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    Subject Term: "Financial incentives"

    10 publications with a total of 31 open recommendations including 3 priority recommendations
    Director: James Cosgrove
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To ensure that the HVBP program accomplishes its goal to balance quality and efficiency and to ensure that it minimizes the payment of bonuses to hospitals with lower quality scores, the Administrator of CMS should revise the formula for the calculation of hospitals' total performance score or take other actions so that the efficiency score does not have a disproportionate effect on the total performance score.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To ensure that the HVBP program accomplishes its goal to balance quality and efficiency and to ensure that it minimizes the payment of bonuses to hospitals with lower quality scores, the Administrator of CMS should revise the practice of proportional redistribution used to correct for missing domain scores so that it no longer facilitates the awarding of bonuses to hospitals with lower quality scores.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Carolyn L. Yocom
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: To improve oversight of states' payment structures for MLTSS, the Administrator of CMS should require all states to collect and report on progress toward achieving MLTSS program goals, such as whether the program enhances the provision of community-based care.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To improve oversight of states' payment structures for MLTSS, the Administrator of CMS should establish criteria for what situations would warrant exceptions to the federal standards that the data used to set rates be no older than the three most recent and complete years.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To improve oversight of states' payment structures for MLTSS, the Administrator of CMS should provide states with guidance that includes minimum standards for encounter data validation procedures.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Brenda S. Farrell
    Phone: (202) 512-3604

    7 open recommendations
    Recommendation: To aid ARNG officials in conducting their oversight of the states and territories, the Secretary of the Army should direct the Director, ARNG, to establish a permanent program for monitoring state-level recruiting activities either by extending the Recruiting Standards Branch or establishing some other similar program.

    Agency: Department of Defense: Department of the Army
    Status: Open

    Comments: Update September 2016: To date no action has been taken. According to the report follow up specialist the next DODIG follow up is December 2016.
    Recommendation: To aid ARNG officials in understanding the effectiveness of efforts to meet force requirements, the Secretary of the Army should direct the Director, ARNG, to take steps to help ensure that the ARNG collects consistent, complete, and valid data on the specific reasons why soldiers do not complete initial military training and when these soldiers separate from the ARNG during the training process. Such steps could include modifying the Standard Installation/Division Personnel System (SIDPERS) to capture this information or if unable to modify SIDPERS, taking actions to ensure that information collected in the Vulcan Recruit Sustainment Program database is valid.

    Agency: Department of Defense: Department of the Army
    Status: Open

    Comments: Update September 2016: To date no action has been taken. According to the DODIG follow up specialist the next DODIG follow up is December 2016.
    Recommendation: To aid ARNG officials in understanding the effectiveness of efforts to meet force requirements, the Secretary of the Army should direct the Director, ARNG, to regularly track whether ARNG soldiers who join in a given fiscal year complete their initial term of service.

    Agency: Department of Defense: Department of the Army
    Status: Open

    Comments: Update September 2016: To date no action has been taken. According to the DODIG follow up specialist the next DODIG follow up is December 2016.
    Recommendation: To aid ARNG officials in understanding the effectiveness of efforts to meet force requirements, the Secretary of the Army should direct the Director, ARNG, to periodically estimate, such as on an annual basis or other time period as appropriate, the total cost of recruiting and initial training for a soldier who joins the ARNG.

    Agency: Department of Defense: Department of the Army
    Status: Open

    Comments: Update September 2016: To date no action has been taken. According to the DODIG follow up specialist the next DODIG follow up is December 2016.
    Recommendation: To help ARNG officials in using financial incentives to fill critical positions as required by Army and National Guard regulation, the Secretary of the Army should direct the Director, ARNG, to provide recruiters with training to better enable the use of available financial incentives.

    Agency: Department of Defense: Department of the Army
    Status: Open

    Comments: Update September 2016: To date no action has been taken. According to the DODIG follow up specialist the next DODIG follow up is December 2016.
    Recommendation: To help determine whether ARNG officials are effectively using financial incentives, the Secretary of the Army should , in conjunction with the Director, ARNG, exercise their oversight responsibilities by evaluating and documenting the effectiveness of ARNG's incentives program in meeting its goals. The evaluation should also determine whether incentives are being effectively awarded in military occupational specialties that have been under or over authorized levels, and whether changes are needed to effectively use existing incentives.

