oversight

United States Antarctic Program's Medical Screening Process

Published by the National Science Foundation, Office of Inspector General on 2013-09-30.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                  National Science Foundation • Office of Inspector General
                  4201 Wilson Boulevard, Suite I-1135, Arlington, Virginia 22230

MEMORANDUM

DATE:                 September 30, 2013

TO:                   Dr. Roger Wakimoto
                      Assistant Director, Directorate for Geosciences


FROM:                 Dr. Brett M. Baker
                      Assistant Inspector General for Audit

SUBJECT:              Audit of the United States Antarctic Program’s Medical Screening
                      Process, Report No. 13-2-009

Attached please find the final report of our audit of the United States Antarctic Program’s
(USAP) Medical Screening Process. The report contains two findings on the need for
NSF to consider opportunities that exist for cost savings on USAP medical screenings
and the need to improve oversight of Antarctic support contract medical processing
payments. We have included NSF’s response as an appendix to the final report.

To comply with Office of Management and Budget Circular A-50 requirements for audit
follow-up, please provide within 60 calendar days a written corrective action plan to
address the report recommendation. This corrective action plan should detail specific
actions and milestone dates.

We appreciate the courtesies and assistance provided by Division of Polar Programs’
staff during the audit. If you have any questions, please contact Marie Maguire, Director
of Performance Audits, at (703) 292-5009.

Attachment

cc:            Allison Lerner                  Kelly Falkner
               Cora B. Marrett                 Cliff Gabriel
               Marie Maguire                   Karen Scott
               Susanne LaFratta                Michael Montopoli
               Brian Stone                     Jeffrey Stitz
               Kelly Stefanko                  G. P. Peterson
Audit of the United States Antarctic Program’s
          Medical Screening Process




          National Science Foundation
          Office of Inspector General


               September 30, 2013
             OIG Report No. 13-2-009




                                         TM#13-P-2-002
Results in Brief
Before going to the Antarctic through the United States Antarctic Program (USAP), potential
travelers must pass a number of medical and dental examinations based on factors such as gender
and age. With minor exceptions, this physical qualification testing is “one size fits all,” meaning
that all candidates, regardless of their deployment duration, job responsibilities, season of travel,
or duty station, must undergo the same medical tests.

We found that NSF may have missed opportunities to reduce the cost of the medical screening
process because it has not implemented certain recommendations from its medical review panel.
For example, for at least five years, the panel has recommended that NSF base required medical
tests on factors, such as how long an individual will be in Antarctica and the assigned duty
station and job responsibilities, rather than require all applicants to undergo the same tests.
Revising the number of medical tests performed to reflect these criteria could lower costs, which
are approximately $860 per person. Furthermore, nearly 20 percent of applicants withdraw each
year before completing the medical screening process, constituting significant time and effort for
staff as well as incurring medical examination costs. To reduce these costs, NSF should examine
the reasons why applicants withdraw from the process and address these causes.

The Antarctic Support Contractor (ASC) and its subcontractors prepare, process, and pay as
many as 1,600 individual reimbursement requests each year for costs related to medical
screening. We found that guidance about what medical expenses will be reimbursed by the
contractor is unclear. As a result, applicants may be submitting claims for expenses that are not
eligible for reimbursement. We also found that the contractor does not have a robust system to
ensure the accuracy of invoices for medical costs. NSF should consider increasing its investment
in the oversight of invoiced costs until it is better assured of the contractor’s internal controls.

We recommend that NSF establish a process to address and track medical panel
recommendations in a timely manner and identify and address the reasons why applicants
withdraw during the medical screening process. We also recommend that NSF require the
contractor to document its internal controls over ASC invoicing for the medical screening
process. NSF agreed with the recommendations.

Background
The United States Antarctic Program
Antarctica is the coldest, driest, windiest, most remote continent on earth. The weather changes
frequently and abruptly. Since 1956, American scientists have been studying the Antarctic and
conducting research to better understand Antarctica and its effects on global processes.

