jurisdiction: US

text: b"\x0cPage 2 \xe2\x80\x93 Mr. Albert Hawkins\n\n\nDirect Reply to HHS Action Official:\n\nMs. Jackie Garner, Consortium Administrator\nConsortium for Medicaid and Children\xe2\x80\x99s Health Operations\nCenters for Medicare & Medicaid Services\n233 North Michigan Avenue, Suite 600\nChicago, Illinois 60601\nrochiora@cms.hhs.gov\n\x0cDepartment of Health and Human Services\n\n OFFICE OF \n\n INSPECTOR GENERAL \n\n\n\n\n\n MEDICAID PAYMENTS MADE \n\nFOR NONEMERGENCY SERVICES \n\nPROVIDED TO UNDOCUMENTED \n\n ALIENS AND LEGAL ALIENS \n\n RESTRICTED TO EMERGENCY \n\n SERVICES IN TEXAS\n\n\n\n\n\n Daniel R. Levinson\n\n Inspector General \n\n\n August 2009\n\n A-06-07-00108\n\n\x0c Office of Inspector General\n http://oig.hhs.gov\n\n\n\nThe mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as\namended, is to protect the integrity of the Department of Health and Human Services (HHS)\nprograms, as well as the health and welfare of beneficiaries served by those programs. This\nstatutory mission is carried out through a nationwide network of audits, investigations, and\ninspections conducted by the following operating components:\n\nOffice of Audit Services\n\nThe Office of Audit Services (OAS) provides auditing services for HHS, either by conducting\naudits with its own audit resources or by overseeing audit work done by others. Audits examine\nthe performance of HHS programs and/or its grantees and contractors in carrying out their\nrespective responsibilities and are intended to provide independent assessments of HHS\nprograms and operations. These assessments help reduce waste, abuse, and mismanagement and\npromote economy and efficiency throughout HHS.\n\nOffice of Evaluation and Inspections\nThe Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS,\nCongress, and the public with timely, useful, and reliable information on significant issues.\nThese evaluations focus on preventing fraud, waste, or abuse and promoting economy,\nefficiency, and effectiveness of departmental programs. To promote impact, OEI reports also\npresent practical recommendations for improving program operations.\n\nOffice of Investigations\nThe Office of Investigations (OI) conducts criminal, civil, and administrative investigations of\nfraud and misconduct related to HHS programs, operations, and beneficiaries. With\ninvestigators working in all 50 States and the District of Columbia, OI utilizes its resources by\nactively coordinating with the Department of Justice and other Federal, State, and local law\nenforcement authorities. The investigative efforts of OI often lead to criminal convictions,\nadministrative sanctions, and/or civil monetary penalties.\n\nOffice of Counsel to the Inspector General\nThe Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG,\nrendering advice and opinions on HHS programs and operations and providing all legal support\nfor OIG\xe2\x80\x99s internal operations. OCIG represents OIG in all civil and administrative fraud and\nabuse cases involving HHS programs, including False Claims Act, program exclusion, and civil\nmonetary penalty cases. In connection with these cases, OCIG also negotiates and monitors\ncorporate integrity agreements. OCIG renders advisory opinions, issues compliance program\nguidance, publishes fraud alerts, and provides other guidance to the health care industry\nconcerning the anti-kickback statute and other OIG enforcement authorities.\n\x0c Notices\n\n THIS REPORT IS AVAILABLE TO THE PUBLIC\n at http://oig.hhs.gov\n\nPursuant to the Freedom of Information Act, 5 U.S.C. ' 552, Office of\nInspector General reports generally are made available to the public to\nthe extent that information in the report is not subject to exemptions in\nthe Act.\n\n OFFICE OF AUDIT SERVICES FINDINGS AND OPINIONS\n\nThe designation of financial or management practices as questionable, a\nrecommendation for the disallowance of costs incurred or claimed, and\nany other conclusions and recommendations in this report represent the\nfindings and opinions of OAS. Authorized officials of the HHS operating\ndivisions will make final determination on these matters.\n\x0c EXECUTIVE SUMMARY \n\n\nBACKGROUND \n\n\nSection 1903(v) of the Social Security Act states that Federal Medicaid funding is available to\nStates for medical services provided to aliens who are not lawfully admitted for permanent\nresidence or otherwise permanently residing in the United States under color of law only when\nthose services are necessary to treat an emergency medical condition. Further, 42 CFR \xc2\xa7\n440.255 states that Federal Medicaid funding is available to States for medical services provided\nto aliens granted lawful temporary resident status or lawful permanent resident status and who\nmeet all other requirements for Medicaid only when those services are necessary to treat an\nemergency medical condition.\n\nIn addition, 42 CFR \xc2\xa7 440.255 states that Federal Medicaid funding is available to States for\nservices provided to pregnant women if a provision is included in the approved State plan.\nThese services include routine prenatal care, labor and delivery, and routine postpartum care.