Recommendations Tracker

We recommend that the Massachusetts Executive Office of Health and Human Services refund to the Federal Government refund $882,892 (Federal share) for claims for top-20 multiple-source physician-administered drugs that were ineligible for Federal reimbursement.

We recommend that the Massachusetts Executive Office of Health and Human Services work with CMS to determine and refund the unallowable portion of Federal reimbursement for physician-administered drugs that were not invoiced for rebates after December 31, 2017.

We recommend that the Minnesota Department of Human Services work with CMS to determine whether the non-top-20 multiple-source physician-administered drugs were eligible for rebates that we calculated to be at least $173,780 (Federal share) and, if so, upon receipt of the rebates, refund the Federal share of the rebates collected.

We recommend that the Minnesota Department of Human Services work with the contractor to confirm that DRAMS is properly identifying drug rebate eligibility to ensure that all rebate-eligible pharmacy and physician-administered drugs are identified and billed for rebates.

We recommend that St. Francis Hospital, 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 of those returned overpayments as having been made in accordance with this recommendation.

We recommend that Gem City for the remaining portion of the estimated $2,667,849 overpayment for claims that are outside of the reopening period, exercise reasonable diligence to identify and return 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 Gem City 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 Cedars-Sinai Medical Center based upon 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 of those returned overpayments as having been made in accordance with this recommendation.

We recommend that Cedars-Sinai Medical Center update its patient checklist to include all of Noridian's specifications for billing bariatric surgeries.

For the 11 MAC jurisdictions with a coverage limitation for the number of facet-joint injection sessions during a rolling 12-month period, we recommend that the Centers for Medicare & Medicaid Services, instruct the MACs to, based upon the results of this audit, notify appropriate physicians (i.e., those for whom CMS determines 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.

For the 11 MAC jurisdictions with a coverage limitation for the number of facet-joint injection sessions during a rolling 12-month period, we recommend that the Centers for Medicare & Medicaid Services direct the MACs that oversee the 11 jurisdictions to review claims for facet-joint injections after our audit period to identify instances in which Medicare paid physicians for more than 5 injection sessions received by beneficiaries during a rolling 12-month period and recover any improper payments identified.

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

We recommend that Clinical Practices of the University of Pennsylvania based upon 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 of those returned overpayments as having been made in accordance with this recommendation.

We recommend that the Colorado Department of Health Care Policy and Financing identify and refund to the Federal Government any payments made on behalf of ineligible beneficiaries for whom services after our audit period were claimed and reimbursed past the termination dates of their eligibility.

We recommend that Alta Bates Summit Medical Center 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 of those returned overpayments as having been made in accordance with this recommendation.

We recommend that Youth For Tomorrow – New Life Center, Inc. strengthen existing procedures to ensure that family reunification packets are sent within required timeframes.

We recommend that Youth For Tomorrow – New Life Center, Inc. ensure that all employees follow policies and procedures requiring Federal and State background investigations to be completed before staff begin working with children, provide relevant training to appropriate staff, and document and maintain documentation of all results.

We recommend that Youth For Tomorrow – New Life Center, Inc. work with ORR to develop allowable methodologies to allocate salaries, develop a procedure or system to capture what programs each employee actually worked on, and determine what portion of the $1,500,218 in salaries charged based on budget estimates was accurately charged to the UAC program and refund to the Federal Government any unallowable portion.

We recommend that Youth For Tomorrow – New Life Center, Inc. develop policies and procedures for identifying allowable shared UAC program costs, including items that need advance approval, determine whether any of the $210,037 in potentially unallowable and $23,390 in potentially unallowable unapproved expenditures would be allowable under the newly approved allocation methodology or plan, and refund to the Federal Government any unallowable or unapproved portion.

We recommend that Youth For Tomorrow – New Life Center, Inc. develop policies and procedures for identifying direct UAC program costs not in compliance with Federal requirements and refund $6,515 in unallowable expenditures not related to the UAC program.

FDA should strengthen the REMS for opioid analgesics (the successor to ER/LA opioids) by requiring prescriber training.

FDA should seek additional authority to ensure that manufacturers are held accountable when appropriate.

We recommended that the North Carolina Department of Health and Human Services, Division of Health Benefits identify capitation payments made to managed care entities on behalf of deceased beneficiaries before and after our audit period and refund the Federal share of amounts recovered.

CMS should identify new approaches to address those States that are consistently failing to meet the required timeframes for investigating the most serious nursing home complaints.

To improve its monitoring activities for ensuring that ACOs report complete and accurate data on quality measures, we recommend that the Centers for Medicare & Medicaid Services update the Statement of Work to require its contractor to confirm that all implemented changes to address the identified issues are included in QAPs before they are approved.

We recommend that the Oregon Health Authority provide additional guidance to CCOs on monitoring subcontractors.

We recommend that the Oregon Health Authority take actions to ensure that the data that CCOs submit on grievances and appeals in the grievance workbooks are accurate and complete.

Strengthen the Unit's fiscal controls by taking the following action: (2) Take steps to ensure that the Unit submits all required financial reports on time.

Strengthen the Unit's fiscal controls by taking the following actions: (4) Establish policies and procedures to properly apply its approved indirect cost rate in calculating its indirect costs for Federal reimbursement.

Take steps to ensure that the Unit staff reports all convictions and adverse actions to Federal partners within the appropriate timeframes.

We recommend that the Connecticut Department of Social Services work with CMS to review Medicaid payments made to HPS after our audit period and refund any overpayments.

We recommend that the North Carolina Department of Health and Human Services work with CMS to develop life safety training for nursing home staff.

We recommend that the North Carolina Department of Health and Human Service work with LEM agencies to develop a process to monitor the submission of emergency plans.

We recommend that the North Carolina Department of Health and Human Services increase collaboration with RHCs and communication with nursing home administrators to ensure nursing homes are aware of resources available to them.