Recommendations Tracker

We recommend that the State agency work with the State's DOH to ensure children's partial hospitalization services are provided by appropriately licensed hospitals

We recommend the State agency improve its monitoring of children's partial hospitalization services providers and adequately test specific services to ensure compliance with Federal and State requirements.

We recommend that the State agency work with CMS to identify claims outside of our audit period that were paid for services that were not provided by a facility licensed as a hospital.

We recommend that the State agency refund to CMS $101,529 for unallowable G&A costs and related profit fees.

We recommend that the State agency conduct unannounced visits for health and safety reviews of group care facilities.

We recommend that the State agency ensure that regional licensors and group care facilities have adequate training and guidance on the best practices for administering medications and maintaining related documentation.

We recommend that the State agency ensure that the handbook Minimum Licensing Requirements for Group Care Facilities is updated with the latest background check requirements.

We recommend that Aurum continue to upgrade its procurement-management and accounting systems to effectively track procurements.

We recommended that CMS establish mechanisms to better monitor the appropriateness of outpatient physical therapy claims.

We recommended that CMS educate providers on the requirements for reporting manufacturer credits for cardiac devices using value code FD and the need to use condition codes to report the reason for device replacement.

We recommended CMS consider studying alternatives to implementing edits in order to eliminate the current Medicare requirements for reporting device credits, for instance, by reducing IPPS and OPPS payments for device-intensive procedures.

Implement CDM tools and RSA Archer at the Department level and at all OPDIVs to enhance its configuration management program in order to maintain and measure its configuration management activities at the enterprise, business process, and information system levels.

Implement and configure DHS' CDM inventory management tools and mechanisms to centrally track and report information systems from all OPDIVs.

We recommend that the State agency ensure that CalHEERS and SAWS have the system functionality to deny or discontinue Medicaid for an ineligible beneficiary after a previous determination has already been made on the basis of the beneficiary's MAGI; properly process cases for beneficiaries who were formerly in the foster-care youth program; use SSA data to verify whether a beneficiary is entitled to or enrolled in Medicare; properly redetermine eligibility when a beneficiary is no longer a child; and retrieve and use information from the Department of Homeland Security to determine whether a beneficiary has met the 5-year-bar requirement to be eligible to receive full-scope Medicaid services.

We recommend that the State agency ensure that all eligibility requirements are properly verified.

We recommend that the State agency develop and implement written policies and procedures, as necessary, to ensure that all payments for nonemergency and non-pregnancy-related services are adjusted for beneficiaries who are subject to the 5-year bar.

We recommended that NIH provide additional training to grants management personnel to ensure awareness of applicable grants management responsibilities and compliance with applicable policies and procedures, including new or updated guidance.

We recommended that NIH update policies and procedures to require the reconciliation of audit reports in the DFAS database to monthly reports generated by NEARC.

We recommend that the State agency work with CMS to determine whether the other physician-administered drugs were eligible for rebates and, if so, upon receipt of the rebates, refund up to an estimated $7,307,853 (Federal share) of rebates collected.

We recommend that the State agency ensure that all physician-administered drugs eligible for rebates are processed for rebates.

We recommend that WPS notify the 208 providers responsible for the remaining 44,820 nonsampled claims, with potential overpayments estimated at $42.3 million, so that those providers can investigate and return any identified overpayments in accordance with the 60-day rule and track any returned overpayments.

We recommend that WPS strengthen its policies and procedures for making payments for HBO therapy, including developing automated prepayment edits in the claim processing system, which would result in millions in future cost savings.

We recommend that CMS strengthen its system edits to prevent improper payments for specimen validity tests and instruct the Medicare contractors to educate providers on properly billing for specimen validity and urine drug tests, which could result in savings of an estimated $12,146,760 over a 5-year period.

We recommend that the Hospital exercise reasonable diligence to identify and return any additional similar overpayments received outside of our audit period, in accordance with the 60-day repayment rule.

We recommend that CMS educate beneficiaries on the types of chiropractic services that are covered by Medicare, inform them that massage and acupuncture services are not covered by Medicare, and encourage them to report to CMS chiropractors who are providing non-Medicare-covered services.

We recommend that CMS establish a threshold for the number of chiropractic services beyond which medical review would be required for additional services.

We recommend that the State agency refund to the Federal Government $1,375,598 (Federal share) for claims for top-20 multiple-source physician-administered drugs that were ineligible for Federal reimbursement.

Work with CMS to determine whether the remaining $1,388,523 (Federal share) of other physician-administered drug claims could have been invoiced to the manufacturers to receive rebates and, if so, upon receipt of the rebates, refund the Federal share of the manufacturers' rebates for those claims.

We recommend that the State strengthen its internal controls to ensure that all physician-administered drugs eligible for rebates are invoiced.