Recommendations Tracker

Kaiser Permanente validate the point-of-sale fee amounts that its PBM disclosed for CYs 2014 and 2015 and refile the CY 2014 and 2015 DIR reports if appropriate.

We recommend that Partners In Care, Inc. refund to the Federal Government the portion of the estimated $11,278,891 for hospice services that did not comply with Medicare requirements and that are within the 4-year reopening period.

We recommend that Partners In Care, Inc. strengthen its policies and procedures to ensure that hospice services comply with Medicare requirements.

We recommend that the Centers for Medicare & Medicaid Services, as part of its ERM program, implement a process to assess all of its programs for national security risks in accordance with OMB Circular No. A-123's requirement to include new or emerging risks in the risk profile.

We recommend that Mission Hospice & Home Care, Inc. refund to the Federal Government the portion of the estimated $10,564,396 for hospice services that did not comply with Medicare requirements and that are within the 4-year reopening period.

We recommend that Mission Hospice & Home Care, Inc.: strengthen its policies and procedures to ensure that hospice services comply with Medicare requirements.

We recommend that Puerto Rico Department of Health revise its EOP, including adding or updating procedures, to comply with HPP-PHEP Cooperative Agreement requirements related to: (1) conducting annual public health and medical preparedness exercises or drills that include at-risk populations in all of its planning and activities; (2) identifying resources for at-risk populations; (3) anticipating storage needs for a surge of human remains; (4) implementing and identifying emergency procurement procedures; (5) clearly defining HCC Specialists' responsibilities; (6) obtaining public comment and input on its EOP; (7) utilizing EMAC or other public health mutual aid agreements to support coordinated activities when responding to public health emergencies; and (8) ensuring that all HCC members can share information regarding resources and resource needs to address an emergency.

We recommend that Puerto Rico Department of Health consider coordinating with appropriate organizations to develop guidance on accurate cause-of-death certifications focusing on whether underlying causes of death were disaster-related.

We recommend that the New York State Department of Health (State agency) refund $6,027,566 to the Federal Government.

Based on the results of this audit, we recommend that the Centers for Medicare & Medicaid Services notify appropriate providers (i.e., those for whom CMS determines that 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 Indiana Family and Social Service Administration refund $22,328,438 to the Federal Government.

We recommend that Lake Hospital System refund to the Medicare contractor the portion of the $4,385,974 in estimated overpayments for the audit period for claims that it incorrectly billed that are within the 4-year reopening period.

We recommend that Lake Hospital System strengthen controls to ensure full compliance with Medicare requirements.

We recommend that Staten Island University Hospital refund to the Medicare contractor the portion of the $11,761,274 in estimated overpayments for the audit period for claims that it incorrectly billed that are within the 4-year reopening period.

We recommend that Staten Island University Hospital strengthen controls to ensure that all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation, all inpatient beneficiaries meet Medicare requirements for inpatient hospital services, the use of bypass modifiers is supported in the medical records, and staff are properly trained.

We recommend that the Centers for Medicare & Medicaid Services make regulatory changes to allow it to require accreditation organizations to perform special surveys of hospitals selected by CMS after it issues new substantive participation requirements or guidance that it determines warrant additional validation to ensure timely compliance.

We recommended that the Kentucky Department for Medicaid Services refund $29,431,268 to the Federal Government.

We recommended that the Kentucky Department for Medicaid Services enhance RMS procedures to ensure that its RMTS methodology complies with Federal requirements for statistical validity.

We recommended that the Kentucky Department for Medicaid Services enhance policies and procedures to ensure that changes to its RMTS methodology are incorporated into a CAP amendment and promptly submitted to DCA for review.

We recommend that Northwest Hospice, LLC refund to the Federal Government the portion of the estimated $3,902,337 for hospice services that did not comply with Medicare requirements and that are within the 4-yearreopening period.

We recommend that Northwest Hospice, LLC strengthen its policies and procedures to ensure that hospice services comply with Medicare requirements.

CMS should identify and implement an appropriate way to address cybersecurity of networked medical devices in its quality oversight of hospitals, in consultation with HHS partners and others.

SAMHSA should develop comprehensive methods and measures to assess access to MAT via waivered providers.

NIH should centrally capture and monitor data on ICs' funding of grant applications out of rank order.

We recommend that the Nebraska Department of Health and Human Services report and refund $1,788,119 (Federal share) of the unreported MFCU-determined Medicaid overpayments that related to paid claims.

We recommend that the Nebraska Department of Health and Human Services determine the value of overpayments, including those related to court-ordered awards, identified after our audit period that have been collected but not reported; report them on the Form CMS-64; and refund the Federal share of the collected overpayments.

We recommend that the Nebraska Department of Health and Human Services improve policies and procedures to ensure that MFCU-determined Medicaid overpayments are reported on line 2 of the Form CMS-64.9C1 if collected or on line 2 of the Form CMS-64.9OFWA if not collected within timelines specified by Federal requirements.

We recommend that Professional Healthcare at Home, LLC refund to the Federal Government the portion of the estimated $3,358,906 for hospice services that did not comply with Medicare requirements and that are within the 4-year reopening period.

We recommend that Professional Healthcare at Home, LLC strengthen its policies and procedures to ensure that hospice services comply with Medicare requirements.

We recommend the State strengthen guidance to nursing facilities on reporting incidents of potential abuse or neglect of Medicaid beneficiaries.

To strengthen program safeguards for preventing and detecting improper payments for drug testing services and to address the three specific weaknesses we identified in this report, we recommend that the Centers for Medicare & Medicaid Services work with its Medicare contractors to take the necessary steps to determine whether clinical evidence exists to support a single, specific reasonable and necessary standard that (1) laboratories could use when determining the number of drug classes to bill for definitive drug testing services and (2) indicates the specific circumstances when direct-to-definitive drug testing is reasonable and necessary, and if clinical evidence exists, establish an NCD or develop LCDs with more consistent requirements for drug testing services.

To strengthen program safeguards for preventing and detecting improper payments for drug testing services and to address the three specific weaknesses we identified in this report, we recommend that the Centers for Medicare & Medicaid Services work with its Medicare contractors to implement a system edit or procedure to identify and limit the frequency of drug testing services per beneficiary across all Medicare jurisdictions. System edits or procedures that CMS and its contractors could consider include (1) adding a modifier to claims that represents the number of days of abstinence to track frequency or (2) determining the number of reasonable and necessary drug tests per calendar year per beneficiary and performing postpayment reviews of those tests that exceed the number.

To strengthen program safeguards for preventing and detecting improper payments for drug testing services and to address the three specific weaknesses we identified in this report, we recommend that the Centers for Medicare & Medicaid Services work with its Medicare contractors to consider adding a modifier to claims for definitive drug tests indicating whether a test was based on results obtained from a presumptive drug test so that Medicare contractors can identify for followup those laboratories that routinely bill direct-to-definitive drug testing for a large number of drug classes.