\n\nIn Texas, the Texas Health and Human Services Commission (the State agency) administers the\nMedicaid program. Texas Administrative Code Rule 354.2103 uses the definition of an\nemergency medical condition contained in Federal regulations. To receive emergency Medicaid\nfunding in Texas, providers are required to fill out an \xe2\x80\x9cEmergency Medical Services Certification\nForm\xe2\x80\x9d (Form 3038) certifying that the patient had received treatment for an emergency medical\ncondition. In addition, the State has a list of medical diagnoses, including labor and delivery,\nthat it considers to be emergency conditions and has an edit (edit 00064) to verify whether the\ncondition coded on a claim is one that the State considers to be an emergency. Coverage is\nlimited to the specific dates of service of the emergency, as stated on the Form 3038, and does\nnot include any service provided after the emergency condition has been stabilized.\n\nDuring our audit period (October 1, 2004, through September 30, 2005), the State agency\nprocessed 303,266 claims totaling approximately $314.2 million ($191.2 million Federal share)\nfor medical services and approximately $148,000 ($90,000 Federal share) for prescription drugs\nprovided to undocumented aliens and legal aliens restricted to emergency services. Of the\n$314.2 million total, approximately $218.3 million (70 percent) was for labor and delivery\nservices.\n\nOBJECTIVE\n\nOur objective was to determine whether the State agency had adequate internal controls to ensure\nthat, for undocumented aliens and legal aliens restricted to emergency services, Federal\nreimbursement was claimed only for those conditions that it defined as emergency services.\n\nSUMMARY OF FINDINGS\n\nThe State agency did not have adequate internal controls to ensure that, for undocumented aliens\nand legal aliens restricted to emergency services, Federal reimbursement was claimed only for\nthose conditions that it defined as emergency services. We reviewed 854 medical claims and 44\n\n\n i\n\x0cprescription drug claims. For the 854 medical claims, we determined that the services contained\non 629 claims totaling $679,588 met the State\xe2\x80\x99s definition of emergency care. However,\nservices contained on 193 claims totaling $262,366 ($159,702 Federal share) did not meet the\ndefinition. The State agency did not have the supporting medical documentation for us to\ndetermine whether the services billed on 32 claims totaling $5,903 were for emergency care.\nTherefore, we are questioning 193 claims for the following reasons:\n\n \xe2\x80\xa2\t The State agency claimed Federal reimbursement for 170 medical claims for\n nonemergency services totaling $165,494 ($100,736 Federal share) because edit 00064\n was inadequate.\n\n \xe2\x80\xa2\t The State agency claimed Federal reimbursement for 23 claims for nonemergency\n services totaling $96,872 ($58,966 Federal share). These claims were initially denied by\n edit 00064; however, upon appeal, the claims were paid.\n\nThe State agency claimed Federal reimbursement for 7,114 claims totaling $147,805 ($89,969\nFederal share) for prescription drugs that did not meet the State\xe2\x80\x99s definition of emergency care.\n\nIn addition, the edit in place to prevent payment of family planning services claims for\nundocumented aliens and legal aliens did not always operate correctly or was manually\noverridden to allow services to be claimed as family planning services, which are paid at an\nenhanced Federal medical assistance rate of 90 percent. The State agency claimed a total of\n$126,178 ($113,560 Federal share) for 350 claims at the enhanced rate of 90 percent. As a result,\nthe State agency claimed overpayments totaling at least $36,756 (Federal share).\n\nFinally, Form 3038 was not completed for 429 of our sampled claims (48 percent) or was not a\nreliable indicator of whether the services provided were for emergency medical services.\n\nRECOMMENDATIONS\n\nWe recommend that the State agency:\n\n \xe2\x80\xa2\t adjust the \xe2\x80\x9cQuarterly Medicaid Statement of Expenditures for the Medical Assistance\n Program\xe2\x80\x9d (Form CMS-64) for the $159,702 (Federal share) claimed for services that did\n not meet the State\xe2\x80\x99s definition of emergency care;\n\n \xe2\x80\xa2\t ensure that officials responsible for reviewing appealed claims for the emergency\n Medicaid program are familiar with Federal and State requirements and have medical\n backgrounds to determine whether claims are for emergency medical treatment;\n\n \xe2\x80\xa2\t adjust the Form CMS-64 for the $89,969 (Federal share) claimed for unallowable\n prescription drugs and for any additional Federal funds paid for prescriptions filled prior\n and subsequent to our audit period;\n\n \xe2\x80\xa2\t adjust the Form CMS-64 for the $36,756 (Federal share) for the 350 claims improperly\n paid at the enhanced Federal medical assistance percentage rate for family planning\n\n\n ii\n\x0c services, review the claims to determine whether the services provided were for\n nonemergencies and make any additional adjustments as necessary;\n\n \xe2\x80\xa2\t require medical personnel to review medical records prior to certifying on Form 3038\n that emergency medical treatment was provided and ensure that the certified dates are\n limited to the specific dates of the emergency;\n\n \xe2\x80\xa2\t strengthen its policies and procedures, including developing edits, to prevent Medicaid\n payments for nonemergency services provided to aliens; and\n\n \xe2\x80\xa2\t periodically sample and review claims paid for emergency medical services provided to\n aliens and refund any payments made in error.