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).

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

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 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 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.

Build upon its efforts to improve the quality of referrals from its primary referral sources.

Update its training plan to include annual minimum training hour requirements for each professional discipline.

We recommend that CMS consider the results of our audit when selecting nursing homes for followup audits by the CMS PBJ auditor.

We recommend that CMS educate nursing homes on the updated guidance available in the PBJ Policy Manual and PBJ Policy Manual FAQs.

We recommend that the North Dakota Department of Health and Human Service's Developmental Disability Section follow up with the residential providers that had the 182 instances of provider noncompliance identified in this report to ensure that they have taken corrective actions.

We recommend that the North Dakota Department of Health and Human Service's Developmental Disability Section work with the residential providers to improve internal controls for health and safety at residential settings, maintenance of records, and training.

CMS should take steps to support States in holding Medicaid managed care plans accountable for the accuracy of their online provider directories.

CMS should work with States to improve the accuracy of the provider data they use to evaluate the adequacy of networks in Medicaid managed care.

We recommend that the State agency refund $7,576,103 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 CBH update its policies and procedures to include: (1) a requirement to reconcile discrepancies between addresses of record and addresses given to treatment providers and (2) a process for determining when a change of residency occurs and notifying the CAO accordingly.

We recommend that CBH coordinate with the State agency to implement a revised initial denial notice that informs enrollees that they have the right to be provided, upon request and free of charge, all documents, records, and other information relevant to the adverse benefit determination as required by 42 CFR section 438.404(b)(2).

We recommend that CBH update its policies to comply with its HealthChoices Agreement by requiring staff to document the following for enrollees under 21 years of age: (1) steps taken to contact the enrollee's representative to request that the enrollee's representative ask the provider to communicate with CBH, and (2) efforts to reach the provider before issuing denial notices.

We recommend that CMS develop and implement additional training for analysts to improve the clarity, accuracy, and consistency of their documentation for reviewing CMS-64s.

We recommend that CMS modify its policies and procedures to specify which CMS departments are responsible for tracking and resolving disallowed payments.