Recommendations Tracker

We recommend that the Wisconsin Department of Health Services refund $12,287,252 (Federal share) to the Federal Government for FFS Medicaid ABA payments that did not comply with Federal and State requirements.

We recommend that the Wisconsin Department of Health Services update guidance for CPT code 97155 to require documentation on how issues were resolved or what changes were made to the treatment protocol or POC.

We recommend that the Wisconsin Department of Health Services develop a procedure to verify the provider who rendered the 97153-focused treatment service and pay the claim based on the rendering provider's specialty level.

We recommend that the Entity enforce and periodically assess compliance with its configuration and change management policy, which requires that a security impact analysis be performed for all newly deployed or modified systems, including contractor-deployed systems, and that any discovered issues or unsecure configuration settings are resolved before a system is deployed or exposed to the internet.

We recommend that the Entity periodically assess and update its configuration management controls in its systems to ensure information system flaws are identified and timely corrected; configuration settings for IT products on its systems are secure and in compliance with established configuration baselines; and systems functionality, including functions, ports, protocols, and services are limited to only those that are necessary.

We recommend that the Entity implement a policy that requires developers to follow secure coding practices for its web applications in accordance with the Entity's approved cybersecurity framework or industry web application security best practices for coding, testing, and maintaining web applications and establish a procedure to confirm adherence to the requirements.

We recommend that HRS Home Health refund the $100,696 in estimated overpayments to the Medicare program.

We recommend that HRS Home Health strengthen its review of medical record documentation to ensure compliance with Medicare billing requirements.

We recommend that the Centers for Medicare & Medicaid Services educate practitioners and encourage the practitioners to educate the practices' staff on its data collection policy requirements for inpatient and outpatient settings and direct the MACs to educate individual practitioners on reporting requirements for postoperative visits after global surgeries.

We recommend that the Centers for Medicare & Medicaid Services take one of the following steps to improve reporting of postoperative visits: establish and maintain a mechanism to identify practitioners that are required to report their postoperative visits and notify them of the reporting requirement; require all practitioners to report postoperative visits; or revise its requirements to clarify which practitioners are required to report.

We recommend that the Centers for Medicare & Medicaid Services update its valuation of the global surgery fees to reflect the number of postoperative visits actually being provided to Medicare patients, which could have reduced payments for the global surgeries in our sampling frame by an estimated $5,723,292 for Medicare and an estimated $1,666,631 for Medicare patients.

We recommend that the Michigan Department of Health and Human Services take corrective action for the 17 improper payments in our sample of 90 HHC applications by refunding $26,763 to the Federal Government for the 15 HHC benefit overpayments.

We recommend that the Michigan Department of Health and Human Services revise the interagency agreement to require MI Treasury to notify MI DHHS of any changes in procedures for processing HHC payments, including edits to the Bridge system.

We recommend that the Michigan Department of Health and Human Services revise its Home Heating Credit Audit Process to incorporate a risk-based approach that includes high-risk HHC applications, such as those with high dollar payments and out-of-State mailing addresses, and require and maintain documentation to support findings identified and corrective actions taken during the monitoring process.

We recommend that the Michigan Department of Health and Human Services test the HHC program data it receives from MI Treasury via the data warehouse to confirm that the data are complete and accurate before reporting HHC program information to ACF.

We recommend that the Maine Department of Health and Human Services follow up with the 16 ICF/IIDs to verify that they have taken corrective actions on the life safety, emergency preparedness, and infection control deficiencies identified during the audit.

We recommend that the Maine Department of Health and Human Services work with CMS to develop standardized life safety training for ICF/IID staff.

We recommend that the Health Resources and Services Administration require the 10 hospitals that we determined as having used PRF payments for unallowable expenditures totaling $63 million to return the unallowable amounts to the Federal Government or ensure that the hospitals properly replace the unallowable expenditures with allowable unreimbursed lost revenues or eligible expenses, if any.

