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    Subject Term: "Medical records"

    18 publications with a total of 53 open recommendations including 10 priority recommendations
    Director: Brenda S. Farrell
    Phone: (202) 512-3604

    3 open recommendations
    Recommendation: The Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to, in coordination with the Director, USMEPCOM, and the military services develop a clear process with defined roles and responsibilities to ensure that complete Existed Prior to Service (EPTS) separation medical records for enlistees who separated within 180 days of service from the military services' basic training sites are provided to USMEPCOM.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: The Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to, in coordination with the Director, USMEPCOM, establish a schedule to repair the internal EPTS database so that USMEPCOM can provide more regular and specific feedback to MEPS chief medical officers.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: The Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to, in coordination with the Under Secretary of Defense for Acquisition, Technology, and Logistics and the DOD Healthcare Management Systems Program Executive Office, develop a schedule of actions for deploying its new electronic health record system, MHS GENESIS, within USMEPCOM that includes key activities such as the major actions required to accomplish this effort, completion dates for all actions leading up to these events, and dates for the system's deployment to MEPS locations.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Valerie Melvin
    Phone: (202) 512-6304

    6 open recommendations
    Recommendation: To provide clinicians and pharmacists with improved tools to support pharmacy services to veterans and reduce risks to patient safety, the Secretary of Veterans Affairs should direct the Assistant Secretary for Information and Technology and the Under Secretary for Health to establish and implement a plan for updating the pharmacy system to address the inefficiencies with viewing patient medication data in the Outpatient Pharmacy application and between the pharmacy application and viewers.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA concurred with our recommendation and in August 2017 stated that it had identified $4 million in fiscal year 2018 to establish a pharmacy graphical user interface. According to the department, it plans to complete its action in response to this recommendation by June 2018.
    Recommendation: To provide clinicians and pharmacists with improved tools to support pharmacy services to veterans and reduce risks to patient safety, the Secretary of Veterans Affairs should direct the Assistant Secretary for Information and Technology and the Under Secretary for Health to complete a plan for the implementation of an approach to data standardization that will support the capability for clinicians and pharmacists to view complete DOD data and receive order checks that consistently include DOD data.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA concurred in principle with our recommendation and in August 2017 stated that it plans to implement the electronic health record system that is being deployed by DOD, which will present VA clinicians with complete DOD data and the ability to perform order checks on DOD data. In parallel, the department is continuing and expanding the implementation of data standardization. According to the department, it plans to complete its action in response to this recommendation by October 2019.
    Recommendation: To provide clinicians and pharmacists with improved tools to support pharmacy services to veterans and reduce risks to patient safety, the Secretary of Veterans Affairs should direct the Assistant Secretary for Information and Technology and the Under Secretary for Health to conduct an assessment to determine to what extent interoperability of VA's pharmacy system with DOD's pharmacy system is impacting transitioning service members.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA concurred with our recommendation and in May 2017 stated that the health executive committee would complete an assessment to determine the extent interoperability with DOD's pharmacy system is impacting transitioning service members. According to the department, it planned to complete its actions in response to this recommendation by September 2017. We will update the status of this recommendation when VA provides documentation of its interoperability assessment to us.
    Recommendation: To provide clinicians and pharmacists with improved tools to support pharmacy services to veterans and reduce risks to patient safety, the Secretary of Veterans Affairs should direct the Assistant Secretary for Information and Technology and the Under Secretary for Health to develop and execute a plan for implementing the capability to send outbound e-prescriptions to non-VA pharmacies, in accordance with National Council for Prescription Drug Programs standards.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA concurred with our recommendation and in August 2017 stated that it will review its plan for e-prescribing functionality after it has signed a contract to adopt the electronic health record system that is being deployed by DOD. According to the department, it plans to complete its action in response to this recommendation by March 2018.
    Recommendation: To provide clinicians and pharmacists with improved tools to support pharmacy services to veterans and reduce risks to patient safety, the Secretary of Veterans Affairs should direct the Assistant Secretary for Information and Technology and the Under Secretary for Health to ensure that the department's evaluation of alternatives for electronic health records includes consideration for additional generation level 3 capability such as navigating from an alert to medication order in the electronic health record system.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA concurred with our recommendation and in August 2017 stated that it had entered into contract negotiations to acquire and deploy a level 3 electronic health record system that is expected to address pharmacy functions. The department plans to award this contract in December 2017. We will update the status of this recommendation when VA provides documentation of its evaluation of alternatives to us.
    Recommendation: To provide clinicians and pharmacists with improved tools to support pharmacy services to veterans and reduce risks to patient safety, the Secretary of Veterans Affairs should direct the Assistant Secretary for Information and Technology and the Under Secretary for Health to reassess the priority for establishing an inventory management capability to monitor and update medication levels and track when to reorder medications.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA concurred with our recommendation and in August 2017 stated that it will reassess the prioritization of medication inventory management after a contract for adoption of the electronic health record system is signed in December 2017. According to the department, it plans to complete its action in response to this recommendation by June 2018.
    Director: Randall B. Williamson
    Phone: (202) 512-7114

    4 open recommendations
    Recommendation: To improve the completeness and accuracy of VA's productivity metrics and efficiency models and strengthen the monitoring of clinical productivity and efficiency VA-wide, the Secretary of the Department of Veterans Affairs should direct the Undersecretary for Health to expand existing productivity metrics to track the productivity of all providers of care to veterans by, for example, including contract physicians who are not VA employees as well as advance practice providers acting as sole providers.

