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    Subject Term: "Medical fees"

    8 publications with a total of 17 open recommendations including 1 priority recommendation
    Director: King, Kathleen M
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: To ensure MACs' provider education efforts are focused on areas vulnerable to improper billing and to strengthen CMS's oversight of those efforts, CMS should require sufficient detail in MAC reporting to allow CMS to determine the extent to which MACs' provider education department efforts focus on areas identified as vulnerable to improper billing.

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

    Comments: HHS concurred with this recommendation and said it would take steps to implement it. In April 2017, CMS released a revised Provider Customer Service Program Activity Report (PAR) template to Medicare Administrative Contractors (MAC). This revised template collects additional information from MACs on their provider outreach and education activities that are specifically geared towards reducing their improper payment rate. All PAR Reports submitted after July 2017 will include information on these topics. Additionally, CMS is implementing increased reporting by MACs in the Provider Customer Service Program Contractor Information Database to track whether education was provided related to the prioritization of efforts to reduce the error rate. CMS expects these additional reporting requirements to be released to the MACs in fall 2017. GAO will continue to monitor CMS efforts.
    Recommendation: To ensure MACs' provider education efforts are focused on areas vulnerable to improper billing and to strengthen CMS's oversight of those efforts, CMS should explicitly require that Medicare Part A and B claims, DME, and home health and hospice MACs work together to educate referring providers on documentation requirements for DME and home health services.

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

    Comments: HHS concurred with this recommendation and said it would take steps to implement it. CMS is developing instructions for the Medicare Administrative Contractors (MAC) that will require MACs to collaborate on a regular basis to provide education to referring providers on documentation and other requirements relative to durable medical equipment and home health services. CMS expects these new instructions to be released to MACs in fall 2017. Additionally, CMS is implementing increased reporting by MACs in the Provider Customer Service Program Contractor Information Database to track the instances of collaboration with other MACs. CMS expects these additional reporting requirements to be released to the MACs in fall 2017. Finally, CMS revised the Provider Customer Service Program Activity Report (PAR) to collect additional information from MACs on education topics where MACs collaborated with each other and with external partners. This new template was released to MACs in April 2017, and all PARs submitted after July 2017 will include information on these topics. GAO will continue to monitor CMS efforts.
    Recommendation: To ensure MACs' provider education efforts are focused on areas vulnerable to improper billing and to strengthen CMS's oversight of those efforts, for any future probe and educate reviews, CMS should establish performance metrics that will help the agency determine the reviews' effectiveness in reducing improper billing.

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

    Comments: HHS concurred with this recommendation and said it would take steps to implement it. Through the Targeted Probe and Educate Pilot, currently under way in Jurisdiction F and set to expand in the near future to additional jurisdictions, CMS has been working to develop more thorough metrics to monitor the outcome and impact of the probe and educate reviews. Detailed metrics in the expanded pilot include service and provider specific error rates, claims metrics, financial impact, education metrics, provider/suppler behavior metrics, as well as volume and outcome of appeals both pre- and post-probe and educate implementation. GAO will continue to monitor CMS efforts.
    Director: James Cosgrove
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: In order to prevent the shift of services from physician offices to HOPDs from increasing costs for the Medicare program and beneficiaries, Congress should consider directing the Secretary of HHS to equalize payment rates between settings for E/M office visits--and other services that the Secretary deems appropriate--and to return the associated savings to the Medicare program.

    Agency: Congress
    Status: Open

    Comments: When we determine what steps the Congress has taken, we will provide updated information.
    Director: James Cosgrove
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: To determine the extent to which Medicare payments are aligned with costs for specific types of dialysis treatment and training, the Administrator of CMS should take steps to improve the reliability of the cost report data for treatment and training associated with specific types of dialysis.

    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: The Administrator of CMS should examine Medicare policies for monthly payments to physicians to manage the care of dialysis patients and revise them if necessary to ensure that these policies are consistent with CMS's goal of encouraging the use of home dialysis among patients for whom it is appropriate.

    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 patients with chronic kidney disease receive objective and timely education related to this condition, the Administrator of CMS should examine the Kidney Disease Education benefit and, if appropriate, seek legislation to revise the categories of providers and patients eligible for the benefit.

    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: James C. Cosgrove
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: To help improve CMS's process for establishing relative values for Medicare physicians' services, the Administrator of CMS should better document the process for establishing relative values for Medicare physicians' services, including the methods used to review RUC recommendations and the rationale for final relative value decisions.

