Recommendations Tracker

We recommend that the Centers for Medicare & Medicaid Services work with its plan sponsors to adjust or delete PDEs, as necessary, and determine the impact to the Federal Government related to the Medicare Part D total costs of $953,370 for drugs associated with our sample items for which payment was available under the Medicare Part A SNF benefit, which included $541,652 for drugs that were administered during Part D enrollees' Part A SNF stays.

We recommend that the Centers for Medicare & Medicaid Services work with its plan sponsors to identify similar instances of noncompliance that occurred before and after our audit period and determine the impact to the Federal Government related to Part D total costs for drugs for which payment was available under the Medicare Part A SNF benefit.

We recommend that the Centers for Medicare & Medicaid Services instruct SNFs to cooperate with plan sponsors to identify and prevent improper Part D payments for drugs for which payment was available under the Part A SNF benefit.

We recommend that the Washington State Health Care Authority work with its contracted MCOs and the Department of Health to ensure that OTPs comply with Federal and State requirements for providing and documenting OTP services, including ensuring that OTPs complete required tests for enrollee admissions and adequately document enrollee admissions.

We recommend that the Washington State Health Care Authority work with its contracted MCOs and the Department of Health to ensure that OTPs comply with Federal and State requirements for providing and documenting OTP services, including ensuring that OTPs provide take-home medications in accordance with Federal and State requirements.

We recommend that the Washington State Health Care Authority work with its contracted MCOs and the Department of Health to ensure that OTPs comply with Federal and State requirements for providing and documenting OTP services, including ensuring that OTPs adequately document the results of drug screens.

We recommend that the Washington State Health Care Authority work with its contracted MCOs and the Department of Health to ensure that OTPs comply with Federal and State requirements for providing and documenting OTP services, including ensuring that OTPs adequately document enrollee assessments.

We recommend that the Washington State Health Care Authority work with its contracted MCOs and the Department of Health to ensure that OTPs comply with Federal and State requirements for providing and documenting OTP services, including ensuring that OTPs complete and adequately document annual medical examinations.

To strengthen program safeguards for preventing and detecting improper payments for short inpatient stays and recovering overpayments for claims that do not comply with Medicare requirements, we recommend that the Centers for Medicare & Medicaid Services work with its contractors to add information to inpatient claims indicating any stay that did not span two or more midnights because of an unforeseen circumstance (e.g., a condition code).

To strengthen program safeguards for preventing and detecting improper payments for short inpatient stays and recovering overpayments for claims that do not comply with Medicare requirements, we recommend that the Centers for Medicare & Medicaid Services work with its contractors to implement prepayment edits for claims for short inpatient stays at risk for noncompliance with the two-midnight rule (i.e., short inpatient stays with risk factors such as canceled procedures or certain MS-DRGs).

We recommend that the Centers for Medicare & Medicaid Services determine why claims that did not have the required modifiers were paid for replacement OTS braces, and take steps to prevent payments for such claims.

We recommend that the Centers for Medicare & Medicaid Services analyze supplier billing patterns and use that information to determine whether to conduct additional prepayment or postpayment reviews of suppliers or impose a temporary moratorium on enrolling new suppliers of OTS braces if CMS determines that there is significant potential for fraud, waste, or abuse.

We recommend that the Centers for Medicare & Medicaid Services educate suppliers and enrollees on telemarketing practices for OTS braces, specifically on not using direct solicitation of enrollees, and consider revoking billing privileges of suppliers that engage in prohibited solicitation practices.

We recommend that the California Department of Health Care Services recover from Los Angeles County $1,681,964 for transitional housing expenditures when closing out the SABG award for our audit period and establish a process to review whether counties, including LA County, were reimbursed for expenditures that had been previously reimbursed.

We also recommend that the California Department of Health Care Services work with Los Angeles County to develop a process to ensure that LA County's claims processing system does not pay transitional housing claims after an individual has been discharged from outpatient treatment.

We also recommend that the California Department of Health Care Services develop procedures for LA County's monitoring activities to identify whether providers are submitting invoices for reimbursement based on actual costs incurred.

We recommend that the Centers for Medicare & Medicaid Services instruct Palmetto GBA to recover $72,208 in unallowable Medicare payments by adjusting the applicable OPOs' cost reports to correct the $148,750 of unallowable professional and public education overhead costs reported, consistent with relevant laws and the agency's policies and procedures.

We recommend that Noridian Healthcare Solutions, LLC recover $4,663 in improper payments made to physicians and qualified nonphysician practitioners for the 26 sampled enrollee-months.

