Recommendations Tracker

We recommend that the Centers for Medicare & Medicaid Services take the following actions for supplier claims for DMEPOS items provided to hospice beneficiaries, which could have saved Medicare an estimated $116.9 million in improper payments and could have saved beneficiaries an estimated $29.8 million in deductibles and coinsurance that may have been incorrectly collected from them or from someone on their behalf during the audit period.

We recommend that the Centers for Medicare & Medicaid Services implement a postpayment edit process to detect claims submitted by suppliers processed before a beneficiary's notice of election of hospice care is processed in the CWF, and instruct the DME Medicare contractors to deny DMEPOS claims identified by the edit process if they do no have the GW modifier.

We recommend that the Centers for Medicare & Medicaid Services study the feasibility of including palliative items and services not related to a beneficiary's terminal illness and related conditions within the hospice per diem. Such a requirement would eliminate the need for Medicare to make additional payments for these services consistent with CMS's longstanding position that payments for services unrelated to a beneficiary's terminal illness and related conditions should be exceptional, unusual, and rare given the comprehensive nature of the services covered under the Medicare hospice benefit. In analyzing the feasibility of such a change, CMS could consider: (1) beneficiary access to care, (2) administrative costs, (3) appropriate adjustments to the per diem rates to reflect the higher costs associated with providing hospice services, and (4) possible improvement of coordination of care.

Refund to the Federal Government the $6,401,297 of estimated net overpayments.

Continue its examination of 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.

Continue to take actions to pursue Notice of Suitability Letters for all individuals identified, and, specifically, conduct all required child abuse and neglect background checks for the three individuals we reviewed who did not have the required checks at the time of our review and whose background checks were not resolved during our audit.

Remind its child care licensing specialists to follow up with child care providers to ensure all Child Protection Register background check results are uploaded to the provider's Facility Profile page in the Division of Early Learning Licensing Tool in a timely manner.

We recommend that Coventry Health Care of Missouri, Inc. refund to the Federal Government the $548,852 of total net overpayments.

We recommend that Coventry Health Care of Missouri, Inc. enhance its compliance procedures to focus on diagnosis codes that are at high risk for being miscoded by 1) educating its providers about the proper use and documentation of these diagnoses and 2) determining whether these diagnosis codes (when submitted to CMS for use in CMS's risk adjustment program) comply with Federal requirements.

We recommend that the Tennessee State Medicaid Agency refund to the Federal Government $397,341,616 in overpayments representing the Federal share of CPEs that the State agency claimed in excess of the allowable amount.

We recommend that the Tennessee State Medicaid Agency establish additional policies and procedures to ensure compliance with the STCs including policies and procedures for adjusting the CPE estimates to actual costs on the CMS-64s upon determining that hospitals have been overpaid or underpaid.

We recommend that the Tennessee State Medicaid Agency establish additional policies and procedures to ensure compliance with the STCs including policies and procedures for ensuring that the State agency identifies and excludes from its actual CPE calculations the net costs of caring for IMD patients between the ages of 21 and 64.

CMS should monitor national EPSDT performance data for blood lead screening tests and target efforts toward low-performing States to develop action plans for increasing tests, according to Medicaid's schedule.

CMS should coordinate with partners to develop and disseminate to State Medicaid agencies educational materials that reaffirm requirements and schedules for blood lead screening tests.

We recommend that the Centers for Medicare & Medicaid Services instruct the Medicare contractors to recover the portion of the $1,205,654 in identified Medicare potential overpayments from the 46 providers for the 54 incorrectly billed claims attributed to 48 sampled beneficiaries that are within the 4-year reopening period.

We recommend that the Centers for Medicare & Medicaid Services instruct the Medicare contractors to determine which of the remaining 58,107 claims in our sampling frame were incorrectly billed, recover the portion of the estimated $636,498,597 in potential Medicare overpayments that are within the 4-year reopening period, and instruct the providers identified with the incorrectly billed clams to refund $54,041,129 in beneficiary coinsurance amounts.

