Recommendations Tracker

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.

We recommend that ACF provide training to Head Start grantees on implementing corrective action plans with sufficient information for ACF to determine whether corrective actions are adequate to resolve audit findings

We recommend that ACF strengthen its policies and procedures to include monitoring of Head Start grantees and conducting site visits, when feasible, to ensure that grantees implement appropriate corrective actions to resolve audit findings

We recommend that HRSA require HJAHC to refund $243,066 to the Federal Government.

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 rule, and identify any returned overpayments as having been made in accordance with this recommendation.

CMS should provide targeted oversight of Medicare Advantage Organizations (MAOs) that submitted a higher percentage of encounter records with potential errors.

CMS should require MAOs to submit ordering and referring provider identifiers for applicable records.

CMS should track MAOs' response to reject edits.

We recommended 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 rule, and identify any returned overpayments as having been made in accordance with this recommendation.

We recommend that the State agency improve the design of its enrollment system to ensure that it maintains applications, verifies income and citizenship eligibility data, and determines eligibility by using available electronic data sources, as appropriate.

We recommend that WPS increase the Other segment pension costs used to calculate its indirect cost rates by $7,155,498 for CYs 2008 through 2013.

We recommend that the State survey agency ensure that it obtains, reviews, and verifies adequate documentation that supports all aspects of nursing home correction plans.