Recommendations Tracker

CMS should update and broaden its lists of hospital-acquired conditions to capture common, preventable, and high-cost harm events.

CMS should develop and release interpretive guidance to surveyors for assessing hospital compliance with requirements to track and monitor patient harm events.

AHRQ should optimize use of the Quality and Safety Review System (QSRS), including assessing the feasibility of automating data capture for national measurement and to facilitate local use.

AHRQ should continue efforts to identify and develop new strategies to prevent common patient harm events in hospitals.

ACF should take steps to improve internal coordination and communication about unaccompanied children.

ACF and CDC should ensure that CDC coordinates with ORR when making future decisions that could affect the number of unaccompanied children placed in ORR's care, including any Title 42 order.

CMS should issue new guidance on the appropriate use of MAO clinical criteria in medical necessity reviews.

CMS should direct MAOs to take additional steps to identify and address vulnerabilities that can lead to manual review errors and system errors.

We recommend that the Massachusetts Executive Office of Health and Human Services, Office of Medicaid continue to coordinate with DDS and DPPC to ensure that all reasonable suspicions of abuse and neglect are properly identified, reported, and investigated as needed.

Continue implementation of an automated CDM solution that provides a centralized, enterprise-wide view of risks across all of HHS.

HHS should perform an enterprise risk assessment over known control weaknesses (e.g., Authority to Operate, incomplete OpDiv provided system inventories, lack of OpDiv adherence to HHS information security policies) due to their federated environment and document an appropriate risk response (e.g., accept, avoid, mitigate, share, or transfer).

HHS OCIO work with all OpDivs to ensure that all operational systems have SSPs and FIPS 199 categorizations completed for information systems in accordance with HHS policy.

HHS OCIO work with all OpDivs to ensure that baseline configuration requirements are implemented and maintained across all systems within its environment. Additionally, ensure that system owners implement procedures to document and retain evidence of current baseline configurations.

HHS OCIO work with all OpDivs to develop a management approved Configuration Management policy that addresses purpose, scope, roles, responsibilities, management commitment and coordination among organizational entities. This document should be tailored to the OpDivs' needs and be reviewed and updated according to HHS policy (at least every 3 years).

HHS OCIO work with the OpDivs to ensure that all OpDivs develop and implement an ICAM strategy and authenticator management policy to ensure all information systems undergo a digital identity risk assessment to determine which systems require strong authentication. Once a risk assessment is complete, OpDivs should ensure that authentication mechanisms are implemented for all information systems.

HHS OCIO work with the OpDivs to ensure that all OpDivs iImplement a process to ensure that privileged user's access is reviewed at least within every 365 days by all system owners in compliance with HHS Information System Security and Privacy Policy (IS2P). Evidence of privileged users access reviews should be retained and provided upon request.

HHS OCIO work with all OpDivs to ensure that ISCM strategy and procedures should clearly define critical reporting metrics for reports utilized by internal and external stakeholders. Additionally, OpDivs should coordinate reporting efforts with the OCIO to ensure the definitions and reporting requirements are consistently implemented.

HHS OCIO work with all OpDivs to ensure that a process exists for monitoring contingency plan testing to prevent CPTs from not being performed in accordance with the established HHS policies. Additionally, OpDiv management should improve their HSDW reporting process by educating system owners on required fields for reportable metrics and validating those fields are provided to the OCIO when consolidating HHS wide data.

HHS OCIO work with all OpDivs to ensure that OpDiv management ensure that all systems are implementing information system backup and storage as documented in HHS policies and procedures. Additionally, management should require that evidence is retained to document backup and storage procedures.

We recommend that the California Department of Health Care Services refund $23,139,767 to the Federal Government.

We recommend that the California Department of Health Care Services consider performing additional postservice prepayment monitoring and postservice postpayment utilization reviews.

We recommend that the California Department of Health Care Services revise the Drug Medi-Cal Billing Manual or provide additional guidance to OTPs regarding the allowable number of counseling service units and work with counties to ensure that their OTP billing manuals do not conflict with State regulations.

We recommend that the California Department of Health Care Services take actions to ensure that OTPs provide the number of counseling services specified in a beneficiary's treatment plan or document the reasons that counseling services were not provided as specified in the treatment plan.

We recommend that the California Department of Health Care Services take actions to ensure that OTPs have their physicians review and countersign beneficiaries' treatment plans within the 14-day period as required.

We recommend that Louisiana's Office of Behavioral Health develop a process to ensure accurate reporting on the Annual Progress Reports.

We recommend that Louisiana's Office of Behavioral Health work with the LGEs and OTPs to identify ways to support clients' access to transportation to obtain treatment and determine how transportation could be addressed in each specific region of the State.

