Recommendations Tracker

We recommend that HHS fulfill the remaining seven covered agency responsibilities established in GDA section 759(a).

We recommend that HHS develop and maintain an inventory of all geospatial data assets in accordance with section 759(b) of the GDA.

We recommend that the State agency adjust its future CMS reports to reflect the Federal share of $99,983,506 in underreported collections during our audit period and refund this amount.

We recommend that the State agency develop and implement written policies and procedures to report the actual amounts from its accounting records on the CMS reports and reconcile its accounting records to the amounts of Medicaid collections it reports on the CMS reports.

We recommend that the Wisconsin Department of Health Services refund the estimated $67,042,719 to the Federal Government related to moments that could not be supported as Medicaid-eligible health services or Medicaid administrative activities.

We recommend that the Wisconsin Department of Health Services ensure that its contractor obtains sufficient information so that the Wisconsin Department of Health Services can validate the contractor's coding of RMTS moments.

We recommend that the Wisconsin Department of Health Services develop an accurate, supportable method to identify Medicaid costs that can be verified with source documents.

We recommend that DHS work with DCFS and CACD to immediately review the nine inappropriately screened-out reports in our sample and act as appropriate.

We recommend that DHS work with DCFS to strengthen its procedures to ensure that notifications to law enforcement, the prosecuting attorneys' offices, school officials, and any other relevant parties are made and documented in CHRIS.

We recommend that DHS work with DCFS to update the CHRIS system to identify custodial and noncustodial parents of the alleged victim as interview roles.

We recommend that the State agency refund to the Federal Government $59,300,776 (Federal share) in overpayments.

Examine position descriptions and salaries to ensure a fair and competitive salary and benefit package that enables the Unit to recruit and retain qualified staff.

Take steps to ensure that periodic supervisory reviews are documented in the case files.

Establish written policies and procedures for maintaining an inventory of the Unit's equipment.

We recommend that CMS instruct Palmetto to recover the $428,325 in unallowable organ transportation costs by adjusting the associated OPOs' cost reports, consistent with relevant regulations and the agency's policies and procedures.

We recommend that UnitedHealthcare Benefits of Texas, Inc. refund to the Federal Government the $24,465,369 of estimated overpayments.

We recommend that UnitedHealthcare Benefits of Texas, Inc. identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred after our audit period and refund any resulting overpayments to the Federal Government.

We recommend that the State agency refund $6,164,734 (Federal share) for unallowable capitation payments made on behalf of incarcerated Medicaid enrollees.

CMS should establish procedures that outline the steps to be taken to address potentially inaccurate Medicaid MLR data submitted by States and follow up with States, as needed.

CMS should improve the efficiency and effectiveness of CMS's oversight of the accuracy of State-submitted Medicaid MLR data.

We recommend that the State agency work with DDS to develop and implement formal written policies and procedures for the provider certification and recertification process.

We recommend that the State agency work with DDS to fully implement its reporting and monitoring system to identify potential cases of reportable incidents involving Medicaid participants with intellectual and developmental disabilities who incurred severe injuries and were treated in hospital emergenc room and inpatient settings and that appropriate follow-up action is taken.

Build upon its efforts to attain sufficient staffing by recruiting and retaining qualified staff and minimizing case disruptions during staffing shortages.

Develop and implement a plan with the DOJ financial office to support robust fiscal controls.

We recommend that the Hospital refund to the Federal government the estimated $12,499,714 in net overpayments for incorrectly billed claims, excluding amounts presumed to be unrecoverable under the Section 1870 waiver of liability provision.

We recommend that the Hospital provide additional training to clinical and billing personnel on its policies and procedures related to IRF admissions and documentation requirements, and inpatient and outpatient coding.

We recommend that the Hospital refund to the Federal government the net overpayments of $38,676 in incorrectly billed claims, excluding amounts presumed to be unrecoverable under the Section 1870 waiver of liability provision.

We recommend that the Hospital provide additional training to clinical and billing personnel on its policies and procedures related to inpatient and outpatient billing and coding.

We recommend that Humana, Inc. refund to the Federal Government the $130,922,653 of estimated overpayments.

We recommend that Humana, Inc. identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred after our audit period and refund any resulting overpayments to the Federal Government.

We recommend that UnitedHealthcare of Wisconsin, Inc. refund to the Federal Government the $46,913,121 of estimated overpayments.

We recommend that UnitedHealthcare of Wisconsin, Inc. identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred after our audit period and refund any resulting overpayments to the Federal Government.

We recommend that the NAIHS follow its internal controls and its established procedures for awards of IIJA funds for SFC Program projects, to include controls regarding the proper review and updates of project cost estimates and the proper review and approval of project summaries.

We recommend that the NAIHS follow its internal controls and its established procedures for the monitoring of SFC Program projects, to include: (1) strengthening project oversight activities, including of review and monitoring of invoices and documentation of construction cost controls; (2) following controls designed to ensure that MOAs are amended for project scope changes; and (3) following controls designed to ensure that construction costs do not exceed limits established in the MOAs.

CMS should ensure that MAOs strengthen checks of out-of-network DMEPOS suppliers.

CMS should require that all DMEPOS suppliers that bill Medicare Advantage be enrolled in Medicare, or seek statutory authority to do so if necessary.

Hire additional staff in accordance with its approved budget and in relation to State Medicaid expenditures

Update its policies to include coordinating cases with Federal partners

Ensure that periodic supervisory reviews of case files are consistently documented

Improve communication with the USAO in the Southern District

Revise the MOU with the State Medicaid Agency to reference the CMS Performance Standard for Referrals

We recommend that the South Carolina Department of Health and Human Services implement policies and procedures for monitoring the MCOs' compliance with parity requirements, including: (1) providing clear, uniform guidance to the MCOs regarding maintaining and providing accurate, complete, and consistent data to support the MCOs' quarterly service authorization reports; (2) reviewing and validating the MCOs' data that support the MCOs' quarterly service authorization reports, so the State agency can accurately complete and report the parity analyses of MH/SUD services compared to M/S services that require prior authorization; and (3) addressing with the MCOs any issues of noncompliance or potential noncompliance with parity requirements and coordinating with the MCOs to develop corrective action plans.