Recommendations Tracker

We recommend that the California Department of Health Care Services report and return the Federal share of Medicaid overpayments for the 14 unreported cases identified in this report that total $113,269,575 ($47,769,205 Federal share).

We recommend that the California Department of Health Care Services work with the MFCU to revise the current notification timeline in the MOU to facilitate the timely notification of final judgments to meet Federal requirements.

We recommend that CMS add worker classification (i.e., employee or contractor) as a required entry in iQIES and require CMS and SAs to record the status of each individual performing any nursing home survey (including an FMS).

We recommend that CMS direct the relevant MAC to recover $154,210 in Medicare reimbursement paid to two CTCs that could not provide documentation to support the numbers of Medicare usable organs that they reported on their Medicare cost reports.

We recommend that CMS issue guidance on timeframes for Part D sponsors to reject payments for OTC drugs sold under obsolete Rx-only labeling after an Rx-to-OTC switch. This step could have helped to prevent $587.7 million in ineligible payments to pharmacies for CYs 2021 through 2023.

Ensure that the Unit Director oversees all aspects of the Unit's investigative work

Implement a case management system that allows efficient access to case information

Revise the Unit's MOU with the PIU to include reference to the CMS Performance Standard for Referrals

We recommend that the State agency improve its policies and procedures to: (1) clarify that MCOs are required to annually perform parity analyses, (2) require MCOs to submit the results of the analyses with reliable supporting documentation (e.g., data) for the State agency's review, and (3) review the MCOs' annual parity analyses and supporting documentation.

We recommend that the State agency improve its policies and procedures for monitoring MCOs' compliance with parity requirements, including: (1) collecting and reviewing supporting data from MCOs for their comparative analyses; (2) providing clear, uniform guidance to MCOs regarding maintaining and providing accurate and consistent data to support and complete their comparative analyses, and correcting issues of noncompliance with parity requirements; and (3) establishing a formal, written policy that includes its denial rate threshold and indicates what actions MCOs are to take when denial rates exceed the threshold.

We recommend that Health Share continue to assess and improve its quarterly reviews of denial notices and related prior authorization documentation by verifying that: denials are made by individuals with the appropriate expertise in addressing the enrollees' medical and oral health needs; denial notices include Health Share's contact information and translated denial notices are provided in non-English languages when appropriate; and denial notices are provided to enrollees and to providers within Federal and State established timeframes.

We recommend that Health Share clarify to its subcontractors when to consult with providers to ensure that provider outreach is conducted when insufficient information is provided with the prior authorization request or there are discrepancies in the provided information.

We recommend that the State agency enhance its oversight of the MCOs by ensuring they: (1) complete and submit the parity analyses annually for each of the four benefit classifications—inpatient, outpatient, prescription drugs, and emergency care—as required in the MCO contracts, (2) maintain and submit complete and accurate data to support those analyses, and (3) correct issues of identified noncompliance with the MHPAEA.

We recommend that the State agency improve its monitoring of the MCOs by developing and implementing policies and procedures that: (1) formally identify whether the State agency or KDADS is responsible for oversight of MCOs' compliance with parity requirements, and (2) formalize procedures for the collection and review of the MCOs' submitted supporting data for the parity analyses.

We recommend that Deistic refund the $43,074 in estimated net overpayments to the Medicare program.

We recommend that CMS work with the five MACs with LCDs and LCD Reference Articles to develop education specific to the Medicare requirements and billing guidance for sacroiliac joint injections to be used for all of the five MACs, which could have saved an estimated $15,156,922 during our audit period.

We recommend that CMS use the results of this audit and other pertinent information to either adopt a national coverage determination (NCD) for sacroiliac joint injections or work with the two MACs without an LCD and LCD Reference Article for sacroiliac joint injections to develop them, thereby promoting greater consistency and reducing duplication of effort.

We recommend that ACF consider the information in this report and work with State agencies to improve data collection and reporting on the use of temporary emergency placements for children in the Federal Foster Care Program, which, in turn, can be used to promote the health and safety of children who are in these placements.

We recommend that the State agency refund $152,728 to the Federal Government.

We recommend that HOV refund to the Federal Government the estimated $8,614,887 in overpayments for claims for hospice services that did not comply with Medicare requirements, excluding amounts presumed to be unrecoverable under the Section 1870 waiver of liability provision.

We recommend that HOV provide additional training to clinical personnel on its policies and procedures to continually validate that the enrollees met the requirements for hospice (i.e., terminal prognosis of a life expectancy of 6 months or less if the terminal illness ran its normal course and the enrollees received the appropriate level of care).

We recommend that the State agency refund $18,541,039 to the Federal Government.

We recommend the State agency review payments made after our audit period to identify any additional overpayments and refund the Federal share to the Federal Government. Additionally, the State agency should clearly identify any additional overpayments refunded as having been made in accordance with this recommendation.

We recommend that the State agency update its policies and procedures for testing and monitoring clinical diagnostic laboratory services to require verification that the CMS annual updates are correctly applied to the professional fee-for-service default rate.

We recommend that WPS confirm to OIG that the $140,182 in overpayments associated with the 123 incorrect claim lines—for which WPS has already processed a corrected claim—has been fully recovered.

We recommend that WPS work with the providers associated with the 15 incorrect claim lines for which WPS had not processed the corrected claims as of the end of our audit work and recover any identified overpayments.

We recommend that WPS use the results of this audit to enhance its provider education activities.

We recommend that the State agency refund $8,072,870 (Federal share) in estimated overpayments to the Federal Government.

We recommend that the State agency improve its EVV system by: (1) establishing system edits and/or formal policy requirements governing attendants' use of manual entries and by implementing limit thresholds for how often manual entries can be used; (2) implementing system edits to verify that all PCS visits have corresponding EVV records; (3) requiring providers to verify that all PCS visits are entered in the EVV system; (4) implementing system edits that capture the location of services provided, and establishing requirements for providers and attendants to document and verify the actual location where PCS is provided; (5) implementing system edits that require providers to review and then correct GPS exceptions; (6) requiring providers to monitor the use of EVV reason codes and confirm their appropriate application; and (7) requiring providers to verify that the names of the attendants identified on EVV records match the names of the attendants who signed the corresponding timesheet

We recommend that the State agency implement system edits to verify that: (1) units paid match the units approved on the enrollees' plans of care, and (2) rates paid are in accordance with the State's approved rates.

CMS should work with States to ensure that all MCOs are contractually required to refer potential fraud promptly.

CMS should work with States to expand the feedback provided to MCOs about provider fraud referrals.

We recommend that Novitas implement additional oversight (e.g., documentation and billing guidance, medical reviews, and/or provider internal audits) to prevent improper payments associated with provider billing of E/M, psychotherapy, and podiatry services, which could have saved an estimated $19,480,109 for our audit period.

We recommend that the New York Department of Health strengthen its monitoring activities to verify that nursing homes comply with requirements that prohibit the employment of individuals with disqualifying backgrounds, such as expanding the timeframe covered by recertification surveys.