    Agency: Department of Defense: Department of the Army
    Status: Open

    Comments: Update September 2016: To date no action has been taken. According to the DODIG follow up specialist the next DODIG follow up is December 2016.
    Recommendation: Given that the reporting of information related to the amounts of incentives obligated has been a requirement but not carried out in recent years, the Office of the Secretary of Defense should, in order to ensure continued reporting in the future, enforce its requirement for the National Guard and Reserve Component to submit information on the amounts of incentives obligated and incorporate the required information in the recruiting resources reports.

    Agency: Department of Defense: Office of the Secretary of Defense
    Status: Open

    Comments: Actions ongoing.
    Director: Charles A. Jeszeck
    Phone: (202) 512-7215

    3 open recommendations
    Recommendation: To address the legal uncertainty stemming from ERISA preemption of state laws while maintaining the advantages of ERISA for both employers and workers, Congress should consider providing states limited flexibility to pursue efforts to increase coverage under workplace retirement savings programs. To do this, Congress could, for example, direct or authorize the Secretary of Labor, in consultation with the Secretary of the Treasury, to (1) promulgate regulations prescribing a limited safe harbor under which state workplace retirement savings programs with sufficient safeguards would not be preempted and would receive tax treatment comparable to that provided to private sector workplace retirement savings programs, or (2) create a pilot program under which DOL could select a limited number of states to establish workplace retirement savings programs subject to DOL and Treasury oversight. In either case, any such initiative should ensure that state programs include adequate participant protections and are subject to agency oversight, appropriate reporting requirements, and meaningful evaluation.

    Agency: Congress
    Status: Open

    Comments: No action taken to date.
    Recommendation: To facilitate state efforts to expand coverage in workplace retirement savings programs, the Secretary of Labor and Secretary of the Treasury should consider their authority and review and revise, if necessary, existing regulations and guidance causing uncertainty for state efforts. For example, the Secretary of Labor could direct the Employee Benefits Security Administration's (EBSA) Assistant Secretary to revise Interpretive Bulletin 99-1 to clarify whether states can offer payroll deduction Individual Retirement Accounts (IRAs) and, if so, whether features in relevant enacted state legislation--such as automatic enrollment and/or a requirement that employers offer a payroll deduction--would cause these programs to be treated as employee benefit plans.

    Agency: Department of Labor
    Status: Open

    Comments: DOL generally agreed with this recommendation. To address uncertainty facing state efforts, EBSA is initiating a regulatory agenda entitled ?Saving Arrangements Established by States for Non-Governmental Employees,? which will appear in the Fall 2015 Semi-Annual Regulatory Agenda. On November 18, 2015, DOL published a Notice of Proposed Rulemaking (NPRM) on state payroll deduction IRA programs. Under the proposed rule, employers complying with the state law requirements would not create a retirement plan subject to ERISA as long as the state and the employer follows certain rules. They also also published a companion Interpretive Bulletin on the same day that describes ways in which states can promote the creation of ERISA-covered plans, fully subject to ERISA?s rules and protections, without triggering ERISA preemption. The public comment period for the proposed rule closed on January 19, 2016. EBSA is evaluating the 67 public comments submitted (and posted on EBSA?s website) and working towards drafting and clearance of a final rule. EBSA has also been providing technical assistance to several states and other jurisdictions about the Interpretive Bulletin. The Administration?s 2017 Budget also included legislative proposals for piloting innovative, more portable approaches to provide retirement and other employment-based benefits.
    Recommendation: To facilitate state efforts to expand coverage in workplace retirement savings programs, the Secretary of Labor and Secretary of the Treasury should consider their authority and review and revise, if necessary, existing regulations and guidance causing uncertainty for state efforts. For example, the Secretary of Labor could direct the Employee Benefits Security Administration's (EBSA) Assistant Secretary to revise Interpretive Bulletin 99-1 to clarify whether states can offer payroll deduction Individual Retirement Accounts (IRAs) and, if so, whether features in relevant enacted state legislation--such as automatic enrollment and/or a requirement that employers offer a payroll deduction--would cause these programs to be treated as employee benefit plans.