The National Science Foundation (NSF) manages all U.S. scientific research and related logistics
in Antarctica and aboard ships in the Southern Ocean through the United States Antarctic
Program (USAP). The USAP costs NSF approximately $350 million a year, which includes
grants supporting 130 to 160 scientific research projects a year as well as the necessary
associated infrastructure and logistics for three year-round research stations in Antarctica



                                                  1
(McMurdo, Amundsen-Scott South Pole and Palmer) and two science vessels in the Southern
Ocean (Laurence M. Gould and Nathaniel B. Palmer).

NSF’s largest contract is for logistical support for the USAP. At the time of our audit, Lockheed
Martin (LM) was in the first full year of a 13 year contract 1 to provide Antarctic support worth
$1.9 billion.

Physical Qualification Screening
Before going to the Antarctic, potential travelers must pass a number of medical and dental
examinations based on factors such as gender and age. With minor exceptions, this physical
qualification testing is “one size fits all,” meaning that all candidates, regardless of their
deployment duration, job responsibilities, season of travel, or duty station, must undergo the
same medical tests. Candidates who anticipate spending the austral winter 2 in Antarctica are
subject to a psychological evaluation.

For the 2012 – 2013 Antarctic travel season, NSF was responsible for determining that at least
2,287 people were physically qualified for travel to Antarctica for the USAP. Of these, 41
percent were NSF staff and grant funded scientists, while 59 percent were contractors providing
logistical support.


                               USAP Deployments by Employer
                 1400

                 1200
                                                              1,243
                 1000

                   800                                                                    929

                   600

                   400

                   200
                                    115
                     0
                            Primary Contractor           Subcontractors             NSF & Grantees


Cost of Medical Processing
Candidates are responsible for scheduling their own examinations but NSF bears the cost of
physical qualification testing. Although contractors have the same physical qualification
requirements to travel to Antarctica as NSF staff and scientists, NSF pays for the testing
differently for each.



1
    The first 4.5 years of the contract are guaranteed. NSF has the option to extend the contract to 13 years total.
2
    Roughly February through October


                                                             2
NSF staff
NSF staff can use the in-house health clinic to get blood taken, a medical exam performed, and
an electrocardiogram test done for no out-of-pocket cost. The health unit provides vouchers to
NSF staff for some required tests that are beyond its capability. The health unit absorbs these
costs within its own annual budget so those costs are not charged to the USAP.

NSF grantees
Grantees budget for and directly charge their NSF grant for the cost of medical testwork. NSF
estimated that the typical cost budgeted for this testing, net of insurance, was from $500 - $1,500
per traveler. Because NSF does not obtain the actual expenses incurred by grantees for medical
testing separately from other grant expenses, we used NSF-provided estimates of the number of
science projects conducted in the Antarctic and the size of the grant teams to calculate an annual
cost of grantee medical testwork charged through grants of $500,000.

Contractor staff
Contractor staff can go to their personal medical provider and receive reimbursement for medical
testwork through LM. LM also established contracts with medical providers that provide for
fixed pricing and direct billing to LM, which allows contractor personnel to avoid paying out of
pocket. At the time of our audit, 5 of the 6 contracted medical providers (doctors, dentists and
psychologist) were in the Denver area. The one nationwide contracted provider performs
laboratory testing services. LM told us that they receive many reimbursement claims for people
without health insurance because subcontractors have applicants undergo medical testing before
offering them a job.

For its first year as the Antarctic Support contractor (April 2012- March 2013), LM reported $1.1
million in medical processing costs. In addition to the cost of testing, medical processing costs
also include the labor involved in reviewing the testing results and determining each applicant’s
suitability for Antarctica. Medical providers send completed test results to the University of
Texas Medical Branch (UTMB), LM’s subcontractor for USAP medical services. Using NSF's
medical screening guidelines, medical officials at UTMB decide, after reviewing the results of
all medical testing, whether or not a candidate is physically qualified to deploy to Antarctica.

