Recommendations Tracker

We recommend that the Louisiana Department of Health refund $1,326,830 to the Federal Government in BIPP funding that it received for ineligible expenditures.

We recommend that the Clinic refund to Noridian $398,625 in estimated overpayments for intravitreal injections of Eylea and for other services provided on the same day as intravitreal injections of Eylea and Lucentis.

We recommend 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 Eylea and Lucentis.

CMS should review States' managed care payment data in T-MSIS and ensure that States have corrective action plans to improve data completeness and quality, as appropriate.

CMS should clarify and expand its initiative on payment data.

Develop and implement a plan to address the challenges presented by the Unit's organizational structure.

Establish a process to coordinate on cases and improve collaboration with Federal partners.

Take steps to ensure that newly hired investigators complete new employee trainings.

We recommend that North Mississippi Medical Center refund to the Medicare program the estimated $67,038 in overpayments for claims that it incorrectly billed.

We recommend that North Mississippi Medical Center educate its staff on properly billing for polysomnography services.

CMS should provide data to consumers on nurse staff turnover and tenure, as required by Federal law.

CMS should consider residents' level of need when identifying nursing homes for weekend inspections.

We recommend that the Florida Agency for Health Care Administration, Division of Health Quality Assurance work with CMS to provide clear guidance to nursing facilities regarding what constitutes a reportable incident.

We recommend that the Florida Agency for Health Care Administration, Division of Health Quality Assurance establish and implement written policies and procedures for incident report processing.

We recommend that the Florida Agency for Health Care Administration, Division of Health Quality Assurance improve the intake process by assessing all Federal 24-Hour Reports to identify whether potential noncompliance with quality of care standards caused the incidents and whether the incident occurred after the last standard survey; assessing the severity and urgency of harm to the resident(s) that may have been caused by abuse, neglect, or nursing facility noncompliance with CoPs to assign a priority level; and using ACTS to create an incident record with start and end dates for all Federal 24-Hour Report assessments and to record priority assignments.

We recommend that the Florida Agency for Health Care Administration, Division of Health Quality Assurance establish and implement written policies and procedures for managing APS complaint notifications and conducting assessments of APS complaints to identify and survey more facilities where resident harm may have been caused by nursing facility noncompliance.

We recommend that Peninsula Regional Medical Center refund to the Medicare program the estimated $66,647 overpayment for claims that it incorrectly billed.

We recommend that Peninsula Regional Medical Center implement policies and procedures to ensure that Medicare claims for polysomnography services comply with Medicare requirements.

We recommend that the Centers for Medicare & Medicaid Services work with Treasury and QHP issuers to recover the $43,455 in improper APTCs identified in our sample, or take other remedial action.

We recommend that the Centers for Medicare & Medicaid Services develop a process for qualified health plan issuers to provide (a) information related to individuals' premium payments paid during the benefit year, and (b) enrollees' policy termination information so that enrollment data provided to the Internal Revenue Service is accurate.

ACF should conduct oversight activities to identify States that may not appoint a GAL to every child victim who undergoes a judicial proceeding, seeking statutory authority as necessary.

ACF should proactively identify and address obstacles that States face in reporting complete and accurate GAL data.

We recommend that Brookdale Home Health, LLC refund to the Medicare program the portion of the estimated $3,286,869 overpayment for claims incorrectly billed that are within the 4-year reopening period.

We recommend that Brookdale Home Health, LLC strengthen its procedures to ensure that the homebound statuses of Medicare beneficiaries are verified and continually monitored and the specific factors qualifying beneficiaries as homebound are documented and beneficiaries are receiving only reasonable and necessary skilled services.

We recommend that Blue Cross Blue Shield Michigan refund to the Federal Government the $14,534,375 of net overpayments.

We recommend that BCBSM examine 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 Tidewell Hospice, Inc. refund to the Federal Government the portion of the estimated $8,305,371 for hospice services that did not comply with Medicare requirements and that are within the 4-year claims reopening period.

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

CMS should conduct targeted reviews of MS-DRGs and stays that are vulnerable to upcoding, as well as the hospitals that frequently bill for them.

We recommend that the Virginia Department of Social Services conduct all required criminal background checks for the 15 individuals in our sample who did not have the required checks at the time of our review.

We recommend that the Virginia Department of Social Services revise State guidelines to increase the number of current employees that inspectors review at all child day centers to ensure provider compliance with criminal background check requirements.

We recommend that Noridian Healthcare Solutions, LLC recover $12,546 in improper payments made to physicians.

We recommend that Noridian Healthcare Solutions, LLC provide annual training to physicians and their billing staff in Jurisdiction E specific to Medicare requirements for billing of facet-joint injections, which could have saved an estimated $4,155,889 for our audit period.

We recommend that BAO establish procedures to reconcile IHS funds recorded in the UFMS on a regular schedule with amounts reported in supporting documents, such as worksheets and funding agreements.

We recommend that BAO establish procedures to evaluate IHS Direct programs' use of current no-year Health Services funds.

We recommend that the New York State Department of Health work with the Office for People With Developmental Disabilities and the Justice Center to reinforce guidance to the provider community on requirements related to the timing and method of initially reporting incidents; the timely completion of incident investigations; and the need to document justifications for investigative delays.

We recommend that the New York State Department of Health work with the Office for People With Developmental Disabilities and the Justice Center to issue guidance and/or provide training to the provider community on the importance of identifying trends in incidents.

We recommend that the Iowa Department of Human Services, Iowa Medicaid Enterprise follow up with the 20 nursing homes to ensure that corrective actions have been taken regarding the life safety and emergency preparedness deficiencies identified in this report.

We recommend that the Iowa Department of Human Services, Iowa Medicaid Enterprise conduct more frequent surveys at nursing homes that have a history of multiple high-risk deficiencies.

We recommend that the Illinois Department of Healthcare and Family Services develop or enhance current procedures to identify beneficiaries with concurrent eligibility in another State, which could have saved the State agency an estimated $3,790,896 ($2,094,545 Federal share) in capitation payments for the month of August 2018.