Recommendations Tracker

We recommend that the Louisiana Department of Education ensure that providers initiate and complete criminal background checks for all required individuals, including those given access to children on a contingency basis.

CMS should evaluate the potential impacts of updating the DRG window policy to include affiliated hospitals, and seek the necessary legislative authority to update the policy as appropriate.

We recommend that the Arkansas Department of Human Services ensure that community-based providers report all suspected adult or child abuse and neglect to the appropriate adult or child abuse hotline.

We recommend that the Arkansas Department of Human Services follow waiver guidance to conduct reviews of the deaths of beneficiaries receiving waiver services.

We recommend that the Arkansas Department of Human Services perform analytical procedures, such as data matches, on Medicaid claims data to identify potential critical incidents that have not been reported and investigate as needed.

Refund to the Medicare contractor $389,973 in estimated overpayments for the audit period for claims that it incorrectly billed that are within the 4-year claim reopening period.

Strengthen internal controls by: strengthening procedures to verify that all inpatient beneficiaries meet Medicare requirements for inpatient hospital services, strengthening processes to ensure that diagnosis codes and HCPCS codes are supported in the medical records, and providing additional training to coding staff on DRG and HCPCS code assignments.

We recommend that the Food and Drug Administration deobligate $88,152 in contract funding and close the six contracts that remained open but eligible for closeout as of June 15, 2021.

We recommend that the FDA add language to the contract awards to require that contractors specify when an invoice is the final contract invoice.

FDA require that CORs communicate a change in COR to the contracting officer before the COR leaves the position.

CMS should conduct additional outreach to beneficiaries to increase awareness about Medicare coverage for the treatment of opioid use disorder.

CMS should assist SAMHSA by providing data about the number of Medicare beneficiaries receiving buprenorphine in office-based settings and the geographic areas where Medicare beneficiaries remain underserved.

CMS should create an action plan and take steps to address disparities in the treatment of opioid use disorder.

We recommend that the Centers for Medicare & Medicaid Services expand the IRF transfer payment policy to apply to early discharges to home health care. If this expanded policy had been in place, Medicare could have saved $993,134,059 in 2017 and 2018.

We recommend that the Centers for Medicare & Medicaid Services direct the MACs to recover $9,528,296 in improper payments made to physicians for selected facet-joint denervation sessions.

We recommend that the Centers for Medicare & Medicaid Services assess the effectiveness of oversight mechanisms specific to preventing or detecting improper payments to physicians for more than two facet-joint denervation sessions related to the lumbar spine or cervical/thoracic spine per beneficiary during a rolling year and modify the oversight mechanisms based on that assessment.

We recommend that the Centers for Medicare & Medicaid Services direct the MACs to review claims for facet-joint denervation sessions after our audit period to identify instances in which Medicare paid physicians for denervation sessions that exceeded the number of allowable sessions in a 12-month period (in accordance with the applicable LCDs) and recover any improper payments identified.

We recommend that the Kentucky Cabinet for Health and Family Services refund to the Federal Government $1,894,643 (Federal share) in unallowable payments.

We recommend that the Kentucky Cabinet for Health and Family Services enhance or establish new controls to ensure that no beneficiary is issued multiple Medicaid ID numbers.

We recommend that the Centers for Medicare & Medicaid Services update its PDE guidance to address margin under sponsor delivery models in which a sponsor owns a pharmacy.

CMS should provide training for nursing homes on Federal requirements for facility-initiated discharge notices.

CMS should implement its deferred initiatives to address inappropriate facility-initiated discharges.

ACL should establish guidance for analysis and reporting of data collected by State Ombudsman programs from facility-initiated discharge notices.

ACL and CMS should ensure that all State Ombudsmen, State agencies, and CMS ROs have an ongoing venue to share information about facility-initiated discharges and potentially other systemic problems in nursing homes.

ACL and CMS should ensure that all State Ombudsmen, State agencies, and CMS ROs have an ongoing venue to share information about facility-initiated discharges and potentially other systemic problems in nursing homes.

We recommend that the Office of Intergovernmental and External Affairs develop and distribute to staff a quick reference document that includes key staff responsibilities for coordinating and vouchering both invitational and staff travel in accordance with the FTR and the HHS Travel Policy Manual and the resources available to staff for ensuring that travel card transactions are compliant with these Federal travel regulations; and a requirement that staff and supervisors read and sign the HHS Traveler Agreement.