    Agency: Department of the Treasury
    Status: Open

    Comments: The Department of the Treasury generally agreed with this recommendation and did not provide additional comments on actions to address it.
    Director: Kathleen M. King
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: CMS should conduct a formal analysis, using its experience and data it has collected since the implementation of the first MAC contracts, to determine whether alternative contracting approaches could be used--even if only for selected MAC contract responsibilities--to help promote improved contractor performance.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Charles Jeszeck
    Phone: (202) 512-7215

    5 open recommendations
    Recommendation: To ensure that federal regulators have better information about lump sum windows and to better ensure that participants have ready access to key information they need to make a decision when presented with a lump sum offer, the Department of Labor should require plan sponsors to notify DOL at the time they implement a lump sum window offer, including the number and category of participants being extended the offer (e.g., separated vested; retiree) as well as examples of the materials provided to them.

    Agency: Department of Labor
    Status: Open

    Comments: The Department of Labor (DOL) agreed that this type of information may be helpful in determining the extent to which lump sum window offers are made, as well as the types of disclosures the participants receive. However, DOL reported that it has not identified authority under ERISA for it to impose such a requirement on plan sponsors either before or shortly after the plan offers the lump sum window. The agency states that ERISA expressly provides specific reporting and disclosure requirements. These include various filings, such as annual financial reports, reports upon plan termination, and reports upon making certain transfers of pension plan assets to health benefit accounts. The agency believes ERISA does not require plans to notify them regarding the benefit distribution options they offer or changes in those options, and does not read the broad rulemaking authority in ERISA in Section 505 (general regulations) and Section 110 (pension reporting and disclosure) as authorizing EBSA to establish the notice filing requirement GAO recommended. The agency also commented that ERISA expressly requires that most pension plans file a Form 5500 annual report with the statute specifying the required contents of this annual report in some detail and requiring ?such other financial and actuarial information as the Secretary may find necessary or appropriate.? Although the agency noted it could, by regulation, require reporting on lump sum window offers on the Form 5500, there would be a substantial time lag because ERISA by statute establishes the reporting cycle for the Form 5500 -- the report is not due until 210 days (7 months) after the plan year closes (e.g., for calendar year plans, July 31st of the following year). The agency recognizes that this might not be responsive to the recommendation, which appears to envision a notification system that is relatively contemporaneous with the lump sum window being offered to participants and beneficiaries.
    Recommendation: To ensure that federal regulators have better information about lump sum windows and to better ensure that participants have ready access to key information they need to make a decision when presented with a lump sum offer, the Department of Labor should coordinate with the Internal Revenue Service and the Pension Benefit Guaranty Corporation (PBGC) to clarify the guidance regarding the information sponsors should provide to participants when extending lump sum window offers and place the guidance on the agency's website. Guidance should include clear and understandable presentations of information, such as the relative value of the lump sum, the role and level of protections provided by PBGC, and the positive and negative ramifications of accepting the lump sum. Such guidance could also include promising practices for information materials from plan sponsors which are particularly effective in facilitating informed participant decision-making.

    Agency: Department of Labor
    Status: Open

    Comments: The Department of Labor agreed with this recommendation, noting it is important to coordinate with the Treasury Department/IRS and PBGC to clarify the guidance regarding the information sponsors and other plan fiduciaries should provide to participants and beneficiaries when extending lump sum window offers. In 2016, the agency noted that the manner of publishing that guidance would be part of that coordination process. They may consider some formal public request for input (such as publishing a Request for Information in the Federal Register) and focus group or other field testing work. In addition, the agency noted that the 2015 ERISA Advisory Council announced that one of its projects this year concerns how to give participants effective notices and disclosures concerning lump sum window offers, including possible development of model participant notices. The 2015 Council developed recommendations and model notices on lump sum window offers in "pension risk transfer transactions," and suggested that DOL make the Model Notices available on its web site to plan sponsors and participant advocates and that plan sponsors use the Model Notices when engaging in risk transfer transactions. Similar to other model communications developed by the 2015 Council, the agency believes the model notice could be further enhanced if subjected to broader public input from, for example, plan sponsors, participant advocates, communications experts, and academics. Subject to the limits on its authority in this area and resource constraints. They are considering efforts to obtain public input on the Council's recommendations and model notice. They also intend to contact the Treasury Department/IRS and PBGC to discuss the Council's recommendations.
    Recommendation: To provide participants with useful information and to provide for lump sums that are based on up-to-date assumptions, Treasury should review its regulations governing the information contained in relative value statements to ensure these statements provide a meaningful comparison of all benefit options, especially in instances where the loss of certain additional plan benefits may not be disclosed.

