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    Subject Term: "Program integrity"

    10 publications with a total of 20 open recommendations including 2 priority recommendations
    Director: Seto Bagdoyan
    Phone: (202) 512-6722

    3 open recommendations
    Recommendation: The Administrator of CMS should provide fraud-awareness training relevant to risks facing CMS programs and require new hires to undergo such training and all employees to undergo training on a recurring basis. (Recommendation 1)

    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 conduct fraud risk assessments for Medicare and Medicaid to include respective fraud risk profiles and plans for regularly updating the assessments and profiles. (Recommendation 2)

    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, using the results of the fraud risk assessments for Medicare and Medicaid, create, document, implement, and communicate an antifraud strategy that is aligned with and responsive to regularly assessed fraud risks. This strategy should include an approach for monitoring and evaluation. (Recommendation 3)

    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: Melito, Thomas
    Phone: (202) 512-9601

    3 open recommendations
    Recommendation: To support efforts to reduce staff fraud at RSCs, the Secretary of State should direct the Bureau of Population, Refugees, and Migration to actively pursue efforts to ensure that RSCs comply with required, applicable measures in the Program Integrity Guidelines.

    Agency: Department of State
    Status: Open

    Comments: The State Department concurred with our recommendation and agreed with GAO's assessment that these measures will support efforts to reduce staff fraud at Resettlement Support Centers (RSC). According to State officials, the Bureau of Population, Refugees, and Migration (PRM) has developed new guidance to enhance monitoring of RSCs. They explained that a new monitoring and evaluation framework serves as the foundational document for this guidance, which has incorporated and formalized PRM's existing RSC monitoring practices and established further requirements to address gaps identified by internal and external evaluative processes. According to the officials, the framework outlines roles, responsibilities, and tools for program officers and refugee coordinators. These responsibilities include formalizing and expanding monitoring of RSC compliance with the Program Integrity Guidelines. When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To better identify risks from RSC staff fraud, the Secretary of State should direct the Bureau of Population, Refugees, and Migration to update guidance, such as the Program Integrity Guidelines, to require each RSC to conduct regular staff fraud risk assessments that are tailored to each RSC's specific operations.

    Agency: Department of State
    Status: Open

    Comments: The State Department concurred with our recommendation and agreed with GAO's assessment that this requirement would strengthen Resettlement Support Centers' (RSCs) ability to identify risks of staff fraud. When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To help ensure that control activities are designed to mitigate identified RSC staff fraud risks, the Secretary of State should direct the Bureau of Population, Refugees, and Migration to regularly review RSC staff fraud risk assessments and use them to examine the suitability of existing staff fraud controls and revise controls as appropriate.

    Agency: Department of State
    Status: Open

    Comments: The State Department concurred with our recommendation and agreed with GAO's assessment that this would help ensure that control activities are designed to mitigate identified Resettlement Support Centers (RSC) staff fraud risks. When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Carolyn L. Yocom
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: To build upon CMS's collaborative audit efforts and help enhance future collaboration, CMS should identify opportunities to address barriers that limit states' participation in collaborative audits. Such opportunities could include improving communication with states before, during, and after audits are completed; and ensuring that audits align with states' program integrity needs, including the need for oversight of services provided in managed care delivery systems.

    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 better support states' efforts to reduce improper payments and communicate effective program integrity practices across the states, CMS should collaborate with states to develop a systematic approach to collect promising state program integrity practices.

    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 better support states' efforts to reduce improper payments and communicate effective program integrity practices across the states, CMS should collaborate with states to create and implement a communication strategy for sharing promising program integrity practices with states in an efficient and timely manner.

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

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

    1 open recommendations
    Recommendation: To ensure the appropriate level of Medicaid program integrity oversight in the territories, the Acting Administrator of CMS should reexamine CMS's program integrity strategy and develop a cost-effective approach to enhancing Medicaid program integrity in the territories. Such an approach could select from a broad array of activities, including--but not limited to--establishing program oversight mechanisms, such as requiring territories to establish a Medicaid Fraud Control Unit or working with them to obtain necessary exemptions or waivers from applicable program oversight requirements; assisting territories in improving their information on Medicaid and CHIP program spending; and conducting additional program assessments of program integrity as warranted.