\n\nSTATE AGENCY COMMENTS\n\nIn its comments on our draft report, the State agency said that it will take corrective action for\neach of the recommendations and analyze the claims identified in the report for services that\nreportedly did not meet the definition of emergency care and refund the Federal share. The State\nagency\xe2\x80\x99s comments are included in their entirety as the Appendix.\n\n\n\n\n iii\n\x0c TABLE OF CONTENTS \n\n\n Page\n\nINTRODUCTION.......................................................................................................................1 \n\n\n BACKGROUND ..............................................................................................................1 \n\n The Medicaid Program\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6.. ...............................................................1 \n\n Federal Emergency Medicaid Funding for Aliens\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6............................1 \n\n State Emergency Medicaid Funding for Aliens\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6................................1 \n\n\n OBJECTIVE, SCOPE, AND METHODOLOGY ............................................................2 \n\n Objective\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6. ..........................................................................................2 \n\n Scope.....................................................................................................................3 \n\n Methodology .........................................................................................................3 \n\n\nFINDINGS AND RECOMMENDATIONS .............................................................................4 \n\n\n UNALLAOWABLE MEDICAL SERVICES CLAIMS\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa64 \n\n Edit To Deny Nonemergency Medical Services Claims\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6...4\n\n Nonemergency Medical Services Claims Paid on Appeal\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa66 \n\n\n UNALLOWABLE PRESCRIPTION DRUG CLAIMS\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6..7 \n\n\n CLAIMS IMPROPERLY PAID AT THE ENHANCED FEDERAL RATE FOR\n FAMILY PLANNING SERVICES\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6..7\n\n\n EMERGENCY MEDICAL SERVICES CERTIFICATION FORM 3038\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa68\n\n RECOMMENDATIONS\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6...8 \n\n\n STATE AGENCY COMMENTS\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6\xe2\x80\xa6..9 \n\n\nAPPENDIX\n\n STATE AGENCY COMMENTS\n\n\n\n\n iv\n\x0c INTRODUCTION \n\n\nBACKGROUND\n\nThe Medicaid Program\n\nPursuant to Title XIX of the Social Security Act (the Act), the Medicaid program provides\nmedical assistance to low-income individuals and individuals with disabilities. The Federal and\nState Governments jointly fund and administer the Medicaid program. At the Federal level, the\nCenters for Medicare & Medicaid Services (CMS) administers the program. Each State\nadministers its Medicaid program in accordance with a CMS-approved State plan. Although the\nState has considerable flexibility in designing and operating its Medicaid program, it must\ncomply with applicable Federal requirements.\n\nFederal Emergency Medicaid Funding for Aliens\n\nSection 1903(v) of the Social Security Act states that Federal Medicaid funding is available to\nStates for medical services provided to aliens who are not lawfully admitted for permanent\nresidence or otherwise permanently residing in the United States under color of law only when\nthose services are necessary to treat an emergency medical condition. Further, 42 CFR \xc2\xa7\n440.255 states that Federal Medicaid funding is available to States for medical services provided\nto aliens granted lawful temporary resident status or lawful permanent resident status and who\nmeet all other requirements for Medicaid only when those services are necessary to treat an\nemergency medical condition.\n\nSection 1903(v) of the Act and 42 CFR \xc2\xa7 440.255 define an emergency medical condition as one\nmanifested by acute symptoms of such severity that the absence of immediate medical attention\ncould reasonably be expected to result in (1) placing the patient\xe2\x80\x99s health in serious jeopardy, (2)\nserious impairment to bodily functions, or (3) serious dysfunction of any body part or organ.