Open Recommendations

Recommendation # 2 - We recommend that the Vermont Office of Child Support refund $48,891 ($32,268 Federal share) for Title IV-D MPRs, which were reimbursed at the incorrect county rate.

Recommendation # 4 - We recommend the State agency work with the court administrator’s office to improve the MPR processing system and establish policies and procedures and application controls to ensure duplicates can be prevented or detected or establish policies and procedures to ensure a manual review of all MPRs is performed .

Recommendation # 6 - We recommend the State agency develop policies and procedures for allocating salaries to the individual family courts which ensures the allocation is supported and accurately reflects the relative benefits received. Specifically: • ensure the courts report their Title IV-D activities each pay period as described within the cooperative agreement, and • ensure the IAG performs its functions as outlined within the cooperative agreement to maintain the key internal control of segregation of key duties by reviewing job positions, employee activity, and interviews managing supervisors and staff to determine the reasonable amount of resources (time and effort)…

Recommendation # 3 - We recommend the State agency work with ACF to determine what portion of the $1,374,320 ($907,051) for unsupported salaries allocated represents Title IV-D eligible costs or refund the entire amount.

Reimburse HUD $30,037 from nonproject funds for the overpayment of housing assistance and utility allowances due to incorrect calculations.

Support or reimburse HUD $159,938 from nonproject funds for the unsupported payments of housing assistance cited in the finding.

Pursue collection from the applicable household or reimburse HUD $26,915 from nonproject funds for the overpayment of housing assistance due to unreported income.

Implement adequate quality control procedures to ensure that housing assistance payments are appropriately calculated and supported. These procedures and controls should ensure that $54,257 in program funds is appropriately used for future payments.

Ensure that the management agent's staff is properly trained and familiar with HUD's and the project's requirements regarding housing assistance payments calculations.

Conduct criminal record background checks in accordance with the project's policies and procedures to ensure that adult members of all households, including the 11 households for which HUD made housing assistance payments totaling $239,500, were eligible to participate in the program. If the participants are deemed ineligible, the owner should follow applicable regulations to terminate or modify assistance and reimburse HUD from nonproject funds for those housing assistance payments deemed ineligible.

ACF’s ORR should develop and implement strategies to assist care provider facilities in overcoming obstacles to hiring and retaining qualified mental health clinicians

ACF’s ORR should identify and disseminate evidence-based approaches to addressing trauma in short-term therapy

ACF’s ORR should assess whether to establish maximum caseloads for individual mental health clinicians

ACF’s ORR should help care provider facilities improve their access to mental health specialists

ACF’s ORR should take all reasonable steps to minimize the time that children remain in ORR custody.

Continue to work with the Labor Relations department to identify opportunities to increase staffing flexibility among agreement employees, especially as the company develops maintenance strategies for the new equipment it is purchasing.

We recommend that the State agency bill for and collect from manufacturers rebates for single-source and top-20 multiple-source pharmacy and physician-administered drugs and refund to the Federal Government the estimated $28,103,346 (Federal share).

We recommend the State agency work with CMS to determine whether the other pharmacy and physician-administered drugs were eligible for rebates and, if so, upon receipt of the rebates, refund up to an estimated $47,426,944 (Federal share) our audit period and $119,561,574 (Federal share) for the nearly 4-year period before our audit period.

We recommend that the State agency ensure that all pharmacy and physician-administered drugs eligible for rebates are processed for rebates.

We recommend that the State agency develop and implement written policies and procedures for its drug rebate program.

We recommend that the State agency strengthen its NDC edit (implemented on January 1, 2015), to ensure that NDCs are captured for all drug utilization data.

We recommended the State agency improve its oversight of the LIP program by establishing policies and procedures for: o providing additional training to its staff members on the RFMD and STCs for the waiver; o providing training to participating hospital personnel on LIP program compliance and preparing the cost-limit calculations; and o monitoring hospital LIP calculations to verify that they comply with the RFMD and STCs including: ¿- reconciling hospital cost-limit calculations to the finalized Medicare cost reports; ¿- reviewing hospital low-income data to verify that it does not include data for undocumented aliens; ¿- reviewing hospital low-income data to…

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

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.

We recommend that the Connecticut Department of Social Services refund to the Federal Government $46,210 (Federal share) for claims for top-20 multiple-source physician-administered drugs that were ineligible for Federal reimbursement.

We recommend that the Connecticut Department of Social Services work with CMS to determine whether the remaining $387,761 (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.

We recommend that Southwest Key comply with ORR staffing ratios to ensure that children receive the necessary case manager and clinician services.