Open Recommendations

We recommend that the Rhode Island Department of Human Services determine whether it is feasible to increase the ratio of State licensing inspectors to child care providers to meet industry standards so that it can review all employee criminal background checks at all child care providers

We recommend that the Rhode Island Department of Human Services require the State licensing agency to increase the number of current employees it reviews at all child care centers to ensure child care provider compliance with criminal background check requirements

We recommend that the Rhode Island Department of Human Services determine whether it is feasible to develop a centralized process to monitor both family homes and childcare centers.

We recommend that the Nebraska Department of Health and Human Services, Division of Medicaid and Long-Term Care refund $13,157,778 to the Federal Government.

We recommend the Under Secretary, Office of Strategy, Policy, and Plans, in consultation with the Under Secretary of Management, coordinate with DHS JTTF contributors to: - ensure agreements governing participation in the JTTF are binding; - evaluate whether new agreements or terms governing JTTF participation are required; and - develop guidance defining each DHS JTTF contributors' authorities, roles and responsibilities, skill sets, and access to systems.

We recommend the HSI Executive Associate Director renegotiate and update the existing 2003 MOA with DOJ on terrorism financing investigations to ensure: - all appropriate action to align guidance on handling of terrorism cases with current operations; - essential requirements defined in DHS Management Directive 0450.1 are included; and - a review and modification process is established to reflect future operational changes.

We recommend the Under Secretary, Office of Strategy, Policy, and Plans, in consultation with the Under Secretary of Management, coordinate with DOJ and State to develop an agreement that facilitates the direct sharing of passport information within the JTTF environment through State's formal MOU process.

We recommend the Under Secretary of Management coordinate with the Information Sharing and Safeguarding Governance Board to ensure: - ICE and TSA develop an agreement for TSA to directly process Secure Flight data requested for use by JTTF or HSI JTTF agents investigating terrorism activities or performing task force specific missions, and - DHS JTTF contributors mitigate data restrictions or delays pertaining to law enforcement and intelligence investigations.

We recommend that Condado Home Care Program, Inc., for the remaining portion of the estimated $97,210 in overpayments that are outside of the Medicare 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 recommend that Condado Home Care Program, Inc., based upon the results of this audit, 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 Condado Home Care Program, Inc. strengthen its procedures to ensure that: - the homebound status of Medicare beneficiaries are verified and continually monitored and the specific factors qualifying beneficiaries as homebound are documented; - beneficiaries are receiving only reasonable and necessary skilled services; - home health episodes are billed correctly; and - plans of care comply with Medicare requirements.

We recommend that Condado Home Care Program, Inc. refund to the Medicare program the portion of the estimated $97,210 in overpayments for claims incorrectly billed that are within the 4-year claim reopening period.

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

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.