Recommendations Tracker

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 medication-assisted treatment via waivered providers.

NIH should centrally capture and monitor data on institutes and centers' 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.

We recommend that University of Michigan Health System refund to the Medicare program the estimated $12,520 overpayment for claims that it incorrectly billed that are within the 4-year reopening period.

We recommend that the University of Michigan Health System implement policies and procedures to ensure that Medicare claims for polysomnography services comply with Medicare requirements.

We recommend that the New Mexico Human Services Department bill for and collect manufacturers' rebates for the 44,790 claim lines related to single-source and top-20 multiple-source physician-administered drugs that we calculated to be at least $1,239,130 ($900,971 Federal share) and refund the Federal share of rebates collected.

We recommend that the New Mexico Human Services Department work with CMS to determine whether the other physician-administered drugs, associated with 183,859 claim lines and rebates of at least $170,674 ($124,097 Federal share), were eligible for rebates and, if so, determine the rebates due and, upon receipt of the rebates, refund the Federal share of the rebates collected.

We recommend that the New Mexico Human Services Department ensure that all pharmacy and physician-administered drugs eligible for rebates after our audit period are processed for rebates.

We recommend that Caretenders based on the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any returned overpayments as having been made in accordance with this recommendation.

We recommend that Gateway refund $932,607 claimed in unallowable costs related to: (1) indirect costs ($356,121), (2) credits received from vendors ($338,363), (3) equipment that was not purchased in accordance with Federal open competition procurement regulations ($208,600), and (4) use of company vehicles ($29,523).

We recommend that Gateway ensure that costs are allocated to Federal awards in accordance with the relative benefits received.

We recommend that BCBS of SC decrease its Excess Plan Partial Medicare Segment pension assets by $2,796,877 and recognize a negative $10,750 as the Excess Plan Partial Medicare Segment pension assets as of January 1, 2017.