Recommendations Tracker

We recommend that the South Carolina Department of Health and Human Services work with the Department of Disabilities and Special Needs to ensure that providers follow the reporting requirements for critical events.

We recommend that the South Carolina Department of Health and Human Services work with the Department of Disabilities and Special Needs to perform analytical procedures, such as data matches, on Medicaid claims data to identify any unreported critical incidents, and investigate as needed.

We recommend that the South Carolina Department of Health and Human Services work with the Department of Disabilities and Special Needs to impose sanctions on providers to compel compliance with timely reporting requirements for allegations of ANE and deaths.

We recommend that the South Carolina Department of Health and Human Services work with the Department of Disabilities and Special Needs to ensure that backup staff members are available to work on incident management activities whenever the primary IMC is unavailable.

CMS should Encourage Part D plans to increase access to and use of biosimilars.

We recommend that the New York City provider refund to the Medicare program the estimated $1,118,789 overpayment.

We recommend that the New York City provider develop policies and procedures to ensure that treatment plans contain all required elements, are maintained and are signed by the treating physician; the performing therapists and supervising physicians comply with the requirements related to incident-to services; psychotherapy services are conducted by therapists that meet Medicare qualification requirements; time spent on psychotherapy services is documented; and treatment notes are signed and maintained to support the services billed.

We recommend that the New York State Department of Health (the State Agency) refund $1,943,190 to the Federal Government.

We recommend that the New Mexico Human Services Department refund $12,422,181 to the Federal Government.

We recommend that the New Mexico Human Services Department establish policies and procedures to account for adjustments MCOs make to IHS encounter data after reconciliations are completed.

We recommend that the New Mexico Human Services Department turn on the edit for encounter data that compares calculated days to paid days to limit the State agency's acceptance of encounter data with dates-of-service spans that do not support the paid days.

To ensure that the State agency complies with Federal requirements and does not claim unallowable costs, we recommend that the Centers for Medicare & Medicaid Services direct the State agency to revise the Process Guide to include days worked during September in RMTSs.

To ensure that the State agency complies with Federal requirements and does not claim unallowable costs, we recommend that the Centers for Medicare & Medicaid Services direct the State agency to revise the Process Guide to prohibit the substitution of sampled personnel.

To ensure that the State agency complies with Federal requirements and does not claim unallowable costs, we recommend that the Centers for Medicare & Medicaid Services direct the State agency to revise the Process Guide to require the collection of information (e.g., student names or case numbers) to support whether an RMTS respondent's time was part of a health care service or a Medicaid administrative activity.

We recommend that Texas expand the scope of its site visits of PATH providers to include reviews of consumers' case files maintained by PATH providers to strengthen its current risk assessment process and ensure that providers only enroll eligible individuals into the PATH program.

We recommend that the Centers for Medicare & Medicaid Services do the following, which could have saved Medicare an estimated $47.8 million during our audit period: determine whether any eligibility specifications in the Medicare contractors' LCDs and LCAs should be added to the NCD for bariatric surgery and, if so, take the necessary steps to update the NCD by, for example; specifying when BMI should be measured; specifying what constitutes medical treatment for obesity (e.g., by including specific requirements for a beneficiary's participation in a weight management program); and including additional requirements needed to ensure that beneficiaries are appropriate candidates for bariatric surgery (e.g., the requirements that a physician other than a surgeon evaluate the beneficiary before surgery and that the beneficiary have a mental health evaluation, which includes a statement regarding the beneficiary's motivation and ability to follow postsurgical requirements).

We recommend that the Centers for Medicare & Medicaid Services do the following, which could have saved Medicare an estimated $47.8 million during our audit period: educate hospitals on the NCD requirements for bariatric surgeries if the NCD has been updated in response to our first recommendation.

We recommend that Tufts Health Plan refund to the Federal Government the $3,758,335 of net overpayments.

We recommend that Tufts Health Plan continue to improve its existing compliance procedures to identify areas where improvements can be made to ensure 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 the Office of Refugee Resettlement issue guidance to care provider facilities regarding the requirement to include all relevant ORR and DHS contacts in their emergency contact lists.

We recommend that the National Cancer Institute coordinate with the National Institutes of Health's DGSI/Closeout Center to update policies and procedures for monitoring grantees' submission of closeout documents to include increased outreach to grantees before the final reports (Final FFR, FRPPR, and FIS) become delinquent.

We recommend that SCAN refund to the Federal Government the $54,318,154 of net overpayments.

We recommend that the Centers for Medicare & Medicaid Services work with States to implement all of the recommendations made in OIG's prior audits.

We recommend that the Centers for Medicare & Medicaid Services explore using or expanding the use of available remedies to prevent and reduce the amount of improper payments made on behalf of ineligible beneficiaries. As appropriate, this could include disallowance of the Federal share associated with eligibility errors or proposing changes to eligibility determination practices and rules.

ASFR should take steps to ensure that HHS's suspension and debarment program has more consistent senior leadership and sufficient staffing.

ASFR should develop and disseminate guidance regarding how to prepare and submit complete referrals.

CMS should actively monitor the use and effectiveness of States' corrective action plans and other remedies, with a focus on making the remedies specific and outcome oriented.

CMS should engage with senior State officials earlier and more frequently to address State performance problems.

CMS should revise the State Operations Manual to reflect current CMS practices in overseeing State survey performance.

We recommend that Healthfirst Health Plan, Inc. refund to the Federal Government the $5,221,901 of estimated net overpayments.

We recommend that Healthfirst Health Plan, Inc. identify, for the potentially mis-keyed diagnosis codes described in this report, similar instances of noncompliance that occurred during our audit period but were not included in our non-statistical sample and refund any resulting overpayments to the Federal Government.

We recommended that Noridian Healthcare Solutions, LLC, work with CMS to ensure that its final settlement of contract costs reflects an increase in Medicare pension costs of $620,072 for CYs 2014 through 2016.

We recommended that Noridian Healthcare Solutions, LLC, increase the Medicare segment pension assets by $1,207,983 and recognize $31,451,287 as the Medicare segment pension assets as of December, 31, 2016.

We recommended that Noridian Healthcare Solutions, LLC, increase the Medicare segment PRB assets by $197,098 as of January 1, 2017.

We recommend that Noridian Healthcare Solutions, LLC, work with CMS to ensure that its final settlement of contract costs reflects an increase in Medicare PRB costs of $1,531,023 for CYs 2014 through 2016.