We recommend that the Centers for Medicare & Medicaid Services take the following actions for supplier claims for DMEPOS items provided to hospice beneficiaries, which could have saved Medicare an estimated $116.9 million in improper payments and could have saved beneficiaries an estimated $29.8 million in deductibles and coinsurance that may have been incorrectly collected from them or from someone on their behalf during the audit period.

We recommend that the Centers for Medicare & Medicaid Services implement a postpayment edit process to detect claims submitted by suppliers processed before a beneficiary's notice of election of hospice care is processed in the CWF, and instruct the DME Medicare contractors to deny DMEPOS claims identified by the edit process if they do no have the GW modifier.

We recommend that the Centers for Medicare & Medicaid Services study the feasibility of including palliative items and services not related to a beneficiary's terminal illness and related conditions within the hospice per diem. Such a requirement would eliminate the need for Medicare to make additional payments for these services consistent with CMS's longstanding position that payments for services unrelated to a beneficiary's terminal illness and related conditions should be exceptional, unusual, and rare given the comprehensive nature of the services covered under the Medicare hospice benefit. In analyzing the feasibility of such a change, CMS could consider: (1) beneficiary access to care, (2) administrative costs, (3) appropriate adjustments to the per diem rates to reflect the higher costs associated with providing hospice services, and (4) possible improvement of coordination of care.

Refund to the Federal Government the $6,401,297 of estimated net overpayments.

Continue its examination of 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.

Continue to take actions to pursue Notice of Suitability Letters for all individuals identified, and, specifically, conduct all required child abuse and neglect background checks for the three individuals we reviewed who did not have the required checks at the time of our review and whose background checks were not resolved during our audit.

Remind its child care licensing specialists to follow up with child care providers to ensure all Child Protection Register background check results are uploaded to the provider's Facility Profile page in the Division of Early Learning Licensing Tool in a timely manner.

We recommend that Coventry Health Care of Missouri, Inc. refund to the Federal Government the $548,852 of total net overpayments.

We recommend that Coventry Health Care of Missouri, Inc. enhance its compliance procedures to focus on diagnosis codes that are at high risk for being miscoded by 1) educating its providers about the proper use and documentation of these diagnoses and 2) determining whether these diagnosis codes (when submitted to CMS for use in CMS's risk adjustment program) comply with Federal requirements.

We recommend that the Tennessee State Medicaid Agency refund to the Federal Government $397,341,616 in overpayments representing the Federal share of CPEs that the State agency claimed in excess of the allowable amount.

We recommend that the Tennessee State Medicaid Agency establish additional policies and procedures to ensure compliance with the STCs including policies and procedures for adjusting the CPE estimates to actual costs on the CMS-64s upon determining that hospitals have been overpaid or underpaid.

We recommend that the Tennessee State Medicaid Agency establish additional policies and procedures to ensure compliance with the STCs including policies and procedures for ensuring that the State agency identifies and excludes from its actual CPE calculations the net costs of caring for IMD patients between the ages of 21 and 64.

CMS should monitor national EPSDT performance data for blood lead screening tests and target efforts toward low-performing States to develop action plans for increasing tests, according to Medicaid's schedule.

CMS should coordinate with partners to develop and disseminate to State Medicaid agencies educational materials that reaffirm requirements and schedules for blood lead screening tests.

We recommend that the Centers for Medicare & Medicaid Services instruct the Medicare contractors to recover the portion of the $1,205,654 in identified Medicare potential overpayments from the 46 providers for the 54 incorrectly billed claims attributed to 48 sampled beneficiaries that are within the 4-year reopening period.

We recommend that the Centers for Medicare & Medicaid Services instruct the Medicare contractors to determine which of the remaining 58,107 claims in our sampling frame were incorrectly billed, recover the portion of the estimated $636,498,597 in potential Medicare overpayments that are within the 4-year reopening period, and instruct the providers identified with the incorrectly billed clams to refund $54,041,129 in beneficiary coinsurance amounts.

We recommend that the Centers for Medicare & Medicaid Services instruct the Medicare contractors 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 they 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 CMS evaluate the impact of its new prior authorization requirement and, if appropriate, consider extending the requirement to neurostimulator implantation surgeries for Parkinson's disease and seizure disorders.

We recommend that the Substance Abuse and Mental Health Services Administration update its policies and procedures to require verification that accreditation bodies maintain records that contain sufficient detail to support each accreditation decision.