Recommendations Tracker

We recommend that the State agency improve its policies and procedures for monitoring MCOs' compliance with parity requirements, including: (1) collecting and reviewing supporting data from MCOs for their comparative analyses; (2) providing clear, uniform guidance to MCOs regarding maintaining and providing accurate and consistent data to support and complete their comparative analyses, and correcting issues of noncompliance with parity requirements; and (3) establishing a formal, written policy that includes its denial rate threshold and indicates what actions MCOs are to take when denial rates exceed the threshold.

We recommend that the State agency enhance its oversight of the MCOs by ensuring they: (1) complete and submit the parity analyses annually for each of the four benefit classifications—inpatient, outpatient, prescription drugs, and emergency care—as required in the MCO contracts, (2) maintain and submit complete and accurate data to support those analyses, and (3) correct issues of identified noncompliance with the MHPAEA.

We recommend that the State agency improve its monitoring of the MCOs by developing and implementing policies and procedures that: (1) formally identify whether the State agency or KDADS is responsible for oversight of MCOs' compliance with parity requirements, and (2) formalize procedures for the collection and review of the MCOs' submitted supporting data for the parity analyses.

We recommend that Deistic refund the $43,074 in estimated net overpayments to the Medicare program.

We recommend that CMS work with the five MACs with LCDs and LCD Reference Articles to develop education specific to the Medicare requirements and billing guidance for sacroiliac joint injections to be used for all of the five MACs, which could have saved an estimated $15,156,922 during our audit period.

We recommend that CMS use the results of this audit and other pertinent information to either adopt a national coverage determination (NCD) for sacroiliac joint injections or work with the two MACs without an LCD and LCD Reference Article for sacroiliac joint injections to develop them, thereby promoting greater consistency and reducing duplication of effort.

We recommend that the State agency refund $152,728 to the Federal Government.

We recommend that HOV refund to the Federal Government the estimated $8,614,887 in overpayments for claims for hospice services that did not comply with Medicare requirements, excluding amounts presumed to be unrecoverable under the Section 1870 waiver of liability provision.

We recommend that HOV provide additional training to clinical personnel on its policies and procedures to continually validate that the enrollees met the requirements for hospice (i.e., terminal prognosis of a life expectancy of 6 months or less if the terminal illness ran its normal course and the enrollees received the appropriate level of care).

We recommend that the State agency refund $18,541,039 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 the State agency update its policies and procedures for testing and monitoring clinical diagnostic laboratory services to require verification that the CMS annual updates are correctly applied to the professional fee-for-service default rate.

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.