Recommendations Tracker

We recommend that the Colorado Department of Health Care Policy and Financing report and refund $3,669,738 (Federal share) in unreported MFCU-determined Medicaid overpayments that related to paid claims and court-ordered awards that have been recovered and collected.

We recommend that the Colorado Department of Health Care Policy and Financing strengthen policies and procedures to ensure that overpayments are reported correctly and in a timely manner on the Form CMS-64 in accordance with Federal requirements, to include adding instructions on how to report court-ordered awards that have been collected and the timely reporting of these overpayments.

We recommend that Indian Health Service ensure that Tribal programs comply with vaccine program requirements by establishing formal reconciliation processes for all IHS Areas to ensure that the data that the Tribal programs submit on doses administered are correct.

We recommend that Indian Health Service work with CMS to disseminate guidance to Tribal programs on vaccine coding and billing.

We recommend that Indian Health Service work with CDC to develop and disseminate additional guidance related to dual enrollment and together implement a formal monitoring process to assist in ensuring that Tribal programs do not enter into unallowable dual-program agreements for Federal programs.

CMS should evaluate how HHAs are using telehealth specifically, the types of services provided via telehealth and the characteristics of patients who benefit from these services.

CMS should in collaboration with ASPR TRACIE, apply lessons learned from the COVID-19 pandemic to update and/or develop emergency preparedness trainings and materials for HHAs on responding to infectious disease outbreaks.

We recommend that Humana, Inc. refund to the Federal Government the $34,414,828 of estimated overpayments.

We recommend that Humana, Inc. examine its existing compliance procedures to identify areas where improvements can be made to ensure that diagnosis codes that are at high risk for being miscoded comply with Federal requirements (when submitted to CMS for use in CMS's risk adjustment program) and take the necessary steps to enhance those procedures.

CMS should implement a plan to increase UPICs' Medicaid program integrity activities, particularly related to managed care.

CMS should implement a plan to help ensure the success of the Major Case Coordination initiative for Medicaid referrals.

We recommend that Highmark Senior Health Company refund to the Federal Government the $6,227,005 of estimated net overpayments.

We recommend that Highmark continue its examination of its existing compliance procedures to identify areas where improvements can be made to ensure diagnosis codes that are at high risk for being miscoded comply with Federal requirements (when submitted to CMS for use in CMS's risk adjustment program) and take the necessary steps to enhance those procedures.

We recommend that the Texas Health and Human Services Commission work with CMS to determine whether the $33,776,649 in UC payments hospitals retained because costs were not reduced by the Medicare payments they received should be recouped and, if so, either refund the related Federal share of $19,661,532 to the Federal Government; or redistribute the recouped funds to participating hospitals that had UC costs that were not covered by the UC payments from the State.

We recommend that the Texas Health and Human Services Commission follow its CMS-approved methodology for calculating actual UC costs when reconciling initial UC payments with providers' actual UC costs, including reducing UC costs by Medicare payments providers receive.

We recommend that BCBST refund to the Federal Government the $7,784,540 of estimated overpayments.

We recommend that BCBST continue its examination of its existing compliance procedures to identify areas where improvements can be made to ensure that diagnosis codes that are at high risk for being miscoded comply with Federal requirements (when submitted to CMS for use in CMS's risk adjustment program) and take the necessary steps to enhance those procedures.

We recommend that Dialysis Clinic, Inc refund to the Federal Government the portion of the estimated $14,193,677 in improper payments for claims incorrectly billed to the Medicare program that are within the 4-year reopening period.

We recommend that Dialysis Clinic, Inc. modify its medical record system to ensure that patient assessments and plans of care are completed and updated timely based on the completion date of the last assessment as required, to ensure all the required elements and signatures are included, and implement written policies and procedures to ensure staff availability during extended leave or vacancies.

We recommend that Dialysis Clinic, Inc. reinforce, through staff and beneficiary training, its internal controls on how to maintain proper documentation of dialysis services in the medical record.

We recommend that the Indiana Department of Child Services ensure that health care records for the children under its care and supervision are maintained in accordance with State requirements by providing training and technical assistance to the FCMs on how to maintain health care records and input medications in MaGIK, implementing additional controls and procedures to ensure medications prescribed for children are input in MaGIK, implementing additional procedures to ensure the required authorizations for psychotropic medications are obtained and documented, and implementing additional procedures to ensure the required 30-day written reports and 90-day medical reviews are obtained and documented for children residing in residential facilities who are prescribed psychotropic medications.