\nFurther, 42 CFR \xc2\xa7 440.255 specifies that there must be \xe2\x80\x9csudden onset\xe2\x80\x9d of the condition. In\naddition, 42 CFR \xc2\xa7 440.255 states that Federal Medicaid funding is available to States for\nservices provided to pregnant women if a provision is included in the approved State plan.\nThese services include routine prenatal care, labor and delivery, and routine postpartum care.\n\nState Emergency Medicaid Funding for Aliens\n\nIn Texas, the Texas Health and Human Services Commission (the State agency) administers the\nMedicaid program. Texas\xe2\x80\x99s State plan authorizes payments and extends coverage to (1) aliens\nnot lawfully admitted for permanent residence or otherwise permanently residing in the United\nStates under color of law and (2) aliens granted lawful, temporary resident status. Coverage is\nlimited, however, to care and services necessary for the treatment of an emergency medical\ncondition (including labor and delivery). An alien granted lawful temporary resident status is\nrestricted to emergency services during the 5-year period beginning on the date the alien is\ngranted such status. 1\n\n1\n The 5-year bar applies to legal aliens who entered the United States on or after August 22, 1996, and who are not\neligible for Medicaid for a period of 5 years from the date they entered the country as legal aliens.\n\n 1\n\n\x0cTexas Administrative Code Rules 358.105 and 354.2103 state that to qualify for emergency\nMedicaid services, undocumented aliens and legal aliens restricted to emergency services must\notherwise be eligible for regular Medicaid services and require emergency medical services after\nthe sudden onset of a medical condition. The medical condition should include acute symptoms\nof sufficient severity, including severe pain, that the absence of immediate medical attention\ncould reasonably result in (1) placing the patient\xe2\x80\x99s health in serious jeopardy, (2) serious\nimpairment of bodily functions, or (3) serious dysfunction of any body part or organ.\n\nThe \xe2\x80\x9cTexas Medicaid Provider Procedures Manual\xe2\x80\x9d states that undocumented aliens and legal\naliens restricted to emergency services are eligible only for emergency services, including labor\nand delivery. Coverage is limited to the specific dates of service of the emergency and does not\ninclude any service provided after the emergency condition has been stabilized.\n\nThe \xe2\x80\x9cTexas Works Handbook\xe2\x80\x9d states that an application for Medicaid received from an\nundocumented alien or legal alien restricted to emergency services cannot be processed unless\nthe State agency has an \xe2\x80\x9cEmergency Medical Services Certification Form\xe2\x80\x9d (Form 3038)\ncompleted by the hospital or other medical services provider certifying that the person received\ntreatment for an emergency medical condition. The Forms 3038 are maintained in the State\nagency\xe2\x80\x99s Medicaid eligibility files for each patient.\n\nTexas also has a list of 3,987 diagnoses that it considers to be emergency medical care.\nExamples of these diagnoses include abdominal pain, shortness of breath, chest pains, normal\ndelivery, and altered mental status. The State uses this list to determine whether claims are for\nemergency care. The State agency has an edit (00064) that determines whether the diagnosis\ncodes on claims match the codes on its list of emergencies and denies claims that do not have\nemergency diagnosis codes (ERDX).\n\nThe State agency claims Federal reimbursement for emergency medical services provided to\nundocumented aliens and legal aliens restricted to emergency services on the \xe2\x80\x9cQuarterly\nMedicaid Statement of Expenditures for the Medical Assistance Program\xe2\x80\x9d (Form CMS-64).\nDuring our audit period (October 1, 2004, through September 30, 2005), the State agency\nprocessed 303,266 claims totaling approximately $314.2 million ($191.2 million Federal share)\nfor emergency medical services provided to undocumented aliens and approximately $148,000\n($90,000 Federal share) for drugs prescribed for them. Of the $314.2 million total,\napproximately $218.3 million (70 percent) was for labor and delivery services.\n\nThe State agency contracts with Texas Medicaid and Healthcare Partnership (TMHP) to process\nand pay its Medicaid medical service claims and with First Health Services Corporation to\nprocess and pay its Medicaid prescription drug claims.\n\nOBJECTIVE, SCOPE, AND METHODOLOGY\n\nObjective\n\nOur objective was to determine whether the State agency had adequate internal controls to ensure\nthat, for undocumented aliens and legal aliens restricted to emergency services, Federal\nreimbursement was claimed only for those conditions that it defined as emergency services.\n\n 2\n\n\x0cScope\n\nWe reviewed a judgmental sample of 854 medical services claims and 44 outpatient prescription\ndrug claims totaling $949,602. During our audit period, the Federal fiscal year ended September\n30, 2005, the State agency processed 303,266 claims totaling approximately $314.2 million\n($191.2 million Federal share) for medical services and approximately $148,000 ($90,000\nFederal share) for prescription drugs provided to undocumented aliens and legal aliens restricted\nto emergency services. We limited our review to the State agency\xe2\x80\x99s internal controls over claims\nfor services provided to undocumented aliens and legal aliens restricted to emergency services.