Recommendations Tracker

We recommend that the State agency refund $13,761,829 to the Federal Government.

We recommend that the State agency work with the MCOs to determine the portion of the $3,968,040 that was unallowable for claims containing PPCs and its impact on current and future year capitation payment rates.

We recommend that the State agency require the MCOs to implement internal controls to prohibit payments for inpatient hospital services related to treating PPCs.

We recommend that the State agency strengthen its monitoring of its MCOs to ensure the MCOs comply with Federal and State requirements and its managed-care contracts relating to the nonpayment of PPCs.

We recommend that the Queens Chiropractor for the remaining portion of the estimated $518,821 in improper payments for claims that are outside of the Medicare reopening period, exercise reasonable diligence to identify and return improper payments in accordance with the 60-day rule, and identify any returned improper payments as having been made in accordance with this recommendation

We recommend that the Queens Chiropractor exercise reasonable diligence to identify and return any additional similar improper payments 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 Pacific Medical refund to the DME MACs $247,493 in estimated overpayments for orthotic braces (of which $4,777 was overpayments identified in our sample).

We recommend that Pacific Medical obtain as much information from beneficiary medical records as it determines necessary to assure itself that claims for orthotic braces meet Medicare requirements.

We recommend that Atlantis refund to the Federal Government the portion of the estimated $403,525 in improper payments for claim incorrectly billed to the Medicare program that are within the reopening period.

We recommend that Atlantis develop or modify procedures to ensure that ESRD measurements and comorbidities noted in beneficiaries' electronic health records are accurately recorded on Medicare claims for services and comply with Medicare requirements.

We recommend that Atlantis strengthen its policies and procedures to ensure that plans of care are signed by all members of the interdisciplinary team, contain all required elements, are updated timely, and are related to the type of dialysis services provided; comprehensive assessments contain all required elements and are updated timely; and physicians' orders for dialysis services are completed and comply with Medicare requirements.

We recommend that Pathways correct all instances of noncompliance that we observed.

We recommend that Pathways strengthen its systems of health and safety practices and management by developing and providing ongoing safety training to staff that has regular contact with children in all State and Federal health and safety requirement related to building and physical premises safety that includes identification of and protection from hazards.

We recommend that Pathways utilize the output from a reliable system to ensure all its employees complete background checks in the timing and frequency required by Federal regulations and State licensing standards.

We recommend that Pathways follow up during a child's enrollment process with the physician's office when evidence demonstrates that the child had not received an age appropriate lead screening and, if necessary, help parents schedule age-appropriate lead screening for their child.

We recommend that First Coast notify the 70 providers responsible for the remaining 46,737 nonsampled claims with potential overpayments estimated at $39.3 million so that those providers can exercise reasonable diligence to investigate and return any identified overpayments, in accordance with the 60-day rule, and identify and track any returned overpayments as having been made in accordance with this recommendation.

We recommend that First Coast work with CMS to the extent possible in developing more effective automated HBO therapy prepayment edits in the claim processing system, which would result in millions of dollars in future cost savings.

We recommend that Midwood refund to the Medicare program the portion of the estimated $19,292,158 overpayment for claims incorrectly billed that are within the recovery period.

We recommend that Midwood exercise reasonable diligence to identify and return any additional similar improper payments outside of our audit period, in accordance with the 60-day rule, and identify any returned improper payments as having been made in accordance with this recommendation.

We recommend that the State agency work with CMS to determine what portion of the $34,939,072 Federal share claimed was unallowable for Federal Medicaid reimbursement and refund to the Federal Government the unallowable amount.

We recommend that the State agency strengthen its internal controls to ensure hospitals submit services related to PPCs using bill type code 110, postpayment reviews for PPCs are conducted, and POA codes are submitted on claims.

We recommend that the State agency refund $27,612,780 to the Federal Government.

We recommend that the State agency implement policies to ensure that all settlements and judgments are reported properly.

We recommend that Texas refund $73,845 to the Federal Government that it inappropriately paid for CFC FFS claims.

We recommend that the State agency redetermine, if necessary, the current Medicaid eligibility of the sampled beneficiaries who did not meet or may not have met Federal and State eligibility requirements.

