Recommendations Tracker

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.

We recommend that Noridian revise its FACPs for FYs 2011-2013 to reduce its claimed Medicare pension costs by $190799.

We recommend that Noridian work with CMS to ensure that its final settlement of contract costs reflects a decrease in Medicare pension costs of $826668 for CYs 2009-2013.

We recommend that Noridian increase the Medicare segment PRB assets by $203,100 as of January 1, 2016.

We recommend that Noridian work with CMS to ensure that its final settlement of contract costs reflects an increase in Medicare PRB costs of $148,216 for CYs 2009-2013.

We recommend that Noridian revise its FACPs for FYs 2011-2013 to decrease its Medicare PRB costs by $103,731.

Direct the Medicare contractors to recover the $54,372,337 in identified overpayments in accordance with CMS's policies and procedures.

Ensure that the Medicare contractors are receiving the postpayment edit's automatic notifications of improperly billed claims and are taking action by adjusting the original inpatient claims to initiate recovery of the overpayments.

We recommend that Geisinger refile its DIR reports for CYs 2013, 2014, and 2015 to report the unreported point-of-sale fees ($149,199 for CY2013, $167,798 for CY 2014, and $152,853 for 2015) received from pharmacies.