Open Recommendations

We recommend that ACF develop mitigating controls and strategies to lower the high and moderate risks we identified.

We recommend that the Centers for Disease Control and Prevention develop an action plan to enforce site visit requirements by CDC's planned date of July 1, 2023.

We recommend that the Centers for Disease Control and Prevention work with program recipients to implement a plan and timeline to: (1) conduct the required site visits that are overdue and (2) verify the completion of followup actions that had not been completed by the deadlines.

We recommend that the Centers for Disease Control and Prevention update its Provider Education, Assessment, and Reporting online system to include interactive reminders or alerts related to overdue site visits and followup actions.

We recommend that the Centers for Disease Control and Prevention complete the development and implementation of internal written policies and procedures for VFC program oversight activities, including oversight of program recipients' site visits to ensure that requirements are met.

We recommend that the Centers for Medicare & Medicaid Services instruct the MACs to, based on the results of this audit, notify appropriate providers (i.e., those for whom CMS determines this audit constitutes credible information of potential overpayments) so that the providers 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 direct the MACs to recover from acute-care hospitals the portion of the $41,401,244 in identified overpayments for our audit period that are within the 4-year reopening period in accordance with CMS's policies and procedures.

Require the Office of Regulations, Appeals, and Policy, in coordination with the Office of General Counsel, to determine whether the Office of Dentistry and the Consolidated Patient Account Center Program have appealable benefits decisions governed by the AMA, and if so, to update program policies, processes, and procedures accordingly, including ensuring that claimants receive written decision notices that meet all act requirements.

Require the Office of Regulations, Appeals, and Policy to evaluate the program offices’ barriers to including all required elements in decision notices and take corrective action, seeking congressional relief if needed.

Using the evaluation findings from recommendation 2, require Payment Operations to update its systems to generate AMA-compliant decision notices to the extent possible.

Using the same evaluation findings, require the Veteran and Family Member Programs to update its systems to generate AMA-compliant decision notices to the extent possible.

Require the Office of Regulations, Appeals, and Policy and the program office for Member Services’ Eligibility and Enrollment Division to ensure that priority group assignment decision notices are provided with enrollment handbooks given to veterans.

Identify resources and assign duties to conduct quality control reviews of decision letters with program offices to remediate deficiencies.

Work with the Office of Information and Technology to update Caseflow to address identified VHA system requirements within specified deadlines, including adding a program identifier and facilitating entries for individuals and entities that are not veterans.

Establish interim tracking procedures with the program offices until Caseflow can be considered a reliable system for VHA oversight.

In coordination with the Office of General Counsel, seek clarification on how the reporting metrics sections of the Appeals Modernization Act apply to VHA, and then develop those measures.

Issue policy and other clear guidance that includes standard tracking processes and procedures, and oversight of that tracking.

Work with VBA and others to allow access to all VHA program offices, and ensure that those offices in turn require that staff use the Centralized Mail Portal for all decision reviews or establish another mechanism that ensures all decision reviews are tracked from request receipt through routing and processing.

Work with the Office of Information and Technology to determine the best way to create a central repository and identify the necessary resources to implement and maintain it.

Develop decision review retention standards and communicate to the relevant programs what types of claims and appeals documentation should be stored, for how long, and where.

Implement training on processing and tracking appeals that is mandatory for VHA staff who process decision reviews.

Rec. A.1.a: The DoD OIG recommended that the Assistant Secretary of Defense (Health Affairs) conduct a study concerning triage levels for sexual assault victims, including a review of industry standards and revise DoD guidance to prescribe a specific triage level for sexual assault victims or a minimum level that meets the requirements for priority and uniformity.

Rec. A.1.b: The DoD OIG recommended that the Assistant Secretary of Defense (Health Affairs) develop a process to review and ensure that emergency department providers implement and consistently apply the new guidance for assigning a triage level for sexual assault victims.

Rec. B.1.a: The DoD OIG recommended that the Assistant Secretary of Defense (Health Affairs) revise guidance to require emergency department providers to document in the sexual assault victim's medical record: (1) the triage level of care assigned; (2) whether providers offered and documented a Sexual Assault Forensic Examination to the victim; and (3) whether the Sexual Assault Response Coordinator, Sexual Assault Prevention and Response Victim Advocate, or Family Advocacy Program clinical provider was notified, and the details of the notification including who was notified and when they were notified.

Rec. B.1.b: The DoD OIG recommended that the Assistant Secretary of Defense (Health Affairs) develop a process to review and ensure that emergency department providers implement and consistently apply the new guidance on documentation requirements for sexual assault victims.