We recommend that the State agency ensure that annual redeterminations are performed as required and properly terminate Medicaid coverage for beneficiaries, if necessary.

We recommend that the State agency ensure that beneficiaries are not determined eligible for Medicaid on the basis of their CalWORKs eligibility without approval from CMS.

We recommend that CMS recover the remaining $1,644,235,438 due the Federal Government from the current period.

We recommend that CMS develop policies and procedures to improve the timeliness of recovering overpayments by setting guidelines for the amount of time CMS has to discuss with State officials regarding the audit findings; obtain documentation to substantiate the State's position; and issue the disallowance letter to the State.

We recommend that CMS require states to submit corrected CMS-64s to identify recovered overpayments on Line 10 when done incorrectly.

We recommend that BCFS HHS install video monitoring equipment in the intake common area of the shelter to help ensure oversight of UAC during the intake process.

We recommend that BCFS HHS develop procedures to ensure that staff are aware of the requirements for the contents of first aid kits and periodically check the kits to ensure compliance with Texas minimum standards.

We recommend that BCFS HHS strengthen its oversight of foster care homes to ensure foster parents are aware of, and are complying with, Texas DFPS Minimum Standards for Child-Placing Agencies Condensed Version for Foster Parents for health and safety.

We recommend that BCFS HHS strengthen existing procedures to ensure all initial intakes assessments, initial medical exams, and UAC assessments are completed in a timely manner; that adequate documentation is maintained; and that the completed dates for the UAC assessment are captured in the case file.

We recommend that BCFS HHS implement quality control procedures to ensure the discharge information in the case file matches the data entered into the ORR UAC Portal.

We recommend that BCFS HHS ensure that reunification information reported to ORR is accurate and can be supported.

We recommend that CMS instruct all State agencies to review, revise, develop, and implement policies and procedures to monitor the SDAC and SBHS programs in their States and thereby ensure that claimed SDAC and SBHS costs comply with Federal requirements with respect to reasonableness, allowability, and supportability; State agencies obtain DCA approval for their cost allocation plans before submitting their RMTS methodologies to CMS for approval; RMTS methodologies comply with Federal requirements for statistical validity, reliability, and allowability and are always submitted to CMS for approval before being implemented; RMTS responses are properly coded and include documentation adequate to support activities performed that were reimbursable by Medicaid and to permit reproduction and verification of sample results; and random moment samples generated through RMTS reflect all of the time and activities performed by employees participating in SDAC and SBHS and do not reflect times whe

Recover from hospitals the portion of the estimated $5,736,313 in identified overpayments for claims incorrectly billed that are within the reopening period.

Identify and recover any additional similar overpayments for IMRT services made after the audit period.

Educate hospitals on properly billing Medicare for IMRT planning services

NIH update RML's and IRF's security plans to include procedures for notifying FSAP if a select agent shipment is not received within 48 hours of the expected time of delivery.

NIH update RML's and IRF's security plans to include procedures for notifying FSAP if a select agent shipment will not be completed within 30 calendar days after transfer authorization issuance or transfer authorization becomes void because the facts supporting the authorization changed.

AHRQ should collaborate with CMS to create and disseminate a list of potential adverse events in LTCHs.

CMS should include information about potential events and patient harm in its quality outreach to LTCHs.

We recommended that SANOS refunds the $4,000 to the Federal government.

Direct the Medicare contractors to recover the $34,014,796 in identified improper payments to suppliers in accordance with CMS's policies and procedures and recommend that the suppliers refund to beneficiaries up to $8,702,539 in deductible and coinsurance amounts that may have been incorrectly collected from them or from someone on their behalf

We recommend that CMS take all necessary actions, including seeking legislative authority, to require suppliers to refund to beneficiaries incorrectly collected Medicare Part B deductible and coinsurance amounts for items and services reimbursable under Medicare Part A.

If the CWF edits had been designed properly since CY 2008, Medicare could have saved $223.1 million, and beneficiaries could have saved $56.3 million in deductibles and coinsurance that may have been incorrectly collected from them or from someone on their behalf.