Open Recommendations

We recommended that the State agency revise its LIP instruction manual to instruct participant hospitals to perform the following steps when preparing the LIP cost-limit calculations: o exclude the cost of non-emergency care for undocumented aliens; o exclude the cost of caring for prisoners in other than an inpatient setting; o review section 6 costs for allowability based on the RFMD; o distribute low-income patient days and ancillary charges to cost centers consistent with the Medicare cost report; o review the calculations for clerical errors and ensure that they exclude noncompliant items; and o reduce calculated costs by all payments…

We recommend that the State agency refund $411,932,576 to the Federal Government, consisting of: o $64,382,543, representing the Federal share of net Hospital self-reported LIP overpayments for the audit period and o $347,550,033, representing the Federal share of LIP cost limits calculated by the Hospital that did not comply with Federal and State requirements as identified in this audit.

Improve the CBMS to ensure that: o it verifies income and determines eligibility by using available electronic data sources on a timely basis, o it has system functionality to terminate Medicaid coverage for beneficiaries who do not provide satisfactory documentation to resolve a citizenship discrepancy after the reasonable opportunity period ends, o the coding errors affecting eligibility determinations are identified and addressed in a timely manner, and o it has the ability to verify income that is self-attested by beneficiaries on a timely basis and through multiple sources, to include one-to-one employer matches

Implement in the CBMS system functions to ensure o benefits of ineligible beneficiaries are terminated in a timely manner and o income verifications are requested from beneficiaries when electronic verification does not occur within 4 months of application;

Redetermine, as appropriate, the current Medicaid eligibility status of the sampled beneficiaries who did not meet Federal and State eligibility requirements, with specific attention to:[17] o beneficiaries who did not meet income requirements, o beneficiaries who were eligible under a mandatory Medicaid eligibility group, o beneficiaries who did not meet citizenship requirements, and o beneficiaries who were not eligible for the new adult group but for whom the State agency claimed enhanced Federal Medicaid reimbursement;

Improve the accuracy of manually input case actions by: o providing eligibility caseworkers with clear policies, procedures, and guidance on eligibility determinations that comply with Federal and State requirements and that address, among other things, income calculations and parent and caretaker definitions, o providing training to and monitoring of caseworkers to improve manual input accuracy, and o implementing a process to identify and review manually input eligibility data;

Implement a process whereby it resolves discrepancies more promptly by reducing the time between the identification of a discrepancy and the dispatch of a discrepancy letter to the beneficiary

Embassy Nassau should review its unliquidated obligations in accordance with Department guidelines and put up to $2.3 million to better use.

We recommended that Oceanside Medical Group refund to the Medicare program the portion of the estimated $2,694,446 overpayment for claims that are within the reopening period.

We recommended that Oceanside Medical Group, for the remaining portion of the estimated $2,694,446 overpayment for claims that are outside of the reopening period, exercise reasonable diligence to identify and return overpayments in accordance with the 60-day rule, and identify any returned overpayments as having been made in accordance with this recommendation.

We recommended that Oceanside Medical Group exercise reasonable diligence to identify and return any additional similar overpayments outside of our audit period, in accordance with the 60-day rule, and identify any returned overpayments as having been made in accordance with this recommendation.

As OIG has previously recommended, CMS should work directly with hospices to ensure that they are providing drugs covered under the hospice benefit and CMS should develop and execute a strategy to ensure that Part D does not pay for drugs that should be covered by the Part A hospice benefit.

We recommend that the Texas Health and Human Services Commission work with CMS to determine whether the other physician-administered drugs, associated with 160,579 claim lines, were eligible for rebates and, if so, determine the rebates due and upon receipt of the rebates refund the Federal share of the rebates collected.

We recommend that the Texas Health and Human Services Commission bill manufacturers for the $3,785,737 ($2,202,921 Federal share) in rebates for single-source and top-20 multiple-source physician-administered drugs, and refund the Federal share of rebates collected.

We recommend that the Texas Health and Human Services Commission work with CMS to determine whether the non-top-20 multiple-source physician-administered drugs were eligible for rebates and, if so, bill manufacturers for the $629,967 ($366,578 Federal share) in rebates and refund the Federal share of rebates collected.

We recommend that the Texas Health and Human Services Commission strengthen internal controls to ensure that all eligible physician-administered drugs are billed for rebate.

We recommend that the Agency refund to the Medicare program the portion of the $1,262,887 in estimated overpayments received during CYs 2014 and 2015 for claims incorrectly billed that are within the reopening and recovery periods

We recommend that the Food and Drug Administration reconcile each month the OIG stewardship reports (or the HHS electronic Single Audit recommendation listing for audits processed on or after October 1, 2018) with FDA’s audit resolution records and follow up on any differences noted.

We recommend that the Food and Drug Administration finalize and implement formal policies and procedures for resolving program and IT audit recommendations, similar to the Framework that FDA has implemented for resolving Single Audit recommendations, which include issuing management decisions and submitting related OCDs to OIG within the required 6-month resolution period.

We recommend that the Food and Drug Administration promptly resolve the 32 outstanding audit recommendations (166 that were past due as of September 30, 2016, less 134 resolved after the end of our audit period).

We recommend that the Connecticut Department of Social Services work with CMS to determine the unallowable portion of $2,380,355 (Federal share) for other claims for outpatient physician-administered drugs that were submitted without NDCs or with invalid NDCs and that may have been ineligible for Federal reimbursement and refund that amount.

We recommend that the Connecticut Department of Social Services refund to the Federal Government $1,065,387 (Federal share) for claims for singlesource physician-administered drugs that were ineligible for Federal reimbursement.

We recommend that the Connecticut Department of Social Services work with CMS to determine and refund the unallowable portion of Federal reimbursement for physician-administered drugs that were not invoiced for rebates after December 31, 2016.

We recommend that the Connecticut Department of Social Services strengthen its internal controls to ensure that all physician-administered drugs eligible for rebates are invoiced.