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

    Comments: CMS has plans that may enhance Medicaid program integrity in the territories, but as of September, 2016, they have not yet been implemented. In May 2016, CMS notified all territories regarding the requirement to create a Medicaid Fraud Control Unit (MFCU) or seek a waiver of this requirement. As of September, 2016, according to CMS, Puerto Rico has indicated interest in establishing a MFCU, American Samoa and Guam have requested a waiver to the MFCU requirement, the Commonwealth of the Northern Mariana Islands has indicated interest in seeking a waiver, and the agency is working with the United States Virgin Islands regarding its response to this requirement. CMS intends to conduct comprehensive reviews of program integrity activities in the territories during fiscal year 2017, which have the potential to strengthen program integrity. Although these planned activities have the potential to strengthen program oversight, they have not yet been implemented. As of September 2016, no territory has established a MFCU or been granted a waiver to this requirement and comprehensive program integrity reviews will not occur until fiscal year 2017.
    Director: Carolyn L. Yocom
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To ensure states have appropriate and current guidance to assist them in designing and administering Medicaid NEMT, the Secretary of HHS should direct CMS to assess current Medicaid NEMT guidance and update that guidance as needed.

    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: Melvin, Valerie C
    Phone: (202) 512-6304

    1 open recommendations
    Recommendation: To ensure that the federal government's and states' investments in information systems result in outcomes that are effective in supporting efforts to save funds through the prevention and detection of improper payments in the Medicaid program, the Secretary of Health and Human Services should direct the Administrator of CMS to require states to measure quantifiable benefits, such as cost reductions or avoidance, achieved as a result of operating information systems to help prevent and detect improper payments. Such measurement of benefits should reflect a consistent and repeatable approach and should be reported when requesting approval for matching federal funds to support ongoing operation and maintenance of systems that were implemented to support Medicaid program integrity purposes.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In comments on our report, agency officials agreed with this recommendation and provided information on CMS's plans to use a template to track cost savings resulting from state Medicaid offices' use of information systems for program integrity purposes. In April 2017, CMS officials said that they were no longer planning to use the template to gather information from the states, because of the varied approaches that states take to implement systems support for program integrity purposes. The officials stated that they are developing an alternative approach for capturing this information from the states, which will be provided to us when completed. We will continue to monitor CMS's progress toward addressing the recommendation.
    Director: Kay E. Brown
    Phone: (202) 512-7215

    2 open recommendations
    Recommendation: To better ensure that WIC participants are aware of the prohibition against selling WIC formula, and to assist states' efforts to prevent and address online formula sales, the Secretary of Agriculture should direct the Administrator of FNS to require state agencies to articulate their procedures for identifying attempted sales of WIC food benefits in their WIC state plans and analyze the information to ascertain the national extent of state efforts.

    Agency: Department of Agriculture
    Status: Open

    Comments: USDA agreed with this recommendation and reported that in April 2015 the agency revised the guidance for WIC state plans to include policies on informing participants that the sale of WIC benefits is a program violation. As part of that document, state agencies were required to report/articulate their policies and procedures for identifying and monitoring online sales of WIC benefits. In October 2015, USDA contracted a study to determine 1) the national extent of WIC state agency policies and procedures intended to prevent, monitor, and take administrative action related to online sales of WIC infant formula; and 2) effective preventative, monitoring, and investigative approaches to address the online sale of WIC infant formula. USDA reported that a narrative state plan report, based on the contractor's review of 2016 and 2017 state plans, is expected to be completed by the end of FY 2017. GAO will close this recommendation once USDA has issued its report.
    Recommendation: To better ensure that WIC participants are aware of the prohibition against selling WIC formula, and to assist states' efforts to prevent and address online formula sales, the Secretary of Agriculture should direct the Administrator of FNS to collect information to help assess the national extent of attempted online sales of WIC formula benefits and determine cost-effective techniques states can use to monitor online classified advertisements.

