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    Subject Term: Claims

    15 publications with a total of 40 open recommendations including 6 priority recommendations
    Director: John E. Dicken
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: In implementing the age and gender adjustment, the Commissioner of Internal Revenue should consider taking steps to mitigate the limitations of the BCBS Standard plan premium cost data--such as by combining data from multiple FEHBP plans. If combining the costs of plans with different benefit structures, the Commissioner should consider whether an appropriate actuarial adjustment should be used. If the Commissioner interprets that the statute does not provide the flexibility to mitigate the limitations of the BCBS Standard plan premium cost data by combining data from multiple sources or by other means, the Commissioner should seek that authority from Congress.

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

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Seto Bagdoyan
    Phone: (202) 512-6722

    2 open recommendations
    Recommendation: To enhance consumer understanding of agency oversight roles and to strengthen agency oversight of Internet marketing, the Secretary of the Department of Health and Human Services and the Chair of the FTC should develop and provide additional guidance to consumers delineating the agencies' differing roles in their shared oversight of memory supplement and other dietary supplement marketing on the Internet.

    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 enhance consumer understanding of agency oversight roles and to strengthen agency oversight of Internet marketing, the Secretary of the Department of Health and Human Services and the Chair of the FTC should develop and provide additional guidance to consumers delineating the agencies' differing roles in their shared oversight of memory supplement and other dietary supplement marketing on the Internet.

    Agency: Federal Trade Commission
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Jeszeck, Charles A
    Phone: (202) 512-7215

    6 open recommendations
    including 1 priority recommendation
    Recommendation: To ensure that key information provided by claims specialists to potential claimants of Social Security retirement benefits is clear and consistent with POMS, the Commissioner of the SSA should take steps to ensure when applicable, claims specialists inform that delaying claiming will result in permanently higher monthly benefit amounts, and at least offer to provide claimants their estimated benefits at their current age, at full retirement age (FRA) (unless the claimant is already older than FRA), and age 70.

    Agency: Social Security Administration
    Status: Open
    Priority recommendation

    Comments: On 10/19/16, SSA sent a message to technicians (including claims representatives who discuss claiming with clients in field offices or over the phone) reminding them to 1) inform claimants that delaying results in permanently higher benefits; and 2) provide estimated benefits at different claiming ages. While the reminder message to claims specialists is a positive step by the agency, SSA should continue to send periodic messages about these requirements to claims specialists. Further, SSA should have field office managers periodically discuss best practices for providing this information to potential claimants at office training sessions.
    Recommendation: To ensure that key information provided by claims specialists to potential claimants of Social Security retirement benefits is clear and consistent with POMS, the Commissioner of the SSA should take steps to ensure claims specialists understand that they should avoid the use of breakeven analysis to compare benefits at different claiming ages.

    Agency: Social Security Administration
    Status: Open

    Comments: On 10/19/16, SSA sent a message to technicians (including claims representatives who discuss claiming with clients in field offices or over the phone) reminding them not to use breakeven analysis or discuss breakeven points with claimants to compare benefits at different claiming ages. While the reminder message to claims specialists is a positive step by the agency, SSA should continue to send periodic messages to claims specialist to ensure that they understand the requirement to avoid use of breakeven analysis to compare benefits at different claiming ages.
    Recommendation: To ensure potential claimants are consistently provided with key information during the claiming process to help them make informed decisions about when to claim benefits, SSA should take steps to ensure that when applicable, claims specialists inform claimants that monthly benefit amounts are determined by the highest (indexed) 35 years of earnings, and that in some cases, additional work could increase benefits.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA reported that, as appropriate, it will issue a reminder to technicians or include instructions in SSA's Program and Operations Manual System (POMS) to reinforce the instructions. The agency did not provide information on how it plans to include this information in the online claims process.
    Recommendation: To ensure potential claimants are consistently provided with key information during the claiming process to help them make informed decisions about when to claim benefits, SSA should take steps to ensure that when appropriate, claims specialists clearly explain the retirement earnings test and inform claimants that any benefits withheld because of earnings above the earnings limit will result in higher monthly benefits starting at FRA.