Travel expenses related to physical qualification testing are also billable to the Antarctic support
contract, but LM charges these costs as travel instead of medical processing and we did not
attempt to quantify those costs.

Length of Deployment
While a physical qualification determination is considered valid for 12 months, only 185 of the
2,287 travelers during the 2012-2013 year (8 percent) planned to stay through the duration of the
austral winter. Also, 397 people (17 percent), were in Antarctica for 30 days or less, but were
held to the same medical testing as those who were staying through the austral winter, with the
exception of the psychological evaluation. The majority of travelers (75 percent) stayed for
summer deployments lasting over 30 days.




                                                  3
                                     Travelers by the Length of
                                 185
                                      64
                                         82
                                            Deployment
                                                                 Summer Deployments < 8
                                               251
                                                                 Days
                                                                 Summer Deployments
                                                                 from 8 to 14 Days
                                                                 Summer Deployments
                                                                 from 15 to 30 Days
                                                                 Summer Deployments > 30
                                                                 Days
                              1,705
                                                                 Winter-Over Deployments




Results of Audit
We found that NSF may have missed opportunities to reduce the cost of the medical screening
process because it has not implemented certain recommendations from its medical review panel.
In particular, NSF has not implemented a recommendation to base required medical tests on
factors such as how long an individual will be in Antarctica, duty station, and job
responsibilities. Revising the number of medical tests performed to reflect these criteria could
lower costs.

We also found that NSF has limited oversight of individual medical processing costs charged.
NSF relies on LM to have a well-controlled system of subcontractor invoice review. However,
LM’s internal controls over invoice accuracy need improvement.

Finding 1 – Opportunities Exist for Cost Savings on USAP
            Medical Screenings

Establish a process to address medical panel recommendations

NSF uses a medical review panel, comprised of medical doctors from other federal agencies, to
provide expert advice and guidance on the USAP medical care system. The panel reviews the
contractor’s annual Healthcare in Antarctica report and holds a 3-day annual meeting where
NSF and contractors present an overview of medical issues and care from the preceding
year. Following the annual meeting, the panel, based on its professional judgment and
experience, makes written recommendations to NSF for refining the USAP medical care
system.




                                                4
We found that NSF may have missed opportunities to reduce the cost of the medical screening
process because it has not implemented certain panel recommendations. During the period we
reviewed, from 2009-2012, the panel made between 18 and 32 recommendations each
year. NSF does not respond to the prior year’s recommendations until the next year’s meeting.
Although it makes progress and addresses some panel recommendations, NSF does not have a
transparent process to address the recommendations. The panel chairman told us that the panel is
“frustrated” because NSF has not acted on its recommendations. Other panel members
acknowledged that a sense of frustration exists.

We identified two outstanding recommendations -- revising the medical screening process and
revising the dental screening guidelines -- that could result in cost savings. For at least five
years, the panel has recommended that NSF revise the medical screening criteria to consider
factors such as length of deployment, job responsibilities, and destination. The current medical
screening process costs approximately $860 per person.

Adjusting the screening criteria to reflect the amount of time the traveler will spend in Antarctica
and other factors, such as job responsibilities and duty station, could decrease the number of
required tests for many USAP travelers, which could in turn reduce the cost to medically qualify
a person to travel to Antarctica. In 2011, a medical panel member proposed revised medical
screening guidelines for NSF. Under these guidelines, required medical tests would vary
depending on whether individuals were overwinter personnel, remote field camp/critical
personnel, whole-season visitors, or short-term visitors. NSF has not determined what, if any,
revisions it will make to its medical screening guidelines.

In 2012, at NSF’s request, the panel recommended that dental screening be included in the
review of USAP screening guidelines. In addition to an annual set of dental bitewing x-rays, the
dental guidelines require travelers to have a panoramic mouth x-ray every five years. The
primary purpose of the panoramic x-ray, which costs $100 per person, is to identify human
remains in the event of a catastrophe. NSF has considered possible alternatives, but has not
made a decision.