    Agency: Department of Veterans Affairs
    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 the completeness and accuracy of VA's productivity metrics and efficiency models and strengthen the monitoring of clinical productivity and efficiency VA-wide, the Secretary of the Department of Veterans Affairs should direct the Undersecretary for Health to help ensure the accuracy of underlying staffing and workload data by, for example, developing training to all providers on coding clinical procedures.

    Agency: Department of Veterans Affairs
    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 the completeness and accuracy of VA's productivity metrics and efficiency models and strengthen the monitoring of clinical productivity and efficiency VA-wide, the Secretary of the Department of Veterans Affairs should direct the Undersecretary for Health to develop a policy requiring VAMCs to monitor and improve clinical efficiency through a standard process, such as establishing performance standards based on VA's efficiency models and developing a remediation plan for addressing clinical inefficiency.

    Agency: Department of Veterans Affairs
    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 the completeness and accuracy of VA's productivity metrics and efficiency models and strengthen the monitoring of clinical productivity and efficiency VA-wide, the Secretary of the Department of Veterans Affairs should direct the Undersecretary for Health to establish an ongoing process to systematically review VAMCs' remediation plans and ensure that VAMCs and Veterans Integrated Service Networks are successfully implementing remediation plans for addressing low clinical productivity and inefficiency.

    Agency: Department of Veterans Affairs
    Status: Open

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

    2 open recommendations
    Recommendation: To help ensure that its efforts to increase patients' electronic access to health information are successful, the Secretary of HHS should direct ONC to develop performance measures to assess outcomes of key efforts related to patients' electronic access to longitudinal health information. Such actions may include, for example, determining whether the number of providers that participate in these initiatives have higher rates of patient access to electronic health information.

    Agency: Department of Health and Human 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 help ensure that its efforts to increase patients' electronic access to health information are successful, the Secretary of HHS should direct ONC to use the information these performance measures provide to make program adjustments, as appropriate. Such actions may include, for example, assessing the status of program operations or identifying areas that need improvement in order to help achieve program goals related to increasing patients' ability to access their health information electronically.

    Agency: Department of Health and Human Services
    Status: Open

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

    2 open recommendations
    Recommendation: To improve efforts to promote EHR use and electronic exchange of health information in post-acute care settings, the Secretary of Health and Human Services should direct the Centers for Medicare & Medicaid Services (CMS) and ONC to evaluate the effectiveness of HHS's key efforts to determine whether they are contributing to HHS's goal for increasing the use of EHRs and electronic exchange of health information in post-acute care settings.

    Agency: Department of Health and Human 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 efforts to promote EHR use and electronic exchange of health information in post-acute care settings, the Secretary of Health and Human Services should direct CMS and ONC to comprehensively plan for how to achieve the department's goal related to the use of EHRs and electronic information exchange in post-acute care settings. This planning may include, for example, identifying specific actions related to post-acute care settings and identifying and considering external factors.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Gregory C. Wilshusen
    Phone: (202) 512-6244

    5 open recommendations
    Recommendation: To improve the effectiveness of HHS guidance and oversight of privacy and security for health information the Secretary of Health and Human Services should update security guidance for covered entities and business associates to ensure that the guidance addresses implementation of controls described in the National Institute of Standards and Technology Cybersecurity Framework.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS concurred with the recommendation and plans to implement it. Subsequent to the agency stating that is has taken action, we plan to verify whether implementation has occurred.
    Recommendation: To improve the effectiveness of HHS guidance and oversight of privacy and security for health information the Secretary of Health and Human Services should update technical assistance that is provided to covered entities and business associates to address technical security concerns.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS concurred with the recommendation and plans to implement it. Subsequent to the agency stating that is has taken action, we plan to verify whether implementation has occurred.
    Recommendation: To improve the effectiveness of HHS guidance and oversight of privacy and security for health information the Secretary of Health and Human Services should revise the current enforcement program to include following up on the implementation of corrective actions.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS neither concurred nor nonconcurred with the recommendation but plans to implement it. Subsequent to the agency stating that is has taken action, we plan to verify whether implementation has occurred.
    Recommendation: To improve the effectiveness of HHS guidance and oversight of privacy and security for health information the Secretary of Health and Human Services should establish performance measures for the Office of Civil Rights (OCR) audit program.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS concurred with the recommendation and plans to implement it. Subsequent to the agency stating that is has taken action, we plan to verify whether implementation has occurred.
    Recommendation: To improve the effectiveness of HHS guidance and oversight of privacy and security for health information the Secretary of Health and Human Services should establish and implement policies and procedures for sharing the results of investigations and audits between OCR and Centers for Medicare & Medicaid Services to help ensure that covered entities and business associates are in compliance with the Health Insurance Portability and Accountability Act of 1996 and the Health Information Technology for Economic and Clinical Health Act.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS neither concurred nor nonconcurred with the recommendation but plans to implement it. Subsequent to the agency stating that is has taken action, we plan to verify whether implementation has occurred.
    Director: James Cosgrove
    Phone: (202) 512-7114

