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    Subject Term: "Risk adjustments"

    4 publications with a total of 10 open recommendations including 4 priority recommendations
    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: Jacqueline M. Nowicki
    Phone: (202) 512-7215

    1 open recommendations
    including 1 priority recommendation
    Recommendation: Using its general authority to collaborate with other federal agencies, the Secretary of Education should convene its federal interagency partners to develop a strategic approach to interagency collaboration on school emergency preparedness. This group could include designees or delegates from the Secretaries of DHS, HHS, and the Attorney General, including representatives from relevant agency components, such as the Federal Emergency Management Agency, Transportation Security Administration, and the Federal Bureau of Investigation, and others as appropriate, and should incorporate leading federal interagency collaboration practices, for example, by: (1) identifying leadership, (2) defining outcomes and assigning accountability, (3) including all relevant participants, and (4) identifying necessary resources.

    Agency: Department of Education
    Status: Open
    Priority recommendation

    Comments: The Department of Education agrees that improved federal coordination will better assist K-12 schools in preparing for emergencies, and noted that other federal agencies, including especially FEMA, play a significant role in school emergency preparedness. Additionally, Education cited the importance of involving other relevant agencies in obtaining agreement on the assignment of roles and responsibilities, including selecting a lead agency charged with primary responsibility for coordinating federal emergency preparedness assistance to K-12 schools. In August 2016, Education convened a committee of Assistant Secretary-level representatives from relevant agencies, including DHS, FEMA, and TSA, among others, to develop a strategic approach to interagency collaboration on school emergency management efforts. Subsequently, in October 2016, it convened a task force consisting of program staff from the relevant agencies to draft a plan for organizational structure, goals, and objectives for the next five years, which it expects will be approved for implementation beginning in January 2017. We are encouraged by these actions and will monitor the group's progress towards developing a strategic approach to school emergency preparedness. Education stated that it expects to complete these efforts very soon. At that time, we will await documentation showing that it has finalized and implemented its strategic approach for interagency collaboration around school emergency management.
    Director: Gerald L. Dillingham, Ph.D.
    Phone: (202) 512-2834

    2 open recommendations
    Recommendation: To help FAA better manage and understand the uncertainties of its forecasts, the Secretary of Transportation should direct the FAA to apply risk-management practices to analyze and report on uncertainty. Specifically, the FAA should, for both the Aerospace and TAF forecasts, analyze and report the forecast's uncertainty, establish forecast error thresholds, and develop an approach that will prompt forecast review when error thresholds are exceeded, and, for TAF forecasts, monitor and publish multi-year historical error performance, as FAA does for the Aerospace Forecast.

    Agency: Department of Transportation
    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 FAA better manage and understand the uncertainties of its forecasts, the Secretary of Transportation should direct the FAA to fully document its methods and assumptions in developing the Aerospace and TAF forecasting models to provide greater transparency to internal users and external stakeholders.

    Agency: Department of Transportation
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    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.