Recommendations Tracker

We recommend that the Centers for Medicare & Medicaid Services establish an interagency process to integrate VHA enrollment, claims, and payment data into the CMS IDR to identify potential fraud, waste, and abuse under the Medicare program.

We recommend that the Centers for Medicare & Medicaid Services issue guidance to providers on not billing Medicare for a medical service that was authorized by VHA.

We recommend that Crow/Northern Cheyenne Hospital, Billings Area Office, and Indian Health Service Headquarters work together to update standard operating procedures for background investigations to address the deficiencies we identified in this report.

We recommend that Crow/Northern Cheyenne Hospital, Billings Area Office, and Indian Health Service Headquarters work together to determine which staff members in contact with Indian children currently have a pending background investigation and take immediate action to ensure that there is adequate documented evidence that these staff members meet IHS sight and supervision requirements when children are in their care.

We recommend that Crow/Northern Cheyenne Hospital, Billings Area Office, and Indian Health Service Headquarters work together to establish a monitoring system to ensure that the Hospital meets sight and supervision requirements for staff with pending background investigations and documents that they are met.

We recommend that the Centers for Medicare & Medicaid Services evaluate whether additional modifications are needed to existing programming in CASPER that prevented the entry of 2 different inspections that were performed on the same date.

We recommend that the Centers for Medicare & Medicaid Services correct existing programming in ASPEN that prevented the 56 emergency preparedness deficiencies from being reported on Care Compare.

We recommend that the Centers for Medicare & Medicaid Services strengthen its processes for reviewing inspection results reported on Care Compare by providing technical assistance and additional training to State survey agencies that are not following procedures in the State Operations Manual and ASPEN Central Office Procedures Guide for reporting deficiencies in ASPEN.

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

Establish policies and/or procedures to ensure that case files are maintained in an effective manner.

Update its policies and procedures manual to reflect current practices.

Take steps to ensure that convictions and adverse actions are reported to Federal partners within the appropriate timeframes.

We recommend that Cigna-HealthSpring Life & Health Insurance Company, Inc. identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government.

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

We recommend that the Maryland Department of Human Services, Child Support Administration periodically review the support of payroll costs invoiced by the AOC.

We recommend that the Centers for Medicare & Medicaid Services instruct the MACs to, based upon the results of this audit, notify appropriate physicians (i.e., those for whom CMS determines this audit constitutes credible information of potential overpayments) so that the physicians can 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 Missouri Department of Social Services, Missouri HealthNet Division ensure that the Missouri Department of Mental Health works to improve the completion timeliness of the certification surveys.

We recommend that the Missouri Department of Social Services, Missouri HealthNet Division ensure that the Missouri Department of Mental Health continues to monitor ISL providers to ensure that providers maintain documentation to support that: ISL provider staff have taken all required trainings; background screenings of all ISL provider staff have been performed in a timely manner; all ISL provider staff who transport recipients possess current and valid driver's licenses; and all recipients have received an annual review of the DMH individual rights brochure and a monthly visit from a service coordinator.

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

We recommend that the Georgia Department of Community Health improve its oversight and monitoring of providers.

We recommend that the Georgia Department of Community Health refund to the Federal Government $9,325 (Federal share) for top-20 multiple-source physician-administered drug claims that were ineligible for Federal reimbursement.

We recommend that the Georgia Department of Community Health complete the process for rebating pharmacy drug claims totaling $1,240,894 (Federal share) for single-source and $360,454 (Federal share) for multiple-source drugs that it had not previously sent for invoicing or refund the Federal share.

We recommend that the Georgia Department of Community Health strengthen its internal controls to ensure that all pharmacy and physician-administered drugs eligible for rebates are invoiced.

We recommend that the Centers for Medicare and Medicaid Services instruct the MACs to, based on the results of this audit, notify appropriate physicians (i.e. those for whom CMS determines this audit constitutes credible information of potential overpauments) so that the physicians can 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 recommended that Centers for Medicare and Medicaid Services direct the MACs (or other CMS-designated entities) to review a sample of claims for epidural steroid injection sessions administered during the period beginning on January 1, 2021, and ending on the date that the revised coverage limitations (i.e., up to four sessions per 12-month period) became effective in the relevant MAC's jurisdiction (I.e. December 5, 2021, and June 19, 2022), to identify instances in which Medicare paid physicians for injection sessions that exceeded the number of allowable sessions (in accordance with the applicable LCDs) and recover any improper payments identified.

We recommend that the Michigan Department of Health assess the effectiveness of all required NIST SP 800-53 controls according to the organization's defined frequency.

We recommend that the Texas Health and Human Services Commission provide its IGT entities with guidance on identifying and documenting the permissibility of the funds they transfer to cover the State share of Medicaid expenditures, emphasizing that the State is required to maintain records that adequately identify the source and application of funds for federally funded activities.

We recommend that the Florida Agency for Health Care Administration work with CMS to determine whether the other claims for multiple-source physician-administered drugs, totaling $40,635 ($24,772 Federal share), were eligible for rebates and, if so, determine the rebates due and, upon receipt of the rebates, refund the Federal share of the rebates collected.

We recommend that the Centers for Medicare & Medicaid Services work with its plan sponsors to identify and delete any unallowable PDEs related to the $19,704,602 of Medicare Part D total costs for beneficiaries whose most recent Medicare claim with a cancer diagnosis was for services provided more than 1 year before the TIRF drugs were dispensed, and determine the impact to the Federal Government.

We recommend that the Centers for Medicare & Medicaid Services work with its plan sponsors to expand the required PDE data elements to include diagnosis codes to enable plan sponsors to confirm that TIRF drugs are prescribed for a medically accepted indication.