Recommendations Tracker

We recommend that Presbyterian 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 the New York State Department of Health work with the New York State Office of Mental Health to improve its monitoring activities by increasing the number of case files reviewed when conducting provider site visits to ensure that service plans and subsequent service plan reviews are timely signed and maintained, community rehabilitation claims meet Medicaid reimbursement standards, and services are appropriately authorized; and providing formal guidance or training to providers to clarify requirements related to service plans and subsequent service plan reviews being timely signed and maintained, community rehabilitation claims meeting Medicaid reimbursement standards, and services being appropriately authorized.

We recommend that the Centers for Medicare & Medicaid Services work with the DME MACs to do the following, which if in effect during our audit period could have saved Medicare as much as $30,051,107 for wheelchair repairs: review accumulated costs for wheelchair repairs that exceed the federally recommended cost limit, and for those wheelchairs that the DME MACs determine will not remain serviceable for their entire 5-year RUL, enforce Federal requirements by requiring the suppliers that transferred ownership of the wheelchairs purchased on a rental basis to enrollees to furnish replacement wheelchairs to those enrollees at no cost to the enrollees or to Medicare.

We recommend that the Centers for Medicare & Medicaid Services work with the DME MACs to do the following, which if in effect during our audit period could have saved Medicare as much as $30,051,107 for wheelchair repairs: take appropriate action for suppliers that consistently bill for repairs made to wheelchairs during their 5-year RUL that exceed the federally recommended cost limit or the cost limit used as the basis for determining when wheelchairs furnished by suppliers will not remain serviceable for their entire 5-year RUL (e.g., by educating suppliers on proper billing and recovering improper payments).

We recommend that the Indian Health Service identify and correct any other Purpose Statute violations relating to funds not used on COVID-19 testing and other testing-related activities from the Families First Act and Paycheck Protection Act funds allocated to the IHS Direct programs within the GPAO, and, if IHS is unable to correct those violations, report any Antideficiency Act violations.

We recommend that the Indian Health Service identify and recover amounts not used for COVID-19 testing or other testing-related activities that we did not sample from remaining Tribal and UIO programs within the GPAO.

We recommend that the Indian Health Service develop and provide adequate guidance to programs within the GPAO on the proper use of Paycheck Protection Act funds in accordance with Federal requirements.

We recommend that the Indian Health Service provide adequate guidance to the programs on how to track and account for funds allocated and used under the Paycheck Protection Act.

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.