Recommendations Tracker

We recommend that the Nebraska Department of Health and Human Services report and refund $1,788,119 (Federal share) of the unreported MFCU-determined Medicaid overpayments that related to paid claims.

We recommend that the Nebraska Department of Health and Human Services determine the value of overpayments, including those related to court-ordered awards, identified after our audit period that have been collected but not reported; report them on the Form CMS-64; and refund the Federal share of the collected overpayments.

We recommend that the Nebraska Department of Health and Human Services improve policies and procedures to ensure that MFCU-determined Medicaid overpayments are reported on line 2 of the Form CMS-64.9C1 if collected or on line 2 of the Form CMS-64.9OFWA if not collected within timelines specified by Federal requirements.

We recommend that Professional Healthcare at Home, LLC refund to the Federal Government the portion of the estimated $3,358,906 for hospice services that did not comply with Medicare requirements and that are within the 4-year reopening period.

We recommend that Professional Healthcare at Home, LLC strengthen its policies and procedures to ensure that hospice services comply with Medicare requirements.

We recommend the State strengthen guidance to nursing facilities on reporting incidents of potential abuse or neglect of Medicaid beneficiaries.

To strengthen program safeguards for preventing and detecting improper payments for drug testing services and to address the three specific weaknesses we identified in this report, we recommend that the Centers for Medicare & Medicaid Services work with its Medicare contractors to take the necessary steps to determine whether clinical evidence exists to support a single, specific reasonable and necessary standard that (1) laboratories could use when determining the number of drug classes to bill for definitive drug testing services and (2) indicates the specific circumstances when direct-to-definitive drug testing is reasonable and necessary, and if clinical evidence exists, establish an NCD or develop LCDs with more consistent requirements for drug testing services.

To strengthen program safeguards for preventing and detecting improper payments for drug testing services and to address the three specific weaknesses we identified in this report, we recommend that the Centers for Medicare & Medicaid Services work with its Medicare contractors to implement a system edit or procedure to identify and limit the frequency of drug testing services per beneficiary across all Medicare jurisdictions. System edits or procedures that CMS and its contractors could consider include (1) adding a modifier to claims that represents the number of days of abstinence to track frequency or (2) determining the number of reasonable and necessary drug tests per calendar year per beneficiary and performing postpayment reviews of those tests that exceed the number.

To strengthen program safeguards for preventing and detecting improper payments for drug testing services and to address the three specific weaknesses we identified in this report, we recommend that the Centers for Medicare & Medicaid Services work with its Medicare contractors to consider adding a modifier to claims for definitive drug tests indicating whether a test was based on results obtained from a presumptive drug test so that Medicare contractors can identify for followup those laboratories that routinely bill direct-to-definitive drug testing for a large number of drug classes.

We recommend that University of Michigan Health System refund to the Medicare program the estimated $12,520 overpayment for claims that it incorrectly billed that are within the 4-year reopening period.

We recommend that the University of Michigan Health System implement policies and procedures to ensure that Medicare claims for polysomnography services comply with Medicare requirements.

We recommend that the New Mexico Human Services Department bill for and collect manufacturers� rebates for the 44,790 claim lines related to single-source and top-20 multiple-source physician-administered drugs that we calculated to be at least $1,239,130 ($900,971 Federal share) and refund the Federal share of rebates collected.

We recommend that the New Mexico Human Services Department work with CMS to determine whether the other physician-administered drugs, associated with 183,859 claim lines and rebates of at least $170,674 ($124,097 Federal share), were eligible for rebates and, if so, determine the rebates due and, upon receipt of the rebates, refund the Federal share of the rebates collected.

We recommend that the New Mexico Human Services Department ensure that all pharmacy and physician-administered drugs eligible for rebates after our audit period are processed for rebates.

We recommend that Caretenders based on the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any returned overpayments as having been made in accordance with this recommendation.

We recommend that Gateway refund $932,607 claimed in unallowable costs related to: (1) indirect costs ($356,121), (2) credits received from vendors ($338,363), (3) equipment that was not purchased in accordance with Federal open competition procurement regulations ($208,600), and (4) use of company vehicles ($29,523).

We recommend that Gateway ensure that costs are allocated to Federal awards in accordance with the relative benefits received.

