Open Recommendations

We recommend that the Centers for Medicare & Medicaid Services promulgate regulations to require that each IPF should have a policy compliant with State law to protect and promote the patient’s right to make informed decisions that includes standards for documenting the patient’s ability to make informed decisions.

We recommend that the Centers for Medicare & Medicaid Services research whether the physician certification and recertification requirements are useful in preventing inappropriate payments and: - if they are useful, continue to enforce them but - if they are not useful, take the steps necessary to eliminate or amend those requirements.

We recommend that the Centers for Medicare & Medicaid Services, while the certification requirements remain in place, revise regulations or guidance to IPFs to require that physician certifications and recertifications be in a specific form, format, or language.

We recommend that the Centers for Medicare & Medicaid Services determine whether patient in-hospital fall rates should be added to the IPFQR program and whether CMS should require present-on-admission indicators on claims as an aid to tracking in-hospital falls.

We recommend that Residential Home Health for the estimated $2,068,902 overpayment for claims that are outside of the Medicare reopening period, exercise reasonable diligence in identifying and returning 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 Residential Home Health 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.

We recommend that Residential Home Health strengthen its procedures to ensure that the homebound statuses of Medicare beneficiaries are verified and continually monitored and the specific factors qualifying beneficiaries as homebound are documented and beneficiaries are receiving only reasonable and necessary skilled services.

We recommend the Regional Administrator, FEMA Region II, provide training and technical assistance to COR3 on: - its roles and responsibilities as the PA grant recipient; - how to provide technical assistance to the subrecipient regarding PA grant requirements; and, - how to provide technical assistance to the subrecipient regarding its ability to use Category Z, Direct Administrative Cost, to support its recovery operation.

We recommend New York State Department of Health 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 $3,039,473 (Federal share) of rebates collected.

We recommend New York State Department of Health strengthen its internal controls to ensure that all pharmacy and physician-administered drugs eligible for rebates are invoiced.

We recommend that New York State Department of Health bill for and collect from manufacturers rebates for single-source and top-20 multiple-source pharmacy and physician-administered drugs and refund the estimated $7,846,147 (Federal share).

We recommend that the Iowa Department of Human Services, Iowa Medicaid Enterprise revise the State plan to define the documentation requirements that health home providers must follow to bill and receive IHH PMPM payments for outreach services, and educate providers on these requirements.

We recommend that the Iowa Department of Human Services, Iowa Medicaid Enterprise refund $37,132,109 to the Federal Government.

We recommend that the Iowa Department of Human Services, Iowa Medicaid Enterprise improve its monitoring of the health home program to ensure that health home providers comply with Federal and State requirements for maintaining documentation to support the services for which the providers billed and received PMPM payments.

We recommend that the Iowa Department of Human Services, Iowa Medicaid Enterprise revise the State plan to define the documentation requirements that health home providers must follow to bill and receive the higher IHH PMPM payments for intense IHH services, and educate providers on these requirements.

(U) Rec. 1.b: The DoD OIG recommended that the Defense Health Agency Director determine whether community-based clinics under Defense Health Agency control have established a baseline level of protection for leased facilities as required by DoD guidance, and established access controls based on risk to limit entry to authorized personnel only.

(U) Rec. 1.c: The DoD OIG recommended that the Defense Health Agency Director assess generator and fuel storage security at each medical treatment facility under Defense Health Agency control and implement controls that meet DoD Unified Facilities Criteria requirements for generator facilities and fuel storage tanks, working with installation commanders when necessary.

(U) Rec. 1.g: The DoD OIG recommended that the Defense Health Agency Director conduct physical security inspections for all medical treatment facilities to determine where weaknesses exist and implement controls to mitigate those weaknesses.

We recommend the Federal Emergency Management Agency Administrator, due to the questioned costs exceeding $3 billion, implement a process to collect documentation and verify eligibility for applicants claiming no homeowner's insurance prior to providing IHP home repair assistance payouts.

We recommend the Federal Emergency Management Agency Administrator include the IHP as susceptible to significant improper payments subject to annual improper payments estimation and reporting.

We recommend that OPM's Healthcare and Insurance office update its IPR calculation, including a plan to do so with target dates, and documentation of any analysis conducted and conclusions reached in developing the updated methodology. This methodology, at a minimum, should include estimations for the population of FEHBP carriers that have not been audited each year and statistically valid sampling to provide a more accurate representation of improper payments for reporting.

We recommend that all payments made to deceased annuitants be classified as improper in the year in which they are identified.

We recommend that Retirement Services provide support to show the final results of the 9,169 cases in which reclamation was initiated and the 43 cases referred to the Survivor Processing Section from its review of returned 2016 tax year Form 1099-Rs.

We recommend that Retirement Services maintain support for future reviews of returned Form 1099-Rs, including an accounting of overpayments made to annuitants dropped from the annuity rolls, identified as deceased, or referred for further research and/or drop action, and include the total of such payments in the annual calculation of improper payments.

We recommend that Retirement Services conduct an analysis to determine if other types of data mining reviews can be performed, using the annuity roll data, to identify improper payments.