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    Results:

    Subject Term: "Health care fraud"

    1 publication with a total of 8 open recommendations including 8 priority recommendations
    Director: Seto J. Bagdoyan
    Phone: (202) 512-6722

    8 open recommendations
    including 8 priority recommendations
    Recommendation: To better oversee the efficacy of PPACA's enrollment control process; to better monitor costs, risk, and program performance; to assist with tax compliance; to strengthen the eligibility determination process; to provide applicants with improved customer service and up-to-date information about submission of eligibility documentation; and to better document agency activities, the Secretary of Health and Human Services should direct the Acting Administrator of CMS to conduct a comprehensive feasibility study on actions that CMS can take to monitor and analyze, both quantitatively and qualitatively, the extent to which data hub queries provide requested or relevant applicant verification information, for the purpose of improving the data-matching process and reducing the number of applicant inconsistencies; and for those actions identified as feasible, create a written plan and schedule for implementing them.

    Agency: Department of Health and Human Services
    Status: Open
    Priority recommendation

    Comments: In April 2016, HHS reported that it considered this recommendation open and it was reviewing options for conducting a feasibility study to monitor and analyze information received from the Hub as recommended. HHS plans to examine the hub process in delivering usable information for applicant verification and analyzing data to identify trends or patterns that could suggest improvements in verification or actions that could reduce the number of inconsistencies that require further attention. HHS reported that this effort began March 2016. In March 2017, the agency said it is making significant progress towards implementing the recommendation. We will continue to monitor HHS's progress in this area.
    Recommendation: To better oversee the efficacy of PPACA's enrollment control process; to better monitor costs, risk, and program performance; to assist with tax compliance; to strengthen the eligibility determination process; to provide applicants with improved customer service and up-to-date information about submission of eligibility documentation; and to better document agency activities, the Secretary of Health and Human Services should direct the Acting Administrator of CMS to track the value of advance premium tax credit and cost-sharing reduction (CSR) subsidies that are terminated or adjusted for failure to resolve application inconsistencies, and use this information to inform assessments of program risk and performance. (See related recommendation 7.)

    Agency: Department of Health and Human Services
    Status: Open
    Priority recommendation

    Comments: In April 2016, HHS reported it considers this recommendation closed because it expanded the use of analytics to analyze the value of premium tax credit and CSR subsidies that are eliminated or adjusted for 2015 actions at the policy level, and that CMS continues to analyze the data to develop future operations changes. In May 2016, we requested documentation of these actions, including (1) information produced using the capability described; (2) ways in which this information is being used for analysis for purposes such as program operations, monitoring, risk assessment, or fraud cleaning; and (3) a description of the future operational changes contemplated based on the analyses done. Once received, we will review to determine whether the efforts taken warrant closing the recommendation. In March 2017, HHS provided us information on their response to this and other recommendations from this report. However, HHS has not provided sufficient documentation to show that they have implemented this recommendation. We will continue to monitor the agency's progress in this area.
    Recommendation: To better oversee the efficacy of PPACA's enrollment control process; to better monitor costs, risk, and program performance; to assist with tax compliance; to strengthen the eligibility determination process; to provide applicants with improved customer service and up-to-date information about submission of eligibility documentation; and to better document agency activities, the Secretary of Health and Human Services should direct the Acting Administrator of CMS to, in the case of CSR subsidies that are terminated or adjusted for failure to resolve application inconsistencies, consider and document, in conjunction with other agencies as relevant, whether it would be feasible to create a mechanism to recapture those costs, including whether additional statutory authority would be required to do so; and for actions determined to be feasible and reasonable, create a written plan and schedule for implementing them.

    Agency: Department of Health and Human Services
    Status: Open
    Priority recommendation

    Comments: In April 2016, HHS reported it considers this recommendation closed because CMS has considered whether it would be feasible to create a mechanism to recapture CSRs and determined that this is not possible under the current statute. HHS also noted that as currently written, the statute does not provide this authority and to pursue developing a mechanism to do so would require Congress to change the statute. In May 2016, we agreed to consider the recommendation closed upon HHS advising us if it made any review or inquiry into the feasibility of recapture apart from statutory authority and providing documentation of such consideration so that we have a full record of the agency's consideration prior to closing the recommendation. In March 2017, HHS provided us information on their response to this and other recommendations from this report. However, HHS has not provided sufficient documentation to show that they have implemented this recommendation. We will continue to monitor the agency's progress in this area.
    Recommendation: To better oversee the efficacy of PPACA's enrollment control process; to better monitor costs, risk, and program performance; to assist with tax compliance; to strengthen the eligibility determination process; to provide applicants with improved customer service and up-to-date information about submission of eligibility documentation; and to better document agency activities, the Secretary of Health and Human Services should direct the Acting Administrator of CMS to identify and implement procedures to resolve Social Security number inconsistencies where the Marketplace is unable to verify Social Security numbers or applicants do not provide them.

    Agency: Department of Health and Human Services
    Status: Open
    Priority recommendation

    Comments: In April 2016, HHS reported that it considered this recommendation open and was working on implementing functionality for updating consumers' Social Security numbers (SSN) and their eligibility based on the correct SSN. HHS reported that is it targeting deployment of the SSN update functionality in 2017. In March 2017, HHS provided us information on their response to this and other recommendations from this report. However, HHS has not provided sufficient documentation to show that they have implemented this recommendation. We will continue to monitor the agency's progress in this area.
    Recommendation: To better oversee the efficacy of PPACA's enrollment control process; to better monitor costs, risk, and program performance; to assist with tax compliance; to strengthen the eligibility determination process; to provide applicants with improved customer service and up-to-date information about submission of eligibility documentation; and to better document agency activities, the Secretary of Health and Human Services should direct the Acting Administrator of CMS to reevaluate CMS's use of Prisoner Update Processing System (PUPS) incarceration data and make a determination to either (a) use the PUPS data, among other things, as an indicator of further research required in individual cases, and to develop an effective process to clear incarceration inconsistencies or terminate coverage, or (b) if no suitable process can be identified to verify incarceration status, accept applicant attestation on status in all cases, unless the attestation is not reasonably compatible with other information that may indicate incarceration, and forego the inconsistency process.