    5 open recommendations
    including 1 priority recommendation
    Recommendation: As CMS continues to implement and refine the contract-level RADV audit process to improve the efficiency and effectiveness of reducing and recovering improper payments and to improve the accuracy of CMS's calculation of coding intensity, the Administrator should modify that calculation by taking actions such as the following: (1) including only the three most recent pair-years of risk score data for all contracts; (2) standardizing the changes in disease risk scores to account for the expected increase in risk scores for all MA contracts; (3) developing a method of accounting for diagnostic errors not coded by providers, such as requiring that diagnoses added by MA organizations be flagged as supplemental diagnoses in the agency's Encounter Data System to separately calculate coding intensity scores related only to diagnoses that were added through MA organizations' supplemental record review (that is, were not coded by providers); and (4) including MA beneficiaries enrolled in contracts that were renewed from a different contract under the same MA organization during the pair-year period.

    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: As CMS continues to implement and refine the contract-level RADV audit process to improve the efficiency and effectiveness of reducing and recovering improper payments. The Administrator should modify CMS's selection of contracts for contract-level RADV audits to focus on those contracts most likely to have high rates of improper payments by taking actions such as the following: (1) selecting more contracts with the highest coding intensity scores; (2) excluding contracts with low coding intensity scores; (3) selecting contracts with high rates of unsupported diagnoses in prior contract-level RADV audits; (4) if a contract with a high rate of unsupported diagnoses is no longer in operation, selecting a contract under the same MA organization that includes the service area of the prior contract; and (5) selecting some contracts with high enrollment that also have either high rates of unsupported diagnoses in prior contract-level RADV audits or high coding intensity 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.
    Recommendation: As CMS continues to implement and refine the contract-level RADV audit process to improve the efficiency and effectiveness of reducing and recovering improper payments. The Administrator should enhance the timeliness of CMS's contract-level RADV process by taking actions such as the following: (1) closely aligning the time frames in CMS's contract-level RADV audits with those of the national RADV audits the agency uses to estimate the MA improper payment rate; (2) reducing the time between notifying MA organizations of contract audit selection and notifying them about the beneficiaries and diagnoses that will be audited; (3) improving the reliability and performance of the agency's process for transferring medical records from MA organizations, including assessing the feasibility of updating Electronic Submission of Medical Documentation for use in transferring medical records in contract-level RADV audits; and (4) requiring that CMS contract-level RADV auditors complete their medical record reviews within a specific number of days comparable to other medical record review time frames in the Medicare program.

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

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: As CMS continues to implement and refine the contract-level RADV audit process to improve the efficiency and effectiveness of reducing and recovering improper payments. The Administrator should improve the timeliness of CMS's contract-level RADV appeal process by requiring that reconsideration decisions be rendered within a specified number of days comparable to other medical record review and first-level appeal time frames in the Medicare program.

    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: As CMS continues to implement and refine the contract-level RADV audit process to improve the efficiency and effectiveness of reducing and recovering improper payments. The Administrator should ensure that CMS develops specific plans and a timetable for incorporating a RAC in the MA program as mandated by the Patient Protection and Affordable Care Act.

    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: Debra A. Draper
    Phone: (202) 512-7114

    1 open recommendations
    including 1 priority recommendation
    Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to monitor the full amount of time newly enrolled veterans wait to be seen by primary care providers, starting with the date veterans request they be contacted to schedule appointments. This could be accomplished, for example, by building on the data collection efforts currently being implemented under the "Welcome to VA" program.

    Agency: Department of Veterans Affairs
    Status: Open
    Priority recommendation

    Comments: In March 2016, GAO recommended that VA monitor the full amount of time newly enrolled veterans wait to be seen by primary care providers, starting with the date veterans request they be contacted to schedule appointments. VA concurred with this recommendation, and in June 2017, reported to GAO that it had taken actions to address this recommendation. Specifically, VA indicated that it revised an internal report to help identify and document all newly enrolled veterans and monitor their appointment request status. The report is intended to enable VHA and its medical centers to oversee the enrollment and appointment process by tracking the following timeframes: (1) application to enrollment, (2) enrollment to initial contact, (3) initial contact to primary care appointment, and (4) total time from application from appointment. However, VA also indicated in its response that it does not have data that captures application dates for all newly enrolled veterans. As a result, this report cannot be used to consistently monitor the full amount of time these veterans wait to be seen by primary care providers. To fully implement this recommendation VA needs to capture the application date for all newly enrolled veterans. Upon receiving further information about how and when VA plans to capture this information, we will assess whether VA's actions are sufficient to warrant closure of this recommendation.
    Director: Rebecca Gambler
    Phone: (202) 512-8777

    1 open recommendations
    Recommendation: To enhance Department of Homeland Security's (DHS) U.S. Immigration and Customs Enforcement's (ICE) ability to make more effective business decisions across immigration detention facilities with respect to the provision of medical care, the Secretary of Homeland Security should direct ICE to track inspection results and conduct analyses of oversight data over time, by standards, and by facility type.

    Agency: Department of Homeland Security
    Status: Open

    Comments: As of May 2017, ICE has not provided a status update regarding the implementation of this recommendation. We will provide updated information after confirming any agency actions.
    Director: Daniel Bertoni
    Phone: (202) 512-7215

    6 open recommendations
    Recommendation: The Acting Commissioner of Social Security should direct the Deputy Commissioner of Operations to further consider cost savings as part of its prioritization of full medical reviews. Such options could include considering the feasibility of prioritizing different types of beneficiaries on the basis of their estimated average savings and, as appropriate, integrating case-specific indicators of potential cost savings, such as beneficiary age and benefit amount, into its modeling or prioritization process.

