Recommendations Tracker

CMS should take action to address any breakdowns in the initial reviews of SNF admission requests that are driving the extremely high overturn rate of SNF admission denials.

CMS should assess reasons for the differences in SNF denial rates between nursing home residents and other enrollees and take action as warranted.

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 ORR conduct required abbreviated monitoring visits at unlicensed facilities approximately every 90 days.

We recommend that the Hospital refund to the Federal government the estimated $17,838,422 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 the following: Two-Midnight Rule; the medical necessity of inpatient services; IRF admissions; IRF documentation requirements ; and Inpatient and outpatient coding.

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.

We recommend that CMS implement a procedure to prevent overpayments to MA organizations when acute stroke diagnosis codes are submitted by MA organizations on a physician data record and the enrollee does not have an acute stroke diagnosis on an inpatient or outpatient hospital data record during the same service year (e.g., CMS filter of EDS data to identify and address these diagnosis codes or instructions to MA organizations to implement a control to prevent the submission of these diagnosis codes), which could have resulted in cost savings of $462 million.

We recommend that DPH strengthen its monitoring activities to ensure that nursing homes comply with requirements that prohibit the employment of individuals with disqualifying backgrounds, such as expanding the timeframe covered by recertification surveys.

We recommend that DPH ensure that all training materials on how to conduct background checks for new employees are made available to nursing homes.

We recommend that CMS revise or clarify IRF documentation requirements related to the: (1) development and individualization of the POC, (2) leadership of IDT meetings by rehabilitation physicians, (3) review at IDT meetings of enrollee progress toward rehabilitation goals and identification of any problems that could impede such progress, and (4) functional status of enrollees during the preadmission screening.

We recommend that CMS revise or clarify IRF-PAI signature requirements.

CMS should monitor billing to identify peripheral vascular procedures that may be medically unnecessary, which may indicate fraud, waste, or abuse.

We recommend that CMS share the results of this report with nursing homes and emphasize the importance of having adequate and reliable emergency power systems.

We recommend that CMS establish and implement internal controls to prevent improper payments for replacement PAP devices, which amounted to an estimated $15.2 million for our audit period.

We recommend that CMS develop the following system edits for billing communication technology-based services that could have saved the Medicare program up to $2.3 million during our audit period: (1) edits to identify payments for further review for (a) virtual check-in services that occur within 7 days after or 24 hours prior to an E/M service and are billed with the same diagnosis code and (b) e-visits that occur and are billed separately with the same diagnosis code but should be billed only once within 7 days; and (2) edits to identify and reject claims where virtual check-in services and E/M services are billed on the same claim.

We recommend that CMS further educate providers on the proper billing requirements for virtual check-in and e-visit services.

We recommend that CMS work with sponsors, as appropriate, to ensure sponsors' claims for Part D compounded drugs are accurately reported on PDE records consistent with CMS guidance.

We recommend that CMS provide guidance to sponsors regarding monitoring active pharmaceutical ingredients in bulk powder form used in compound drugs.

We recommend that Vibrent Health work with NIH to refund the $1.9 million of unapproved fringe benefits and indirect costs.

We recommend that Vibrent Health create an oversight function to independently ensure it complies with applicable terms and conditions of future Federal awards.

We recommend that Priority Health refund to the Federal Government the $4,479,698 of estimated net overpayments.

We recommend that Priority Health continue its examination of its existing compliance procedures to identify areas where improvements can be made to ensure that diagnosis codes that are at high risk for being miscoded comply with Federal requirements (when submitted to CMS for use in CMS's risk adjustment program) and take the necessary steps to enhance those procedures.

We recommend that VNS Health refund the $2,965,484 in estimated overpayments to the Medicare program, excluding amounts presumed to be unrecoverable under the Section 1870 waiver of liability provision.

We recommend that VNS Health strengthen its review of medical record documentation to ensure compliance with Medicare billing requirements.

We recommend that HHS develop a formal process for creating and maintaining cybersecurity profiles (current and target), including developing policies and procedures and implementing these policies and procedures at the Department level and at the Division level.

We recommend that HHS require and ensure Divisions implement SCRM policy and procedures.

We recommend that HHS conduct the workforce skills assessment/gap analysis timely and periodically update the assessment/gap analysis to account for changes in the risk environment across HHS and the Divisions.

We recommend that HHS develop policies, procedures, and guidance for the creation and maintenance of data and metadata inventories. These policies, procedures, and guidance should be implemented throughout HHS. HHS should establish a process to monitor Divisions' adherence to department-level policies, procedures, and guidance.

We recommend that HHS enforce HHS policies and procedures for provisioning and monitoring access of all privileged users and confirm implementation aligns with the policies and procedures. Privileged user access requests with the required approval should be documented and retained.

CMS should build on its efforts to reduce inappropriate schizophrenia diagnoses in nursing homes.

CMS should increase efforts to ensure that nursing home residents and their families are fully informed when antipsychotic drugs are given.

CMS should further develop resources for nursing homes and increase transparency in order to reduce inappropriate use of antipsychotic drugs and improve dementia care in nursing homes.

CMS should take steps to ensure that nursing home pharmacists fulfill their role in reducing the inappropriate use of antipsychotic drugs.