Recommendations Tracker

We recommend that Palmetto work with CMS to ensure that its final settlement of contract costs reflects a decrease in Medicare Excess Plan costs of $406,791 for CYs 2015 and 2016.

We recommend that the Centers for Medicare & Medicaid Services direct the Medicare contractors to recover the $1,918,278 for claims that are within the reopening period, and instruct providers to refund up to $540,680, which beneficiaries were required to pay; these amounts consist of $1,427,930 in overpayments to providers that billed noncomplex or complex CCM services more than once for the same beneficiaries for the same service periods and up to $406,080 in cost-sharing overcharges to these beneficiaries; $438,262 in overpayments to providers that billed for both noncomplex or complex CCM services and overlapping care management services rendered to the same beneficiaries for the same service periods and up to $121,166 in cost-sharing overcharges to these beneficiaries; and $52,086 in overpayments to providers that billed for incremental complex CCM services associated with overpayments for complex CCM services that we identified and up to $13,434 in cost-sharing overcharges to th

We recommend that the Centers for Medicare & Medicaid Services direct the Medicare contractors to implement claim system edits to prevent and detect overpayments for noncomplex and complex CCM services.

We recommend that CDS LLC work with CMS to ensure that its final settlement of contract costs reflects a decrease in Medicare pension costs of $8989 for CYs 2012 through 2016.

We recommend that the Arkansas Department of Human Services refund the $4,361,850 Federal share to the Federal Government.

We recommend that the Texas Health and Human Services Commission refund $856,456 to the Federal Government.

We recommend that the Texas Health and Human Services Commission identify any other beneficiaries who are assigned more than one identification number and refund any unallowable CHIP payments associated with those beneficiaries.

We recommend that the New York State Department of Health refund to the Federal Government or provide documentation of such refund, totaling $97,998,292. Specifically refund to the Federal Government $77,152,491 related to random moments that could not be supported as Medicaid-eligible health services; refund to the Federal Government $1,238,102 for intergovernmental agreement payments that the State agency did not support that it did not double-claim; and refund to the Federal Government or provide documentation of the refund to CMS of $19,607,699 for excess costs claimed on the Form CMS-64 for 1 year.

We recommend that the New York State Department of Health refund $308,972,870 to the Federal Government or provide documentation that it can reasonably support, under the circumstances, its allocation of health services costs to Medicaid without using unverifiable IEP ratios.

We recommend that the New York State Department of Health revise its certified public expenditures SSHSP to (1) include September days worked in its random moment time study and (2) develop an accurate, supportable method to identify Medicaid costs instead of unverifiable IEP ratios.

We recommend that Palmetto GBA, LLC, discontinue using its internal policies of waiving certain overpayment collections related to lookback years and start collecting all hospice cap overpayments and paying refunds in accordance with CMS requirements.

We recommend that Palmetto GBA, LLC, collect $545,639 in lookback overpayments and return $17,513 in lookback refunds resulting from 2017 hospice cap calculations for lookback years.

Kaiser Permanente validate the point-of-sale fee amounts that its PBM disclosed for CYs 2014 and 2015 and refile the CY 2014 and 2015 DIR reports if appropriate.

We recommend that Partners In Care, Inc. refund to the Federal Government the portion of the estimated $11,278,891 for hospice services that did not comply with Medicare requirements and that are within the 4-year reopening period.

We recommend that Partners In Care, Inc. strengthen its policies and procedures to ensure that hospice services comply with Medicare requirements.

We recommend that the Centers for Medicare & Medicaid Services, as part of its ERM program, implement a process to assess all of its programs for national security risks in accordance with OMB Circular No. A-123's requirement to include new or emerging risks in the risk profile.

We recommend that Mission Hospice & Home Care, Inc. refund to the Federal Government the portion of the estimated $10,564,396 for hospice services that did not comply with Medicare requirements and that are within the 4-year reopening period.

We recommend that Mission Hospice & Home Care, Inc.: strengthen its policies and procedures to ensure that hospice services comply with Medicare requirements.

We recommend that Puerto Rico Department of Health revise its EOP, including adding or updating procedures, to comply with HPP-PHEP Cooperative Agreement requirements related to: (1) conducting annual public health and medical preparedness exercises or drills that include at-risk populations in all of its planning and activities; (2) identifying resources for at-risk populations; (3) anticipating storage needs for a surge of human remains; (4) implementing and identifying emergency procurement procedures; (5) clearly defining HCC Specialists' responsibilities; (6) obtaining public comment and input on its EOP; (7) utilizing EMAC or other public health mutual aid agreements to support coordinated activities when responding to public health emergencies; and (8) ensuring that all HCC members can share information regarding resources and resource needs to address an emergency.

We recommend that Puerto Rico Department of Health consider coordinating with appropriate organizations to develop guidance on accurate cause-of-death certifications focusing on whether underlying causes of death were disaster-related.

We recommend that the New York State Department of Health (State agency) refund $6,027,566 to the Federal Government.

Based on the results of this audit, we recommend that the Centers for Medicare & Medicaid Services notify appropriate providers (i.e., those for whom CMS determines that 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.

We recommend that the Indiana Family and Social Service Administration refund $22,328,438 to the Federal Government.

We recommend that Lake Hospital System refund to the Medicare contractor the portion of the $4,385,974 in estimated overpayments for the audit period for claims that it incorrectly billed that are within the 4-year reopening period.

We recommend that Lake Hospital System strengthen controls to ensure full compliance with Medicare requirements.

We recommend that Staten Island University Hospital refund to the Medicare contractor the portion of the $11,761,274 in estimated overpayments for the audit period for claims that it incorrectly billed that are within the 4-year reopening period.

We recommend that Staten Island University Hospital strengthen controls to ensure that all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation, all inpatient beneficiaries meet Medicare requirements for inpatient hospital services, the use of bypass modifiers is supported in the medical records, and staff are properly trained.

We recommend that the Centers for Medicare & Medicaid Services make regulatory changes to allow it to require accreditation organizations to perform special surveys of hospitals selected by CMS after it issues new substantive participation requirements or guidance that it determines warrant additional validation to ensure timely compliance.

We recommended that the Kentucky Department for Medicaid Services refund $29,431,268 to the Federal Government.

We recommended that the Kentucky Department for Medicaid Services enhance RMS procedures to ensure that its RMTS methodology complies with Federal requirements for statistical validity.

We recommended that the Kentucky Department for Medicaid Services enhance policies and procedures to ensure that changes to its RMTS methodology are incorporated into a CAP amendment and promptly submitted to DCA for review.

We recommend that Northwest Hospice, LLC refund to the Federal Government the portion of the estimated $3,902,337 for hospice services that did not comply with Medicare requirements and that are within the 4-yearreopening period.

We recommend that Northwest Hospice, LLC strengthen its policies and procedures to ensure that hospice services comply with Medicare requirements.