    Agency: Department of Agriculture
    Status: Open

    Comments: USDA agreed with this recommendation and reported that it would explore options for using available resources to assess the extent of online sales of WIC formula and to identify and share best practices, cost-effective techniques, or new approaches with state agencies to use in monitoring online advertisements. In October 2015, USDA contracted a case study analysis of two state agencies in order to provide examples of prevention, monitoring, investigation, and sanctioning practices related to the online sale of WIC infant formula. As part of this study, the contractor sought to identify cost-effective techniques State agencies can use to monitor sales of WIC infant formula. USDA reported that the Case Study Analysis Report is expected to be completed by the end of FY 2017, and after it is completed, USDA will work to disseminate the study results to state agencies. GAO supports these efforts and will close this recommendation when the study is completed, providing the study identifies cost-effective techniques states can use to monitor online sales of infant formula.
    Director: Kathleen M. King
    Phone: (202) 512-7114

    1 open recommendations
    including 1 priority recommendation
    Recommendation: In order to improve the efficiency and effectiveness of Medicare postpayment claims review efforts and simplify compliance for providers, the Administrator of CMS should monitor the Recovery Audit Data Warehouse to ensure that all postpayment review contractors are submitting required data and that the data the database contains are accurate and complete.

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

    Comments: As of March 2017, CMS had taken initial steps to monitor the Recovery Audit Data Warehouse, including implementing a new process to monitor monthly compliance reports on the data that contractors enter into the Warehouse. However, CMS noted that as it is in the beginning stages of implementing these compliance reports, it does not currently verify that contractors upload all of the records that they reviewed, nor does it assess the accuracy of the records they entered into the Warehouse. Also, CMS indicated that it does not currently monitor whether certain contractors "suppress" claims in the Warehouse that those contractors are considering for review as part of an investigation. CMS said it was considering additional options for future monitoring of compliance reports, but did not indicate when it would determine what additional steps to take. To close this recommendation, CMS should take additional steps to improve its oversight of the Recovery Audit Data Warehouse, such as verifying that contractors upload all of the records that they reviewed and taking steps to assess the accuracy of the records they uploaded.
    Director: James R. McTigue, Jr.
    Phone: (202) 512-9110

    3 open recommendations
    including 1 priority recommendation
    Recommendation: As a result of turnover in IRS's Senior Executive Team and in order to enhance budget planning and improve decision making and accountability, the Commissioner of Internal Revenue should develop a long-term strategy to address operations amidst an uncertain budget environment. As part of the strategy, IRS should take steps to improve its efficiency, including (1) reexamining programs, related processes, and organizational structures to determine whether they are effectively and efficiently achieving the IRS mission, and (2) streamlining or consolidating management or operational processes and functions to make them more cost-effective.

    Agency: Department of the Treasury: Internal Revenue Service
    Status: Open
    Priority recommendation

    Comments: IRS agreed with our recommendation and is taking steps to implement it. For example, IRS has adopted a new, more strategic approach to identify and select budget program priorities. In its fiscal year 2017 budget justification, IRS introduced six themes of its Future State Initiative for tax administration, which in part aims to deliver service improvements across different taxpayer interactions such as individual account assistance, refunds, identity theft, and billings and payments. The budget also linked requested spending increases to the themes laid out in the initiative. The themes were derived from a subset of its 19 objectives identified in the IRS 2014-2017 Strategic Plan. In addition to the future state themes and strategic objectives, IRS has identified enterprise goals to guide the IRS toward the future state. As of December 2016, IRS has yet to set targets for meeting the goals but plans to have targets in place by June 2017. We acknowledge the steps IRS has taken and will continue to monitor its progress as the process is further developed.
    Recommendation: Because ROI provides insights on the productivity of a program and is one important factor in making resource allocation decisions, the Commissioner of Internal Revenue should calculate actual ROI for implemented initiatives, compare the actual ROI to projected ROI, and provide the comparison to budget decision makers for initiatives where IRS allocated resources.