\n\nWe performed our fieldwork at the State agency in Austin, Texas, and at selected medical\nproviders.\n\nMethodology\n\nTo accomplish our objective, we:\n\n \xe2\x80\xa2\t reviewed applicable Federal and State laws and regulations and the State plan;\n\n \xe2\x80\xa2\t reviewed the State agency\xe2\x80\x99s policies and procedures and the program instructions related\n to the payment of claims for emergency medical services provided to undocumented\n aliens and legal aliens restricted to emergency services;\n\n \xe2\x80\xa2\t interviewed State agency personnel, selected medical providers, State Medicaid\n eligibility workers, and private sector workers involved with the eligibility process;\n\n \xe2\x80\xa2\t judgmentally selected 898 claims (854 for medical services and 44 for outpatient\n prescription drugs) totaling $949,602;\n\n \xe2\x80\xa2\t reviewed the Medicaid eligibility files and medical records that supported our sample\n claims to determine whether aliens were restricted to emergency medical services as\n defined by the State and whether the files contained a completed Form 3038; and\n\n \xe2\x80\xa2\t obtained the professional opinion of the State agency Medical Director\xe2\x80\x99s Office medical\n personnel, including a physician and registered nurse, on whether selected claims for\n emergency services were valid based on the supporting medical records, language in\n section 1903(v) of the Act, and the State agency\xe2\x80\x99s definition of emergency services.\n\nWe conducted this performance audit in accordance with generally accepted government\nauditing standards. Those standards require that we plan and perform the audit to obtain\nsufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions\nbased on our audit objectives. We believe that the evidence obtained provides a reasonable basis\nfor our findings and conclusions based on our audit objective.\n\n\n\n\n 3\n\n\x0c FINDINGS AND RECOMMENDATIONS \n\n\nThe State agency did not have adequate internal controls to ensure that, for undocumented aliens\nand legal aliens restricted to emergency services, Federal reimbursement was claimed only for\nthose conditions that it defined as emergency services. For the 854 medical claims we reviewed,\nwe determined that the services contained on 629 claims totaling $679,588 met the State\xe2\x80\x99s\ndefinition of emergency care. However, services contained on 193 claims totaling $262,366\n($159,702 Federal share) did not meet the definition. The State agency did not have the\nsupporting medical documentation for us to determine whether the services billed on 32 claims\ntotaling $5,903 were for emergency care. Therefore, we are questioning 193 claims for the\nfollowing reasons:\n\n \xe2\x80\xa2\t The State agency claimed Federal reimbursement for 170 medical claims for\n nonemergency services totaling $165,494 ($100,736 Federal share) because edit 00064\n was inadequate.\n\n \xe2\x80\xa2\t The State agency claimed Federal reimbursement for 23 claims for nonemergency\n services totaling $96,872 ($58,966 Federal share). These claims were initially denied by\n edit 00064; however, upon appeal, the claims were paid.\n\nThe State agency claimed Federal reimbursement for 7,114 claims totaling $147,805 ($89,969\nFederal share) for prescription drugs that did not meet the State\xe2\x80\x99s definition of emergency care.\n\nIn addition, the edit in place to prevent payment of family planning services claims for\nundocumented aliens and legal aliens did not always operate correctly or was manually\noverridden to allow services to be claimed as family planning services, which are paid at an\nenhanced Federal medical assistance rate of 90 percent. The State agency claimed a total of\n$126,178 ($113,560 Federal share) for 350 claims at the enhanced rate of 90 percent. As a result,\nthe State agency claimed overpayments totaling at least $36,756 (Federal share).\n\nFinally, Form 3038 was not completed for 429 of our sampled claims (48 percent) or was not a\nreliable indicator of whether the services provided were for emergency medical services.\n\nUNALLOWABLE MEDICAL SERVICES CLAIMS\n\nThe State agency claimed $262,366 ($159,702 Federal share) for nonemergency services for\nundocumented aliens and legal aliens restricted to emergency services. Of the total, $165,494\n($100,736 Federal share) was claimed because edit 00064 did not deny nonemergency services\nclaims and $96,872 ($58,966 Federal share) was claimed for nonemergency services claims that\nwere initially denied by edit 00064 but paid on appeal.\n\nEdit To Deny Nonemergency Medical Services Claims\n\nEdit 00064 was inadequate in preventing Medicaid payments for nonemergency medical services\nprovided to aliens restricted to emergency services for three types of claims: (1) claims for\nnonemergency services that included emergency diagnoses; (2) claims in which nonemergency\n\n\n 4\n\n\x0cservices were billed on the same claims as emergency services; and (3) claims containing\nnonemergency ancillary services.