    Agency: Department of the Treasury
    Status: Open

    Comments: Treasury generally agreed with this recommendation but did not provide specific comments on plans to address it.
    Recommendation: To provide participants with useful information and to provide for lump sums that are based on up-to-date assumptions, Treasury should review the applicability and appropriateness of allowing sponsors to select a "lookback" interest rate for use in calculating lump sums associated with a lump sum window that can serve to advantage the interests of the sponsor.

    Agency: Department of the Treasury
    Status: Open

    Comments: Treasury generally agreed with this recommendation but did not provide specific comments on plans to address it.
    Recommendation: To provide participants with useful information and to provide for lump sums that are based on up-to-date assumptions, Treasury should establish a process and a timeline for periodically updating the mortality tables used to determine minimum required lump sums-- including a means for monitoring when experts' views may indicate that mortality tables may have become outdated, and for taking expedited action if warranted.

    Agency: Department of the Treasury
    Status: Open

    Comments: Treasury generally agreed with this recommendation but did not provide specific comments on plans to address it.
    Director: Kay E. Brown
    Phone: (202) 512-7215

    2 open recommendations
    Recommendation: The Secretary of Agriculture should direct the Administrator of FNS to establish additional guidance to help states analyze SNAP transaction data to better identify SNAP recipient households receiving replacement cards that are potentially engaging in trafficking, and assess whether the use of replacement card benefit periods may better focus this analysis on high-risk households potentially engaged in trafficking.

    Agency: Department of Agriculture
    Status: Open

    Comments: FNS officials reported that, in September 2013, they awarded a contract to provide expert business consultation and technical assistance in the area of recipient fraud prevention and detection to 7 states. The purpose of the contract was to improve how effectively recipients suspected of trafficking SNAP benefits were identified and investigated, including the use of predictive analytics involving transaction and replacement card data to uncover potential recipient trafficking. As of August 2017, FNS officials reported that they have completed studies in 10 states, helping the states build predictive analytics models that incorporate use of replacement card data to better identify SNAP recipient trafficking. FNS officials report that the models have demonstrated a significant improvement in state effectiveness. FNS officials also report that, in the fourth quarter of fiscal year 2016, the agency conducted a training program for state technical staff to teach them how to build predictive models that incorporate the use of replacement card data. In addition, FNS officials report that the agency is currently developing a SNAP Fraud Framework to provide guidance to states on improving fraud prevention and detection, including the use of excessive card replacements and other data sources, as potential indicators of fraud. FNS tentatively anticipates releasing the framework by the end of calendar year 2017. GAO will monitor these efforts and await information, including related technical assistance materials and documentation, on how these activities are used to guide states' efforts to use transaction and replacement card data to better focus on high-risk households for potential investigation.
    Recommendation: The Secretary of Agriculture should direct the Administrator of FNS to reassess the effectiveness of the current guidance and tools recommended to states for monitoring e-commerce and social media websites, and use this information to enhance the effectiveness of the current guidance and tools.