    Agency: Social Security Administration
    Status: Open

    Comments: On 10/19/16, SSA sent a message to technicians (including claims representatives who discuss claiming with clients in field offices or over the phone) reminding them to inform claimants that any amounts withheld due to earnings (over limits) will result in higher benefits later on. While the reminder message to claims specialists is a positive step by the agency, SSA should continue to send periodic messages to claims specialist reinforcing the importance of explaining the earnings test, and informing potential claimants that any benefits withheld due to earnings will result in higher benefits starting at FRA. Further, SSA should have field office managers periodically discuss best practices for providing this information to potential claimants at office training sessions.
    Recommendation: To ensure potential claimants are consistently provided with key information during the claiming process to help them make informed decisions about when to claim benefits, SSA should take steps to ensure that claims specialists explain that lump sum retroactive benefits will result in a permanent reduction of monthly benefits. For the online claiming process, SSA should evaluate removing or revising the online question that asks claimants to provide a reason for not choosing retroactive benefits.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA stated that it will issue a reminder to technicians, instructing them to explain that a lump sum retroactive benefit would result in a permanent reduction in monthly benefits; or include instructions in SSA's Program and Operations Manual System (POMS). As for the question included in the online process, SSA said it will explore the underlying rationale for this question and consider modifying the question.
    Recommendation: To ensure potential claimants are consistently provided with key information during the claiming process to help them make informed decisions about when to claim benefits, SSA should take steps to ensure that the claims process include basic information on how life expectancy and longevity risk may affect the decision to claim benefits.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA updated Pub No. 05-10147 to mention that: 1) monthly benefits are higher for the rest of one's life the longer one delays claiming; 2) retirement may be longer than you think; and 3) for married couples, delaying claiming may increase survivor benefits. SSA also added a new question on this topic to its frequently asked questions (FAQ) page, "At what age should I start receiving my Social Security Retirement benefits?" The answer provides key information for individuals to consider, and links to the newly updated publication, the Retirement Estimator tool, and other resources that SSA offers. Updating and improving a key publication on this topic is a positive step by the agency. However, it is not clear if claimants will be able to access this information while they are applying for retirement benefits online. Further, SSA did not specify how it plans to instruct claims specialists to provide information on life expectancy and longevity risk during the in-person claims process.
    Director: Michele Mackin
    Phone: (202) 512-4841

    3 open recommendations
    Recommendation: To improve the use of warranties and guarantees in Navy shipbuilding, the Secretary of the Defense should direct the Secretary of the Navy, in arrangements where the shipbuilder is paid to correct defects, to structure contract terms such that shipbuilders do not earn profit for correcting construction deficiencies following delivery that are determined to be their responsibility.

    Agency: Department of Defense
    Status: Open

    Comments: In providing comments on this report, the Department of Defense partially concurred with this recommendation, and has completed a study reviewing our findings. The study, conducted by the CNA Analysis and Solutions, found that our recommendations were well founded and appropriate. In response to our report and the study, the Navy states it will provide written guidance by the end of 2017 to prevent shipbuilders from earning profit for correcting shipbuilder-responsible defects.
    Recommendation: To improve the use of warranties and guarantees in Navy shipbuilding, the Secretary of the Defense should direct the Secretary of the Navy to establish and document a clear objective for using a guaranty, and then create guidance for contracting officers that illustrates how to implement a guaranty that meets this objective. This guidance should describe how contracting officers should use aspects of the guaranty, including determining an appropriate limitation of liability, to achieve the objective and include considerations as to when a guaranty should be a separate contract line item.

    Agency: Department of Defense
    Status: Open

    Comments: In providing comments on this report, the Department of Defense partially concurred with this recommendation, and agreed to conduct a study to determine what policy and guidance changes are necessary to provide guidance on the many factors that should be considered to effectively implement warranty and guaranty provisions. As of April 2017, this study is complete and the Navy states that it now concurs with our recommendation. In doing so, the Navy is drafting an instruction, including a decision template, laying out the considerations underlying the decision to use warranties, guarantees or other mechanisms. This instruction will help contracting officers choose an appropriate tool and document the decision in a business clearance memorandum. The Navy plans to implement the instruction by the end of 2017.
    Recommendation: To improve the use of warranties and guarantees in Navy shipbuilding, the Secretary of the Defense should direct the Secretary of the Navy, for future ship construction contracts, to determine whether or not a warranty as provided in the FAR, provides value and document the costs, benefits, and other factors used to make this decision. To inform this determination, the Navy should begin differentiating the government's and shipbuilder's responsibility for defects and track the costs to correct all defects after ship delivery.