    Agency: Social Security Administration
    Status: Open

    Comments: In July 2017, SSA stated that there is no accepted way to accurately predict future benefit payments at the individual level and that any improvement from implementing this recommendation would be minimal - and would be reduced over time as the continuing disability review (CDR) backlog diminishes - because SSA already considers expected return on investment by cohort in its overall approach to releasing CDRs. It is unclear whether SSA will be able to achieve and sustain currency in its CDR workloads. Even if SSA were to eliminate the backlog of full medical reviews, refining its prioritization process would enable the agency to more efficiently use its resources with any future backlogs. SSA could use actuarial considerations to prioritize refined cohorts of beneficiaries (e.g., types of DI beneficiaries) on the basis of their estimated average savings. SSA Operations could collaborate with SSA's Office of the Actuary on this work as needed. SSA previously agreed that it could look for ways to improve its return on conducting CDRs, but also stated that its statistical models and prioritization process already do much of what we recommend. For example, SSA stated that age is already a strong variable in its statistical models. However, these models predict medical improvement and are not designed to take expected cost savings into account. We continue to believe that to maximize expected cost savings SSA could refine its prioritization process by factoring in additional actuarial considerations.
    Recommendation: The Acting Commissioner of Social Security should direct the Deputy Commissioner of Budget, Finance, Quality, and Management to complete a re-estimation of the statistical models that are used to prioritize CDRs and determine a plan for re-estimating these models on a regular basis to ensure that they reflect current conditions.

    Agency: Social Security Administration
    Status: Open

    Comments: In July 2016, SSA re-estimated the statistical models that it uses to prioritize CDRs. However, as of October 2017, SSA has not yet produced a plan for re-estimating the models on a regular basis to ensure that they continually reflect current conditions.
    Recommendation: The Acting Commissioner of Social Security should direct the Deputy Commissioner of Budget, Finance, Quality, and Management to monitor the characteristics of CDR errors to identify potential root causes and report results to the Disability Determination Services. For example, SSA could analyze CDRs with and without errors to identify trends by impairment, beneficiary type, or other characteristics.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA agreed with this recommendation and stated that it reports all errors to the relevant DDS for corrective action. SSA further stated that its identification of root causes is limited by the relatively few reviewed CDRs that have errors. However, in fiscal year 2014 as an example, SSA identified over 600 CDRs with errors. Although these CDRs make up a small percentage of the CDRs reviewed by SSA that year, the agency could analyze the characteristics of CDRs with errors by comparing relevant percentages without modeling. In addition, SSA could combine data from multiple years if it determined that considering more CDRs with errors would be helpful. There is no change in the status of this recommendation for 2017.
    Recommendation: The Acting Commissioner of Social Security should direct the Deputy Commissioner of Budget, Finance, Quality, and Management to regularly track the number and rate of date errors, which can affect benefit payments (e.g., incorrect cessation dates), and consider including those errors in its reported CDR accuracy rates.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA disagreed with this recommendation and stated that, per SSA regulation, the agency does not consider date errors when calculating accuracy rates because date errors do not affect the decision to cease or continue benefits. SSA also stated its stewardship reviews examine the non-medical quality of benefit payment decisions. However, these reviews are not focused on CDRs, and SSA does not report results from them for CDRs specifically. SSA also explained that it does not track the number and rate of date errors because they are infrequent. However, SSA's regulations do not prevent the agency from tracking date errors, and until it does, SSA cannot definitively determine the frequency of these errors. In addition, we found that considering date errors substantially reduced some states' estimated CDR accuracy rates. Without tracking these errors, SSA cannot assess their effect and consider whether including them in its reported CDR accuracy rates has merit. There is no change in the status of this recommendation for 2017.
    Recommendation: The Acting Commissioner of Social Security should direct the Deputy Commissioner of Budget, Finance, Quality, and Management to adjust its approach to sampling CDRs to efficiently produce reliable accuracy rate estimates for continuances and cessations separately in each state.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA disagreed with this recommendation and stated that some states do not generate enough CDR decisions, particularly cessations, to generate statistically valid samples. However, for states with CDR samples that are consistently too small to produce reliable results, SSA could, for example, pool decisions from more months than it currently does to generate statistically valid samples by state. Conversely, for states with CDR samples that are consistently larger than necessary to efficiently achieve reliable results, SSA could, for example, reduce sample sizes. Because CDR accuracy rates vary by state and cessations are consistently less accurate than continuances, we maintain that SSA should adjust its approach to sampling CDRs. There is no change in the status of this recommendation for 2017.
    Recommendation: The Acting Commissioner of Social Security should direct the Chief Actuary to better document the methods including data sources, assumptions, and limitations that factor into its estimates of CDR cost savings.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA agreed with this recommendation and stated that it will improve and expand its existing documentation as time and resources permit. As of July 2017, SSA had begun to improve documentation of its OASDI estimates and plans further enhancements including documenting the methods of its SSI estimates.
    Director: Valerie C. Melvin
    Phone: (202) 512-6304

    4 open recommendations
    Recommendation: To facilitate oversight and inform decision making regarding their respective department's interoperability-related activities, the Secretaries of Defense and Veterans Affairs, working with the Interagency Program Office, should ensure related goals are defined to provide a basis for assessing and reporting on the status of interoperability-related activities and the extent to which interoperability is being achieved by the departments' modernized electronic health record systems.

