Open Recommendations

Use the fraud risk inventory to enhance program-specific fraud risk assessments for the HOME program.

Implement a policy identifying criteria for the inclusion of a service within the Working Capital Fund (WCF); once the criteria are formalized, JMD should evaluate and ensure that the services currently included in the WCF are appropriate, meet the documented criteria, and are clearly presented to the WCF Board for discussion of any necessary changes.

Review the Office of the Chief Information Officer's (OCIO) cost allocation methodology and update as necessary to ensure that component cost allocations are sensible, equitable, and commensurate with benefits of the services provided.

Update its policy to include specific criteria for identifying "basic activities" appropriate to be included in a Rate Memo and reevaluate OCIO's Rate Memos to ensure that the selected services reflect a consistent approach and "basic activities."

Implement a formal process for the CIO Council and WCF Board of Directors to coordinate to improve collaboration and information sharing about the financial and service provision aspects of implementing IT initiatives.

Evaluate procedures for providing components with their expected charges to ensure that components have sufficient information to evaluate the use and associated costs for IT services, as well as enough time to provide feedback and obtain support for any discrepancies.

Evaluate processes to ensure that JMD and OCIO meet the intended requirements of the WCF Handbook, including the implementation of the annual WCF Customer Survey and the development of a comprehensive IT Service Catalog.

Evaluate the administrative operations of OCIO, as well as the information and outcomes of the working groups to enhance the financial management structure and access to clear and complete WCF IT service information.

Review the 20 loans identified in this report as ineligible for the COVID-19 EIDL that the applicants received and recover approximately $2 million improperly disbursed to the applicants.

Review the COVID-19 EIDL disbursements with suspect Taxpayer Identification Numbers made after December 27, 2020 to determine if the loan files contain conclusive evidence that the applicant business existed on January 31, 2020, and therefore, met the CARES Act eligibility requirements. If not, flag the borrower as ineligible and recover the funds.

We recommend that Highmark Senior Health Company refund to the Federal Government the $6,227,005 of estimated net overpayments;

We recommend that Highmark 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 Highmark continue its examination of its existing compliance procedures to identify areas where 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.

Refund to the Federal Government the $7,784,540 of estimated overpayments

Identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before and after our audit period and refund any resulting overpayments to the Federal Government

Continue its examination of its existing compliance procedures to identify areas where improvements can be made to ensure that 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.

In the system that will replace eWork, incorporate controls to increase the accurate processing of work CDRs and functionality to expand automation of work CDR processing and effectuation, including those involving multiple entitlements, reducing the need for manual actions.

Update subsidy policy to include specific instructions for Social Security Administration (SSA) employees to verify, document, and apply the correct subsidy amount.

Modify its system to ensure it alerts Social Security Administration employees to review and resolve SPAs for beneficiaries in suspended or other non-payment status.

Improve controls to ensure employees properly resolve SPAs in a timely manner, such as establishing more timely periodic or follow-up alerts.

(HCTM) We recommend that Deputy Administrator for Management and Resources oversee that HCTM, in consultation with BHA and OTI: Incorporate PSC and ISC staffing mechanisms into its workforce planning, including through tracking relevant direct hire metrics, such as the number of employees and their pay levels and responsibilities.

(HCTM) We recommend that the Deputy Administrator for Management and Resources oversee that HCTM, in coordination with BHA, OTI, and other stakeholders: Conduct a workforce assessment and develop a comprehensive plan with options and actionable steps for how to create a sustainable humanitarian and stabilization workforce.

CMS should make improvements to the Unified Case Management system.

CMS should implement a plan to help ensure the success of the Major Case Coordination initiative for Medicaid referrals.

CMS should identify the reasons for the unexplained variation in program integrity activities across UPICs.