Recommendations Tracker

OCSS should bolster State agency resilience during emergencies.

We recommend that the Centers for Medicare & Medicaid Services instruct MACs, based upon the results of this audit, to 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, up to $17,817,121, 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 revise its billing guidance to specify that OTPs should not bill add-on HCPCS codes for take-home supplies of medication for the same episode of care that was already covered by a weekly bundle that included medication, and instruct MACs to implement edits in their claims processing systems to identify improperly billed claims for take?home medication.

We recommend that the Centers for Medicare & Medicaid Services work with MACs to provide education on proper billing of intake activities to the 8 OTPs that billed 14 or more intake activity claims per enrollee during our audit period.

We recommend that the Centers for Medicare & Medicaid Services update applicable Medicare requirements to clarify which types of professional and public education overhead costs are unallowable (e.g., clarify whether the costs of meals provided to non-OPO employees for professional education and the costs of tickets to entertainment events purchased for the purpose of public education are unallowable), which could have saved Medicare an estimated $664,295 for professional and public education overhead costs during our audit period.

We recommend that the Texas Department of Health and Human Services Commission ensure DIR costs are allocated to Medicaid based on an approved methodology in the CAP.

We recommend that the Texas Department of Health and Human Services Commission strengthen policies and procedures to track its private MMIS contractor costs to APDs and ensure that the Federal match is claimed at the approved rate and ensure that it doesn't claim costs when it is reimbursed for those costs by other agencies.

We recommend that Presbyterian Health Plan, Inc., identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government.

We recommend that the New York State Department of Health work with the New York State Office of Mental Health to improve its monitoring activities by increasing the number of case files reviewed when conducting provider site visits to ensure that service plans and subsequent service plan reviews are timely signed and maintained, community rehabilitation claims meet Medicaid reimbursement standards, and services are appropriately authorized; and providing formal guidance or training to providers to clarify requirements related to service plans and subsequent service plan reviews being timely signed and maintained, community rehabilitation claims meeting Medicaid reimbursement standards, and services being appropriately authorized.

We recommend that the Centers for Medicare & Medicaid Services work with the DME MACs to do the following, which if in effect during our audit period could have saved Medicare as much as $30,051,107 for wheelchair repairs: review accumulated costs for wheelchair repairs that exceed the federally recommended cost limit, and for those wheelchairs that the DME MACs determine will not remain serviceable for their entire 5-year RUL, enforce Federal requirements by requiring the suppliers that transferred ownership of the wheelchairs purchased on a rental basis to enrollees to furnish replacement wheelchairs to those enrollees at no cost to the enrollees or to Medicare.

We recommend that the Centers for Medicare & Medicaid Services work with the DME MACs to do the following, which if in effect during our audit period could have saved Medicare as much as $30,051,107 for wheelchair repairs: take appropriate action for suppliers that consistently bill for repairs made to wheelchairs during their 5-year RUL that exceed the federally recommended cost limit or the cost limit used as the basis for determining when wheelchairs furnished by suppliers will not remain serviceable for their entire 5-year RUL (e.g., by educating suppliers on proper billing and recovering improper payments).

We recommend that the Indian Health Service identify and correct any other Purpose Statute violations relating to funds not used on COVID-19 testing and other testing-related activities from the Families First Act and Paycheck Protection Act funds allocated to the IHS Direct programs within the GPAO, and, if IHS is unable to correct those violations, report any Antideficiency Act violations.

We recommend that the Indian Health Service identify and recover amounts not used for COVID-19 testing or other testing-related activities that we did not sample from remaining Tribal and UIO programs within the GPAO.

We recommend that the Indian Health Service develop and provide adequate guidance to programs within the GPAO on the proper use of Paycheck Protection Act funds in accordance with Federal requirements.

We recommend that the Indian Health Service provide adequate guidance to the programs on how to track and account for funds allocated and used under the Paycheck Protection Act.

We recommend that the Virginia Medicaid Department of Medical Assistance Services identify and recover unallowable capitaiton payments, which we estimate to be at least $21,849,401, made to MCOs during our audit period on behalf of deceased enrollees.

We recommend that the Virginia Medicaid Department of Medical Assistance Services continue to pursue development and implementation of an automated matching and eligibility update process.

CMS should require States to collect data on MCO prior authorization decisions.

CMS should require States to implement automatic external medical reviews of upheld MCO prior authorization denials.

We recommend that the Florida Department of Children and Families coordinate with the Florida Agency for Health Care Administration to obtain access to Medicaid claim data for all children under its care and supervision.

We recommend that HRSA identify additional improper UIP payments for services provided to insured individuals or services unrelated to COVID-19, which we estimate to be $783.6 million, and take remedial action.

We recommend that Excellus Health Plan, Inc. identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government.

We recommend that Noridian Healthcare Solutions, LLC notify the physicians and qualified nonphysician practitioners to refund $1,162 in coinsurance that was collected for the 26 sampled enrollee-months.

We recommend that Noridian Healthcare Solutions, LLC update the educational material on its website as well as any previously provided webinars to include all Medicare requirements and guidance for billing and documenting ESRD-related services and continue to perform medical record reviews as part of the TPE program, which could have saved the Medicare program an estimated $8,844,899 and could have saved Medicare enrollees up to an estimated $2,204,799 for our audit period.

We recommend that the Centers for Medicare & Medicaid Services direct the appropriate Medicare contractors to determine the amount of improper payments for the claims that did not comply with Medicare requirements and, for those that are within the 4-year claim-reopening period, in accordance with CMS's policies and procedures, recover up to $888,169,038 for claims that were at risk of improper payment during our audit period.