Recommendations Tracker

We recommend that the Virginia Medicaid Department of Medical Assistance Services identify and recover unallowable capitaiton payments, which we estimate to be at least $21,849,401, made to MCOs during our audit period on behalf of deceased enrollees.

We recommend that the Virginia Medicaid Department of Medical Assistance Services continue to pursue development and implementation of an automated matching and eligibility update process.

CMS should require States to collect data on MCO prior authorization decisions.

CMS should require States to implement automatic external medical reviews of upheld MCO prior authorization denials.

We recommend that the Florida Department of Children and Families coordinate with the Florida Agency for Health Care Administration to obtain access to Medicaid claim data for all children under its care and supervision.

We recommend that HRSA identify additional improper UIP payments for services provided to insured individuals or services unrelated to COVID-19, which we estimate to be $783.6 million, and take remedial action.

We recommend that Excellus Health Plan, Inc. identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government.

We recommend that Noridian Healthcare Solutions, LLC notify the physicians and qualified nonphysician practitioners to refund $1,162 in coinsurance that was collected for the 26 sampled enrollee-months.

We recommend that Noridian Healthcare Solutions, LLC update the educational material on its website as well as any previously provided webinars to include all Medicare requirements and guidance for billing and documenting ESRD-related services and continue to perform medical record reviews as part of the TPE program, which could have saved the Medicare program an estimated $8,844,899 and could have saved Medicare enrollees up to an estimated $2,204,799 for our audit period.

We recommend that the Centers for Medicare & Medicaid Services direct the appropriate Medicare contractors to determine the amount of improper payments for the claims that did not comply with Medicare requirements and, for those that are within the 4-year claim-reopening period, in accordance with CMS's policies and procedures, recover up to $888,169,038 for claims that were at risk of improper payment during our audit period.

We recommend that the National Institutes of Health provide additional training and implement oversight controls to ensure that contractor performance assessments are completed and uploaded to the Contractor Performance Assessment Reporting System timely.

We recommend that the Office of Children's Services continue to identify ways to address the challenges related to meeting the requirements for conducting monthly caseworker visits and home inspections, including consulting with ACF.

We recommend that Saint Louis University ensure that it always manages NIH awards in accordance with Federal and award requirements by strengthening procedures for reconciliation of payroll costs to approved salaries and wages and to payroll reports, and strengthening controls to ensure the timely completion and certification of employee time and effort reports after completion of each 6-month reporting period.

We recommend that Saint Louis University strengthen its controls, to include policies and procedures, to ensure that it properly monitors its subaward subrecipients, to include: evaluating its current risk assessment policies and procedures and implementing procedures to improve monitoring of subrecipients classified as high or medium risk and developing and implementing notification and followup procedures to be executed in cases of subrecipient subaward or contract cancellation.

We recommend that Keystone identify, for the high-risk diagnoses included in the report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government.

We recommend that Keystone ensure that it collects, for audits of risk adjustment data, medical records that comply with CMS requirements.

We recommend that the Centers for Medicare & Medicaid Services notify appropriate practitioners (i.e., those for whom CMS determines this audit constitutes credible information of potential overpayments) so that 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 the Centers for Medicare & Medicaid Services take the necessary steps, including seeking legislative authority, if necessary, to revise its regulations to ensure that Medicare pays the facility rate for physician services furnished while enrollees are Part A SNF or hospital inpatients irrespective of where the services are actually furnished or otherwise ensure that Medicare does not pay twice for any of the practice expenses incurred for physician services furnished while enrollees were Part A SNF or hospital inpatients, which could have resulted in the Medicare program paying up to $22,142,489 less and enrollees paying up to $5,609,125 less in cost-sharing during our 2-year audit period.

We recommend that the Centers for Medicare & Medicaid Services provide additional education to practitioners on the appropriate use of place-of-service codes while an enrollee is a Part A inpatient.

We recommend that the Florida Department of Children and Families, instruct PATH providers to review consumers' case files to determine if consumers are eligible and disenroll ineligible consumers from the PATH program.

We recommend that the Maryland Department of Health assess the effectiveness of all required NIST SP 800-53 controls according to the organization's defined frequency.

We recommend that the Maryland Department of Health perform periodic phishing exercises and enhance employee and contractor cybersecurity awareness training based on the results of the phishing exercises, if needed.

We recommend that the Vermont Department of Health, Division of Substance Use Programs require subrecipients to provide and retain supporting documentation for invoices submitted for reimbursement under Federal grants as recommended in Bulletin No. 5.

We recommend that the Vermont Department of Health, Division of Substance Use Programs provide training to State employees responsible for conducting pre-award risk assessments of potential subrecipients of Federal grant funds.

We recommend that the Centers for Medicare & Medicaid Services update security controls to align with the most current NIST SP 800-53 requirements.

We recommend that the Office of Refugee Resettlement strengthen oversight of transfers between care provider facilities by requiring that all transfer documentation be maintained in the UC Portal and by developing procedures for tracking and reviewing that documentation.

We recommend that the Office of Refugee Resettlement assess needs to expand the Office of Refugee Resettlement's network capacity to serve the needs of children with mental health and behavioral issues.

We recommend that HHS continue to work with OMB and other stakeholders to develop and implement an approach to reporting on TANF IPs going forward. This process will aid in identifying root causes of TANF IPs and allow HHS to report CAPs in the AFR.

We recommend that HHS continue to work with OMB and other stakeholders to develop and implement an approach to reporting on COVID-19 UIP in FY 2023.

We recommend that HHS focus on the root causes of the IP percentage and evaluate critical and feasible action steps to assist states with their compliance efforts for these requirements. This would include working with the states to bring their respective systems into full compliance with the requirements to decrease the IP rate percentage below 10 percent. HHS should work with the states to follow up on repeat root causes of errors and enhance the CAPs for implementation. In addition, as HHS reviews only 17 states each year for the Medicaid and CHIP IP rate, HHS should continue to follow up with states during the interim period to verify that corrective actions identified after the Payment Error Rate Measurement (PERM) review are being implemented. HHS should also consider sharing corrective action best practices across states to help address these issues.

While HHS continues to make improvements in certain areas of the Medicare FFS program that have reduced IP, the impact of IP stemming from the two drivers mentioned above outweighed this progress in FY 2022. We recommend that HHS continue to focus on the root causes of the IP percentage, especially the new drivers related to SNF and Hospice, and evaluate and document critical and feasible action steps to meet the Medicare FFS reduction target.

We recommend that the Health Resources and Services Administration work with the 13 health centers identified in our report that may not have properly allocated COVID-19 supplemental grant funding costs to determine what portion of the $15,056,835 is allocable to their COVID-19 supplemental grant funding and require the health centers to refund the improperly allocated funds to the Federal Government.