    Agency: Department of Defense
    Status: Open

    Comments: The Department of Defense (DOD) and the Department of Veterans Affairs (VA) are working to define goals to provide a basis for assessing and reporting on the status of interoperability-related activities and the extent to which interoperability is being achieved by the departments' modernized electronic health record systems. Specifically, according to the DOD/VA Interagency Program Office (IPO), the office, in conjunction with the departments, has employed use cases in the Joint Interoperability Plan to define the interoperability-related goal areas, which are to be used as the basis for the development of outcome-oriented metrics, assessments, and reporting. The departments, the IPO, and workgroups within the Health Executive Committee's data sharing areas have focused on the feasibility and development of metrics aligned to six use cases as they relate to electronic health record interoperability between DOD and VA and outcomes to service members, veterans, and healthcare providers. The IPO reports that the work to establish these goals will be completed by December 2017. GAO will continue to review the results of these efforts.
    Recommendation: To facilitate oversight and inform decision making regarding their respective department's interoperability-related activities, the Secretaries of Defense and Veterans Affairs, working with the Interagency Program Office, should ensure related goals are defined to provide a basis for assessing and reporting on the status of interoperability-related activities and the extent to which interoperability is being achieved by the departments' modernized electronic health record systems.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: The Department of Veterans Affairs (VA) and the Department of Defense (DOD) are working to define goals to provide a basis for assessing and reporting on the status of interoperability-related activities and the extent to which interoperability is being achieved by the departments' modernized electronic health record systems. Specifically, according to the DOD/VA Interagency Program Office (IPO), the office, in conjunction with the departments, has employed use cases in the Joint Interoperability Plan to define the interoperability-related goal areas, which are to be used as the basis for the development of outcome-oriented metrics, assessments, and reporting. The departments, the IPO, and workgroups within the Health Executive Committee's data sharing areas have focused on the feasibility and development of metrics aligned to six use cases as they relate to electronic health record interoperability between VA and DOD and outcomes to service members, veterans, and healthcare providers. The IPO reports that the work to establish these goals will be completed by December 2017. GAO will continue to review the results of these efforts.
    Recommendation: To facilitate oversight and inform decision making regarding their respective department's interoperability-related activities, the Secretaries of Defense and Veterans Affairs, working with the Interagency Program Office, should update IPO guidance to reflect the metrics and goals identified.

    Agency: Department of Defense
    Status: Open

    Comments: According to the Department of Defense (DOD)/Department of Veterans Affairs (VA) Interagency Program Office (IPO), the office has issued an update to the Health Data Interoperability Management Plan that documents the IPO's role and outlines governance for supporting interoperability between the departments. The IPO is also in the process of updating additional guidance to describe the benefits of interoperability and reflect associated outcome-oriented metrics and goals. Specifically, IPO officials reported that the IPO's Joint Interoperability Plan is transitioning to the Joint Interoperability Strategic Plan and is expected to be finalized in November 2017. GAO will review this guidance once it is approved by DOD and VA.
    Recommendation: To facilitate oversight and inform decision making regarding their respective department's interoperability-related activities, the Secretaries of Defense and Veterans Affairs, working with the Interagency Program Office, should update IPO guidance to reflect the metrics and goals identified.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: According to the Department of Defense (DOD)/Department of Veterans Affairs (VA) Interagency Program Office (IPO), the office has issued an update to the Health Data Interoperability Management Plan that documents the IPO's role and outlines governance for supporting interoperability between the departments. The IPO is also in the process of updating additional guidance to describe the benefits of interoperability and reflect associated outcome-oriented metrics and goals. Specifically, IPO officials reported that the IPO's Joint Interoperability Plan is transitioning to the Joint Interoperability Strategic Plan and is expected to be finalized in November 2017. GAO will review this guidance once it is approved by VA and DOD.
    Director: Vijay D'Souza
    Phone: (202) 512-7114

    2 open recommendations
    including 2 priority recommendations
    Recommendation: To better assess and address the full extent of improper payments in the TRICARE program, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to implement a more comprehensive TRICARE improper payment measurement methodology that includes medical record reviews, as done in other parts of its existing postpayment claims review programs.

    Agency: Department of Defense
    Status: Open
    Priority recommendation

    Comments: The Department of Defense's Defense Health Agency (DHA) has taken some action to incorporate medical record reviews in its improper payment estimate, as GAO recommended in February 2015. In October 2016, DHA released a request for proposals for claim record reviews, including medical record reviews, that the agency plans to use to support the agency's requirement to identify and report on the potential of improper payments to the Office of Management and Budget. This is a good first step. Once DHA incorporates medical record reviews in its improper payment rate calculation methodology, GAO will be able to close this recommendation.
    Recommendation: To better assess and address the full extent of improper payments in the TRICARE program, and once a more comprehensive improper payment methodology is implemented, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to develop more robust corrective action plans that address underlying causes of improper payments, as determined by the medical record reviews.