The dental guidelines also require consideration of unopposed third molars. Because these
molars can become impacted or infected, this condition has resulted in a “not physically
qualified” determination for a number of applicants. NSF reported that all these determinations
were waived. The waiver process is costly and time consuming, but NSF has not made a decision
on accepting the panel’s recommendation to revise the guidelines on unopposed third molars.

When we asked NSF why it had not addressed the panel’s recommendations, particularly in light
of the potential costs savings, officials told us that the agency is not required to respond to the
recommendations as the panel serves in an “advisory” role. NSF also informed us that it had not
taken more action because the official in charge of implementing the recommendations
unexpectedly had extended military leave. Finally, NSF stated due to the change in contractors
managing the USAP medical program, it delayed the review of medical guidelines.

NSF does not have a transparent process to evaluate and implement panel recommendations,
which includes clear roles and responsibilities and milestones. Because of this, NSF may have



                                                 5
missed cost savings it could have realized by implementing risk-based guidelines that
would reduce the types and number of required tests.

Identify and address reasons candidates withdraw from the medical screening process
For the past three travel seasons, 19 percent of candidates, on average, withdrew each year
before completing the medical screening process. While we were unable to determine how far
along candidates were in the screening process or how much NSF had spent on medical tests
before these candidates withdrew, the process costs approximately $860 per applicant. In
addition, the former contractor reported that processing those who do not complete the process
constituted significant time and effort for staff. To reduce costs, NSF should examine the
reasons why applicants withdraw from the process and address these causes.

The chart that follows contains information on the number of candidates annually undergoing the
medical review process, including those who were determined to be physically qualified for
travel, those determined to be not physically qualified, and those that withdrew from
consideration.

                        Annual Results of the Medical Review Process
                                                                 Average        Percent of
                         2009-2010 2010-2011 2011-2012
      Category                                                  2009-2012        Average
 Candidates
 Determined to be
 Physically Qualified          2,608       2,766         2,633         2,669       75%
 Candidates
 Determined to be
 Not Physically
 Qualified                      265          227           204           232       6%
 Candidates Dropped
 Prior to Completion             680         656           669           668       19%
               Total:          3,553       3,649         3,506         3,569

Recommendation 1: We recommend that NSF establish a process to address and track medical
panel recommendations in a timely manner and identify and address the reasons why nearly 20
percent of applicants withdraw before completing the medical screening process.

Finding 2 – Improvements Needed in the Oversight of Antarctic
            Support Contract Medical Processing Payments
Individual reimbursement requests for medical testing costs should be better controlled

LM and its subcontractors prepare, process, and pay as many as 1,600 individual reimbursement
requests a year for costs related to contractor staff physically qualifying to travel to the Antarctic.
Based on our review of a sample of invoices, these claims are generally for amounts of $3,000 or
less. Reimbursement claims are paper-based, so there are no automated checks against the
accuracy of the claim. LM staff manually review each of these claims for payment.


                                                   6
We found that the guidance about what medical expenses will be reimbursed by the contractor is
not clear. For example, the guidance states that applicants will be approved for out-of-pocket
expenses but does not provide a detailed listing of such expenses. As a result, applicants may be
submitting claims for expenses that are not eligible for reimbursement.

We did not attempt to verify the validity of all of the medical and laboratory tests submitted for
reimbursement in the sample of payments that we obtained, which covered hundreds of
employee medical payments and reimbursements, but of the $253,213 charges we reviewed, we
found six for teeth cleaning and one for an electric toothbrush that clearly should not have been
reimbursed.

