Recommendations Tracker

We recommend that CMS instruct Part D sponsors to adjust PDE records for $658,396 in validated Coverage Gap discounts and, of this amount, instruct the sponsors to remit $363,287 to the beneficiaries who overpaid for their prescriptions at the point of sale.

We recommend that the National Institutes of Health update its policies and procedures related to the audit resolution process, to include issuing management decisions and submitting related OCDs to OIG; regardless of whether any corrective action has yet been taken—within the required 6-month resolution period in accordance with Federal requirements and OIG policy.

We recommend that the Pennsylvania Department of Human Services record the unreported 24-hour reportable incidents noted in this report.

Work with community-based providers to ensure that all community-based providers' staff understand the requirements for reporting 24-hour reportable incidents within required timeframes

We recommend that the Pennsylvania Department of Human Services work with community-based providers to ensure that administrative reviews and investigations are conducted and reported appropriately and consider all previous 24-hour reportable incidents related to the beneficiary.

Send a written report of death to law enforcement or the district attorney's office when a death is determined to be suspicious or when abuse or neglect is suspected

We recommend that the Tennessee Department of Human Services conduct all required background checks for the two individuals we identified as not having the required checks at the time of our review.

We recommend that Florida refund $8,772 to the Federal Government.

We recommend that the Centers for Medicare & Medicaid Services improve its system controls by checking the EDB's date-of-death information as close as reasonably possible to the date that card mailing data are sent to the print/mail contractor to ensure that Medicare cards are not mailed to deceased beneficiaries.

We recommend that the Centers for Medicare & Medicaid Services instruct the Medicare contractors to review the $2,263,465 in improper payments for claims with dates of service after the beneficiaries' dates of death and initiate recoupment for the amounts identified as improper payments.

We recommend that the New York Department of Health refund $614,530 to the Federal Government.

We recommend that the New York Department of Health ensure providers are maintaining the required documentation, according to the provisions in The Children's Waiver, to support claims for Federal Medicaid reimbursement for waiver program services.

IHS should extend policies to address more types of perpetrators, victims, and abuse.

IHS should designate a central owner in IHS headquarters to ensure clear roles and responsibilities for shared ownership in implementing patient protection policies, and managing and responding to abuse reports.

IHS should conduct additional outreach to Tribal communities to inform them of patient rights, solicit community concerns, and address barriers to reporting of patient abuse.

We recommend Seminole Nation of Oklahoma implement controls and develop policies and procedures that restrict access to the accounting system to include terminating access when employees leave, limiting permissions granted to the accounting system, providing coverage when key positions are vacant and properly segregating duties between accounting system users and personnel responsible for managing the accounting system.

We recommend Seminole Nation of Oklahoma develop and implement a cost allocation plan policy and procedures that identify and assign its Head Start and Early Head costs to the benefitted activities on a reasonable and consistent basis.

We recommend that Seminole Nation of Oklahoma develop and implement policies and procedures to create vehicle logs to identify the purpose of trips when using Head Start vehicles.

We recommend Seminole Nation of Oklahoma strengthen monitoring procedures to ensure that costs claimed benefit the program during the grant period, and ensure that equipment purchased is operational and put to use timely.

We recommend that Novitas Solutions, Inc. work with the Centers for Medicare & Medicaid Services to clarify guidance to providers, which could have resulted in savings totaling an estimated $2,373,676 during our audit period.

We recommend that Novitas Solutions, Inc. educate providers on their responsibility to bring any previously paid claims to their MAC's attention if they were paid using the wrong rate.

To address the 50 incorrect net incentive payments in our sample, we recommend that the Centers for Medicare & Medicaid Services recover from acute-care hospitals, in accordance with CMS policies, the portion of the $1,266,111 in incorrect net incentive payments that are within the reopening period.