We recommend that BCBS of SC decrease its Excess Plan Partial Medicare Segment pension assets by $2,796,877 and recognize a negative $10,750 as the Excess Plan Partial Medicare Segment pension assets as of January 1, 2017.

We recommend that the Centers for Medicare & Medicaid Services direct the Medicare contractors to recover the $3,963,618 for instances in which different physicians reported CPT codes and received MCPs for monthly ESRD-related services provided to the same beneficiary for the same month of service (for claims that are within the 4-year reopening period.

We recommend that the Centers for Medicare & Medicaid Services direct the Medicare contractors to instruct the physicians to refund beneficiaries the $1,092,149 in beneficiary cost-sharing (deductible and coinsurance) amounts that may have been incorrectly collected from beneficiaries or from someone on their behalf.

We recommend that the Centers for Medicare & Medicaid Services based on the results of this audit, notify appropriate physicians (i.e., those for whom CMS determines that this audit constitutes credible information of potential overpayments) so that the physicians 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 Anthem Community Insurance Company, Inc. refund to the Federal Government the $3,468,954 of net overpayments.

We recommend that Anthem Community Insurance Company, Inc. enhance its compliance procedures to focus on diagnosis codes that are at high risk for being miscoded by determining whether these diagnosis codes (when submitted to CMS for use in CMS�s risk adjustment program) comply with Federal requirements and educating its providers about the proper use of these diagnosis codes.

We recommend that Sleep Management refund to the Federal Government the portion of the estimated $29,131,187 in Medicare overpayments for claim lines incorrectly billed that are within the 4-year reopening period.

We recommend that Sleep Management follow existing policies and procedures to help ensure that it: (1) obtains medical record documentation that is sufficient to satisfy Medicare medical necessity requirements and (2) discontinues service when beneficiaries do not continually use the device.

We recommend that the New York State Office of Temporary and Disability Assistance work with its local districts and TANF-funded State programs to develop financial management procedures that would enable the State agency to determine if TANF and MOE expenditures are accurately reported to ACF, including the $4.8 billion in TANF and MOE expenditures reported for FY 2016.

We recommend that Franciscan refund to the Federal Government the portion of the estimated $13,027,841 for hospice services that did not comply with Medicare requirements and that are within the 4-year reopening period.

We recommend that Franciscan strengthen its policies and procedures to ensure that hospice services comply with Medicare requirements.

We recommend that Alive Hospice, Inc. refund to the Federal Government the portion of the estimated $7,389,854 for hospice services that did not comply with Medicare requirements and that are within the 4-year reopening period.

We recommend that Alive Hospice, Inc. strengthen its policies and procedures to ensure that hospice services comply with Medicare requirements.

We recommend that Ambercare Hospice, Inc. refund to the Federal Government the portion of the estimated $24,665,520 for hospice services that did not comply with Medicare requirements and that are within the 4-year reopening period.

We recommend that Ambercare Hospice, Inc. strengthen its policies and procedures to ensure that hospice services comply with Medicare requirements.

We recommend that the Centers for Medicare & Medicaid revise its regulations to provide sufficient guidance to ensure that providers meet coverage requirements for outpatient cardiac and pulmonary rehabilitation services.

We recommend that the New York State Department of Health refund $9,325,338 to the Federal Government.

We recommend that the New York State Department of Health ensure that improvements made to its processes for determining whether an individual applying for Medicaid has already been assigned a Medicaid ID number are effective by verifying that system queries are adequate to identify all individuals with existing Medicaid ID numbers and local district and Marketplace staff are following guidance on identifying individuals with Medicaid ID numbers and using all available resources to identify and prevent the issuance of more than one Medicaid ID number to the same individual.

We recommend that the Centers for Medicare & Medicaid Services direct the Medicare contractors to develop oversight mechanisms to identify at-risk providers (e.g., by reviewing claims for providers that routinely billed direct LDL tests in addition to lipid panels for the same beneficiary on the same date of service and appended to those claim lines an NCCI associated modifier) and prevent improper payments to these providers, which could have saved up to $20,351,424 for our audit period.

We recommend that Suncoast Hospice refund to the Federal Government the portion of the estimated $47,363,971 for hospice services that did not comply with Medicare requirements and that are within the 4-year claims reopening period.

We recommend that Suncoast Hospice strengthen its policies and procedures to ensure that hospice services comply with Medicare requirements.