Recommendations Tracker

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.

We recommend that the State agency refund $10,930,063 to the Federal Government, consisting of $1,496,725 (Federal share) of capitation payments made on behalf of deceased beneficiaries who had a date of death recorded in the KEES, $8,264,519 (Federal share) of capitation payments made on behalf of deceased beneficiaries who did not have a date of death recorded in the KEES but who did have a date of death recorded in the DMF, and $1,168,819 (Federal share) in overreported Medicaid expenditures that were related to prior-period adjustments.

We recommend that the State agency identify and recover unallowable capitation payments made to MCOs during our audit period on behalf of deceased beneficiaries who did not have a date of death recorded in the KEES but who did have a date of death recorded in the DMF, which we estimate to be at least $14,648,662.

We recommend that the State agency strengthen internal controls, to include strengthening policies and procedures and enhancing training on the research and application of date-of-death information and other eligibility data, to ensure that the State agency's KEES is accurately updated based on information provided by Federal data sources, that the KEES generates tasks to update eligibility status of deceased beneficiaries, and that all eligibility update tasks are completed in a timely manner by State agency staff.

We recommend that the Centers for Medicare & Medicaid Services assess the costs and benefits of implementing the following recommendations and if CMS determines that the benefits outweigh the costs, take action to develop a process to identify nursing homes that do not report required data for all of the data elements related to COVID-19 cases and deaths among residents and staff and PPE and supplies and request that they submit the required data.

We recommend that the Centers for Medicare & Medicaid Services assess the costs and benefits of implementing the following recommendations and if CMS determines that the benefits outweigh the costs, take action to revise its quality assurance checks for ratios 2 and 4, which use the numbers of confirmed cases and admissions among residents and confirmed cases among staff in the denominator, by adding the number of suspected COVID-19 cases to the denominator in both ratios and adjust the ratios� thresholds to reflect the change.

We recommend that the Centers for Medicare & Medicaid Services assess the costs and benefits of implementing the following recommendations and if CMS determines that the benefits outweigh the costs, take action to contact nursing homes that failed quality assurance checks to verify the accuracy of reported data or to correct inaccurate data.

We recommend that the National Institutes of Health direct the National Human Genome Research Institute to improve its policies and procedures to ensure Grants Specialists monitor whether required audit reports are submitted for foreign applicants.

We recommend that the National Institutes of Health direct the National Human Genome Research Institute to update policies and procedures for Grants Specialists to require that they review available IRS Form 990s regarding grant applicants� risk factors before awarding grant funds.

We recommend that the Centers for Medicare & Medicaid Services work with the Medicare administrative contractors to educate providers about the documentation requirements for phlebotomy travel allowances.

We recommend that the Centers for Medicare & Medicaid Services issue regulations related to phlebotomy travel allowances clarifying: whether specimen collections refer only to specimens that were drawn by a technician or whether it includes all specimens that were drawn by another individual and were merely picked up by a technician; whether a specimen includes blood, urine, and micros; whether to prorate based on the number of patients or on the number of specimens; how to calculate mileage when a location is included without any specimens collected; and how to calculate mileage when personal miles are included (i.e., when to start or stop counting mileage) in their proration calculations.