Recommendations Tracker

We recommend that the Nebraska Department of Health and Human Services, Division of Medicaid and Long-Term Care refund $22,484 (Federal share) in overpayments to the Federal Government.

We recommend that the Florida Agency for Health Care Administration refund $1,441,107 to the Federal Government.

We recommend that the Florida Agency for Health Care Administration improve its policies and procedures to ensure that it is adequately monitoring school-based service claims to ensure compliance with Federal and State requirements.

We recommend that Hospice Compassus, Inc., of Payson, Arizona exercise reasonable diligence to identify, report, and return the estimated $1,872,291 for hospice services that did not comply with Medicare requirements in accordance with the 60-day rule, and identify any of those returned overpayments as having been made in accordance with this recommendation.

We recommend that Hospice Compassus, Inc., of Payson, Arizona strengthen its procedures to ensure that hospice services comply with Medicare requirements.

We recommend that The Palace, based on the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.

We recommend that Cahaba work with CMS to ensure that its final settlement of contract costs reflects a decrease in Medicare PRB costs of $4,320,303 for CYs 2014 through 2016.

We recommend that Cahaba Safequard Administrators, LLC, work with CMS to ensure that its final settlement of contract costs reflects a decrease in Medicare PRB costs of $675,457 for CYs 2014 through 2016.

We recommend that CMS instruct the Medicare contractors to recover, in accordance with Federal regulations, the portion of the $33,095,068 in identified Medicare potential overpayments from the 911 hospitals for the 3,233 incorrectly billed claims that are within the 4-year reopening period.

We recommend that CMS require hospitals to use condition codes 49 or 50 on claims for a device-replacement procedure that resulted from a recall or premature failure, regardless of whether the hospital received a reportable credit prior to billing for the device replacement procedure.

We recommend that CMS obtain device credit listings from manufacturers and determine whether providers reported the credits as required by Medicare regulations.

We recommend that CMS, as an alternative to our third, fourth, and fifth recommendations, consider eliminating the current Medicare requirements for reporting device credits by reducing IPPS and OPPS payments for cardiac device replacement procedures.

We recommend that the Health Resources and Services Administration improve its procedures for monitoring how health centers meet targets for future HRSA grant funding opportunities.

We recommend that the Health Resources and Services Administration require the 34 health centers in our sample identified as having improperly allocated AIMS grant costs to refund $1,722,271 to the Federal Government or work with the health centers to determine what portion of these costs is allocable to their AIMS grants, and work with other health centers in our sampling frame to determine what portion of an estimated $9,207,958 in improperly allocated grant costs is allocable.

We recommend that Edward W. Sparrow Hospital based on the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.

We recommend that the Ohio Department of Medicaid develop or enhance current procedures to identify beneficiaries with concurrent eligibility in another State, which could have saved the State agency an estimated $5,859,881 ($4,152,838 Federal share) in capitation payments for the month of August 2018.

We recommend that the Ohio Department of Medicaid redetermine, if necessary, the current Medicaid eligibility of the sampled beneficiaries who did not meet or may not have met Federal and State eligibility requirements.

We recommend that the Ohio Department of Medicaid educate eligibility caseworkers on how to properly determine an applicant’s or beneficiary’s household income and household size.

We recommend that the Ohio Department of Medicaid ensure that documentation supporting a beneficiary’s initial and continuing eligibility determination is maintained in the beneficiary’s record.

We recommend that Cahaba work with CMS to ensure that its final settlement of contract costs reflects an increase in Medicare pension cost of $593,158 for CYs 2014 through 2016.

We recommend that Cahaba work with CMS to ensure that is final settlement of contract costs reflects a decrease in Medicare pension costs of $127,002 for CYs 2014 through 2016.

We recommend that CMS work with the MACs to recover from hospitals Medicare OPPS overpayments, which total as much as an estimated $35,398,147.

We recommend that CMS revise the OPPS regulations or the Manual instructions to resolve the conflict between these requirements for OPPS claims with medical device credits.

We recommend that VNA of Central Jersey refund to the Medicare program the portion of the estimated $2,015,925 overpayment for claims incorrectly billed that are within the 4-year reopening period.

We recommend that VNA of Central Jersey exercise reasonable diligence to identify and return any additional similar overpayments outside of our audit period, in accordance with the 60-day rule, and identify any returned overpayments as having been made in accordance with this recommendation.

We recommend that the Massachusetts Executive Office of Health and Human Services refund to the Federal Government $10,518,114 (Federal share) for claims for single-source physician-administered drugs that were ineligible for Federal reimbursement.

We recommend that the Massachusetts Executive Office of Health and Human Services work with CMS to determine the unallowable portion of $4,154,511 (Federal share) for other claims for covered outpatient physician-administered drugs that were submitted without NDCs or with invalid NDCs and that may have been ineligible for Federal reimbursement and refund that amount, and whether the remaining $782,917 (Federal share) of other physician-administered drug claims could have been invoiced to the manufacturers to receive rebates and, if so, upon receipt of the rebates, refund the Federal share of the manufacturers’ rebates for those claims.

We recommend that the Massachusetts Executive Office of Health and Human Services strengthen its internal controls to ensure that all physician-administered drugs eligible for rebates are invoiced.

We recommend that the Minnesota Department of Human Services bill for and collect manufacturers’ rebates for pharmacy drugs and for single-source and top-20 multiple-source physician-administered drugs that we calculated to be $5,899,308 (Federal share) and refund the Federal Government.

We recommend that the Minnesota Department of Human Services work with CMS to ensure that all pharmacy and physician-administered drugs eligible for rebates after our audit period are processed for rebates.

We recommend that St. Francis Hospital refund to the Medicare contractor the portion of the $1,620,452 in estimated overpayments for the audit period for claims that it incorrectly billed that are within the 4-year reopening period.

We recommend that St. Francis Hospital strengthen controls to ensure full compliance with Medicare requirements; specifically, ensure that all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation; all inpatient beneficiaries meet Medicare requirements for inpatient hospital services; procedure and diagnosis codes are supported in the medical records and staff are properly trained; and medical records accurately document distinct procedural services and staff are properly trained.

We recommend that Gem City refund to the Medicare program the portion of the estimated $2,667,849 in overpayments for incorrectly billed claims that are within the 4-year reopening period.

We recommend that Gem City exercise reasonable diligence to identify and return any additional similar overpayments outside of our audit period, in accordance with the 60-day rule, and identify any returned overpayments as having been made in accordance with this recommendation.

We recommend that Cedars-Sinai refund to the Medicare program the portion of the $154,074 in overpayments for bariatric surgery claims that did not comply with the specifications in the LCDs and that are within the 4-year reopening period.

We recommend that Cedars-Sinai Medical Center work with Noridian to take action deemed necessary by CMS or Noridian, or both, regarding $175,199 in payments for bariatric surgery claims with dates of service on or after the effective date of the LCA

We recommend that Cedars-Sinai obtain supporting medical record documentation from other providers, such as primary care physicians, mental health providers, or dietitians, before performing any future bariatric surgeries.