We recommend that the Centers for Medicare & Medicaid Services instruct the Medicare contractors to based on the results of this audit, notify appropriate providers (i.e., those for whom CMS determines this audit constitutes credible information of potential overpayments), so 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 CMS evaluate the impact of its new prior authorization requirement and, if appropriate, consider extending the requirement to neurostimulator implantation surgeries for Parkinson's disease and seizure disorders.

We recommend that the Substance Abuse and Mental Health Services Administration update its policies and procedures to require verification that accreditation bodies maintain records that contain sufficient detail to support each accreditation decision.

Missouri foster care agency should develop policies to help identify (a) children who have a heightened risk of going missing from care and (b) interventions that could reduce their risk.

Missouri foster care agency should implement improvements to the case management system to enable accurate identification of children who are missing from care.

ACF should support Missouri as it works to reduce children's risk for going missing from foster care and to improve compliance with Federal and State requirements related to children who go missing.

We recommend that the Centers for Medicare & Medicaid Services develop and share with the HHA industry information on COVID-19 infection prevention and control best practices that HHA providers can use to comply with CMS requirements and follow CMS guidance.

We recommend that the California Department of Health Care Services, in coordination with the Department of Developmental Services provide additional guidance to providers, such as a standard reporting form that includes the types of incidents that are required to be reported, and provide additional training to providers on critical incident identification and reporting.

We recommend that the California Department of Health Care Services, in coordination with the Department of Developmental Services perform additional analytical procedures, such as data matches, to identify potential critical incidents that have not been reported and follow up on them as required.

We recommend that the California Department of Health Care Services, in coordination with the Department of Developmental Services ensure that reported critical incidents involving the death of a beneficiary are reviewed by a mortality review committee as appropriate.

We recommend that the Colorado Department of Health Care Policy and Financing work with the Colorado Department of Human Services to strengthen its biennial audits of OTPs to ensure that services provided are in accordance with Federal and State requirements.

We recommend that the Colorado Department of Health Care Policy and Financing work with the Colorado Department of Human Services to educate OTPs on the deficiencies we identified in this report to increase their awareness of compliance issues regarding Federal and State requirements.

CMS should share information to help States address challenges with using telehealth to provide behavioral health services to Medicaid enrollees.

CMS should ensure that the three States that are unable to distinguish telehealth from in-person services implement indicators to identify which services are provided via telehealth.

CMS should conduct monitoring for fraud, waste, and abuse, and support State efforts to oversee telehealth for behavioral health services.

Develop and implement an action plan to reduce turnover of management and staff and to ensure continuity of Unit operations should turnover occur.

Ensure that investigations are completed within the appropriate timeframes and that delays are documented in the case files.

Ensure that supervisory reviews of case files are conducted periodically and documented in accordance with Unit policy.

Revise the Unit's MOU with the State Medicaid agency to establish procedures by which the Unit will receive referrals of potential fraud from MCOs.

IHS should solicit feedback from CCRTs regarding their observations of potential need for broader IHS-wide improvements.

IHS should assess whether IHS could use the CCRT model to provide support and training to facilities needing assistance with non-COVID-19-related care.

CMS should provide oversight of the 20 Medicare Advantage (MA) companies that had a disproportionate share of the risk-adjusted payments from chart reviews and health risk assessments (HRAs).

CMS should perform periodic monitoring to identify MA companies that had a disproportionate share of risk-adjusted payments from chart reviews and HRAs.

We recommend that the Colorado Department of Health Care Policy and Financing work with CMS to determine the total amount of claims that were eligible for rebates as well as the unallowable portion of the physician-administered drug claims, invoice drug manufacturers for the calculated rebates, and refund the Federal share of rebates collected for the years covered by our audit period and for years after our audit period.

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

Seek approval from the South Carolina Office of the Attorney General to implement a new case management system.

Take steps to ensure that all convictions and adverse actions are reported to Federal partners within the appropriate timeframes.

We recommend that the Clinic refund to First Coast $215,606 in estimated overpayments for other services provided on the same day as intravitreal injections of Avastin, Eylea, and Lucentis.

We recommended that the Clinic implement policies and procedures to ensure that it does not bill for services that are not separately payable from intravitreal injections of Avastin, Eylea, and Lucentis.