Once medical expenses are incurred and submitted, the contractor told us that a cost analyst
performs a high level cursory review of each invoice it receives, and then a manager does a more
detailed review to ensure each charge is allowable. However, we did not see evidence of such
review in the support for the 11 payments that we examined. LM’s lack of clear policy and
procedures as well as the volume of reimbursement claims increases the risk of paying for
medical costs that are not allowable.

The Contracting Officer’s Representative told us that NSF cannot tell if it is being accurately
invoiced by LM for medical processing costs and is instead reliant on the contractor to charge
them accurately. According to the Contracting Officer’s Representative, he reviews the
electronic copy of the invoice to see if it looks reasonable. He relies on one contractor employee
to examine the LM invoices, including medical processing costs, more closely. We found that
LM does not have policies and procedures for reviewing Antarctic Support Contract invoices.
While we recognize that medical processing only constitutes approximately $1 million out of the
first full year’s contract value of $173 million, finding a less than robust internal control system
over relatively small costs of medical processing raises the possibility that a similar level of
control could exist over larger contractor costs. NSF should consider increasing its investment
in the oversight of invoiced costs until it is better assured of LM’s internal controls over
invoicing accuracy.

Internal control needs to be clearly documented, the documentation should appear in
management directives, administrative policies, or operating manuals, and all documentation and
records should be properly managed and maintained 3. Because of the relatively small dollar
value of individual reimbursement claims, priority should also be given to reducing the volume
of reimbursement claims submitted, such as by having more candidates use contracted medical
providers.

Recommendation 2: We recommend that NSF require LM to document its internal controls
over Antarctic Support Contract invoicing for the medical screening process in the form of
directives or policies.




3
    GAO's Standards for Internal Control in the Federal Government


                                                         7
Other Matters
Contracted Medical Providers
We were unable to determine the extent to which contracted medical providers were being used
or the cost savings resulting from using them. LM receives numerous invoices and receipts from
its subcontractors supporting hundreds of smaller charges from several providers. Determining
the number of tests that were provided by contracted versus non contracted medical providers
would require manually reviewing each bill to identify each medical test procured for each of the
thousands of candidates. If information on the rate of use and the cost of contracted medical
providers was available, it would better enable LM and NSF to evaluate the cost savings of using
contracted medical providers.

However, we did find that the price difference between non-contracted and contracted laboratory
rates was significant, with some non-contracted tests costing from 5 to 10 times more than the
same tests under a contracted rate.

Because LM personnel in Denver, where the contracted medical providers are available,
constitute only 115 of 1,358 personnel deploying to Antarctica this past year, NSF could
consider contracting with additional medical providers, which may result in cost savings. Since
LM does not track the specific costs of each candidate’s medical testing, or how many tests are
done by a contracted medical provider, we were not able to quantify the potential cost savings of
using contracted providers.

Psychiatric evaluations
Everyone who spends the austral winter in Antarctica is required to have a psychiatric
evaluation. Currently, there is only one, sole source provider for psychiatric evaluations and that
provider is located in the Denver area. We found that last year NSF paid for 347 psychiatric
evaluations at a cost of $260 per person, (not including travel costs). To reduce costs, NSF could
direct LM to explore a lower cost for psychiatric evaluations by opening this contract to
competition.

Summary of Agency Response and OIG Comments
In its response, NSF concurred with the OIG’s recommendations. In responding to
recommendation 1, NSF agreed to formalize its process for addressing and tracking medical
panel recommendations. NSF also stated that it would direct Lockheed Martin to collect
information on the reasons why applicants withdraw before completing the medical screening
process in order to have a basis for determining whether additional action is necessary.

In response to recommendation 2, NSF will direct Lockheed Martin to document its internal
controls over subcontractor management regarding receipt and flow-through of subcontractor’s
invoices costs for medical screening.