    Agency: Department of Health and Human Services
    Status: Open
    Priority recommendation

    Comments: In April 2016, HHS reported it considers this recommendation closed because in 2015, it made the determination to no longer require application filers to submit documentation regarding incarceration status. We were aware of that determination, but the recommendation was to reevaluate use of PUPS from the specific standpoint of using the data as it was intended to be used as in indicator of further research and then draw a conclusion on the use of the data. In May 2016, we requested documentation demonstrating that in the period since we made this recommendation, CMS has undertaken the reevaluation in the fashion that we indicated. Once received, we will review to determine whether the efforts taken warrant closing the recommendation. In March 2017, HHS provided us information on their response to this and other recommendations from this report. However, HHS has not provided sufficient documentation to show that they have implemented this recommendation. We will continue to monitor the agency's progress in this area.
    Recommendation: To better oversee the efficacy of PPACA's enrollment control process; to better monitor costs, risk, and program performance; to assist with tax compliance; to strengthen the eligibility determination process; to provide applicants with improved customer service and up-to-date information about submission of eligibility documentation; and to better document agency activities, the Secretary of Health and Human Services should direct the Acting Administrator of CMS to create a written plan and schedule for providing Marketplace call center representatives with access to information on the current status of eligibility documents submitted to CMS's documents processing contractor.

    Agency: Department of Health and Human Services
    Status: Open
    Priority recommendation

    Comments: In April 2016, HHS reported it considers this recommendation closed because since May 2015, call center representatives have received daily updates on the status of eligibility documentation. It is working to provide call center representatives with real-time data that is tentatively scheduled for later in 2016. In May 2016, we noted that our recommendation was focused on providing such real-time capability and requested (1) confirmation that call center representatives currently have on-demand, real-time access to up-to-date, application-level document status; and documentation showing development and implementation of this capability; or (2) a written plan and schedule for providing this capability as recommended. Once received, we will review to determine whether the efforts taken warrant closing the recommendation. In March 2017, HHS provided us information on their response to this and other recommendations from this report. However, HHS has not provided sufficient documentation to show that they have implemented this recommendation. We will continue to monitor the agency's progress in this area.
    Recommendation: To better oversee the efficacy of PPACA's enrollment control process; to better monitor costs, risk, and program performance; to assist with tax compliance; to strengthen the eligibility determination process; to provide applicants with improved customer service and up-to-date information about submission of eligibility documentation; and to better document agency activities, the Secretary of Health and Human Services should direct the Acting Administrator of CMS to conduct a fraud risk assessment, consistent with best practices provided in GAO's framework for managing fraud risks in federal programs, of the potential for fraud in the process of applying for qualified health plans through the federal Marketplace.

    Agency: Department of Health and Human Services
    Status: Open
    Priority recommendation

    Comments: In April 2016, HHS reported that it considered this recommendation open. It noted that CMS has launched a Marketplace Integrated Project Team (IPT) through the Program Integrity Board, which includes senior staff from across CMS. An objective of the IPT is to complete the fraud risk assessment of Marketplace eligibility and enrollment based on GAO's Fraud Risk Framework, as required by the recommendation. HHS said the first three steps of GAO's framework for this part were to be completed by early summer. Once HHS has completed all relevant steps of the framework, and the agency has fully documented its implementation efforts-including discussion of any items contemplated by the framework that HHS elected not to follow-we will review to determine whether the efforts taken warrant closing the recommendation. In March 2017, HHS provided us information on their response to this and other recommendations from this report. However, HHS has not provided sufficient documentation to show that they have implemented this recommendation. We will continue to monitor the agency's progress in this area.
    Recommendation: To better oversee the efficacy of PPACA's enrollment control process; to better monitor costs, risk, and program performance; to assist with tax compliance; to strengthen the eligibility determination process; to provide applicants with improved customer service and up-to-date information about submission of eligibility documentation; and to better document agency activities, the Secretary of Health and Human Services should direct the Acting Administrator of CMS to fully document prior to implementation, and have readily available for inspection thereafter, any significant decision on qualified health plan enrollment and eligibility matters, with such documentation to include details such as policy objectives, supporting analysis, scope, and expected costs and effects.

    Agency: Department of Health and Human Services
    Status: Open
    Priority recommendation

    Comments: In April 2016, HHS reported it considers this recommendation closed because CMS prepares an annual Marketplace and Related Programs Cycle Memo to fulfill reporting requirements for internal control. The Memo describes all significant eligibility and enrollment policy and process changes, including new internal key controls associated with these changes, and the 2015 Memo was released in September 2015. In May 2016, we notified HHS that its actions do not close the recommendation. Information contained in the Memos is after-the-fact and while useful, does not meet the full range of documentation contemplated by our recommendation, especially development and analysis of changes prior to implementation. In March 2017, HHS provided us information on their response to this and other recommendations from this report. However, HHS has not provided sufficient documentation to show that they have implemented this recommendation. We will continue to monitor the agency's progress in this area.