    Agency: Department of Defense
    Status: Open
    Priority recommendation

    Comments: Until the department implements a more comprehensive TRICARE improper payment measurement methodology and identifies the underlying causes of improper payments, the full extent of improper payments in the TRICARE program will likely not be identified and addressed. As of October 2016, the Department of Defense's Defense Health Agency has not yet implemented a more comprehensive TRICARE improper payment measurement methodology, and has, therefore, not developed more robust corrective action plans.
    Director: Daniel Bertoni
    Phone: (202) 512-7215

    3 open recommendations
    including 1 priority recommendation
    Recommendation: To improve the ability of the agency to detect and prevent potential physician-assisted fraud, and to address potential disincentives for staff to detect and prevent physician-assisted fraud, SSA should review the standards used to assess DDS performance; and develop and distribute promising practices to incentivize staff to better balance the goal of processing claims promptly with the equally important goal of identifying and reporting evidence of potential fraud.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA partially agreed with this recommendation, citing that their employees take their stewardship responsibilities seriously and that field office and disability determination services (DDS) employees are the agency's first and best line of defense against fraud. In 2016, the agency reported that it was working with experts in its OIG and Office of Anti-Fraud Programs to develop and disseminate promising practices on identifying and reporting fraud. We will close this recommendation once SSA takes steps to review its standards for assessing DDS performance and disseminates the best practices it is developing.
    Recommendation: To improve the ability of the agency to detect and prevent potential physician-assisted fraud, and to address the potential risks associated with medical evidence submitted by sanctioned physicians, SSA should evaluate the threat posed by this information and, if warranted, consider changes to its policies and procedures.

    Agency: Social Security Administration
    Status: Open

    Comments: As of 2016, SSA reported that it was pursuing several options to address the potential risks of medical evidence submitted by sanctioned physicians. This included determining how it could use licensure information from the List of Excluded Individuals and Entities. SSA stated that it believes the best opportunity to further evaluate the possible review of the license statuses of medical evidence providers is in conjunction with the implementation of the National Vendor File, part of the national Disability Case Processing System, which is under development. In addition, SSA reported it had drafted two Social Security Rulings to define fraud and to provide processes for disregarding evidence and making redeterminations in disability claims when there is reason to believe that fraudulent evidence was provided. We will close this recommendation once SSA articulates a strategy for using license status information in the vendor file and it finalizes its rulings.
    Recommendation: To improve the ability of the agency to detect and prevent potential physician-assisted fraud, and to help ensure new initiatives that use analytics to identify potential fraud schemes are successful, SSA should develop an implementation plan that identifies both short- and long-term actions, including: (1) timeframes for implementation; (2) resources and staffing needs; (3) data requirements, e.g., the collection of unique medical provider information; (4) how technology improvement will be integrated into existing technology improvements such as the Disability Case Processing System and National Vendor File; and (5) how different initiatives will interact and support each other.

    Agency: Social Security Administration
    Status: Open
    Priority recommendation

    Comments: Since fiscal year 2015, SSA has taken several steps that will help the agency to combat fraud, waste, and abuse. SSA established the Office of Anti-Fraud Programs to provide centralized oversight and accountability for the agency's initiatives, which, in consultation with the Office of the Inspector General and other SSA components, will lead the development of SSA's anti-fraud initiatives and activities. This includes efforts to mitigate fraud through data analytics that utilize SSA's existing data systems. SSA developed a strategic plan for fiscal years 2016-2018 to guide its anti-fraud efforts that includes the use of data analytics. However, this plan does not specifically address actions to combat potential physician-assisted fraud. As of April 2017, SSA stated that it continued to develop a fraud management strategy that is consistent with the leading practices identified in GAO's report. Once the strategy is complete, SSA plans to conduct a fraud risk assessment on its major lines of business, beginning with the disability program in fiscal year 2017. We will continue to monitor SSA's progress to identify and prevent fraud schemes that include physicians.
    Director: Bertoni, Daniel
    Phone: (202) 512-7215

    1 open recommendations
    including 1 priority recommendation
    Recommendation: The Secretary of Veterans Affairs should take steps to better understand both the difficulties faced by readjusting veterans and the characteristics of those who may be more likely to face such difficulties, and use the results to determine how best to enhance its benefits and services to these veterans.

    Agency: Department of Veterans Affairs
    Status: Open
    Priority recommendation

    Comments: VA has begun taking steps to better understand the difficulties faced by readjusting veterans but has not yet completed them. Since November 2014, VA reported that it has been working with DOD to develop the joint process for conducting Care Coordination Process Reviews (formerly known as Qualitative Case Reviews), which will focus on reviewing care coordination processes and effectiveness. VA's Interagency Care Coordination Committee (IC3) Policy and Oversight Work Group is revising the policies and procedures for these reviews and has begun a national roll out of the Lead Coordinator initiative, which, according to VA, will improve the level of complex care coordination within and between DOD and VA. After completing a tabletop exercise of case review presentations on October 3, 2016, VA identified areas which needed fine tuning, so it developed open forums for lead coordinators to discuss process and resources. In an effort to enhance its briefings under the Transition Assistance Program, now known as the Transition Goals, Plans, Success program, VA used participant satisfaction data and is developing a long-term survey instrument that will assist VA in identifying and tracking recommended process improvements. In January 2015, VA produced a report on veteran economic competitiveness that recommended that VA develop targeted strategies for vulnerable populations, such as veterans who separate from the military without a GED or high school diploma and veterans who are separating after their rehabilitation. The report also recommended that VA continue to research the educational and economic status of veterans and coordinate with other federal agencies to identify and address gaps in current programs and policies that may result in barriers to economic success among vulnerable segments of the veteran population. GAO will consider this recommendation closed when VA has completed the joint Care Coordination Process Reviews, developed the long-term survey instrument for the Transition Goals, Plans, and Success program, and used the results from these reviews and survey to determine how best to enhance its benefits and services to veterans.
    Director: James Cosgrove
    Phone: (202) 512-7114

