Recommendations Tracker

CMS should take additional steps to improve electronic communication between Part D sponsors and prescribers to reduce avoidable pharmacy rejections and coverage denials.

CMS should take action to reduce inappropriate coverage denials.

CMS should issue guidance related to the areas identified in the report, specifically value based purchasing arrangements.

CMS should implement a system to share responses to manufacturer inquiries for technical assistance.

CMS should identify States that have limited availability of behavioral health services and develop strategies and share information to ensure that Medicaid managed care enrollees have timely access to these services.

New Mexico Human Services Department should increase behavioral health providers' participation in Medicaid managed care.

New Mexico Human Services Department should improve access to transportation for Medicaid managed care enrollees needing behavioral health services.

New Mexico Human Services Department should expand the use of telehealth to increase the availability of behavioral health services.

New Mexico Human Services Department should identify and share information about strategies to improve care coordination.

New Mexico Human Services Department should share information about open-access scheduling and the Treat First Clinical Model and promote expansion.

We recommend that the Ohio Department of Medicaid refund $6,729,855 (Federal share) in overpayments to the Federal Government.

We recommend that the Ohio Department of Medicaid implement a process that addresses beneficiary system updates to MITS with retroactive eligibility status and category changes on a case-by-case basis.

We recommend that the Centers for Medicare & Medicaid Services develop a fraud prevention model specific to emergency ambulance transports from hospitals to skilled nursing facilities to help ensure that payments for these ambulance transports comply with Federal requirements, which could have saved an estimated $849,170 during our audit period and $119,548 in calendar year 2018.

We recommend that the Vermont Office of Child Support refund $48,891 ($32,268 Federal share) for Title IV-D MPRs, which were reimbursed at the incorrect county rate.

We recommend the State agency work with ACF to determine what portion of the $1,374,320 ($907,051) for unsupported salaries allocated represents Title IV-D eligible costs or refund the entire amount.

We recommend the State agency refund $180,288 ($118,990 Federal share) for duplicate Title IV-D MPRs.

ORR should identify and disseminate evidence-based approaches to addressing trauma in short-term therapy.

ORR should assess whether to establish maximum caseloads for individual mental health clinicians.

ORR should increase therapeutic placement options for children who require more intensive mental health treatment.

We recommend that the State agency bill for and collect from manufacturers rebates for single-source and top-20 multiple-source pharmacy and physician-administered drugs and refund to the Federal Government the estimated $28,103,346 (Federal share).

We recommend that the State agency strengthen its NDC edit (implemented on January 1, 2015), to ensure that NDCs are captured for all drug utilization data.

We recommend that the State agency ensure that all pharmacy and physician-administered drugs eligible for rebates are processed for rebates.

We recommend that Twin Palms refund to the Federal Government the portion of the estimated $317,038 overpayment for claims for chiropractic services that did not comply with Medicare requirements and are within the 4-year claims reopening period.

We recommend that Twin Palms 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 the State agency refund $411,932,576 to the Federal Government, consisting of $64,382,543, representing the Federal share of net Hospital self-reported LIP overpayments for the audit period and $347,550,033, representing the Federal share of LIP cost limits calculated by the Hospital that did not comply with Federal and State requirements as identified in this audit.

We recommend that the State agency establish procedures to ensure that it returns to the Federal Government the Federal share of overpayments reported by hospitals.

We recommended that the State agency review the cost-limit calculations to verify that hospitals have included these payments (i.e., Medicaid payments (other than DSH and LIP) that are not related to specific claims and the dual-eligible patient portion of payments for Medicare cost report settlements, direct graduate medical education, Medicare bad debts, and organ acquisition costs.

We recommended the State agency improve its oversight of the LIP program by establishing policies and procedures for providing additional training to its staff members on the RFMD and STCs for the waiver; providing training to participating hospital personnel on LIP program compliance and preparing the cost-limit calculations; and monitoring hospital LIP calculations to verify that they comply with the RFMD and STCs including reconciling hospital cost-limit calculations to the finalized Medicare cost reports; reviewing hospital low-income data to verify that it does not include data for undocumented aliens; reviewing hospital low-income data to verify that it does not include data for prisoners in other than an inpatient setting; testing or verifying the accuracy and completeness of the data being used by hospitals in their LIP cost-limit calculations; reviewing hospital cost-limit calculations to verify that the hospitals properly incorporate observation days and charges into the calc

We recommend that the State agency redetermine, as appropriate, the current Medicaid eligibility status of the sampled beneficiaries who did not meet Federal and State eligibility requirements, with specific attention to beneficiaries who did not meet income requirements; beneficiaries who were eligible under a mandatory Medicaid eligibility group; beneficiaries who did not meet citizenship requirements; and beneficiaries who were not eligible for the new adult group but for whom the State agency claimed enhanced Federal Medicaid reimbursement.

We recommend that the State agency implement in the CBMS system functions to ensure benefits of ineligible beneficiaries are terminated in a timely manner and income verifications are requested from beneficiaries when electronic verification does not occur within 4 months of application.

We recommend that the State agency implement a process whereby it resolves discrepancies more promptly by reducing the time between the identification of a discrepancy and the dispatch of a discrepancy letter to the beneficiary.

Ensure that it accurately reports all data on quality measures through the CMS web portal.

We recommended that Oceanside Medical Group refund to the Medicare program the portion of the estimated $2,694,446 overpayment for claims that are within the reopening period.

We recommended that Oceanside Medical Group 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.

Develop and implement a plan to increase Medicaid fraud referrals from the Utah Medicaid Inspector General and ACOs

Develop and implement written procedures for storing, maintaining, and efficiently accessing case information

We recommend that the Administration for Children and Families continue to monitor the States' actions and progress toward implementation of the new background check requirements.

CMS must do more to avoid paying twice for the same drugs. As we have previously recommended, CMS should work directly with hospices to ensure that they are providing drugs covered under the hospice benefit. In addition, we recommend that CMS should develop and execute a strategy to ensure that Part D does not pay for drugs that should be covered by the Part A hospice benefit, which would save at least an estimated $160.8 million a year in Part D total cost, with potentially much higher annual savings associated with the drugs that hospices said they were not responsible for providing. This should include working with Part D sponsors and seeking whatever authorities are necessary to develop proper controls.

We recommend that the Texas Health and Human Services Commission bill manufacturers for the $3,785,737 ($2,202,921 Federal share) in rebates for single-source and top-20 multiple-source physician-administered drugs, and refund the Federal share of rebates collected.

We recommend that the Texas Health and Human Services Commission work with CMS to determine whether the other physician-administered drugs, associated with 160,579 claim lines, were eligible for rebates and, if so, determine the rebates due and upon receipt of the rebates refund the Federal share of the rebates collected.

We recommend that the New York State Department of Health redetermine, as appropriate, the current Medicaid coverage group of the sampled beneficiaries for whom services were incorrectly reimbursed at an enhanced FMAP rate.

We recommend that the NYS Department of Health maintain the necessary documentation to determine whether it enrolled individuals who did not meet Federal and State Medicaid eligibility requirements in the new adult group.

We recommend that the New York State Department of Health follow up with the 20 nursing homes to ensure corrective actions have been taken regarding the life safety and emergency preparedness deficiencies identified in this report.

We recommend that the New York State Department of Health conduct more frequent surveys at nursing homes with a history of multiple high-risk deficiencies.

We recommend that the Illinois Department of Healthcare (State agency) and Family Services refund $3,174,262 to the Federal Government.

We recommend that the Illinois Department of Healthcare and Family Services identify capitation payments made on behalf of deceased beneficiaries before and after our audit period, and repay the Federal share of amounts recovered.