\n\nNonemergency Services Claims That Included Emergency Diagnoses\n\nThe State agency claimed $140,428 ($85,479 Federal share) on 79 claims for nonemergency\nservices that included an ERDX. Edit 00064 did not deny claims containing nonemergency\nservices when they contained at least one ERDX. For these claims, we obtained the professional\nopinion of the State agency\xe2\x80\x99s Medical Director\xe2\x80\x99s Office, which agreed that the claims were billed\nfor nonemergency medical services. The following are examples of paid claims that were billed\nfor nonemergency medical services and that had not been adjusted at the time of our review:\n\n \xe2\x80\xa2\t A patient with cervical cancer received chemotherapy treatments at a hospital, and the\n provider submitted claims with diagnosis codes for chemotherapy and convulsions. The\n patient had a history of a seizure disorder but was not having convulsions at the time of\n the treatments. The diagnosis code for chemotherapy is not an ERDX, but the diagnosis\n code for convulsions is an ERDX. Because the diagnosis code for convulsions is an\n ERDX, the claims were paid. The State agency claimed $19,102 ($11,627 Federal share)\n for services that the patient received during several hospital stays.\n\n \xe2\x80\xa2\t A pregnant individual was admitted to a hospital for alcohol intoxication and was\n released the next day. The provider submitted a claim with a diagnosis of mental\n disorder-antepartum, which is treated as an emergency. However, review of the medical\n records did not indicate that the patient had a mental disorder. The State agency claimed\n $357 ($217 Federal share) for the services that the patient received.\n\nEmergency Service Claims That Included Nonemergency Services\n\nThe State agency claimed $20,380 ($12,405 Federal share) on 19 claims for patients who\nreceived emergency medical treatment and nonemergency medical treatment during the same\nepisode of care. (The dollar figures represent only the amounts for nonemergency services.) We\nobtained the professional opinion of the State agency\xe2\x80\x99s Medical Director\xe2\x80\x99s Office, which\ndetermined that the patients had been seen for both emergency and nonemergency medical\ntreatment during the same episode of care. The following example illustrates an inpatient claim\ncontaining both emergency and nonemergency services:\n\n \xe2\x80\xa2\t A patient who had a history of convulsions, hypertension, asthma, and circulatory\n disease, and who had previously had a colostomy performed, arrived at a hospital\n experiencing abdominal pain. She remained in the hospital for 3 days and received\n computed tomography (CT) scans of her abdomen and pelvis. When her abdominal pain\n subsided, she was discharged. The inpatient claim contained diagnoses for abdominal\n pain, convulsions, hypertension, and a history of circulatory disease, asthma, and\n colostomy status. While abdominal pain was an ERDX, the other diagnoses were not.\n The State agency claimed $2,323 ($1,414 Federal share) for the nonemergency medical\n services.\n\n\n\n 5\n\n\x0cNonemergency Ancillary Services Claims\n\nThe State agency claimed $4,686 ($2,852 Federal share) on 72 claims for nonemergency\nancillary services such as laboratory and radiology tests, ambulance service, and radiation\ntherapy. The State agency allowed claims for ancillary charges to bypass edit 00064 because\nancillary service providers render a service, which may or may not be related to an emergency\nservice, rather than diagnose a condition. The State agency did not have other controls in place\nto determine whether the claims submitted were for emergency care. For these claims, we\nobtained the professional opinion of the State agency\xe2\x80\x99s Medical Director\xe2\x80\x99s Office, which\ndetermined that the medical services were for nonemergencies. The following example\nillustrates these types of claims:\n\n \xe2\x80\xa2\t A patient with no acute distress was admitted to the hospital for a repeat lymph node\n biopsy because the results of the first biopsy were inconclusive. The patient remained in\n the hospital for more than 3 weeks while he had various consultations and awaited the\n biopsy results. The State agency claimed more than $716 ($436 Federal share) for the\n patient\xe2\x80\x99s ancillary services, which included x-rays and tissue exams. In addition, the\n State agency claimed $3,299 ($2,008 Federal share) for the patient\xe2\x80\x99s hospitalization.\n\nNonemergency Medical Services Claims Paid on Appeal\n\nThe State agency claimed $96,872 ($58,966 Federal share) for 23 claims that initially were\ndenied by edit 00064, but then paid after the providers appealed. When a provider appeals a\ndenied claim, TMHP requests documentation to determine whether the services were for an\nemergency. TMHP analysts follow an adjudication process to review the documentation for\nemergency circumstances, conditions, or symptoms; e.g., abdominal pain, shortness of breath,\nchest pain, fever, vomiting, diarrhea, that may not have been referenced diagnoses in a\nsubmitted claim. If the claim indicates one of these emergency conditions, TMHP processes the\nclaim for payment. If TMHP continues to deny the claim, the provider may appeal to the State\nagency\xe2\x80\x99s Medical Director\xe2\x80\x99s Office.