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

    Comments: To help improve the Centers for Medicare & Medicaid Service's (CMS) process for establishing relative values for Medicare physicians' services, in May 2015 we recommended that the Administrator of CMS better document the process, including the methods used to review recommendations from the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) and the rationale for final relative value decisions. CMS concurred with this recommendation, stating that CMS establishes relative values for new, revised, and potentially misvalued physicians' services based on its review of a variety of sources of information, including the RUC. CMS officials told us the agency continues to improve the transparency of its process by proposing and finalizing changes to the process in the annual rule for the Physician Fee Schedule. Officials also told us that the agency is developing a means of displaying the direct practice expense inputs component of relative values in a consistent manner that will allow for greater transparency and documentation of the process, since currently the RUC recommends direct practice expense inputs to CMS through inconsistent formats that are not conducive to public transparency. Officials estimated that this process will take several years to complete. In order to close this recommendation as implemented, CMS will need to demonstrate that it has improved its internal and external documentation of its process for establishing relative values. As of August 2016, CMS has not provided any additional information about actions to address this recommendation.
    Recommendation: To help improve CMS's process for establishing relative values for Medicare physicians' services, the Administrator of CMS should develop a process for informing the public of potentially misvalued services identified by the RUC, as CMS already does for potentially misvalued services identified by CMS or other stakeholders.

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

    Comments: To help improve the Centers for Medicare & Medicaid Service's (CMS) process for establishing relative values for Medicare physicians' services, in May 2015 we recommended that the Administrator of CMS develop a process for informing the public of potentially misvalued services identified by the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC), as CMS already does for potentially misvalued services identified by CMS or other stakeholders. CMS did not concur with this recommendation, asserting that the RUC is completely independent of CMS, and as such CMS has no authority to set the RUC's agenda for which services are reviewed. CMS reiterated their non-concurrence in February 2016. CMS officials noted that they recognize that some stakeholders, including those who are not participants in the RUC process, may not be aware of the new, revised, and potentially misvalued services that are under review by CMS prior to the establishment of interim final values in a final rule. For this reason and others, CMS proposed and finalized a change in its process for establishing or revising relative values for new, revised, or potentially misvalued services. Beginning in 2016, CMS will begin including proposed values for some of services in the annual proposed rulemaking for the Physician Fee Schedule, which means that the changes in values for these services will be open for public comment prior to them being finalized. In 2017, changes in values for almost all services will be included in the proposed rule for the Physician Fee Schedule. We continue to believe that CMS needs to inform the public of potentially misvalued services identified by the RUC, as the agency does for potentially misvalued services identified by other stakeholders for review. While the elimination of most interim final values in 2017 will allow stakeholders to comment on values before they become effective, we believe it is still important for CMS to inform stakeholders of those services identified by the RUC as potentially misvalued before CMS received RUC recommendations for these services and subsequently publishes the values in the proposed rule each year. Doing so would give stakeholders more time to provide input on values for services if they so choose before CMS included its proposed values in the annual proposed rulemaking, and we worded our recommendation to allow CMS to determine how to inform stakeholders of these services without delaying the timing of its revision of misvalued services.
    Recommendation: To help improve CMS's process for establishing relative values for Medicare physicians' services, the Administrator of CMS should incorporate data and expertise from physicians and other relevant stakeholders into the process as well as develop a timeline and plan for using the funds appropriated by the Protecting Access to Medicare Act of 2014.

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

    Comments: To help improve the Centers for Medicare & Medicaid Service's (CMS) process for establishing relative values for Medicare physicians' services, in May 2015 we recommended that the Administrator of CMS incorporate data and expertise from physicians and other relevant stakeholders into the process, as well as develop a timeline and plan for using the funds appropriated by the Protecting Access to Medicare Act of 2014 (PAMA). CMS concurred with this recommendation, stating that stakeholders have the opportunity each year to nominate potentially misvalued services for review through a public nomination process. In order to develop a timeline and plan for using the funds appropriated by PAMA, CMS is assessing the research conducted by two external contractors to determine the most effective and fiscally responsible way to use the funds. This work is ongoing, and CMS is using this work to understand the data collection limitations that exist and help inform the development of a timeline for the use of PAMA funds. CMS anticipates releasing a contract solicitation prior to the end of the calendar year. In order to close this recommendation as implemented, CMS will need to demonstrate that it has incorporated data and expertise from relevant stakeholders and has developed a timeline and plan for using the funds appropriated by PAMA. As of August 2016, CMS has not provided any additional information about actions to address this recommendation.
    Director: Cosgrove, James C
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To increase beneficiaries' awareness of providers' financial interest in a particular treatment, Congress should consider directing the Secretary of Health and Human Services to require providers who self-refer IMRT services to disclose to their patients that they have a financial interest in the service.

    Agency: Congress
    Status: Open

    Comments: In August 2013, to increase beneficiaries' awareness of providers' financial interest in a particular treatment, we suggested that Congress should consider directing the Secretary of Health and Human Services to require providers who self-refer IMRT services to disclose to their patients that they have a financial interest in the service. As of June 2017, Congress has not implemented this suggestion.
    Recommendation: The Administrator of CMS should insert a self-referral flag on its Medicare Part B claims form, require providers to indicate whether the IMRT service for which a provider bills Medicare is self-referred, and monitor the effects that self-referral has on costs and beneficiary treatment selection.