We recommend that Noridian Healthcare Solutions, LLC based on the results of this audit, notify appropriate physicians and qualified nonphysician practitioners (i.e., those for whom Noridian determines this audit constitutes credible information of potential overpayments) so that the physicians and practitioners can exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.

We recommend that the Centers for Medicare & Medicaid Services work with the MACs to recover $35,560 in improper payments made to providers for the 128 sampled enrollee days that did not meet Medicare requirements. 

Now that CMS has reinstituted most program integrity measures, we also recommend that CMS take the following steps, which if in effect during the audit period could have saved Medicare an estimated $579,667,510 during that period: Conduct medical reviews of psychotherapy services, including services provided via telehealth, to verify that the services are documented and billed in accordance with Medicare requirements.

Now that CMS has reinstituted most program integrity measures, we also recommend that CMS take the following steps, which if in effect during the audit period could have saved Medicare an estimated $579,667,510 during that period: Strengthen educational efforts to make providers aware of educational materials on how to meet Medicare requirements and guidance for psychotherapy services, including services provided via telehealth.

We recommend that Geisinger Health Plan refund to the Federal Government the $566,476 of net overpayments.

We recommend that Geisinger Health Plan examine its existing compliance procedures to identify areas where improvements can be made to ensure that diagnosis codes that are at high risk for being miscoded comply with Federal requirements (when submitted to CMS for use in CMS's risk adjustment program) and take the necessary steps to enhance those procedures.

We recommend that the Centers for Medicare & Medicaid Services expand program safeguards to prevent and detect at-risk payments to at-risk providers for the definitive drug testing service with the highest reimbursement amount (procedure code G0483), which could have saved up to $215.8 million for our audit period.

We recommend that the Centers for Medicare & Medicaid Services notify appropriate providers (i.e., those for whom CMS determines this audit constitutes credible information of potential overpayments) so that the providers can exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.

As the postpayment quality control review processes are being fully implemented, we recommend that the Health Resources and Services Administration do the following to verify that providers received the correct PRF payments from the Phase 1 General Distribution of the PRF. Continue to perform postpayment quality control reviews, including the review of 3,767 providers that attested to acceptance of payments and kept payments of about $756 million under wave 5 based on the estimated revenue losses in March and April 2020, and seek repayment of any overpayments from providers. If it is not feasible to review all providers, HRSA could consider reviewing 189 providers that were identified for manual review and attested to acceptance of payments and kept a total of $538 million, which was about 71 percent of the $756 million. Furthermore, HRSA could conduct a cost-benefit analysis for manual review of additional providers and, if the benefit outweighs the cost, it could select additional

As the postpayment quality control review processes are being fully implemented, we recommend that the Health Resources and Services Administration do the following to verify that providers received the correct PRF payments from the Phase 1 General Distribution of the PRF. Ensure that PSC collects payments made to the 118 providers that did not return their rejected payments as of March 9, 2022.

As the postpayment quality control review processes are being fully implemented, we recommend that the Health Resources and Services Administration do the following to verify that providers received the correct PRF payments from the Phase 1 General Distribution of the PRF. Determine whether there were other providers that were impacted by the use of incorrect TINs for subsidiary organizations, recalculate the payments for these providers, and seek repayment of any overpayments.

We recommend that the Nevada Department of Health and Human Services ensure that child care providers notify DPBH when a new household member is added or a new employee is hired so that the State may conduct the required criminal background checks.

We recommend that the Nevada Department of Health and Human Services ensure that all required criminal background checks are conducted for all employees who are under the age of 18.

We recommend that the Nevada Department of Health and Human Services add a written requirement and policy to conduct the in-State sex offender registry check, as required by Federal regulations, for all child care staff members.

We recommend that the Centers for Medicare & Medicaid Services direct the MACs to recover $9,528,296 in improper payments made to physicians for selected facet-joint denervation sessions.

We recommend that the Centers for Medicare & Medicaid Services assess the effectiveness of oversight mechanisms specific to preventing or detecting improper payments to physicians for more than two facet-joint denervation sessions related to the lumbar spine or cervical/thoracic spine per beneficiary during a rolling year and modify the oversight mechanisms based on that assessment.

We recommend that the Centers for Medicare & Medicaid Services direct the MACs to review claims for facet-joint denervation sessions after our audit period to identify instances in which Medicare paid physicians for denervation sessions that exceeded the number of allowable sessions in a 12-month period (in accordance with the applicable LCDs) and recover any improper payments identified.