    Agency: Department of Defense
    Status: Open

    Comments: In providing comments on this report, the Department of Defense partially concurred with this recommendation, and has completed a study reviewing our findings. The study, conducted by the CNA Analysis and Solutions, found that our recommendations were well founded and appropriate. In response to our report and the study, the Navy states it will include separate contract line items for FAR-type warranties in at least two solicitations for ship construction. In addition, the Navy states that it plans to revise data requirements to better gather and track contractor responsible defects, and then develop analytical methods to help make better determinations in the future as to the optimal guaranty duration and limit of liability. They expect to complete these activities by December 2017.
    Director: Valerie C. Melvin
    Phone: (202) 512-6304

    5 open recommendations
    including 1 priority recommendation
    Recommendation: To improve VA's efforts to effectively complete the development and implementation of VBMS, the Secretary of Veterans Affairs should direct the Under Secretary for Benefits and the Chief Information Officer to develop an updated plan for VBMS that includes (1) a schedule for when VBA intends to complete development and implementation of the system, including capabilities that fully support disability claims, pension claims, and appeals processing and (2) the estimated cost to complete development and implementation of the system.

    Agency: Department of Veterans Affairs
    Status: Open
    Priority recommendation

    Comments: The Department of Veterans Affairs (VA) concurred with our recommendation calling for an updated plan for the Veterans Benefits Management System. However, as of June 2017, the department had not developed a plan that included a schedule for when the Veterans Benefits Administration intends to complete development and implementation of the system, as well as the estimated cost of doing so. We will continue to monitor VA's actions in response to this recommendation.
    Recommendation: To improve VA's efforts to effectively complete the development and implementation of VBMS, the Secretary of Veterans Affairs should direct the Under Secretary for Benefits and the Chief Information Officer to establish goals for system response time and use the goals as a basis for periodically reporting actual system performance.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: The Department of Veterans Affairs (VA) concurred with this recommendation and reported that the Veterans Benefits Management System (VBMS) program office has developed draft metrics for performance of the system. Specifically, VA stated that the office has established key performance indicators as a basis for monitoring the response times of the most commonly executed user transactions (or work events) within VBMS. According to the department, these indicators have been incorporated into the application's continuous monitoring tools for all service level agreements and these agreements are enforced by the VA Service Level Management Board. Nevertheless, as of June 2017, VA had not identified its goals for VBMS response times, nor had the department reported actual system response times. We will continue to monitor VA's actions toward addressing this recommendation.
    Recommendation: To improve VA's efforts to effectively complete the development and implementation of VBMS, the Secretary of Veterans Affairs should direct the Under Secretary for Benefits and the Chief Information Officer to reduce the incidence of high- and medium-priority level defects that are present at the time of future VBMS releases.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: The Department of Veterans Affairs (VA) concurred with this recommendation and, in June 2017, reiterated its plans and procedures for decreasing the incidences of defects in each system release. However, the incidences of high- and medium-priority level defects at the time of recent VBMS releases (i.e., releases 10.1 and 11.0) had increased relative to the number of defects present at the time of the earlier release (i.e., release 8.1) that we described in our report. We will continue to monitor VA's actions and progress in response to this recommendation.
    Recommendation: To improve VA's efforts to effectively complete the development and implementation of VBMS, the Secretary of Veterans Affairs should direct the Under Secretary for Benefits and the Chief Information Officer to develop and administer a statistically valid survey of VBMS users to determine the effectiveness of steps taken to make improvements in users' satisfaction.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: The Department of Veterans Affairs (VA) concurred with this recommendation and in January 2017, conducted a survey of VBMS users that was sent to over 16,000 claims processors at each of its 56 regional offices. Although 52 percent of respondents indicated that they were very satisfied or satisfied with VBMS, the department received only about 2500 responses to the survey for a 15 percent response rate. This low response rate raises concern about whether the survey results are statistically valid. We have requested additional information from VA to determine any actions the department has taken to ensure the statistical validity of its survey results and will assess any information that is provided.
    Recommendation: To improve VA's efforts to effectively complete the development and implementation of VBMS, the Secretary of Veterans Affairs should direct the Under Secretary for Benefits and the Chief Information Officer to establish goals that define customer satisfaction with VBMS and report on actual performance toward achieving the goals based on the results of GAO's survey of VBMS users and any future surveys VA conducts.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: The Department of Veterans Affairs (VA) concurred with this recommendation and conducted a survey of VBMS users in January 2017. However, as of June 2017, the department had yet to develop customer satisfaction goals for VBMS that would provide users with an expectation of the system response times they should anticipate, and management with an indication of how well the system is performing relative to performance goals.
    Director: Johana Ayers
    Phone: (202) 512-5741

