Recommendations Tracker

We recommend that the Utah Department of Health and Human Services improve its estate recovery program by implementing formal procedures to periodically review open cases and establish a timeframe for doing so.

We recommend that the Centers for Medicare & Medicaid Services take the following actions, which could have saved Medicare an estimated $190.1 million in payments made to acute-care hospitals for outpatient services provided to hospice enrollees and could have saved enrollees an estimated $43.6 million in deductibles and coinsurance that may have been incorrectly collected from them or from someone on their behalf during our audit period: Educate acute-care hospitals to understand that each hospice enrollee's hospice election statement addendum is available on request, and educate hospices to provide the addendum if requested to help an acute-care hospital assess whether an outpatient service palliated or managed an enrollee's terminal illness and related conditions.

We recommend that the Centers for Medicare & Medicaid Services take the following actions, which could have saved Medicare an estimated $190.1 million in payments made to acute-care hospitals for outpatient services provided to hospice enrollees and could have saved enrollees an estimated $43.6 million in deductibles and coinsurance that may have been incorrectly collected from them or from someone on their behalf during our audit period: Educate acute-care hospitals to analyze not only whether outpatient services palliated or managed enrollees' terminal illnesses but also whether outpatient services palliated or managed a condition related to a terminal illness.

We recommend that the Centers for Medicare & Medicaid Services take the following actions, which could have saved Medicare an estimated $190.1 million in payments made to acute-care hospitals for outpatient services provided to hospice enrollees and could have saved enrollees an estimated $43.6 million in deductibles and coinsurance that may have been incorrectly collected from them or from someone on their behalf during our audit period: Direct MACs or other appropriate contractors, such as Recovery Audit Contractors, to: (1) analyze Medicare claims data to identify acute-care hospitals that have aberrant billing patterns for condition code 07, and conduct Targeted Probe and Educate reviews of these acute-care hospitals; and (2) conduct prepayment or postpayment reviews of acute-care hospital claims for outpatient services provided to hospice enrollees and billed with condition code 07.

We recommend that the Health Resources and Services Administration work with the hospice identified in our report as having used $3,967,025 of its PRF payments for potentially unallowable expenditures to determine what amounts should have been allocated and require the hospice to return unallowable amounts to the Federal Government or ensure that the hospice properly replaces these unallowable expenditures with unreimbursed lost revenues or eligible expenses, if applicable.

We recommend that the Maine Department of Health and Human Services, Office of Child and Family Services develop written policies and procedures that require its supervisors to review and approve documentation of caseworker interviews with children and adults.

We recommend that the Maine Department of Health and Human Services, Office of Child and Family Services develop written policies and procedures that outline the steps a caseworker must take to override a report from screened-out to screened-in and manually input a response time.

We recommend that the Centers for Medicare & Medicaid Services use the information in this report and consider implementing changes suggested by hospitals, including providing written guidance clarifying the definition of "shoppable services" and developing a training and compliance program that is tailored for smaller hospitals.

We recommend that National Government Services, Inc. develop and implement enhanced procedures so that supervisors are better qualified to detect incorrect audit adjustments.

We recommend that the Massachusetts Department of Public Health work with CMS to develop standardized life safety training for ICF/IID staff.

We recommend that the California Department of Aging work with ACL to determine the allowability of the estimated $2,484,631 in local service provider expenses and refund any amount determined to be unallowable.

We recommend that the California Department of Aging update procedures to include approving advanced payments as close as administratively feasible to when the AAAs will expend the funds.

CMS should conduct audits to validate diagnoses reported only on in-home HRAs and HRA-linked chart reviews.

We recommend that the Centers for Medicare & Medicaid Services work with its plan sponsors to identify similar instances of noncompliance that occurred during our audit period and determine the impact to the Federal Government, which could have amounted up to an estimated $465,077,908 in Part D total cost, including $245,365,324 for drugs that were administered during enrollees' Part A SNF stays.

We recommend that the Centers for Medicare & Medicaid Services provide plan sponsors with timely and accurate information, such as dates of covered Part A SNF stays, to reduce instances of inappropriate Part D payment for drugs for which payment is available under the Part A SNF benefit.

We recommend that the Massachusetts Department of Public Health work with CMS to develop a risk-based approach to identify nursing homes at which surveys should be conducted more frequently than once every 15 months, such as those with a history of multiple high-risk deficiencies or frequent management turnover.

We recommend that the Massachusetts Department of Public health work with CMS to develop standardized life safety training for nursing home staff.

We recommend that the Department of Health and Human Services ensure that the HHS Office of the Chief Data Officer oversees, coordinates, and facilitates HHS's implementation of geospatial-related requirements, policies, and activities.

We recommend that the Department of Health and Human Services prepare the required annual reports regarding the achievements of the covered agency in preparing and implementing the strategic plan for the National Spatial Data Infrastructure (section 759(a)(1)) and complying with the other requirements in section 759(a).

CMS should clarify the requirement that States have a provider-specific OB/GYN network adequacy standard.

We recommend that EmblemHealth continue to ensure that its policies and procedures have been adequately designed and implemented to prevent, detect, and correct noncompliance with Federal requirements for diagnosis codes that are used to calculate risk-adjusted payments.

We recommend that the Indian Health Service work with Gallup Indian Medical Center and the Navajo Area Office to monitor background investigations to ensure all elements are completed within required timeframes in accordance with Federal requirements.

We recommend that the Indian Health Service work with Gallup Indian Medical Center and the Navajo Area Office to determine which staff members in contact with Indian children currently have a pending background investigation and take immediate action to supervise these staff members when children are in their care and adequately document such supervision.

We recommend that CVS Health 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 Humana 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.

CMS should require that remote patient monitoring be ordered and that information about the ordering provider be included on claims and encounter data for remote patient monitoring.

CMS should conduct provider education about billing of remote patient monitoring.

CMS should work with States to assess whether their Medicaid reimbursement rates for treatment with MOUD are sufficient to recruit and retain enough MOUD providers.

CMS should geographically target efforts to increase the number of MOUD providers that treat Medicaid enrollees in high-need counties.