Recommendations Tracker

CMS should address persistent problems related to inappropriate denials and insufficient denial letters in Medicare Advantage.

We recommend that IHS update policies and procedures related to the Federal audit resolution process to include specifying the detailed steps to be taken to ensure that management decisions are issued within the required 6-month resolution period.

We recommend that IHS follow the quarterly reconciliation process that it implemented at the end of our audit period.

Develop and implement a plan to pursue more nonglobal fraud cases as civil matters, and revise the MOU with MFD to include guidance for handling such cases.

Assess the adequacy of existing staffing levels and, if appropriate, consider a plan to expand the size of the Unit.

Ensure that all case files include documentation of supervisory oversight.

Create policies and procedures for conducting periodic supervisory reviews of Unit case files, and take steps to ensure that case files include documentation of periodic supervisory reviews.

Ensure that the Federal government, consistent with Unit policy, is reimbursed its share of proceeds received from the sale and transfer of vehicles and any other equipment.

We commend that Heartland maintain children's case file documentation in accordance with Office of Refugee Resettlement policy.

We recommend that Etheredge exercise reasonable diligence to identify and return the overpayments in accordance with the 60-day rule, for the remaining portion of the estimated $169,737 overpayment for claims that are outside of the reopening period, and identify any returned overpayments as having been made in accordance with this recommendation.

We recommend that Etherege establish adequate policies and procedures to ensure that chiropractic services billed to Medicare are medically necessary and adequately documented in the medical records.

ACF should assist States in strengthening their requirements for oversight of psychotropic medication by incorporating professional practice guidelines for monitoring children at the individual level.

FDA should include cybersecurity documentation as a criterion in FDA's Refuse-to-Accept checklists.

We recommend that NIT exercise reasonable diligence to identify and return any additional similar overpayments related to cost reports that were not part of our audit in accordance with the 60-day rule, and identify any returned overpayments as having been made in accordance with this recommendation.

We recommend that the Fort Peck Tribes develop and implement controls to verify that FFRs and Carryover Reports accurately report the amount of unobligated funds in the current year and to ensure that the tribes repay to the Federal Government amounts that can no longer be obligated because those amounts exceeded the 2-year grant period.

We recommend that the Fort Peck Tribe develop and implement policies and procedures to track credit balances in beneficiaries' accounts held by energy suppliers to ensure that all unused LIHEAP funds are returned to the tribe so that excess funds can be used to provide assistance for additional benefits and for other purposes, such as crisis situations and residential weatherization, as described in the Manual.

We recommend that the Fort Peck Tribes maintain documentation, to include an up-to-date client listing and data on the number of households receiving LIHEAP assistance, to support the information reported in the Household Reports that they submit to ACF.

We recommend that the State agency improve its oversight and monitoring of providers.

We recommend that Liberty 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 Liberty improve its order-processing system to maintain adequate proof-of-delivery documentation.

We recommend that CMS work with the Medicare contractors to educate hospitals on properly billing Medicare for IMRT planning services.

We recommend that CMS direct the Medicare contractors to review claim lines that are within the 4-year claim-reopening period for emergency ambulance transports to destinations other than hospitals or SNFs that might have been covered by Medicare for nonemergency ambulance transports and recover any improper payments identified, which could represent $928,092 in improper payments.

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

We recommend that CMS based on the results of the Medicare contractors' review of emergency ambulance transports to destinations other than hospitals or SNFs that might have been covered by Medicare for nonemergency ambulance transports, consider (1) directing the Medicare contractors to review claim lines after our audit period and recover any improper payments identified and (2) requiring the Medicare contractors to implement nation-wide prepayment edits specific to emergency ambulance transports that would either deny payment or mandate prepayment review for emergency ambulance transports to destinations other than hospitals or SNFs that might have been covered by Medicare for nonemergency ambulance transports.

We recommend that CMS work with Treasury and QHP issuers to resolve the potentially improper financial assistance payments, which we estimate to be $504,889,518, for policies for which there was no documentation provided to verify enrollees had paid their premiums.

We recommend that the State agency work with CMS to resolve the $1,154,016,418 of additional Medicaid placeholders reported on the CMS-64 for FY 2013 and any placeholders reported on the CMS-64 for prior and later FYs and determine whether adjustments should be made to the amounts reported.

We recommend that the State agency report on the CMS-64 only actual expenditures that are supported by documentation.

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 implementing oversight procedures, such as conducting more frequent and focused reviews of the health plans, providing additional training and technical assistance to the plans, and imposing fines, sanctions, or penalties on the plans.

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 implementing policies and procedures to follow up on the implementation of each health plan's plan of correction in a timely manner.

CMS should conduct additional analysis on compounded topical drugs.

CMS should follow up on pharmacies with questionable Part D billing and the prescribers associated with these pharmacies.