Recommendations Tracker

We recommend that Jewish Hospital refund to the Medicare contractor $13,486,524 in estimated overpayments for the audit period for claims that it incorrectly billed that are within the 4-year claim reopening period.

We recommend that Jewish Hospital strengthen internal controls by: strengthening procedures to verify that all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation, developing processes to ensure that procedure and diagnosis codes are supported in the medical records, providing additional training to inpatient and outpatient coding staff on the use of bypass modifiers, and developing procedures to verify that the use of bypass modifiers is supported in the medical records.

We recommend that CGS Administrators, LLC, work with CMS to ensure that its final settlement of contract costs reflects a decrease in Medicare pension costs of $293,893 for CYs 2012 through 2016.

We recommend that CGS Administrators, LLC, work with CMS to ensure that its final settlement of contract costs reflects a decrease in Medicare SERP III costs of $6,705 for CYs 2015 and 2016.

Repay Federal matching funds spent on the case that was ineligible for Federal funding.

Examine the Unit's intake process for complaints of patient abuse or neglect and identify improvements.

Develop and implement a plan to increase fraud referrals from the Medicaid agency and other sources.

Implement processes to ensure that it reports convictions and adverse actions to Federal partners within the appropriate timeframes.

Repay Federal matching funds spent on cases that were ineligible for Federal funding.

Work with the Mississippi Division of Medicaid to ensure the return of the Federal Government's share of all recoveries.

Develop written policies and procedures and take other steps to ensure that periodic supervisory reviews are conducted and documented in the case files.

We recommend that the Centers for Medicare & Medicaid Services review the findings in this report and, if it determines that a separate payment methodology for capital costs at new hospitals is no longer warranted, change its regulations to require new hospitals to have their Medicare capital costs paid through the IPPS with an option for payment adjustments or supplemental payments if necessary.

We recommend that the Oklahoma Health Care Authority consider whether more of an emphasis on counseling could improve OUD outcomes and, if so, take steps to increase the appropriate use of counseling with OUD drugs in outpatient OUD treatment.

We recommend that the Missouri Department of Social Services refund $3,411,531 to the Federal Government.

We recommend that Palmetto work with CMS to ensure that its final settlement of contract costs reflects an increase in Medicare pension costs of $998,912 for CYs 2012-2016.

We recommend that CDS work with CMS to ensure that its final settlement of contract costs reflects a decrease in Medicare PRB costs for $73,594 for CYs 2012-2016.

We recommend that CDS work with CMS to ensure that its final settlement of contract costs reflects a decrease in Medicare EP costs of $8581 for CYs 2015 and 2016.

We recommend that Palmetto work with CMS to ensure that its final settlement of contract costs reflects a decrease in Medicare PRB costs of $2,848,586 for CYs 2012-2016.

We recommend that Palmetto work with CMS to ensure that its final settlement of contract costs reflects a decrease in Medicare SERP III costs of $25,162 for CYs 2015 and 2016.

We recommend that Palmetto work with CMS to ensure that its final settlement of contract costs reflects a decrease in Medicare Excess Plan costs of $406,791 for CYs 2015 and 2016.

We recommend that the Centers for Medicare & Medicaid Services direct the Medicare contractors to recover the $1,918,278 for claims that are within the reopening period, and instruct providers to refund up to $540,680, which beneficiaries were required to pay; these amounts consist of $1,427,930 in overpayments to providers that billed noncomplex or complex CCM services more than once for the same beneficiaries for the same service periods and up to $406,080 in cost-sharing overcharges to these beneficiaries; $438,262 in overpayments to providers that billed for both noncomplex or complex CCM services and overlapping care management services rendered to the same beneficiaries for the same service periods and up to $121,166 in cost-sharing overcharges to these beneficiaries; and $52,086 in overpayments to providers that billed for incremental complex CCM services associated with overpayments for complex CCM services that we identified and up to $13,434 in cost-sharing overcharges to th

We recommend that the Centers for Medicare & Medicaid Services direct the Medicare contractors to implement claim system edits to prevent and detect overpayments for noncomplex and complex CCM services.

We recommend that CDS LLC work with CMS to ensure that its final settlement of contract costs reflects a decrease in Medicare pension costs of $8989 for CYs 2012 through 2016.

We recommend that the Arkansas Department of Human Services refund the $4,361,850 Federal share to the Federal Government.

We recommend that the Texas Health and Human Services Commission refund $856,456 to the Federal Government.

We recommend that the Texas Health and Human Services Commission identify any other beneficiaries who are assigned more than one identification number and refund any unallowable CHIP payments associated with those beneficiaries.

We recommend that the New York State Department of Health refund to the Federal Government or provide documentation of such refund, totaling $97,998,292. Specifically refund to the Federal Government $77,152,491 related to random moments that could not be supported as Medicaid-eligible health services; refund to the Federal Government $1,238,102 for intergovernmental agreement payments that the State agency did not support that it did not double-claim; and refund to the Federal Government or provide documentation of the refund to CMS of $19,607,699 for excess costs claimed on the Form CMS-64 for 1 year.

We recommend that the New York State Department of Health refund $308,972,870 to the Federal Government or provide documentation that it can reasonably support, under the circumstances, its allocation of health services costs to Medicaid without using unverifiable IEP ratios.

We recommend that the New York State Department of Health revise its certified public expenditures SSHSP to (1) include September days worked in its random moment time study and (2) develop an accurate, supportable method to identify Medicaid costs instead of unverifiable IEP ratios.

We recommend that Palmetto GBA, LLC, discontinue using its internal policies 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 Palmetto GBA, LLC, collect $545,639 in lookback overpayments and return $17,513 in lookback refunds resulting from 2017 hospice cap calculations for lookback years.