NSF provided comments in its response that conflict with the evidence that we gathered and
reported on during the course of the audit. For finding 1, we specifically did not render
judgment on whether any required test was essential because we did not have the medical


                                                 8
expertise needed. We report that the group NSF utilizes for medical expertise, the medical
review panel, has recommended for 5 years that the medical screening criteria be revised. In
addition, we did report the difference in the physical qualification process based on operating
season and duration of stay is that candidates who anticipate spending the austral winter in
Antarctica are subject to a psychological evaluation. As reported in the background section, we
found that 64 travelers were deployed to Antarctica during the austral summer for less than 8
days. Under the current medical screening guidelines, those travelers were required to undergo
the same medical tests as travelers staying the entire summer.

NSF’s response noted that a single medical evacuation flight can cost as much as $625,000.
During the audit, when asked about the cost of medical evacuations, an USAP senior official
explained that during the summer there is not usually additional cost for medical evacuation
flights because NSF has the ability to change the flight schedule and utilize regularly scheduled
flights. During the winter, the risk of NSF incurring cost for a medical evacuation flight is low
because nearly everyone in Antarctica then is a contractor and the contractor is required to have
medical evacuation insurance.

As discussed in finding 1 of the report, NSF’s existing “process” to address and track medical
panel recommendations is to provide a response to the panel for each recommendation at the
next year’s meeting. Although NSF makes progress and addresses some panel
recommendations, this has not proven to be an effective method to address recommendations as
medical panel recommendations have shown to repeat from year to year. When we briefed an
USAP senior official on the need for a process to address medical panel recommendations, this
official agreed that NSF’s process to address panel recommendations needs to be improved.

Finally, for finding 1, NSF responded that it advised us that it discontinued the requirement to
repeat the panoramic x-rays every five years. NSF did not inform or provide us evidence that it
made this change to its requirements despite having received a draft of this report in advance of
the exit conference. Similarly, in its response, NSF stated that it made the decision that the
presence of unopposed third molars absent attendant complications is no longer a disqualifying
condition. NSF neither mentioned that it had changed its guidelines on unopposed third molar at
the exit conference nor provided revised guidelines evidencing a change had been made.

In response to NSF’s claim that we incorrectly characterized the Contracting Officer’s
Representative’s statements regarding the invoice review process, we reviewed the three report
statements attributed to the Contracting Officer’s Representative and confirmed that they
accurately reflected the conversation that we had with this individual.

We consider management’s planned actions to be responsive to our recommendations. We look
forward to receiving the Corrective Action Plan and working with NSF officials to confirm its
implementation. We have included NSF's response to this report in its entirety as Appendix A.

OIG Contact and Staff Acknowledgements
Marie Maguire – Director of Performance Audits
(703) 292-5009 or mmaguire@nsf.gov
In addition to Ms. Maguire, Kelly Stefanko and Jeff Stitz made key contributions to this report.


                                                9
Appendix A: Agency Response


                                     NATIONAL SCI ENCE FOUNDATION
                                           4201 WLLSONBOULCVARD
                                         ARLINGTON, VIRGIN IA 22230




    GEOSCIENCES DffiECTORA TE



    MEMORANDUM

    DATE:         September 17, 2013

    TO:           Dr. Brett M. Baker
                  Assistant inspector General for Audit
                  Office of Inspector General

    fROM:         Dr. Roger Wal<imoto {t.,.,._   U~
                  Assistant Director
                  Directorate for Geosciences

    SUBJECT:      Official Draft Report, Audit of the United States Antarctic l'rogram's Medical
                  Screening Process


    Thank you for providing NSF the oppot·tunity to provide a f01·mal response to the Official Draft
    Report of the Audit of tile United St.ntes Antarr.t.ir. Prngrnm:c; Medir.al Screening Process. Our
    response is attached to this Memorandum.

    Recognizing that the Inspector General's report is preliminary, NSF requests the opportunity to
    revise its response in the event that the report is reVised.