    1 open recommendations
    Recommendation: To ensure that the Defense Civilian Personnel Advisory Service (DCPAS) and DOD components are determining LQA eligibility consistently with DOD's LQA Instruction, the DSSR, and OPM compensation claim decisions, the Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to require the Deputy Assistant Secretary of Defense for Civilian Personnel Policy or DCPAS, as delegated, to monitor reviews of LQA eligibility determinations conducted by DOD components.

    Agency: Department of Defense
    Status: Open

    Comments: On February 11, 2016, the Deputy Assistant Secretary of Defense for Civilian Personnel Policy issued a memorandum to conduct a review of overseas allowances and differentials (including Living Quarters Allowance (LQA)) paid to civilian employees. This memorandum orders DOD components to review 5 percent of their employees who received LQA during the calendar year 2015. These reports are to identify the employees locations, the annual amount of each allowance each employee receives, the laws and regulations authorizing the allowance, and confirmation that supporting documents used to determine employee eligibility for the allowance were reviewed and found acceptable. The February 2016 memorandum states that these reviews should be completed within 90 days of its issuance. However, the memorandum does not require the monitoring of these reviews by the Defense Civilian Personnel Advisory Service. In the absence of such a requirement, Defense Civilian Personnel Advisory Service officials told us in May 2016 that they had started receiving the results of these reviews and would assess them as soon as possible for any inconsistencies. These officials have not yet provided any documents demonstrating their monitoring of these reviews.
    Director: Charlie Jeszeck
    Phone: (202) 512-7215

    5 open recommendations
    including 1 priority recommendation
    Recommendation: To better protect the retirement savings of individuals who change jobs, while retaining policies that provide 401(k) plans relief from maintaining small, inactive accounts, Congress should consider amending current law to permit the Secretary of Labor and the Secretary of the Treasury to identify and designate alternative default destinations for forced transfers greater than $1,000, should they deem them more advantageous for participants.

    Agency: Congress
    Status: Open

    Comments: There has been no congressional action as of 2017.
    Recommendation: To better protect the retirement savings of individuals who change jobs, while retaining policies that provide 401(k) plans relief from maintaining small, inactive accounts, Congress should consider amending current law to repeal the provision that allows plans to disregard amounts attributable to rollovers when determining if a participant's plan balance is small enough to forcibly transfer it.

    Agency: Congress
    Status: Open

    Comments: There has been no congressional action as of 2017.
    Recommendation: To ensure that individuals have access to consolidated online information about their multiple 401(k) plan accounts, the Secretary of Labor should convene a taskforce to consider establishing a national pension registry. The taskforce could include industry professionals, plan sponsor representatives, consumer representatives, and relevant federal government stakeholders, such as representatives from Social Security Administration, Pension Benefit Guaranty Corporation, and Internal Revenue Service, who could identify areas to be addressed through the regulatory process, as well as those that may require legislative action.