\n\nRegarding the 23 appealed claims, we obtained the professional opinion of the State agency\xe2\x80\x99s\nMedical Director\xe2\x80\x99s Office, which determined that the medical services were not for emergency\nconditions.\n\n The following examples illustrate claims paid based on providers\xe2\x80\x99 appeals:\n\n \xe2\x80\xa2\t A paraplegic was admitted to a hospital because his personal care home refused further\n care and he was out of his medications. After 1 month, the hospital was able to place the\n patient in a new personal care home. While in the hospital, the patient received several\n CT scans and other physician services. The individual\xe2\x80\x99s only complaint while in the\n hospital was occasional headaches, which were relieved with Tylenol. The State agency\n claimed $5,534 ($3,369 Federal share) for the inpatient hospital services.\n\n \xe2\x80\xa2\t A patient with cervical cancer received chemotherapy and radiation treatments. The\n State agency\xe2\x80\x99s Medical Director\xe2\x80\x99s Office determined that the claims were for cancer\n\n\n 6\n\n\x0c treatments, which are nonemergency services. The State agency claimed $22,389\n ($13,628 Federal share) for these services.\n\nUNALLOWABLE PRESCRIPTION DRUG CLAIMS\n\nWe identified 44 claims totaling $1,744 for nonemergency drugs prescribed by one provider.\nWe reviewed the medical records that supported the 44 claims and determined that patients were\ngiven prescription medications after they had been treated and stabilized and/or discharged from\nthe hospital. The State agency\xe2\x80\x99s Medical Director\xe2\x80\x99s Office said that a prescription drug could\nnot be considered necessary for an emergency if it was provided to a patient after stabilization or\nupon discharge. The claims were paid because the State agency did not have controls in place to\nprevent nonemergency drugs from being provided to undocumented aliens and legal aliens\nrestricted to emergency services.\n\nBased on discussions with the State regarding the 44 prescription drug claims, we determined\nthat all of the prescription drug claims identified during our audit period were outpatient claims\nand that the drugs did not meet the State\xe2\x80\x99s definition of emergency care because they were\nprovided to patients after they had been treated and stabilized and/or discharged from the\nhospital. Drugs provided during emergency care are billed on inpatient claims. As a result, the\nState agency inappropriately claimed a total of $147,805 ($89,969 Federal share) for 7,114\nprescription drug claims.\n\nCLAIMS IMPROPERLY PAID AT THE ENHANCED FEDERAL RATE FOR FAMILY\nPLANNING SERVICES\n\nMedicaid pays for family planning services at an enhanced Federal medical assistance rate of 90\npercent rather than the standard rate of 60.87 percent. However, undocumented aliens and legal\naliens are not eligible for family planning services or the enhanced rate that is paid for these\nservices. TMHP has an edit (00008) in place to prevent the payment of family planning services\nclaims for undocumented aliens and legal aliens. This edit did not always operate correctly or\nwas manually overridden to allow services to be claimed as family planning services. As a\nresult, the State agency claimed family planning services at the enhanced medical assistance rate\nof 90 percent and received $126,178 ($113,560 Federal share) for 350 claims.\n\nWe did not review the medical records supporting these claims to determine whether the services\nprovided were related to family planning, and therefore not reimbursable. We also did not\ndetermine whether the services qualified as emergencies but were incorrectly coded as family\nplanning. If these services were for nonemergencies, they were ineligible for reimbursement. At\nmost, these services should have been claimed at the medical assistance rate of 60.87 percent, or\n$76,805 (Federal share). Therefore, the State claimed overpayments totaling at least $36,756\n(Federal share), which is the difference between the enhanced rate of 90 percent and the\napplicable rate of 60.87 percent. TMHP stated that it would review its policies and procedures\nand make any necessary changes to prevent payment for family planning services for\nundocumented aliens and legal aliens.\n\n\n\n\n 7\n\n\x0cEMERGENCY MEDICAL SERVICES CERTIFICATION FORM 3038\n\nThe State agency requires providers to submit Form 3038 for all emergency medical services\nprovided to undocumented aliens and legal aliens restricted to emergency services prior to\nestablishing eligibility for emergency Medicaid. The State agency requires that Form 3038\ninclude the date(s) that emergency medical services were provided and the signature of the\nattending physician or other designated medical personnel, certifying that the patient was treated\nfor an emergency condition. The \xe2\x80\x9cTexas Medicaid Provider Procedures Manual\xe2\x80\x9d states that\ncoverage is limited to the specific dates of service of the emergency; any service provided after\nthe emergency condition is stabilized is not payable.