rockville, MD 20857.

Contact Person: Rehana A. Chowdhury,

Parklawn Building, Room 9C–26, 5600

Fishers Lane, Rockville, MD 20857,

Telephone: 301, 443–6470.

Committee Name: National Institute of

Mental Health Special Emphasis Panel.

Date: July 8, 1996.

Time: 12 p.m.

Place: Parklawn Building, Room 9C–26,

5600 Fishers Lane, Rockville, MD 20857.

Contact Person: Sheri L. Schwartzback,

Parklawn Building, Room 9C–26, 5600

Fishers Lane, Rockville, MD 20857,

Telephone: 301, 443–4843.

Committee Name: National Institute of

Mental Health Special Emphasis Panel.

Date: July 8, 1996.

Time: 12 p.m.

Place: Parklawn Building, Room 9C–26,

5600 Fishers Lane, Rockville, MD 20857.

Contact Person: Jean G. Noronha, Parklawn

Building, Room 9C–26, 5600 Fishers Lane,

Rockville, MD 20857, Telephone: 301, 443–

6470.

Committee Name: National Institute of

Mental Health Special Emphasis Panel.

Date: July 9, 1996.

Time: 1 p.m.

Place: Parklawn Building, Room 9C–26,

5600 Fishers Lane, Rockville, MD 20857.

Contact Person: Jean G. Noronha, Parklawn

Building, Room 9C–26, 5600 Fishers Lane,

Rockville, MD 20857, Telephone: 301, 443–

6470.

Committee Name: National Institute of

Mental Health Special Emphasis Panel.

Date: July 9, 1996.

Time: 12 p.m.

Place: Parklawn Building, Room 9C–26,

5600 Fishers Lane, Rockville, MD 20857.

Contact Person: Sheri L. Schwartzback,

Parklawn Building, Room 9C–26, 5600

Fishers Lane, Rockville, MD 20857,

Telephone: 301, 443–4843.

The meetings will be closed in accordance

with the provisions set forth in secs.

552b(c)(4) and 552b(c)(6), Title 5, U.S.C.

Applications and/or proposals and the

discussions could reveal confidential trade

secrets or commercial property such as

patentable material and personal information

concerning individuals associated with the

applications and/or proposals, the disclosure

of which would constitute a clearly

unwarranted invasion of personal privacy.

This notice is being published less

than fifteen days prior to the meetings

due to the urgent need to meet timing

limitations imposed by the review and

funding cycle.

(Catalog of Federal Domestic Assistance

Program Numbers 93.242, 93.281, 93.282)

Dated: June 10, 1996.

Susan K. Feldman,

Committee Management Officer, NIH.

[FR Doc. 96–15230 Filed 6–14–96; 8:45 am]

BILLING CODE 4140–01–M

Substance Abuse and Mental Health

Services Administration

Block Grant Allocation Processes

AGENCY: Substance Abuse and Mental

Health Services Administration, HHS.

ACTION: Notice and opportunity for

public comment.

SUMMARY: The Substance Abuse and

Mental Health Services Administration

(SAMHSA) allocates funding to States

and territories for the Community

Mental Health Services (CMHS) Block

Grant and the Substance Abuse

Prevention and Treatment (SAPT) Block

Grant. This notice describes the

formulas which the law requires be used

for distributing these funds and the

information used in making the

calculations.

This notice has five parts. Section I

provides background information on the

allocation process. Section II describes

the legislation and the formulas

applicable to the Community Mental

Health Services Block Grant. Section III

describes the legislation and the

formulas applicable to the Substance

Abuse Prevention and Treatment Block

Grant. Section IV provides detailed

information on the sources of data used

in the calculations. Section V contains

technical information important in

making the actual calculations.

DATES: Written comments must be

received by August 1, 1996. Any written

comments received will be taken into