    Agency: Department of Labor
    Status: Open
    Priority recommendation

    Comments: In April 2017, The Department of Labor (DOL) reported that it has not allocated any resources to this recommendation and, as previously stated, that it continues to believe that the Department should not undertake to convene a taskforce at this time, in light of the Pension Benefit Guaranty Corporation's (PBGC) initiative, the Department's limited authority, and resource constraints. In October 2016, DOL stated that it does not have regulatory authority to establish a pension registry and could not provide sufficient funding to operate a registry. GAO's recommendation is to convene a taskforce to look at what would be needed to create such a registry. Indeed, DOL's stated constraints are exactly the constructive input that would need to be first addressed by such a taskforce for a registry to be created. The agency further noted that the PBGC is in the process of looking at expanding its own registry of accounts left in closed defined benefit plans to include accounts in 401(k) plans. However, PBGC is only looking at expanding its program, as instructed by the Pension Protection Act, to include accounts left in terminated 401(k) plans. However, in June 2016, Congress proposed that a new national, online, lost and found for Americans' retirement accounts be created, in cooperation with the Commissioner of Social Security and the Secretary of the Treasury, using data that employers are already required to report. Until Congress' proposal becomes law, we continue to recommend that DOL facilitate a taskforce to discuss legal and other logistical questions that would need to be worked out to create a pension registry.
    Recommendation: To ensure that 401(k) plan participants have timely and adequate information to keep track of all their workplace retirement accounts, the Social Security Administration's Acting Commissioner should make information on potential vested plan benefits more accessible to individuals before retirement. For example, the agency could consolidate information on potential vested benefits, currently sent in the Potential Private Retirement Benefit Information notice, with the information provided in the Social Security earnings and benefits statement.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA disagreed with this recommendation, but did seek legal guidance to determine if it is permissible to include a general statement encouraging potential beneficiaries to pursue any external pension benefits in its benefit Statement. SSA's Office of the General Counsel determined that it would be permissible as long as it includes information required by law and the information is accurate. However, SSA continues to believe that adding such information would place SSA in a position to respond to issues or questions about ERISA and private pension plans, which SSA considers to be outside its mission and about which the agency has no firsthand legal or operational knowledge. Also, SSA believes that the current benefit Statement adequately covers the fact that people need other savings, pensions, and investments. Also, SSA sends notices to people who it believes quality for other pensions. In FY17, SSA reported no change in status to this recommendation. We continue to agree with SSA's view about providing information or advice about private pension plans generally. However, SSA's Notice of Potential Private Retirement Benefit Information already directs recipients to contact DOL with any questions, and we would expect that any changes made to make information on potential vested plan benefits more accessible to individuals before retirement - such as including the information in Social Security earnings and benefit statements - would continue to direct recipients to contact DOL with questions about ERISA policy. Furthermore, we continue to believe that individuals should receive information on any potential vested plan benefits prior to retirement.
    Recommendation: To prevent forced-transfer IRA balances from decreasing due to the low returns of the investment options currently permitted under the Department of Labor's safe harbor regulation, the Secretary of Labor should expand the investment alternatives available. For example, the forced-transfer IRA safe harbor regulations could be revised to include investment options currently under the qualified default investment alternatives regulation applicable to automatic enrollment, and permit forced-transfer IRA providers to change the investments for IRAs already established.