    2 open recommendations
    including 2 priority recommendations
    Recommendation: To ensure that MA encounter data are of sufficient quality for their intended purposes, the Administrator of CMS should establish specific plans and time frames for using the data for all intended purposes in addition to risk adjusting payments to MAOs.

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

    Comments: HHS was in general agreement with this recommendation. In January 2017 we reported that CMS had made progress in defining its objectives for using MA encounter data for risk adjustment and in communicating its plans and time frames to MAOs. However, although CMS had formed general ideas of how it would use MA encounter data for purposes other than risk adjustment, it had not specified plans and time frames for most of the additional purposes for which encounter data may be used. These other purposes include activities to support program integrity. As of July 2017, CMS officials told us that the agency had not taken any further actions in response to this July 2014 recommendation.
    Recommendation: To ensure that MA encounter data are of sufficient quality for their intended purposes, the Administrator of CMS should complete all the steps necessary to validate the data, including performing statistical analyses, reviewing medical records, and providing MAOs with summary reports on CMS's findings, before using the data to risk adjust payments or for other intended purposes.

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

    Comments: While in general agreement with this recommendation, HHS did not commit to completing data validation before using MA encounter data for risk adjustment. In January 2017 we reported that CMS had made limited progress toward validating encounter data by having begun compiling basic statistics on the volume and consistency of data submissions and preparing automated summary reports for MAOs indicating the diagnosis information used for risk adjustment. However the agency had not yet taken other important steps identified in its Medicaid encounter data validation protocol, such as establishing benchmarks for completeness and accuracy. In July 2017, CMS officials told us that the agency had not taken any further actions in response to this July 2014 recommendation.
    Director: Stephen M. Lord
    Phone: (202) 512-6722

    1 open recommendations
    Recommendation: To assist states that rely on or are planning to contract with an MCO to administer Medicaid prescription benefits, and to help provide effective oversight of psychotropic medications prescribed to children in foster care, the Secretary of Health and Human Services should issue guidance to state Medicaid, child-welfare, and mental-health officials regarding prescription-drug monitoring and oversight for children in foster care receiving psychotropic medications through MCOs.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In a July 2016 written response, Health and Human Services (HHS) stated that the Centers for Medicare & Medicaid Services (CMS) in collaboration with the Substance Abuse and Mental Health Services Administration (SAMHSA), issued an informational bulletin in August 2012 and in July 2013, that addressed this recommendation. However, in the report, we acknowledged that CMS issued this bulletin along with other guidance. Further, as we stated in our report, the HHS guidance did not address third-party MCOs administering medications. We continue to believe that additional HHS guidance that helps states implement oversight strategies within the context of a managed-care environment is needed to help ensure appropriate monitoring of psychotropic medications prescribed to children in foster care.
    Director: Linda T. Kohn
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To address challenges that affect the ability of providers to electronically exchange health information, the Secretary of Health and Human Services should direct CMS and ONC to develop and prioritize specific actions that HHS will take consistent with the principles in HHS's strategy to advance health information exchange.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of August 28, 2014, HHS provided some information indicating that it had begun the process of developing milestones with time frames for its actions toward advancing exchange, and that it plans to make them publicly available. Because HHS has only just begun the process and has not provided documentation, these actions are in progress and therefore not complete. We will follow up in fiscal year 2015 to gather additional information to determine if the actions fully address the recommendation.
    Recommendation: To address challenges that affect the ability of providers to electronically exchange health information, the Secretary of Health and Human Services should direct CMS and ONC to develop milestones with time frames for the actions to better gauge progress toward advancing exchange, with appropriate adjustments over time.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of August 28, 2014, HHS provided some information indicating that it had begun the process of developing milestones with time frames for its actions toward advancing exchange, and that it plans to make them publicly available. Because HHS has only just begun the process and has not provided documentation, these actions are in progress and therefore not complete. We will follow up in fiscal year 2015 to gather additional information to determine if the actions fully address the recommendation.
    Director: Williamson, Randall B
    Phone: (206)287-4860

    3 open recommendations
    including 2 priority recommendations
    Recommendation: To ensure that servicemembers have equitable access to the military services' wounded warrior programs, including the RCP, and to establish central accountability for these programs, the Secretary of Defense should establish or designate an office to centrally oversee and monitor the activities of the military services' wounded warrior programs to include the following: (1) Develop consistent eligibility criteria to ensure that similarly situated recovering servicemembers from different military services have uniform access to these programs; (2) Direct the military services' wounded warrior programs to fully comply with the policies governing care coordination and case management programs and any future changes to these policies; (3) Develop a common mechanism to systematically monitor the performance of the wounded warrior programs--to include the establishment of common terms and definitions--and report this information on a biannual basis to the Armed Services Committees of the House of Representatives and the Senate.