We recommend that the Health Resources and Services Administration require the eight nursing facilities that we determined as having used PRF payments for unallowable expenditures and lost revenues totaling $2,256,504 to return the unallowable amounts to the Federal Government or ensure that the nursing facilities properly replace the unallowable expenditures and lost revenues with allowable unreimbursed lost revenues or eligible expenses, if any.

We recommend that Coventry Health and Life Insurance Company refund to the Federal Government the $6,995,522 of estimated net overpayments.

We recommend that Coventry Health and Life Insurance Company continue to examine its existing compliance procedures to identify areas where improvements can be made to ensure that 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 the Program Support Center implement a control environment that includes fraud mitigation, in accordance with GAO's A Framework for Managing Fraud Risks in Federal Programs.

We recommend that the Program Support Center implement automated verification processes for bank account information changes.

We recommend that the Program Support Center conduct information system level risk assessments that include integration of fraud risk in accordance with NIST guidance for all PSC financial management systems.

We recommend that the Indian Health Service consider additional project prioritization procedures to fund the highest priority SFC projects based on readiness.

We recommend that the Indian Health Service validate the eligibility of homes and users by regularly reviewing and updating the HITS data.

We recommend that Indian Health Service develop formal guidance for the proration of Tier 1 design costs and Tier 2 and 3 planning costs between eligible and ineligible homes or users.

FDA should increase the number of facilities inspected each year and ensure that all facilities are inspected within the required timeframes.

FDA should assess reasons for the decrease in number of facilities inspected by FDA with significant violations and take action as appropriate.

CMS should inform States of nursing homes that appear from PBJ data to violate the required number of daily RN staffing hours.

Refund the Federal grant for the unsupported costs, excess purchases, and improperly claimed indirect costs.

Update its periodic supervisory review policies to reflect current operations and develop a process to ensure that its policies and procedures manual is current.

Work with the Department of Health Care Services to improve the Unit's access to and the quality of Medicaid claims data.

Implement policies and procedures to ensure effective fiscal control of its funds, property, and other assets.

We recommend that the Centers for Medicare & Medicaid Services update Medicare requirements for billing E&M services provided on the same day as intravitreal injections to help providers understand the appropriate use of modifier 25 (e.g., clarify the definition of a "significant and separately identifiable" E&M service and identify the circumstances that allow for an E&M service to be billed on the same date of service as an intravitreal injection).

We recommend that the Centers for Medicare & Medicaid Services provide more education to providers on billing E&M services provided on the same day as intravitreal injections and the appropriate use of modifier 25 to help prevent improper payments for those services. For example, CMS could: (1) emphasize that the decision to perform an intravitreal injection is part of the minor surgical procedure and a separate E&M service should not be billed for that work; (2) provide a clear definition of a "significant and separately identifiable" E&M service that is "above and beyond" the usual care associated with an intravitreal injection; and (3) provide examples of E&M services that would be considered significant and separately identifiable and above and beyond the usual care associated with an intravitreal injection.

We recommend that the Minnesota Department of Human Services work with the childcare providers to collect, as appropriate, overpayments of CCAP claims identified by our audit.

We recommend that the Minnesota Department of Human Services continue to take steps to automate childcare attendance records through real-time electronic reporting as recommended by the Minnesota Office of the Legislative Auditor.

We recommend that Maryland's Department of Health verify that providers correct the 253 instances of provider noncompliance identified in this report.

We recommend that Maryland's Department of Health collaborate with providers to enhance their facilities, staffing, and training.

CMS should obtain the Federal shares of MLR remittances from States that failed to return these amounts to CMS for the 2017-2018 and 2018-2019 MLR reporting years.

CMS should improve internal communication to confirm that States return the Federal shares of the MLR remittance amounts reported annually to CMS.

CMS should develop procedures to track (a) when each State is expected to return the required Federal shares of MLR remittances owed and (b) whether States have returned the Federal shares timely.

We recommend that ACL develop mitigating controls and strategies to address the high and moderate risks we identified.

We recommend that the Ohio Department of Medicaid ensure providers correct the 117 instances of provider noncompliance identified in this report.

We recommend that the Ohio Department of Medicaid work with providers to improve their facilities, staffing, and training.