Recommendations Tracker

We recommend that Cigna-HealthSpring of Tennessee, Inc. 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.

Develop and implement procurement policies and procedures to avoid acquiring unnecessary items and to perform analyses to determine the most reasonable approach for future vehicle purchases.

We recommend that the State agency enhance the monitoring of provider compliance by conducting periodic reviews of telehealth payments for compliance with requirements.

Review all pediatric skilled nursing service requests for which overnight care was completely denied and determine whether the overnight care requests meet the medical necessity requirement regardless of whether the caregiver provided work or school verification documentation.

We recommend that the Pennsylvania Department of Human Services, Office of Medical Assistance Program, revise the initial denial notice template referenced under Exhibit N in the HealthChoices Agreement to include information regarding the beneficiary's right to request a State fair hearing after exhausting the MCO's appeals process.

We recommend that CMS re-educate providers on the requirement for all home health claims to be submitted with the FIPS code for the county where the service was provided.

CMS should issue guidance to reiterate State obligations under the EPSDT benefit to ensure access to services to correct or ameliorate confirmed blood lead levels identified during screenings.

FDA should complete its rulemaking on non-face-to-face sales of tobacco products, as required by the Tobacco Control Act.

FDA should publish information and performance data on its oversight of online tobacco retailers.

We recommend that the Centers for Medicare & Medicaid Services instruct the MACs to, based on the results of this audit, notify appropriate providers (i.e., those for whom CMS determines this audit constitutes credible information of potential overpayments) so that the providers 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 Centers for Medicare & Medicaid Services update its Medicare requirements and corresponding educational material to improve providers' understanding of the Medicare Part B billing requirements for co-surgery procedures, including: updating the Medicare Claims Processing Manual, chapter 12, section 40.8, to ensure billing providers understand that two physicians performing procedures as co-surgeons (including bilateral procedures) must append the co-surgery modifier regardless of whether they are in the same specialty or in different specialties, and providing additional education material to providers clarifying that spinal instrumentation procedure codes must be billed with a co-surgery modifier under Medicare Part B when performed as a co-surgery.

The Centers for Medicare & Medicaid Services should instruct the MACs to recoup $33,332 for ACP services paid in error for claims in our sample.

The Centers for Medicare & Medicaid Services should establish Medicare requirements that address when it is appropriate to provide multiple ACP services for a single beneficiary and how these services should be documented when required to support the need for multiple services.

We recommend that the Puerto Rico Department of Health assess and adjust, if necessary, at least annually, the cryptographic configurations of public servers.

We recommend that NGS discontinue its internal policy of waiving certain overpayment collections related to lookback years and start collecting all hospice cap overpayments and paying refunds in accordance with CMS requirements.

We recommend that Blue Cross & Blue Shield of Rhode Island 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.

CMS should use data to identify nursing homes or nursing home characteristics that are associated with a higher use of psychotropic drugs and focus oversight on nursing homes in which trends may signal inappropriate use.

We recommend that California Physicians' Service, 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 Houlton Band of Maliseet Indians develop and implement policies and procedures that ensure the Tribe conducts FBI fingerprint background investigations using FBI-approved procedures for individuals in contact with Indian children, conducts inquiries to State and Tribal law enforcement agencies based on the 5 years of residency information on each application, and assesses criminal history results to verify that applicants meet the required minimum character standards.

We recommend that the Passamaquoddy Tribe at Indian Township perform background investigations, as required by the Act, on individuals who currently have contact with Indian children and determine whether the individuals meet the required minimum character standards.

We recommend that the Narragansett Indian Tribe perform background investigations, as required by the Act, on individuals who currently have contact with Indian children and determine whether the individuals meet the required minimum character standards.

We recommend that the Indian Health Service continue to provide additional training and technical assistance, in collaboration with other organizations as needed, to ensure that Tribes understand and comply with the requirements to conduct background investigations and the character assessment requirements of the Act.