    Agency: Department of Defense
    Status: Open
    Priority recommendation

    Comments: DOD did not concur with our part (1) of our recommendation to develop consistent eligibility criteria, explaining that the three military department secretaries should have the ability to control entrance criteria into their wounded warrior programs and that varying eligibility criteria have not resulted in noticeable differences in access to these programs by recovering servicemembers or their families. In attachments to a memo dated April 8, 2014, DOD provided an update on progress made to implement parts (2) and (3) of the DOD-specific recommendation made in GAO-13-5. Regarding part (2), DOD reported that budget constraints had delayed its plan to conduct oversight visits to 63 service sites over a 12-month period to ensure that military wounded warrior programs were operating in compliance with DOD Recovery Coordinator Program policy. DOD stated that the Warrior Care Policy office, in coordination with the military service branches, had intended to begin these oversight visits and interviews in September 2013; that as of March 2014, five sites had been reviewed; and that results of the compliance visits would be available upon completion. Regarding part (3) of the recommendation, DOD's memo stated that DOD and VA continue work on developing policies on clinical and non-clinical care coordination. It also noted that interagency metrics for monitoring complex care coordination performance were under development by the DOD/VA Interagency Care Coordination Committee. Further, DOD stated that because the Joint Executive Council publishes an annual report, that reporting the progress in developing common terms and definitions used by wounded warrior programs to congressional committees would be of limited value. As of October 2016, when we determine what additional steps the agency has taken to implement this recommendation, we will update this information.
    Recommendation: To ensure that persistent challenges with care coordination, disability evaluation, and the electronic sharing of health records are fully resolved, the Secretaries of Defense and Veterans Affairs should ensure that these issues receive sustained leadership attention and collaboration at the highest levels with a singular focus on what is best for the individual servicemember or veteran to ensure continuity of care and a seamless transition from DOD to VA. This should include holding the Joint Executive Council accountable for (1) ensuring that key issues affecting recovering servicemembers and veterans get sufficient consideration, including recommendations made by the Warrior Care and Coordination Task Force and the Recovering Warrior Task Force; (2) developing mechanisms for making joint policy decisions; (3) involving the appropriate decision-makers for timely implementation of policy; and; (4) establishing mechanisms to systematically oversee joint initiatives and ensure that outcomes and goals are identified and achieved.

    Agency: Department of Defense
    Status: Open
    Priority recommendation

    Comments: As of October 2016, under the joint DOD/VA Interagency Care Coordination Committee, the departments have made progress to improve nonclinical care coordination procedures, primarily through the development of two initiatives?the Lead Coordinator initiative (in which a single care coordinator serves as the primary point of contact for a recovering servicemember) and through the use of a single, interagency care plan (ICP) for each recovering servicemember. As of March 2016, the departments were continuing the national rollout of the Lead Coordinator initiative and had trained nearly 3,700 DOD and VA personnel on the new process. In addition, DOD and VA continued the development of the ICP initiative, which will depend upon their ability to electronically exchange the information needed to implement servicemembers' care plans. In December 2015, DOD awarded a contract to support the ICP and to create electronic interoperability with VA. The departments anticipate testing their ability to exchange information digitally in June 2016 and achieving full operational capability by September 2016. We will continue to monitor progress to implement the joint Lead Coordinator and the ICP care coordination initiatives.
    Recommendation: To ensure that persistent challenges with care coordination, disability evaluation, and the electronic sharing of health records are fully resolved, the Secretaries of Defense and Veterans Affairs should ensure that these issues receive sustained leadership attention and collaboration at the highest levels with a singular focus on what is best for the individual servicemember or veteran to ensure continuity of care and a seamless transition from DOD to VA. This should include holding the Joint Executive Council accountable for (1) ensuring that key issues affecting recovering servicemembers and veterans get sufficient consideration, including recommendations made by the Warrior Care and Coordination Task Force and the Recovering Warrior Task Force; (2) developing mechanisms for making joint policy decisions; (3) involving the appropriate decision-makers for timely implementation of policy; and; (4) establishing mechanisms to systematically oversee joint initiatives and ensure that outcomes and goals are identified and achieved.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: As of October 2016, under the joint DOD/VA Interagency Care Coordination Committee, the departments have made progress to improve nonclinical care coordination procedures, primarily through the development of two initiatives?the Lead Coordinator initiative (in which a single care coordinator serves as the primary point of contact for a recovering servicemember) and through the use of a single, interagency care plan (ICP) for each recovering servicemember. As of March 2016, the departments were continuing the national rollout of the Lead Coordinator initiative and had trained nearly 3,700 DOD and VA personnel on the new process. In addition, DOD and VA continued the development of the ICP initiative, which will depend upon their ability to electronically exchange the information needed to implement servicemembers' care plans. In December 2015, DOD awarded a contract to support the ICP and to create electronic interoperability with VA. The departments anticipate testing their ability to exchange information digitally in June 2016 and achieving full operational capability by September 2016. We will continue to monitor progress to implement the joint Lead Coordinator and the ICP care coordination initiatives.