We recommend that the South Carolina Department of Health and Human Services work with the Department of Disabilities and Special Needs to ensure that providers follow the reporting requirements for critical events.

We recommend that the South Carolina Department of Health and Human Services work with the Department of Disabilities and Special Needs to perform analytical procedures, such as data matches, on Medicaid claims data to identify any unreported critical incidents, and investigate as needed.

We recommend that the South Carolina Department of Health and Human Services work with the Department of Disabilities and Special Needs to impose sanctions on providers to compel compliance with timely reporting requirements for allegations of ANE and deaths.

We recommend that the South Carolina Department of Health and Human Services work with the Department of Disabilities and Special Needs to ensure that backup staff members are available to work on incident management activities whenever the primary IMC is unavailable.

CMS should Encourage Part D plans to increase access to and use of biosimilars.

We recommend that the New York City provider refund to the Medicare program the estimated $1,118,789 overpayment.

We recommend that the New York City provider develop policies and procedures to ensure that treatment plans contain all required elements, are maintained and are signed by the treating physician; the performing therapists and supervising physicians comply with the requirements related to incident-to services; psychotherapy services are conducted by therapists that meet Medicare qualification requirements; time spent on psychotherapy services is documented; and treatment notes are signed and maintained to support the services billed.

We recommend that the New York State Department of Health (the State Agency) refund $1,943,190 to the Federal Government.

We recommend that the New Mexico Human Services Department refund $12,422,181 to the Federal Government.

We recommend that the New Mexico Human Services Department establish policies and procedures to account for adjustments MCOs make to IHS encounter data after reconciliations are completed.

We recommend that the New Mexico Human Services Department turn on the edit for encounter data that compares calculated days to paid days to limit the State agency's acceptance of encounter data with dates-of-service spans that do not support the paid days.

To ensure that the State agency complies with Federal requirements and does not claim unallowable costs, we recommend that the Centers for Medicare & Medicaid Services direct the State agency to revise the Process Guide to include days worked during September in RMTSs.

To ensure that the State agency complies with Federal requirements and does not claim unallowable costs, we recommend that the Centers for Medicare & Medicaid Services direct the State agency to revise the Process Guide to prohibit the substitution of sampled personnel.

To ensure that the State agency complies with Federal requirements and does not claim unallowable costs, we recommend that the Centers for Medicare & Medicaid Services direct the State agency to revise the Process Guide to require the collection of information (e.g., student names or case numbers) to support whether an RMTS respondent's time was part of a health care service or a Medicaid administrative activity.

We recommend that Texas expand the scope of its site visits of PATH providers to include reviews of consumers' case files maintained by PATH providers to strengthen its current risk assessment process and ensure that providers only enroll eligible individuals into the PATH program.

We recommend that the Centers for Medicare & Medicaid Services do the following, which could have saved Medicare an estimated $47.8 million during our audit period: determine whether any eligibility specifications in the Medicare contractors' LCDs and LCAs should be added to the NCD for bariatric surgery and, if so, take the necessary steps to update the NCD by, for example; specifying when BMI should be measured; specifying what constitutes medical treatment for obesity (e.g., by including specific requirements for a beneficiary's participation in a weight management program); and including additional requirements needed to ensure that beneficiaries are appropriate candidates for bariatric surgery (e.g., the requirements that a physician other than a surgeon evaluate the beneficiary before surgery and that the beneficiary have a mental health evaluation, which includes a statement regarding the beneficiary's motivation and ability to follow postsurgical requirements).

We recommend that the Centers for Medicare & Medicaid Services do the following, which could have saved Medicare an estimated $47.8 million during our audit period: educate hospitals on the NCD requirements for bariatric surgeries if the NCD has been updated in response to our first recommendation.

We recommend that Tufts Health Plan refund to the Federal Government the $3,758,335 of net overpayments.

We recommend that Tufts Health Plan continue to improve its existing compliance procedures to identify areas where improvements can be made to ensure 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 Office of Refugee Resettlement issue guidance to care provider facilities regarding the requirement to include all relevant ORR and DHS contacts in their emergency contact lists.

We recommend that the National Cancer Institute coordinate with the National Institutes of Health's DGSI/Closeout Center to update policies and procedures for monitoring grantees' submission of closeout documents to include increased outreach to grantees before the final reports (Final FFR, FRPPR, and FIS) become delinquent.

We recommend that SCAN refund to the Federal Government the $54,318,154 of net overpayments.

We recommend that the Centers for Medicare & Medicaid Services work with States to implement all of the recommendations made in OIG's prior audits.

We recommend that the Centers for Medicare & Medicaid Services explore using or expanding the use of available remedies to prevent and reduce the amount of improper payments made on behalf of ineligible beneficiaries. As appropriate, this could include disallowance of the Federal share associated with eligibility errors or proposing changes to eligibility determination practices and rules.