We recommend that the Indiana Department of Child Services continue efforts with the Indiana Family and Social Services Administration to obtain access to Medicaid claim history.

Build upon its efforts to increase fraud referrals from the State Medicaid agency.

Assess the adequacy of existing staffing levels and, if appropriate, develop a plan to expand the size of the Unit.

Develop and implement processes to ensure that all convictions and adverse actions are reported to Federal partners within the appropriate timeframes.

Ensure that Unit supervisors track and verify that all staff in professional disciplines document their training.

Revise its MOU with the State Medicaid agency to reflect current practice and law.

We recommend that the Department of Health and Human Services ensure that it and its components fully implement the covered agency responsibilities found in GDA section 759(a).

We recommend that the Department of Health and Human Services maintain an inventory of all geospatial data assets, per section 759(b) of the GDA.

We recommend that Inter Valley Health Plan, Inc. refund to the Federal Government the $5,372,998 of estimated net overpayments.

As the postpayment quality control review processes are being fully implemented, we recommend that the Health Resources and Services Administration do the following to verify that providers received the correct PRF payments from the Phase 1 General Distribution of the PRF. Continue to perform postpayment quality control reviews, including the review of 3,767 providers that attested to acceptance of payments and kept payments of about $756 million under wave 5 based on the estimated revenue losses in March and April 2020, and seek repayment of any overpayments from providers. If it is not feasible to review all providers, HRSA could consider reviewing 189 providers that were identified for manual review and attested to acceptance of payments and kept a total of $538 million, which was about 71 percent of the $756 million. Furthermore, HRSA could conduct a cost-benefit analysis for manual review of additional providers and, if the benefit outweighs the cost, it could select additional

As the postpayment quality control review processes are being fully implemented, we recommend that the Health Resources and Services Administration do the following to verify that providers received the correct PRF payments from the Phase 1 General Distribution of the PRF. Ensure that PSC collects payments made to the 118 providers that did not return their rejected payments as of March 9, 2022.

As the postpayment quality control review processes are being fully implemented, we recommend that the Health Resources and Services Administration do the following to verify that providers received the correct PRF payments from the Phase 1 General Distribution of the PRF. Determine whether there were other providers that were impacted by the use of incorrect TINs for subsidiary organizations, recalculate the payments for these providers, and seek repayment of any overpayments.

ACF should improve Head Start grant recipients' self-reporting of incidents of child abuse, lack of supervision, and unauthorized release through better guidance and stronger consequences for failure to report.

ACF should improve data-sharing with States about incidents of child abuse, lack of supervision, and unauthorized release in Head Start centers.

Refund to the Federal Government the portion of the estimated $42,336,162 for hospice services that did not comply with Medicare requirements and that are within the 4-year claims reopening period.

Strengthen its policies and procedures to ensure that hospice services comply with Medicare requirements.

We recommend that the Centers for Medicare & Medicaid Services direct the MACs to recover from acute-care hospitals the portion of the $39,310,499 in identified improper payments for our audit period that are within the 4-year reopening period in accordance with CMS's policies and procedures.

We recommend that the Centers for Medicare & Medicaid Services, based upon the results of this audit, notify appropriate providers (i.e., those for whom CMS determines 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 Centers for Medicare & Medicaid Services continue to review the CWF edits to determine whether any refinements are necessary to prevent improper payments to acute-care hospitals for outpatient services provided to beneficiaries who are inpatients of other facilities (i.e., LTCHs, IRFs, IPFs, and CAHs).

Reimburse New York's BHP Trust Fund $8,615 associated with the improper monthly payments identified in our sample.

Implement system changes to ensure that BHP enrollees with a pending coverage end-date are transferred from BHP to Medicaid upon the end of their 5-year bar.

Implement system changes to ensure that claims for BHP payments are not made on behalf of deceased individuals.

CMS should design an annual MLR reporting template for States to provide to their Medicaid managed care plans.

CMS should clarify that States should review their Medicaid managed care plans' MLR reports to verify the accuracy of reported data elements.

CLA recommends that the National Institutes of Health assess its grant award programs to determine which grants should require additional cybersecurity protections due to research potentially including sensitive and confidential data or NIH intellectual property or both.

CLA recommends that the National Institutes of Health strengthen the NIHGPS to establish clear and measurable standards for cybersecurity protections.

CLA recommends that the National Institutes of Health strengthen its post-award process to confirm that cybersecurity protections have been implemented to adequately safeguard sensitive and confidential data. ?