Open Recommendations

We recommend that Visionquest Industries, Inc.: refund to the DME MACs the portion of the $2,504,829 in estimated overpayments for claims that are within the 4-year reopening period.

We recommend that Visionquest Industries, Inc.: exercise reasonable diligence to identify and return any additional similar overpayments in accordance with the 60-day rule,20 and identify any of those returned overpayments as having been made in accordance with this recommendation

Rec. 1: The DoD OIG recommended that the Assistant Secretary of Defense for Health Affairs update Memorandum, "TRICARE Policy for Access to Care," February 23, 2011, to remove the eight-visit limitation for outpatient mental health care.

Rec. 2.a: The DoD OIG recommended that the Defense Health Agency Director develop a single Military Health System-wide staffing approach for the Behavioral Health System of Care that estimates the number of appointments and personnel required to meet the enrolled population's demand for mental health services.

Rec. 2.c.1: The DoD OIG recommended that the Defense Health Agency Director update and clarify DoD and Defense Health Agency policy, including TRICARE policy to update the access to care standard for a non?urgent initial behavioral health assessment in Defense Health Agency and TRICARE policy to be consistent with the 7?day standard established by the Assistant Secretary of Defense for Health Affairs Memorandum, TRICARE Policy for Access to Care, dated February 23, 2011.

Rec. 2.c.2: The DoD OIG recommended that the Defense Health Agency Director update and clarify DoD and Defense Health Agency policy, including TRICARE policy to develop a standard definition and required elements for an initial non?urgent mental health assessment and develop a way to track whether the assessment is completed within the 7?day standard, in either a primary care or a specialty mental health clinic.

Rec. 2.c.3: The DoD OIG recommended that the Defense Health Agency Director update and clarify DoD and Defense Health Agency policy, including TRICARE policy to describe standard procedures for implementing centralized appointing for behavioral health services.

Rec. 2.c.4: The DoD OIG recommended that the Defense Health Agency Director update and clarify DoD and Defense Health Agency policy, including TRICARE policy to standardize the outpatient mental health care process of providing behavioral health services from first patient contact through follow?up care for a patient needing non?urgent outpatient mental health care.

Rec. 2.f.1: The DoD OIG recommended that the Defense Health Agency Director develop standardized mental health access to care measures for direct and purchased care for both active duty service members and their families, to include tracking the time from patient request or referral for mental health care to the time of the initial non?urgent mental health assessment.

Rec. 2.f.4: The DoD OIG recommended that the Defense Health Agency Director develop standardized mental health access to care measures for direct and purchased care for both active duty service members and their families, to include tracking reasons patients are unable to book an appointment.

The Assistant Secretary for Employment and Training should issue guidance directing states to provide access to state UI claimant data, in order to prevent and detect fraud.

We recommend that Desoto Home Health Care, Inc. based upon the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule14 and identify any of those returned overpayments as having been made in accordance with this recommendation.

We recommend that Desoto Home Health Care, Inc. obtain as much information from beneficiary medical records as it determines necessary to assure itself that claims for orthotic braces meet Medicare requirements for medical necessity.

CMS should seek legislative authority to establish a mechanism to control costs for automated chemistry tests

We recommended that CMS direct its Medicare contractors to reprocess the remaining inpatient claims identified in our sample frame with an incorrect patient discharge status code when beneficiaries resumed home health services within 3 days of discharge and recover the portion of the estimated $218,538,919 in overpayments that are within the 4-year reopening period along with similarly coded inpatient claims after our audit period.

We recommended that CMS use data analytics to identify hospitals that disproportionately use condition code 42 when the diagnosis codes on the inpatient claim and the respective home health claim appear related.

We recommended that CMS direct its Medicare contractors to analyze the remaining inpatient claims in our sample frame with a condition code 42, determine which claims were overpaid, and recover the portion of the estimated $40,610,333 in potential overpayments that are within the 4-year reopening period along with similarly coded inpatient claims paid after our audit period.

We recommended that CMS consider reducing the need for clinical judgment when processing claims under the post-acute-care transfer policy by taking the necessary actions, including seeking legislative authority if necessary, to deem any home health service within 3 days of discharge to be “related” (which would have saved an estimated $46.6 million during our 2-year audit period).

We recommended that CMS create CWF edits to prevent the use of condition code 43 from allowing the hospital to receive the full MS-DRG payment when the beneficiary receives home health services within 3 days of discharge.

We recommended that CMS correct its CWF edits to ensure that the edits use the home health services on each line within a home health claim rather than only the first line, which will allow the edits to capture home health claims that overlap a hospital stay.

Determine the allowability of the questioned transactions and recover $3,440,165, if applicable.

(U) Rec. 2.a: The DoD OIG recommended that the Commander of the Air Force Material Command schedule threat-level electromagnetic pulse protection tests for the KC-135 Block 45 and implement protection efforts.

(U) Rec. 3.a: The DoD OIG recommended that the Commander of Air Mobility Command, in conjunction with the Chief of the Air Force Reserve and the Director of the National Guard Bureau develop plans to ensure that Air Refueling Wing facilities meet Air Mobility Command Instruction 13-520 and Air Force Manual 32-1084 requirements. (ARFC)

(U) Rec. 3.a: The DoD OIG recommended that the Commander of Air Mobility Command, in conjunction with the Chief of the Air Force Reserve and the Director of the National Guard Bureau develop plans to ensure that Air Refueling Wing facilities meet Air Mobility Command Instruction 13-520 and Air Force Manual 32-1084 requirements. (NGB)

(U) Rec. 4: The DoD OIG recommended that the Deputy Chief of Staff of the Air Force for Manpower, Personnel, and Services, in conjunction with the Chief of the Air Force Reserve and the Director of the National Guard Bureau, determine the anticipated future manning levels for aircrew, security forces, and maintenance crews, and develop recruiting and retention efforts to ensure that the U.S. Strategic Command nuclear mission can be performed. (AF/A1)