\n\nOf the 898 claims in our sample, Form 3038 was not completed for 429 claims (48 percent).\nHowever, we determined that 290 were for allowable emergency services. Of the 469 claims\nsupported by a Form 3038, 92 were for nonemergency services.\n\nState agency eligibility personnel and medical providers said that they knew of instances in\nwhich providers presigned blank Forms 3038 and provided us with a copy of a presigned form.\nAdditionally, the individuals who signed the Forms 3038 were not always the individuals who\ntreated the patients and did not always review the medical records to verify that the patients had\nreceived emergency medical services. The individuals who prepared the forms sometimes\nverified only that the patients had received some type of care on the date certified on the forms.\nTherefore, the Forms 3038 were not a reliable indicator of whether the services provided were\nfor emergency services.\n\nUnder a new policy implemented during our review, the State agency samples, on a quarterly\nbasis, claims paid for emergency services provided to aliens to ensure that providers completed a\nForm 3038 and that the forms are maintained properly and can be easily accessed for review.\n\n RECOMMENDATIONS\n\nWe recommend that the State agency:\n\n \xe2\x80\xa2\t adjust the \xe2\x80\x9cQuarterly Medicaid Statement of Expenditures for the Medical Assistance\n Program\xe2\x80\x9d (Form CMS-64) for the $159,702 (Federal share) claimed for services that did\n not meet the State\xe2\x80\x99s definition of emergency care;\n\n \xe2\x80\xa2\t ensure that officials responsible for reviewing appealed claims for the emergency\n Medicaid program are familiar with Federal and State requirements and have medical\n backgrounds to determine whether claims are for emergency medical treatment;\n\n \xe2\x80\xa2\t adjust the Form CMS-64 for the $89,969 (Federal share) claimed for unallowable\n prescription drugs and for any additional Federal funds paid for prescriptions filled prior\n and subsequent to our audit period;\n\n \xe2\x80\xa2\t adjust the Form CMS-64 for the $36,756 (Federal share) for the 350 claims improperly\n paid at the enhanced Federal medical assistance percentage rate for family planning\n services, review the claims to determine whether the services provided were for\n\n 8\n\n\x0c nonemergencies, and make any additional adjustments as necessary;\n\n \xe2\x80\xa2\t require medical personnel to review medical records prior to certifying on Form 3038\n that emergency medical treatment was provided and ensure that the certified dates are\n limited to the specific dates of the emergency;\n\n \xe2\x80\xa2\t strengthen its policies and procedures, including developing edits, to prevent Medicaid\n payments for nonemergency services provided to aliens; and\n\n \xe2\x80\xa2\t periodically sample and review claims paid for emergency medical services provided to\n aliens and refund any payments made in error.\n\nSTATE AGENCY COMMENTS\n\nIn its comments on our draft report, the State agency said that it will take corrective action for\neach of the recommendations and analyze the claims identified in the report for services that\nreportedly did not meet the definition of emergency care and refund the Federal share. The State\nagency\xe2\x80\x99s comments are included in their entirety as the Appendix.\n\n\n\n\n 9\n\n\x0cAPPENDIX \n\n\x0cAPPENDIX\n Page 1 of 6 \n\n\x0cAPPENDIX\n Page 2 of 6 \n\n\x0cAPPENDIX\n Page 3 of 6 \n\n\x0cAPPENDIX\n Page 4 of 6 \n\n\x0cAPPENDIX\n Page 5 of 6 \n\n\x0cAPPENDIX\n Page 6 of 6 \n\n\x0c"


type: caselaw

jurisdiction: EU

text:
 11.8.2014
 EL
 Επίσημη Εφημερίδα της Ευρωπαϊκής Ένωσης
 C 261/6
 Διάταξη του Δικαστηρίου (όγδοο τμήμα) της 22ας Μαΐου 2014 — Bilbaína de Alquitranes, SA κ.λπ. κατά Ευρωπαϊκού Οργανισμού Χημικών Προϊόντων (ECHA)
 (Υπόθεση C-287/13 P) (1)
 ([Αίτηση αναιρέσεως - Άρθρο 181 του Κανονισμού Διαδικασίας του Δικαστηρίου - Κανονισμός (ΕΚ) 1907/2006 (κανονισμός REACH) - Άρθρο 59 και παράρτημα ΧΙΙΙ - Χαρακτηρισμός της πίσσας από λιθανθρακόπισσα υψηλής θερμοκρασίας ως ουσίας λίαν ανησυχητικής, η οποία πρέπει να υπαχθεί στη διαδικασία αδειοδοτήσεως - Ίση μεταχείριση])
 2014/C 261/08
 Γλώσσα διαδικασίας: η αγγλική
 Διάδικοι
 Αναιρεσείουσες): Bilbaína de Alquitranes, SA, Cindu Chemicals BV, Deza, a.s., Industrial Química del Nalón, SA, Koppers Denmark A/S, Koppers UK Ltd, Rütgers Germany GmbH, Rütgers Belgium NV, Rütgers Poland Sp. z o.o. (εκπρόσωπος: K. Van Maldegem, avocat)
 Αντίδικος κατ’ αναίρεση: Ευρωπαϊκός Οργανισμός Χημικών Προϊόντων (ECHA) (εκπρόσωποι: M. Heikkilä, W. Broere και T. Zbihlej, επικουρούμενοι από του J. Stuyck και A.-M. Vandromme, advocaten)
 Διατακτικό
 Το Δικαστήριο διατάσσει:
 1)
 Απορρίπτει την αίτηση αναιρέσεως.
 2)
 Καταδικάζει τις Bilbaína de Alquitranes SA, Cindu Chemicals BV, Deza a.s., Industrial Química del Nalón SA, Koppers Denmark A/S, Koppers UK Ltd, Rütgers Germany GmbH, Rütgers Belgium NV και Rütgers Poland sp. z o.o στα δικαστικά έξοδα.
 (1) ΕΕ C 252 της 31.8.2013.