    Attachment

    cc:     Cliff Gabriel
            Kelly Falkner
            Susanne LaFratta
            Michael Montopoli
            Brian Stone




                                                  10
                      National Science Foundation Response

                   Audit of the USAP Medical Screening Process
                                  TM#13-P-2-002


The Office of Inspector General (OIG) conducted a performance audit of the U.S.
Antarctic Program's (USAP) process for physically qualifying personnel who travel
to Antarctica. In addition to responding to the two recommendations, NSF provides
additional information relevant to some of the statements included in the report in
order to provide the reader with an accurate context.

Finding 1.

)}- The report indicates that NSF may have missed opportunities to reduce the cost
    of the medical screening process because certain recommendations made by the
    medical review panel have not been implemented, "in particular, ... a
    recommendation to base required medical tests on factors such as how long an
    individual will be in Antarctica, duty station, and job responsibilities." The report
    also states that revising the number of medical tests performed to reflect these
    criteria could lower costs. The report does not indicate which of the required
    tests the Inspector General deems unessential or on what medical evidence the
    conclusion is based.

   In fact, there are already differences in the physical qualification process
   depending on factors such as length of stay and purpose of trip as well as age,
   duty station and operating season.

   Further, despite the Inspector General's apparent impression, NSF manages its
   medical program using a variety of inputs and the Medical Review Panel is but
   one aspect. For example, NSF continually reviews and updates, with its Medical
   Review Panel, its contracted service providers and other subject matter experts
   as appropriate, the medical guidelines that are used in making physical
   qualification decisions; there are several instances of recent changes that NSF
   has made to the guidelines as a result of this practice. For example, although the
   report still discusses a requirement to repeat the panoramic x-rays every five
   years, NSF had advised the Inspector General that it discontinued this
   requirement.

   Decisions such as these are rarely made solely on the basis of cost, however,
   since NSF must also balance the very real risk that it will have to medically
   evacuate personnel from its stations or ships. As the Inspector General
   indicates, the medical screening process costs approximately $860 per person. A
   single medical evacuation flight can cost as much as $625,000. Diverting the
   research vessel for even one day costs $45,000. Changes to the guidelines
   therefore require clear and convincing medical evidence that a given test is not




                                            11
     useful for determining an individual's general health or the care he or she would
     need while deployed.

}>   In its discussion of "not physically qualified" determinations for participants
     with unopposed third molars, the Inspector General states, "The waiver process
     is costly and time consuming ...", but does not present any supporting cost data.

     NSF considers the waiver process an important aspect of its physical
     qualification process. The waiver process provides an opportunity to consider
     other factors that would be relevant to an individual's deployment on a case-by-
     case basis- ironically, something the Inspector General seems to advocate
     elsewhere in its report. Data resulting from consideration of waivers and
     outcomes is also used to update the physical qualification process, as happened
     recently when NSF made the decision that the presence of unopposed third
     molars absent attendant complications are no longer a disqualifying condition.

Recommendation 1, Part 1. We recommend that NSF establish a process to
address and track medical panel recommendations in a timely manner.

     NSF Response. NSF has a process to address and track medical panel
     recommendations and so while it is not necessary to establish a process, the
     process will be formalized by incorporating a description in the Medical Panel
     Charter that is currently under revision.

Recommendation 1, Part 2. We recommend that NSF identify and address the
reasons why nearly 20 percent of applicants withdraw before completing the
medical screening process.

     NSF Response. The report seems to assume that "nearly 20 percent" is more
     than it should be, and that by reducing the percentage of applicants who
     withdraw before completing the medical screening process NSF will lower its
     costs. While it is not possible to know whether the percentage or the costs can
     be reduced, NSF will direct Lockheed Martin to collect information on the
     reasons that applicants withdraw before completing the medical screening
     process in order to have a basis for determining whether additional action is
     necessary.

Finding 2.

}>   The Inspector General incorrectly characterizes the Contracting Officer's
     Representative statements regarding the invoice review process.