To attempt recovery of the $93,591,531 in estimated incorrect net incentive payments made during our audit period and to ensure that all final and non-final payments made after our audit period are correct, we recommend that the Centers for Medicare & Medicaid Services instruct the MACs to review all hospitals' supporting documentation to identify errors in the hospitals' cost-report numbers used to calculate the incentive payments, including supporting documentation for labor and delivery inpatient bed-days for cost reports with cost-reporting periods beginning on or after October 1, 2013.

CMS should provide targeted oversight of Medicare Advantage Organizations (MAOs) that had risk-adjusted payments resulting from unlinked chart reviews for beneficiaries who had no service records in the 2016 encounter data.

CMS should reassess the risks and benefits of allowing chart reviews that are not linked to service records to be used as sources of diagnoses for risk adjustment.

We recommend that the Texas Health Presbyterian Hospital Dallas refund to the Medicare contractor $10,597,133 ($10,711,548 less $114,415 that the Hospital has already repaid) in estimated overpayments for the audit period for claims that it incorrectly billed.

We recommend that the Texas Health Presbyterian Hospital Dallas ensure all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation and all required documentation is included in the medical record; ensure all inpatient beneficiaries meet Medicare criteria for inpatient hospital services; ensure procedure and diagnosis codes are supported in the medical records and staff are properly trained; and ensure HCPCS codes are supported in the medical records and staff are properly trained.

Refund to the Medicare program the portion of the estimated $680,884 in overpayments for claims incorrectly billed that are within the reopening period.

We recommend that Palos Community Hospital Home Health Agency 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 Pathways for Children, Inc. refund to the Federal Government $296,982 for FY 2017 unallowable non-Federal share expenses or provide documentation showing that Federal sources were not billed for IEP services.

We recommend that Pathways for Children, Inc. implement policies and procedures to ensure that revenue generated from non-Federal match fundraising expenses are allocated to Head Start program in accordance with the relative benefits received.

We recommend that Pathways for Children, Inc. implement policies and procedures to request prior written approval from ACF before purchasing capital assets.

We recommend that St. Vincent Hospital refund to the Medicare contractor $2,111,647 (of which $293,404 was net overpayments identified in our sample) in estimated overpayments for incorrectly billed services.

We recommend that St. Vincent Hospital strengthen controls to ensure full compliance with Medicare requirements; specifically, ensure that all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation, all inpatient beneficiaries meet Medicare criteria for inpatient hospital services, diagnosis, discharge status, and admission source codes are supported in the medical records and staff are properly trained, and medical records accurately document the appropriate number of units and distinct procedural services and that staff are properly trained.

We recommend that the Hospital refund to the Medicare contractor $3,461,279 ($3,461,376 less $97 that has already been repaid) in estimated overpayments for the audit period for claims that it incorrectly billed.

We recommend that the Hospital strengthen controls to ensure full compliance with Medicare requirements, specifically ensure all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation; ensure documentation supporting the medical necessity for inpatient hospital services is contained in the medical records; ensure procedure and diagnosis codes are supported in the medical records and staff are properly trained; ensure procedures are in place to properly bill claims subject to SNF consolidated billing requirements; and ensure medical records accurately document distinct procedural services and staff are properly.

We recommend that Northwest Medical Center refund to the Medicare contractor $1,203,705 ($1,207,729 less $4,024 that has already been repaid) in estimated overpayments for the audit period for claims that it incorrectly billed.

We recommend that Northwest Medical Center strengthen controls to ensure full compliance with Medicare requirements, to ensure that all IRF beneficiaries meet Medicare criteria for acute inpatient rehabilitation; documentation supporting the medical necessity for inpatient hospital services is contained in the medical records; diagnosis codes are supported in the medical records and staff are properly trained; and medical records accurately document distinct procedural services and staff are properly trained.

We recommend that CMS require reconciliation of all hospital cost reports with outlier payments during a cost-reporting period. If the reconciliation requirement had been in effect for the 60 hospitals in our audit, CMS would have saved approximately $125 million per year.

We recommend that Noridian work with CMS to ensure that its final settlement of contract costs reflects an increase in Medicare nonqualified costs of $1,516,058 for CYs 2009-2013.