Recommendations Tracker

We recommend that the State agency refund to the Federal Government $180,688,616 for unallowable Federal reimbursement claimed for SMHS expenditures.

We recommend that the State agency strengthen its oversight of the health plans to ensure that SMHS claims comply with Federal and State requirements by assessing whether those oversight procedures are effective and, if they are not effective, identifying and implementing additional oversight procedures.

CMS should clarify Part D policies for coverage of compounded topical drugs and use of utilization management tools.

CMS should conduct training for Part D sponsors on fraud schemes and safety concerns related to compounded topical drugs.

CMS should expand the price substitution policy to include additional drugs.

CMS should ensure records contain all required data.

CMS should revise the definition of the device name data element so that the information reported in this field is required to be more specific.

We recommend that the Hospital refund to the Medicare program $697,608 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.

CMS should analyze claims data to inform the survey process.

CMS should seek statutory authority to establish additional, intermediate remedies for poor hospice performance.

CMS should work with its partners, such as hospitals and caregiver groups, to make available consumer-friendly information explaining the hospice benefit to beneficiaries and their families and caregivers.

CMS should analyze claims data to identify hospices that engage in practices or have characteristics that raise concerns.

CMS should increase oversight of general inpatient care claims and focus particularly on general inpatient care provided in SNFs, given the higher rate at which these stays were inappropriate.

CMS should develop and execute a strategy to work directly with hospices to ensure that they are providing drugs covered under the hospice benefit as necessary and that the cost of drugs covered under the benefit are not inappropriately shifted to Part D.

CMS should adjust payments based on these analyses, if appropriate, to ensure that the payment system is aligned with beneficiary needs and quality of care.

CMS should modify the payments for hospice care in nursing facilities.

We recommend that the Passamaquoddy Tribe at Pleasant Point ensures PPHC is under the medical direction of a physician, in accordance with Federal and Tribal requirements.

We recommend that the Passamaquoddy Tribe at Pleasant Point develop, approve, and implement with the advice of the required group of professional medical staff written medical policies and procedures that include pain-management treatment prioritization requirements for opioid prescription and compliance monitoring and requirements for timely completion, signature, and review of patient health records.

We recommend that the Passamaquoddy Tribe at Pleasant Point implement Federal and Tribal preemployment screening controls for employees who have not been fully screened prior to employment and for new staff hired at PPHC, including the performance of fingerprinting and FBI background checks for all staff currently working with Indian children.

We recommend that WPS reduce its FACP for FY 2013 by $99,649 to eliminate the unallowable costs identified in this report.

We recommend that WPS reduce its FACP for FY 2013 by $1,480,904 to eliminate the unallowable costs identified in this report.

We recommend that DHS refund to the Federal Government $300,000 in unallowable expenditures.

We recommend that DHS ensure that OPF and other subrecipients appropriately claim indirect costs in accordance with Federal requirements.

We recommend that the State agency ensure that the 105 instances of noncompliance with health and safety and administrative requirements identified in this report are corrected.

We recommended that the State agency consider developing templates for administrative records the State requires.

We recommend that FCSO work with CMS to ensure that FCSO's final settlement of contract costs reflects a decrease in Medicare pension costs of $43,835 for CYs 2008 through 2010.

We recommend that FCSO work with CMS to ensure that FCSO's final settlement of contract costs reflects an increase in Medicare SERP costs of $1,064,636 for CYs 2008 through 2010.

CMS should work with States to improve managed care organization (MCO) identification and referral of cases of suspected fraud or abuse.

CMS should work with States to clarify the information managed care organizations are required to report regarding providers who are terminated or otherwise leave the managed care organization network.

CMS should work with States to improve coordination between MCOs and other State program integrity entities.

CMS should work with states to ensure that managed care organizations provide complete, accurate, and timely encounter data.

CMS should require plan sponsors to report Part C and Part D fraud and abuse incidents and the corrective actions taken to address them to a centralized system.

CMS should require that Part C and Part D providers and pharmacies enroll in Medicare.

CMS should ensure that the MEDIC has the ability to require medical records from prescribers of Part D drugs not under contract with plan sponsors, obtaining legislative authority, if necessary.

We recommend that the Office of the Secretary review the lack of compliance with the OMB Circular A-126, Federal Travel Regulations, and HHS Travel Policy Manual related to the authorization and use of chartered aircraft during former Secretary Price's tenure, and on the basis of the review, determine and take appropriate administrative actions to recoup $333,014 of identified waste, including the $12,178 for the June 6 trip to Nashville for which the chartered aircraft was not cancelled after receiving confirmation that the White House event would not occur, providing an opportunity for the use of commercial flights; the $36,313 for the June 24–26 trip to San Diego, Aspen, and Salt Lake City that included only 3.5 hours of official engagements; the $10,001 for the September 15 trip to Philadelphia for not using options other than chartered aircraft; the $12,346 for the Raleigh to Brunswick travel leg in which former Secretary Price used the chartered aircraft to attend an event in a p

We recommend that the Office of the Secretary review the lack of compliance with the FTR and the HHS Travel Policy Manual related to other excess travel costs, and on the basis of the review, determine and take appropriate action to recoup $2,960 of identified waste the $1,568 of excess lodging costs that were not pre-authorized; the $727 of excess costs incurred for a rental vehicle and pre-paid fuel; and the $665 to Government travelers for travel costs that included unallowable meal costs and incorrect amounts entered on vouchers.

We recommend that the Office of the Secretary train responsible HHS personnel and put controls in place to ensure that the following requirements are met for future procurements; preparing and maintaining documentation regarding the rationale for quote selections when the lowest quote is not selected is prepared and included in the contract file as required by the FAR; and verifying that sole-source justification requirements are adhered to and documentation related to sole-source awards is prepared in accordance with the FAR.

We recommend that the Office of the Secretary assess the roles, responsibilities, and actions of Federal personnel involved in scheduling, preparing, procuring, and approving the use of chartered aircraft for former Secretary Price's travel and take all appropriate actions related to their performance or conduct.

We recommend that CMS direct the Medicare contractors to recover the portion of the $8,633,940 in improper payments made to providers for claim lines that are within the 4-year claim-reopening period.

We recommend that CMS direct the Medicare contractors to review claim lines for nonemergency ambulance transports to destinations not covered by Medicare after our audit period and recover any improper payments identified.

We recommend that the Colorado marketplace refund to the Federal Government $1,998,617 in costs that were improperly transferred between grants.

We recommend that the Colorado marketplace work with CMS to certify the cost transfers associated with the remaining 352 expenditures totaling $3,177,310, ensure that each expenditure transferred was allowable, and refund any unallowable expenditures to the Federal Government.

We recommend that IHS strengthen controls to ensure that purchase cardholders comply with Federal requirements and IHS's own policy by ensuring that purchase card usage is adequately monitored for compliance with Federal requirements and IHS's own policy.

Direct the Medicare contractors to recover the portion of the $6,682,531 in overpayments to providers for claims that are within the reopening period in accordance with CMS's policies and procedures.

Revise the claims processing edits to ensure that all claims for items and services ordered by chiropractors are denied.