Recommendations Tracker

We recommend that Novitas Solutions, Inc. work with the Centers for Medicare & Medicaid Services to clarify guidance to providers, which could have resulted in savings totaling an estimated $2,373,676 during our audit period.

We recommend that Novitas Solutions, Inc. educate providers on their responsibility to bring any previously paid claims to their MAC's attention if they were paid using the wrong rate.

To address the 50 incorrect net incentive payments in our sample, we recommend that the Centers for Medicare & Medicaid Services recover from acute-care hospitals, in accordance with CMS policies, the portion of the $1,266,111 in incorrect net incentive payments that are within the reopening period.

To attempt recovery of the $93,591,531 in estimated incorrect net incentive payments made during our audit period and to ensure that all final and non-final payments made after our audit period are correct, we recommend that the Centers for Medicare & Medicaid Services instruct the MACs to review all hospitals' supporting documentation to identify errors in the hospitals' cost-report numbers used to calculate the incentive payments, including supporting documentation for labor and delivery inpatient bed-days for cost reports with cost-reporting periods beginning on or after October 1, 2013.

CMS should provide targeted oversight of Medicare Advantage Organizations (MAOs) that had risk-adjusted payments resulting from unlinked chart reviews for beneficiaries who had no service records in the 2016 encounter data.

CMS should reassess the risks and benefits of allowing chart reviews that are not linked to service records to be used as sources of diagnoses for risk adjustment.

We recommend that the Texas Health Presbyterian Hospital Dallas refund to the Medicare contractor $10,597,133 ($10,711,548 less $114,415 that the Hospital has already repaid) in estimated overpayments for the audit period for claims that it incorrectly billed.

We recommend that the Texas Health Presbyterian Hospital Dallas ensure all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation and all required documentation is included in the medical record; ensure all inpatient beneficiaries meet Medicare criteria for inpatient hospital services; ensure procedure and diagnosis codes are supported in the medical records and staff are properly trained; and ensure HCPCS codes are supported in the medical records and staff are properly trained.

Refund to the Medicare program the portion of the estimated $680,884 in overpayments for claims incorrectly billed that are within the reopening period.

We recommend that Palos Community Hospital Home Health Agency exercise reasonable diligence to identify and return any additional similar overpayments outside of our audit period, in accordance with the 60-day rule, and identify any returned overpayments as having been made in accordance with this recommendation.

We recommend that Pathways for Children, Inc. refund to the Federal Government $296,982 for FY 2017 unallowable non-Federal share expenses or provide documentation showing that Federal sources were not billed for IEP services.

We recommend that Pathways for Children, Inc. implement policies and procedures to ensure that revenue generated from non-Federal match fundraising expenses are allocated to Head Start program in accordance with the relative benefits received.

We recommend that Pathways for Children, Inc. implement policies and procedures to request prior written approval from ACF before purchasing capital assets.

We recommend that St. Vincent Hospital refund to the Medicare contractor $2,111,647 (of which $293,404 was net overpayments identified in our sample) in estimated overpayments for incorrectly billed services.

We recommend that St. Vincent Hospital strengthen controls to ensure full compliance with Medicare requirements; specifically, ensure that all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation, all inpatient beneficiaries meet Medicare criteria for inpatient hospital services, diagnosis, discharge status, and admission source codes are supported in the medical records and staff are properly trained, and medical records accurately document the appropriate number of units and distinct procedural services and that staff are properly trained.

We recommend that the Hospital refund to the Medicare contractor $3,461,279 ($3,461,376 less $97 that has already been repaid) in estimated overpayments for the audit period for claims that it incorrectly billed.

We recommend that the Hospital strengthen controls to ensure full compliance with Medicare requirements, specifically ensure all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation; ensure documentation supporting the medical necessity for inpatient hospital services is contained in the medical records; ensure procedure and diagnosis codes are supported in the medical records and staff are properly trained; ensure procedures are in place to properly bill claims subject to SNF consolidated billing requirements; and ensure medical records accurately document distinct procedural services and staff are properly.

We recommend that Northwest Medical Center refund to the Medicare contractor $1,203,705 ($1,207,729 less $4,024 that has already been repaid) in estimated overpayments for the audit period for claims that it incorrectly billed.

We recommend that Northwest Medical Center strengthen controls to ensure full compliance with Medicare requirements, to ensure that all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation; documentation supporting the medical necessity for inpatient hospital services is contained in the medical records; diagnosis codes are supported in the medical records and staff are properly trained; and medical records accurately document distinct procedural services and staff are properly trained.

We recommend that CMS require reconciliation of all hospital cost reports with outlier payments during a cost-reporting period. If the reconciliation requirement had been in effect for the 60 hospitals in our audit, CMS would have saved approximately $125 million per year.

We recommend that Noridian work with CMS to ensure that its final settlement of contract costs reflects an increase in Medicare nonqualified costs of $1,516,058 for CYs 2009-2013.

We recommend that Noridian revise its FACPs for FYs 2011-2013 to increase its Medicare nonqualified costs by $103,072.

We recommend that Cahaba GBA decrease the Medicare segment pension assets by $2,724 and recognize $14,771,220 as the Medicare segment pension assets as of January 1, 2017.

We recommend that the Centers for Medicare & Medicaid Services promote hospices' compliance with the condition-of-participation standard that requires registered nurses to visit hospice beneficiaries' homes at least once every 14 days to assess the quality of care and services provided by hospice aides, which could include working with State survey agencies and accreditation organizations to increase emphasis on oversight of this requirement; educating hospices about the requirements associated with this standard; and making this standard a quality measure.

We recommend that the California Department of Public Health follow up with the 19 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 California Department of Public Health ensure that all surveyors consistently enforce CMS requirements.

We recommend that the skilled nursing facility at Highlands of Little Rock West Markham refund the $25,494 in questioned costs.

We recommend that the New Jersey Department of Human Services refund $63,786,406 in Federal Medicaid payments.

We recommend that the University of Minnesota refund $1,924 to NIH for unallowable costs claimed.

We recommend that the Centers for Medicare & Medicaid Services recoup $640,452 from providers, and instruct providers to refund overcharges totaling up to $173,495 to beneficiaries, consisting of $436,877 in overpayments to providers that billed for the same CCM services for the same beneficiaries and up to $121,573 in overcharges to these beneficiaries; and $203,575 in overpayments to providers that billed for both CCM services and overlapping care management services for the same beneficiaries and up to $51,922 in overcharges to these beneficiaries.

We recommend that the Centers for Medicare & Medicaid Services implement claim processing controls, including system edits, to prevent and detect overpayments for CCM services.

We recommend that Noridian increase the Medicare segment assets by $1,572,698 and recognize $30,224,354 as the Medicare segment pension assets as of January 1, 2016.