Open Recommendations

For the estimated $2,979,377 overpayment for all claims 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

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

The Office of Programs should update all control documentation (including policies and procedures, charts of controls, and other related documentation) to reflect the changes that occurred to unapplied cash as a result of the migration to the Financial Management Integrated System.

The Office of Programs should test the updated unapplied cash controls to ensure that they are present and operating as intended.

The Office of Programs should work with the Railroad Retirement Board’s Bureau of Information Services to implement Overpayment Recovery Correspondence System modifications to ensure that unapplied cash historical files [carried over from prior years, and receipts disposed of (applied to debt)] are maintained for completeness and accountability.

The Office of Programs should work with the Bureau of Fiscal Operations to establish and implement control activities to ensure that the Overpayment Recovery Correspondence System Unapplied Cash Application is fully interfaced with the Financial Management Integrated System so that all unapplied cash transactions are properly processed and recorded in the Overpayment Recovery Correspondence System Unapplied Cash Application.

The Bureau of Fiscal Operations should update all control documentation (including policies and procedures, charts of controls, and other related documentation) to reflect the changes that occurred to unapplied cash as a result of the migration to the Financial Management Integrated System.

The Bureau of Fiscal Operations should test the updated unapplied cash controls to ensure that they are present and operating as intended.

The Bureau of Fiscal Operations should develop and implement a formal reconciliation process to ensure accountability, completeness, and accuracy of unapplied cash transactions.

Review the 1,030 terminated contingently liable records and take action to adjust benefits.

Review and take action to remove the overpayment balance from the 4,690 terminated contingently liable beneficiaries and transfer the debt balance to the original debtor for an immediate payment of the overpayment or seek recovery through additional debt collection tools.

Establish controls to remove the outstanding debt from terminated contingently liable beneficiaries and transfer the balance to the original debtor for an immediate payment of the overpayment or seek recovery through additional debt collection tools when available.

Recommendation is not publicly available.

Work with CMS to determine the unallowable portion of $7,889 (Federal share) for other claims for covered outpatient physician-administered drugs that were submitted without NDCs and that may have been ineligible for Federal reimbursement and refund that amount,

Work with CMS to determine whether the remaining $1,109,110 (Federal share) of other physician-administered drug claims could have been invoiced to the manufacturers to receive rebates and, if so, upon receipt of the rebates, refund the Federal share of the manufacturers’ rebates for those claims.

Strengthen its internal controls to ensure that all physician-administered drugs eligible for rebates are invoiced.

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;

Develop and implement formal written policies and procedures for its drug rebate program.

Refund to the Federal Government $7,578,002 (Federal share) for claims for single-source physician-administered drugs that were ineligible for Federal reimbursement;

Refund to the Federal Government $561,937 (Federal share) for claims for top-20 multiple-source physician-administered drugs that were ineligible for Federal reimbursement;

Perform quarterly reviews of eligibility system records to ensure that beneficiaries with dates of death are removed from Medi-Cal

Identify and recover unallowable payments made to MCOs during our audit period on behalf of deceased beneficiaries, which we estimated to be at least $70,989,604

We recommend that the State Agency refund $53,425,143 to the Federal Government