Open Recommendations

We recommend that Keystone Health Plan East, Inc. refund to the Federal Government the $550,391 in overpayments.

We recommend that Keystone identify, for the high-risk diagnoses included in the 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 Keystone continue its examination of existing compliance procedures to identify areas in which improvements can be made to ensure diagnosis codes that are at high risk for being miscoded comply with Federal requirements (when submitted to CMS for use in CMS's risk adjustment program) and take the necessary steps to enhance those procedures.

We recommend that Keystone ensure that it collects, for audits of risk adjustment data, medical records that comply with CMS requirements.

Include additional terms and conditions within future AmeriCorps General Grant and Cooperative Agreement Terms and Conditions policy documents to address the root causes of improper payments. Repeat recommendation for FY 2022.

Implement financial consequences or additional reporting requirements for grantees that have confirmed improper payments. Repeat recommendation for FY 2022.

Reconcile the differences between grantees’ internal accounting records and Federal Financial Reports (FFRs)to determine the propriety of the component payments or require grantees to perform this reconciliation; or treat unmatched reporting errors as unknown payment errors in the projection of the improper payment estimate. Repeat recommendation for FY 2022.

Include NST as a program susceptible to improper payments for future risk assessments. (New)

Publish improper payment and unknown payment estimates for NST in the accompanying materials provided with future annual financial statements in accordance with OMB guidance. (New)

Develop and implement a nationwide protocol for field offices, describing how PHA self-inspections should be reviewed, based on REAC's determination of the number and frequency of PHA self-inspections. Status

We recommend that the Centers for Medicare & Medicaid Services direct its Medicare contractors to reprocess the physician service claim lines during our audit period for which enrollees were Part A SNF inpatients but the services were incorrectly coded with the nonfacility place-of-services 32 (NF or SNF with no part A coverage) to recover $22,463,193.

We recommend that the Centers for Medicare & Medicaid Services notify appropriate practitioners (i.e., those for whom CMS determines this audit constitutes credible information of potential overpayments) so that they can exercise reasonable diligence to identify, report, and return any overpayments 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 establish CWF system edits to detect instances in which practitioners incorrectly use the nonfacility place-of-service code 32 (NF or SNF with no Part A coverage) while an enrollee is a Part A SNF inpatient and the nonfacility place-of-service-code causes a higher payment rate, and direct its Medicare contractors to apply these recommended CWF system edits retroactively or otherwise reprocess the claim lines for similarly coded physician services furnished after our audit period and before CMS establishes these edits.

We recommend that the Centers for Medicare & Medicaid Services take the necessary steps, including seeking legislative authority, if necessary, to revise its regulations to ensure that Medicare pays the facility rate for physician services furnished while enrollees are Part A SNF or hospital inpatients irrespective of where the services are actually furnished or otherwise ensure that Medicare does not pay twice for any of the practice expenses incurred for physician services furnished while enrollees were Part A SNF or hospital inpatients, which could have resulted in the Medicare program paying up to $22,142,489 less and enrollees paying up to…

We recommend that the Centers for Medicare & Medicaid Services consider developing a mechanism for SNFs and hospitals to indicate on the claim when a Part A inpatient leaves the facility and returns on the same day to help ensure that Medicare does not pay twice for any of the practice expenses incurred for physician services furnished while enrollees were Part A SNF or hospital inpatients.

We recommend that the Centers for Medicare & Medicaid Services provide additional education to practitioners on the appropriate use of place-of-service codes while an enrollee is a Part A inpatient.

We recommend the DHS Chief Financial Officer ensure FEMA conducts payment integrity testing of the Funeral Assistance program.

We recommend the DHS Chief Financial Officer ensure FEMA assesses and conducts payment integrity testing, as applicable, for any program with COVID-19 funding that meets the Payment Integrity Information Act of 2019 threshold.

We recommend the DHS Chief Financial Officer ensure DHS’ Risk Management and Assurance Division follows OMB requirements for programs that do not comply with the Payment Integrity Information Act of 2019, as stated in Appendix C of OMB Circular A-123.

We recommend the Executive Associate Director of Enforcement and Removal Operations direct the Seattle Field Office, responsible for Northwest, to: Ensure responses to grievances occur within 5 days.

We recommend the Executive Associate Director of Enforcement and Removal Operations direct the Seattle Field Office, responsible for Northwest, to: Ensure responses to requests and grievances are in a language understood by the detainee.

We recommend the Executive Associate Director of Enforcement and Removal Operations direct the Seattle Field Office, responsible for Northwest, to: Update the facility’s food service policy to ensure the food service department’s pre-existing weekly mandatory inspections include checking that products are used before their “best-by” or expiration dates, in accordance with the shelf-life reference guide used by the facility.

We recommend the Executive Associate Director of Enforcement and Removal Operations direct the Seattle Field Office, responsible for Northwest, to: Review and update ICE’s contract with the facility by better identifying housing requirements and determining an appropriate guaranteed minimum.

We recommend the Executive Assistant Commissioner, Operations Support, U.S. Customs and Border Protection: Ensure that current guidance and operational procedures for managing detainees with confirmed or suspected contagious diseases are communicated to agents across the Border Patrol.

We recommend that CPB management require WAPS-FM to identify the corrective actions and controls it will implement to ensure future compliance with Act and CPB requirements for open financial records.