    Agency: Department of the Treasury: Internal Revenue Service
    Status: Open

    Comments: No executive action taken. While IRS agreed that having actual ROI data for implemented initiatives would be useful, it did not believe it was feasible to produce such estimates, as GAO recommended in June 2014. GAO maintains that IRS should be able to provide some information on past initiatives, such as whether funds requested were used in the manner originally proposed. As of December 2016, IRS officials reported there is no timeline for full implementation. In March 2017, IRS officials confirmed that they do not isolate the revenue attributable to a specific initiative, but pointed to other efforts to help manage IRS's budget, including establishing the Office of Planning, Programming and Audit Coordination and the Planning Community of Practice, which are intended to improve investment planning processes. While these efforts are intended to help IRS act more strategically, comparing projected ROI to actual ROI can help hold managers and IRS accountable for the funding received.
    Recommendation: Because ROI provides insights on the productivity of a program and is one important factor in making resource allocation decisions, the Commissioner of Internal Revenue should use actual ROI calculations as part of resource allocation decisions.

    Agency: Department of the Treasury: Internal Revenue Service
    Status: Open

    Comments: No executive action taken as of March 2017. IRS's Research, Analysis, and Statistics Division has begun to estimate marginal direct revenues and marginal costs attributable to specific compliance projects. The estimates are necessary inputs to establish a measure of ROI, which in turn can guide resource allocation decisions. IRS plans to use these estimates to inform future examination plans, but considerable work remains in this long-term effort. In October 2016, IRS officials reported there is no timeline for full implementation, but that the work is on-going. In June 2016, IRS officials confirmed that projected revenue will be considered in investment decision making as part of fiscal year 2018 enterprise planning guidance, but did not report any progress in using actual ROI data. Until such action is taken, IRS may not be allocating its resources in the most effective way, thus potentially forgoing additional revenues.
    Director: Melvin, Valerie C
    Phone: (202)512-6304

    2 open recommendations
    Recommendation: To help ensure that the development and implementation of IDR and One PI are successful in helping the agency meet the goals and objectives of its program integrity initiatives, the Administrator of CMS should implement and manage plans for incorporating data in IDR to meet schedule milestones.

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

    Comments: While CMS has incorporated shared systems Medicare Part A (insurance for hospital and other inpatient services), Part B (insurance for hospital outpatient, physician, and other services), and three states' Medicaid data into IDR, it has not yet implemented and managed plans for incorporating all states' Medicaid data, as GAO recommended in June 2011. As a result, the repository does not yet include all the data that were planned to be incorporated by the end of 2012, and efforts to add the remaining states' Medicaid data to IDR continue to be behind schedule. As of March 2017, agency officials are working to develop plans to integrate all states' data into IDR as part of ongoing program integrity initiatives.
    Recommendation: To help ensure that the development and implementation of IDR and One PI are successful in helping the agency meet the goals and objectives of its program integrity initiatives, the Administrator of CMS should define any measurable financial benefits expected from the implementation of IDR and One PI.

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

    Comments: As of March 2017, CMS officials reported that they have identified areas of potential cost savings to be achieved by requiring program integrity contractors to use IDR and One PI, as GAO recommended in June 2011. CMS is awarding new contracts to include this requirement, which is expected to result in the agency no longer funding contractors' efforts to establish and maintain their own data warehouses and analytical tools. However, not all of the contracts have been awarded and, therefore, the requirement has not been fully implemented. Until all the new contracts have been awarded that require the contractors to use IDR and One PI for program integrity purposes, CMS will not have reasonable assurance that using the systems will help improve CMS's ability to detect fraud, waste, and abuse in the Medicare and Medicaid programs, and to achieve the $21 billion in financial benefits program officials projected.