     The Inspector General was advised that NSF has no privity of contract with
     Lockheed Martin subcontractors, and that it is Lockheed Martin's responsibility
     to ensure that it has sufficient internal controls for validating and paying
     invoices for subcontractor charges. In addition, the Contracting Officer's




                                      12
  Representative follows the approved NSF procedure for reviewing invoices to
  certify that costs are reasonably consistent with supplies and services received.
  The NSF OIG has authorized the Defense Contracts Audit Agency (DCAA) to audit
  Lockheed Martin's costs incurred to determine whether they are allowable,
  allocable and reasonable.

Recommendation 2. We recommend that NSF require LM to document its internal
controls over Antarctic Support Contract invoicing for the medical screening
process in the form of directives or policies.

   NSF Response. The LM billing system has been found adequate and due to
   subcontract privity constraints, the root issue is with LM's review of
   subcontractor invoices prior to submission of costs to NSF. Therefore, we will
   direct that LM document its internal controls over their subcontractor
   management regarding receipt and flow-through of subcontractor's invoice
   costs for medical screening.




                                     13
Appendix B: Objectives, Scope and Methodology
We performed this audit to determine the adequacy of NSF’s oversight of the medical screening
process required of individuals seeking to travel to Antarctica under sponsorship of the United
States Antarctic Program (USAP) and whether opportunities exist for cost savings. Our scope
included the $1.1 million in costs incurred between April 1, 2012 and March 31, 2013 to
determine if contractor candidates were physically qualified for travel to the Antarctic. We did
not include in our scope the cost of required medical, dental, psychiatric, and laboratory tests for
grantees, estimated at $500,000, or NSF employees which does not get billed through the
Antarctic support contractor.

To determine the adequacy of NSF’s oversight of the medical screening process, we reviewed
the USAP medical guidelines and annual USAP medical reports from 2009 to 2012; attended the
annual medical review panel meeting in May 2013, and reviewed the annual medical review
panel meeting notes and recommendations from 2009-2012. We also interviewed NSF Division
of Polar Programs and LM Antarctic Support Contract staff members. We assessed the
information obtained against GAO's Standards for Internal Control in the Federal Government.

To identify opportunities for cost savings, we reviewed a judgmental sample of 11 payments
representing 23 percent of the approximate $1.1 million billed to NSF for the medical screening
program. These payments included charges covering hundreds of participants’ medical charges
and reimbursements. From this sample, we identified variations in medical costs due to the use
of personally chosen versus contracted medical providers. We did not project the results of this
sample to the population of $1.1 million in payments. We also determined the number of people
that travelled to Antarctica for various lengths of deployments. We interviewed NSF and
contractor staff to understand the invoice, reimbursement, and oversight of the payment process
for the medical screening program. We assessed this information against our implicit criteria
that lower costing alternatives (that also maintained effectiveness) were advantageous in
reducing USAP’s medical screening costs.

We reviewed applicable provisions of pertinent laws and guidance, including 45 CFR, PART
675 – Medical Clearance Process for Deployment to Antarctica and the USAP Medical
Screening Guidelines. Absent medical expertise, we did not attempt to test NSF’s compliance
with these regulations and guidelines.

Through interviewing NSF and contractor staff and reviewing documentation, we also obtained
an understanding of the management controls over the USAP medical screening program. We
identified ways that costs associated with this program could be reduced. We identified
improvements needed in the oversight of Antarctic Support Contract medical payments but did
not identify any instances of fraud, illegal acts, violations, or abuse.

During the course of this audit, we relied on information and data received from NSF and USAP
contractors in electronic format that had been entered into a spreadsheet or that resulted from
computer processing. We tested the reliability of the computer-processed data through a variety
of means including manually reperforming calculations, reviewing data using automated data
analysis software, and matching numbers against original source documents. Based on our


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assessment, we concluded the computer-processed data was sufficiently reliable to use in
meeting the audit’s objectives.

We conducted this performance audit between March 2013 and August 2013 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
finding 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.

We held an exit conference with NSF management on August 21, 2013.




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