Recommendations Tracker

We recommend that WPS confirm to OIG that the $140,182 in overpayments associated with the 123 incorrect claim lines—for which WPS has already processed a corrected claim—has been fully recovered.

We recommend that WPS work with the providers associated with the 15 incorrect claim lines for which WPS had not processed the corrected claims as of the end of our audit work and recover any identified overpayments.

We recommend that WPS use the results of this audit to enhance its provider education activities.

We recommend that the State agency refund $8,072,870 (Federal share) in estimated overpayments to the Federal Government.

We recommend that the State agency improve its EVV system by: (1) establishing system edits and/or formal policy requirements governing attendants' use of manual entries and by implementing limit thresholds for how often manual entries can be used; (2) implementing system edits to verify that all PCS visits have corresponding EVV records; (3) requiring providers to verify that all PCS visits are entered in the EVV system; (4) implementing system edits that capture the location of services provided, and establishing requirements for providers and attendants to document and verify the actual location where PCS is provided; (5) implementing system edits that require providers to review and then correct GPS exceptions; (6) requiring providers to monitor the use of EVV reason codes and confirm their appropriate application; and (7) requiring providers to verify that the names of the attendants identified on EVV records match the names of the attendants who signed the corresponding timesheet

We recommend that the State agency implement system edits to verify that: (1) units paid match the units approved on the enrollees' plans of care, and (2) rates paid are in accordance with the State's approved rates.

CMS should work with States to ensure that all MCOs are contractually required to refer potential fraud promptly.

CMS should work with States to expand the feedback provided to MCOs about provider fraud referrals.

We recommend that Novitas implement additional oversight (e.g., documentation and billing guidance, medical reviews, and/or provider internal audits) to prevent improper payments associated with provider billing of E/M, psychotherapy, and podiatry services, which could have saved an estimated $19,480,109 for our audit period.

We recommend that the New York Department of Health strengthen its monitoring activities to verify that nursing homes comply with requirements that prohibit the employment of individuals with disqualifying backgrounds, such as expanding the timeframe covered by recertification surveys.

Build upon its efforts to improve the quality of referrals from its primary referral sources.

Update its training plan to include annual minimum training hour requirements for each professional discipline.

We recommend that CMS work with the hospice MACs to consider this high-risk area in their hospice eligibility reviews and to possibly develop pre- or postpayment review procedures for new hospice enrollees without an inpatient or emergency room claim 18 months prior to starting hospice care, which could have saved an estimated $255.1 million in hospice claim payments during our audit period.

We recommend that CMS consider the results of our audit when selecting nursing homes for followup audits by the CMS PBJ auditor.

We recommend that CMS educate nursing homes on the updated guidance available in the PBJ Policy Manual and PBJ Policy Manual FAQs.

We recommend that the Hospital refund to the Federal government the estimated $4,701,168 in net overpayments for incorrectly billed claims, excluding amounts presumed to be unrecoverable under the Section 1870 waiver of liability provision.

We recommend that the Hospital provide additional training to clinical and billing personnel on its policies and procedures related to the Two-Midnight Rule, IRF admissions requirements, and inpatient and outpatient coding.

We recommend that the North Dakota Department of Health and Human Service's Developmental Disability Section follow up with the residential providers that had the 182 instances of provider noncompliance identified in this report to ensure that they have taken corrective actions.

We recommend that the North Dakota Department of Health and Human Service's Developmental Disability Section work with the residential providers to improve internal controls for health and safety at residential settings, maintenance of records, and training.

CMS should take steps to support States in holding Medicaid managed care plans accountable for the accuracy of their online provider directories.

CMS should work with States to improve the accuracy of the provider data they use to evaluate the adequacy of networks in Medicaid managed care.

CMS should regularly collect request-level prior authorization data that include standardized service type and contractor information.

CMS should take action to address any breakdowns in the initial reviews of SNF admission requests that are driving the extremely high overturn rate of SNF admission denials.

CMS should assess reasons for the differences in SNF denial rates between nursing home residents and other enrollees and take action as warranted.

We recommend that the State agency refund $7,576,103 to the Federal Government.

We recommend the State agency review payments made after our audit period to identify any additional overpayments and refund the Federal share to the Federal Government. Additionally, the State agency should clearly identify any additional overpayments refunded as having been made in accordance with this recommendation.

We recommend that CBH update its policies and procedures to include: (1) a requirement to reconcile discrepancies between addresses of record and addresses given to treatment providers and (2) a process for determining when a change of residency occurs and notifying the CAO accordingly.

We recommend that CBH coordinate with the State agency to implement a revised initial denial notice that informs enrollees that they have the right to be provided, upon request and free of charge, all documents, records, and other information relevant to the adverse benefit determination as required by 42 CFR section 438.404(b)(2).

We recommend that CBH update its policies to comply with its HealthChoices Agreement by requiring staff to document the following for enrollees under 21 years of age: (1) steps taken to contact the enrollee's representative to request that the enrollee's representative ask the provider to communicate with CBH, and (2) efforts to reach the provider before issuing denial notices.

We recommend that ORR conduct required abbreviated monitoring visits at unlicensed facilities approximately every 90 days.

We recommend that the Hospital refund to the Federal government the estimated $17,838,422 in net overpayments for incorrectly billed claims, excluding amounts presumed to be unrecoverable under the Section 1870 waiver of liability provision.

We recommend that the Hospital provide additional training to clinical and billing personnel on its policies and procedures related to the following: Two-Midnight Rule; the medical necessity of inpatient services; IRF admissions; IRF documentation requirements ; and Inpatient and outpatient coding.

We recommend that CMS develop and implement additional training for analysts to improve the clarity, accuracy, and consistency of their documentation for reviewing CMS-64s.

We recommend that CMS modify its policies and procedures to specify which CMS departments are responsible for tracking and resolving disallowed payments.

We recommend that CMS implement a procedure to prevent overpayments to MA organizations when acute stroke diagnosis codes are submitted by MA organizations on a physician data record and the enrollee does not have an acute stroke diagnosis on an inpatient or outpatient hospital data record during the same service year (e.g., CMS filter of EDS data to identify and address these diagnosis codes or instructions to MA organizations to implement a control to prevent the submission of these diagnosis codes), which could have resulted in cost savings of $462 million.