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

    Comments: In August 2013, we recommended that the Administrator of the Centers for Medicare & Medicaid Services (CMS) insert a self-referral flag on its Medicare Part B claims form, require providers to indicate whether the intensity-modulated radiation therapy (IMRT) service for which a provider bills Medicare is self-referred, and monitor the effects that self-referral has on costs and beneficiary treatment selection. 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, would be complex to administer, and may have unintended consequences. 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 IMRT services and monitor the effects of self-referral. As of June 2017, CMS has not provided any additional information about actions it has taken to address this recommendation.
    Director: Williamson, Randall B
    Phone: (202) 512-7114

    3 open recommendations
    including 1 priority recommendation
    Recommendation: To effectively manage fee basis care spending, the Secretary of Veterans Affairs should revise the beneficiary travel eligibility regulations to allow for the reimbursement of travel expenses for veterans to another VAMC to receive needed medical care when it is more cost-effective and appropriate for the veteran than seeking similar care from a fee basis provider.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: As of September 2015, VA has taken some actions to address this recommendation, but additional actions are needed to fully implement it. We will update the status of this recommendation when we receive additional information from VA.
    Recommendation: To effectively manage fee basis care wait times and spending, the Secretary of Veterans Affairs should direct the Under Secretary for Health to analyze the amount of time veterans wait to see fee basis providers and apply the same wait time goals to fee basis care that are used as VAMC-based wait time performance measures.

    Agency: Department of Veterans Affairs
    Status: Open
    Priority recommendation

    Comments: In October 2014, VHA established a new wait-time goal, which is that veterans should be seen within 30 days of the date that an appointment is deemed clinically appropriate by a VA health care provider, or if no such clinical determination has been made, the date a veteran prefers to be seen for hospital care or medical services. While VHA has been monitoring the timeliness of VHA-based care according to this standard, it has not been applying the same standard to community-based care, including care delivered through the Veterans Choice Program. Therefore, VHA cannot determine whether veterans are receiving care in the community sooner or later than they otherwise would receive care at VA medical facilities. To fully implement this recommendation, VHA needs to take steps to ensure that its wait-time policies and procedures for both VHA-based care and community-based care (fee basis care) are aligned.
    Recommendation: To ensure that VA Central Office effectively monitors fee basis care, the Secretary of Veterans Affairs should direct the Under Secretary for Health to ensure that fee basis data include a claim number that will allow for VA Central Office to analyze the episode of care costs for fee basis care.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: As of September 2015, VA has taken some actions to address this recommendation, but additional actions are needed to fully implement it. We will update the status of this recommendation when we receive additional information from VA.
    Director: Cosgrove, James C
    Phone: (202)512-7029

    1 open recommendations
    Recommendation: To ensure that savings are realized from the implementation of an MPPR or other policies that reflect efficiencies occurring when services are furnished together, Congress may wish to consider exempting these savings from budget neutrality.

    Agency: Congress
    Status: Open

    Comments: As of May 2017, we are awaiting an update from HHS on the status of this recommendation. We will update the status of this recommendation when we receive additional information.
    Director: Steinwald, Alan Bruce
    Phone: (202)512-3000

    1 open recommendations
    Recommendation: Given the contribution of physicians to Medicare spending in total, the Administrator of CMS should develop a profiling system that identifies individual physicians with inefficient practice patterns and, seeking legislative changes as necessary, use the results to improve the efficiency of care financed by Medicare. The profiling system should include methods for measuring the impact of physician profiling on program spending and physician behavior.

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

    Comments: Physician feedback reporting was initiated under section 131(c) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), and was expanded by section 3003 of the Patient Protection and Affordable Care Act (PPACA). In addition, PPACA required the Department of Health and Human Services to coordinate the physician feedback program with a Value Modifier (VM) that will adjust fee-for-service physician payments for the relative quality and cost of care provided to beneficiaries. In 2012, CMS provided Quality and Resource Use Reports (QRUR) to large providers nationwide and physician-focused QRURs to groups with 25 or more eligible providers in 9 states; by 2014, CMS sent QRURs to all group practices and solo practitioners. Also, as required in the act, CMS applied the VM to select physicians in 2015, with all physicians being subject to VM by 2017. The Act requires the VM to be implemented in a budget neutral manner, meaning that any upward payment adjustments for high performance must balance the downward payment adjustments applied for poor performance. CMS officials said they develop and will continue to develop experience reports related to each year's QRUR/VM cycle. In 2015, CMS used VM results for physicians in groups of 100 or more in public engagement of stakeholders, encouraging them to report quality, because quality performance was the driver of the payment adjustments in 2015. CMS is working with its Center for Clinical Standards and Quality to think of how to better engage physicians and groups in reporting, to avoid the automatic downward adjustment. As the program gains experience, CMS will use the experience reports to examine the impact of QRURs and VM on the Medicare program. In order for this recommendation to be closed as implemented, CMS will need to expand its efforts to measure the impact of QRURs and VM on program spending and physician behavior.