    Agency: Department of Agriculture
    Status: Open

    Comments: FNS officials reported that, in 2016, the agency conducted additional analysis to evaluate states' current use of social media in their detection of SNAP trafficking and develop a proof of concept for the use of market-leading tools to assist states in more efficient monitoring. Based on the information gained through this analysis, FNS officials reported in August 2017 that a draft of the social media guidance is currently in FNS clearance and is expected to be released by the end of the calendar year. GAO will await the issuance of this guidance.
    Director: Cosgrove, James C
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: In order to improve CMS's ability to identify self-referred anatomic pathology services and help CMS avoid unnecessary increases in these services, the Administrator of CMS should insert a self-referral flag on Medicare Part B claim forms and require providers to indicate whether the anatomic pathology services for which the provider bills Medicare are self-referred or not.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: In June 2013, we recommended that the Administrator of the Centers for Medicare & Medicaid Services (CMS) insert a self-referral flag on Medicare Part B claim forms and require providers to indicate whether the anatomic pathology services for which the provider bills Medicare are self-referred or not. The Department of Health and Human Services (HHS) did not concur with this recommendation, noting that CMS does not believe that this recommendation will address overutilization that occurs as a result of self-referral. We continue to believe that such a flag on Part B claims would likely be the easiest and most cost-effective way for CMS to identify self-referred anatomic pathology services and monitor the behavior of those providers who self-refer these services. As of June 2017, CMS has not provided any additional information about actions to address this recommendation.
    Recommendation: In order to improve CMS's ability to identify self-referred anatomic pathology services and help CMS avoid unnecessary increases in these services, the Administrator of CMS should determine and implement an approach to ensure the appropriateness of biopsy procedures performed by self-referring providers.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: In June 2013, we recommended that the Administrator of the Centers for Medicare & Medicaid Services (CMS) implement an approach to ensure the appropriateness of biopsy procedures performed by self-referring providers. The Department of Health and Human Services (HHS) does not concur with this recommendation and does not believe it would address overutilization that occurs as a result of self-referral. HHS noted that it would be difficult to make recommendations regarding whether anatomic pathology services are appropriate without reviewing a large number of claims. We continue to believe that it is important for CMS to monitor the self-referral of anatomic pathology services on an ongoing basis and determine if those services are inappropriate or unnecessary. We also continue to believe this can be achieved without reviewing a large number of claims. CMS could, for example, consider performing targeted audits of providers that perform a higher average number of biopsy procedures compared to providers of the same specialty treating similar numbers of Medicare beneficiaries. As of June 2017, CMS has not provided any additional information about actions to address this recommendation.
    Recommendation: In order to improve CMS's ability to identify self-referred anatomic pathology services and help CMS avoid unnecessary increases in these services, the Administrator of CMS should develop and implement a payment approach for anatomic pathology services that would limit the financial incentives associated with referring a higher number of specimens--or anatomic pathology services--per biopsy procedure.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: In June 2013, we recommended that the Administrator of the Centers for Medicare & Medicaid Services (CMS) develop and implement a payment approach for anatomic pathology services under the Physician Fee Schedule that would limit the financial incentives associated with referring a higher number of specimens--anatomic pathology services--per biopsy procedure. Although health care providers have discretion in determining the number of tissue samples from biopsy procedures that become specimens (anatomic pathology services), CMS's current payment system under the Physician Fee Schedule provides a financial incentive for providers to refer more specimens per biopsy procedure. Specifically, CMS pays for each specimen that a provider submits to be analyzed. HHS indicated that it concurred with our recommendation and that it had addressed this recommendation by reducing payment for the most commonly furnished anatomic pathology service (Current Procedural Terminology [CPT] code 88305) by approximately 30 percent in calendar year 2013. However, CMS's payment reduction did not change the financial incentive providers have to refer more specimens per biopsy procedure because they will still be paid separately for each specimen submitted. We continue to believe that CMS should develop a payment approach that addresses this incentive. As of June 2017, CMS had not provided any additional information about actions it has taken to address this recommendation.
    Director: Cosgrove, James C
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: As CMS continues to implement and refine the Value Modifier program to enhance the quality and efficiency of physician care, the Administrator of CMS should consider whether certain private-sector practices could broaden and strengthen the program's incentives. Specifically, she should consider (1) developing at least some performance benchmarks that reward physicians for improvement as well as for meeting absolute performance benchmarks, and (2) making Value Modifier adjustments more timely in order to better reflect recent physician performance.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: CMS stated that it is working to implement GAO's recommendation. Previously, the agency noted that it would investigate accelerating the timeline of the Value Modifier, keeping in mind reporting requirements, data availability, and the need for valid and reliable measures. In addition, Congress passed legislation in 2015 requiring CMS to incorporate certain benchmark methodology and timing aspects that reflect GAO's 2013 recommendation, and the agency is replacing the Value Modifier with a new merit-based incentive payment system. CMS's efforts may, in time, address GAO recommendations to improve performance benchmarks and the timeliness of payment adjustments, but they have yet to be fully implemented. As of August 2017, CMS officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: The Administrator should develop a strategy to reliably measure the performance of solo and small physician practices, such as by aggregating their performance data to create informal practice groups.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: CMS stated that it is working to implement GAO's recommendation to measure the performance of solo and small physician practices. CMS included in its Value Modifier policies the amount of payment adjustments for solo and small physician practices, along with the parameters for measurement. In addition, Congress passed legislation in 2015 requiring CMS to establish a process to allow solo and physician practices under ten eligible professionals to be measured in a virtual group, and the agency is replacing the Value Modifier with a new merit-based incentive payment system. CMS's efforts may, in time, address GAO recommendations to reliably measure the performance of solo and small physician practices, but they have yet to be fully implemented. As of August 2017, CMS officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Director: Cosgrove, James C
    Phone: (202)512-7029

    3 open recommendations
    including 3 priority recommendations
    Recommendation: In order to improve CMS's ability to identify self-referred advanced imaging services and help CMS address the increases in these services, the Administrator of CMS should insert a self-referral flag on its Medicare Part B claims form and require providers to indicate whether the advanced imaging services for which a provider bills Medicare are self-referred or not.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: HHS did not concur with this recommendation, noting that CMS did not think this recommendation would be effective in addressing overutilization resulting from self-referral and that it would be complex to administer. We continue to believe that such a flag on Part B claims would likely be the easiest and most cost-effective way for CMS to identify self-referred advanced imaging services and monitor the behavior of those providers who self-refer these services even though the agency has no plans to take further action. As of October 2016, CMS has not provided any additional information about actions to address this recommendation.
    Recommendation: In order to improve CMS's ability to identify self-referred advanced imaging services and help CMS address the increases in these services, the Administrator of CMS should determine and implement a payment reduction for self-referred advanced imaging services to recognize efficiencies when the same provider refers and performs a service.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: HHS did not concur with this recommendation, noting that CMS did not believe that a payment reduction would address overutilization that occurs as a result of self-referral and that the agency's multiple procedure payment reduction policy for advanced imaging already captures efficiencies inhering in providing multiple advanced imaging services by the same physician. Further, CMS officials stated that providers in self-referring arrangements could avoid this reduction by having one provider refer an advanced imaging service while having another perform the service. Finally, CMS questioned whether implementing our recommendation would violate the Medicare statute prohibiting paying a differential by physician specialty for the same service. Our recommendation, however, refers to specific self-referral arrangements in which the same provider refers and performs an imaging service, and therefore would not be addressed by CMS's multiple procedure payment reduction policy. As noted in our report, this payment reduction would affect about 10 percent of advanced imaging services referred by self-referring providers. In addition, while CMS raised questions about whether implementing our recommendation would violate Medicare's prohibition on paying a differential by physician specialty for the same service, the agency did not indicate how it would do so as of October 2016. We continue to believe that CMS should determine and implement a payment reduction to recognize efficiencies for advanced imaging services referred and performed by the same provider even though, as of October 2016, the agency has no plans to take further action.
    Recommendation: In order to improve CMS's ability to identify self-referred advanced imaging services and help CMS address the increases in these services, the Administrator of CMS should determine and implement an approach to ensure the appropriateness of advanced imaging services referred by self-referring providers.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: HHS noted that it would consider this recommendation. The Secretary of HHS has the authority to establish a program to promote the use of appropriate use criteria - criteria that are evidenced-based (to the extent feasible) and that assist professionals to make the most appropriate treatment decisions for a specified clinical condition - for advanced imaging services under the Protecting Access to Medicare Act of 2014. CMS has begun developing its appropriate use criteria program (e.g., in November 2015, CMS established criteria to identify Qualified Provider Led Entities that are responsible for developing appropriate use criteria and has since selected Qualified Provider Led Entities), but full implementation of the program will not occur until at least January 1, 2018. If it - and the subsequent prior authorization program that incorporates appropriate use criteria - are implemented broadly enough (i.e., they ensure the appropriateness of advanced imaging services by all physicians, including those who self-refer), we could close the recommendation.