    Agency: Department of Labor
    Status: Open

    Comments: As of July 2017, DOL declines to adopt this recommendation. DOL noted if GAO?s comments are interpreted to mean that the recommended safe harbor revisions would free plan fiduciaries from an obligation to make a prudent selection among such a broader range of investment alternatives, then it raises significant policy issues regarding the administration of ERISA?s fiduciary duty provisions. DOL also noted that if, on the other hand, GAO's recommendation would have the safe harbor require the responsible plan fiduciary be responsible for prudently deciding whether to use a higher risk investment alternative, employers and other plan sponsors may oppose such a change. Our recommendation does not comment on or suggest changes to the obligations of plan fiduciaries as part of a change to the safe harbor. Further, GAO has made prior recommendations that DOL clarify the definition of fiduciary for purposes of investment, including a requirement that plan service providers, when assisting participants with distribution options, disclose any financial interests they may have in the outcome of those decisions in a clear, consistent, and prominent manner; the conditions under which they are subject to any regulatory standards (such as ERISA fiduciary standards, SEC standards, or others); and what those standards mean for the participant. Our recommendation is to "expand the investment options available" and we have noted that qualified default investment alternatives could be one option. Previously, DOL has stated that the limited investments under the safe harbor are appropriate because Congress' intent for the safe harbor was to preserve principal transferred out of plans. DOL noted that given the small balances and the inability of absent participants to monitor investments, the current conservative investment options are a more appropriate way to preserve principal. However, the current forced-transfer IRA investment options like money market funds can protect principal from investment risk, but not from the risk that fees (no matter how reasonable) and inflation can result in decreased account balances due to returns on these small balance accounts not keeping pace with fees. The reality has been that many forced-transfer IRAs have experienced very large and even complete declines in principal. Our recommendation did not aim to eliminate any investment alternatives covered by the safe harbor, rather it aims to expand the alternatives available so that plans and providers that want to operate under the safe harbor have the opportunity to choose the most suitable investment. We continue to encourage DOL to expand the safe harbor to include investment alternatives more likely to preserve principal and even increase it over time.
    Director: Cosgrove, James C
    Phone: (202) 512-7114

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

    Agency: Congress
    Status: Open

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

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

    Comments: In August 2013, we recommended that the Administrator of the Centers for Medicare & Medicaid Services (CMS) insert a self-referral flag on its Medicare Part B claims form, require providers to indicate whether the intensity-modulated radiation therapy (IMRT) service for which a provider bills Medicare is self-referred, and monitor the effects that self-referral has on costs and beneficiary treatment selection. The Department of Health and Human Services (HHS) did not concur with this recommendation, noting that CMS does not believe that this recommendation will address overutilization that occurs as a result of self-referral, would be complex to administer, and may have unintended consequences. We continue to believe that such a flag on Part B claims would likely be the easiest and most cost-effective way for CMS to identify self-referred IMRT services and monitor the effects of self-referral. As of June 2017, CMS has not provided any additional information about actions it has taken to address this recommendation.
    Director: Cosgrove, James C
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: In order to improve CMS's ability to identify self-referred anatomic pathology services and help CMS avoid unnecessary increases in these services, the Administrator of CMS should insert a self-referral flag on Medicare Part B claim forms and require providers to indicate whether the anatomic pathology services for which the provider bills Medicare are self-referred or not.

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

    Comments: In June 2013, we recommended that the Administrator of the Centers for Medicare & Medicaid Services (CMS) insert a self-referral flag on Medicare Part B claim forms and require providers to indicate whether the anatomic pathology services for which the provider bills Medicare are self-referred or not. The Department of Health and Human Services (HHS) did not concur with this recommendation, noting that CMS does not believe that this recommendation will address overutilization that occurs as a result of self-referral. We continue to believe that such a flag on Part B claims would likely be the easiest and most cost-effective way for CMS to identify self-referred anatomic pathology services and monitor the behavior of those providers who self-refer these services. As of June 2017, CMS has not provided any additional information about actions to address this recommendation.
    Recommendation: In order to improve CMS's ability to identify self-referred anatomic pathology services and help CMS avoid unnecessary increases in these services, the Administrator of CMS should determine and implement an approach to ensure the appropriateness of biopsy procedures performed by self-referring providers.

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

    Comments: In June 2013, we recommended that the Administrator of the Centers for Medicare & Medicaid Services (CMS) implement an approach to ensure the appropriateness of biopsy procedures performed by self-referring providers. The Department of Health and Human Services (HHS) does not concur with this recommendation and does not believe it would address overutilization that occurs as a result of self-referral. HHS noted that it would be difficult to make recommendations regarding whether anatomic pathology services are appropriate without reviewing a large number of claims. We continue to believe that it is important for CMS to monitor the self-referral of anatomic pathology services on an ongoing basis and determine if those services are inappropriate or unnecessary. We also continue to believe this can be achieved without reviewing a large number of claims. CMS could, for example, consider performing targeted audits of providers that perform a higher average number of biopsy procedures compared to providers of the same specialty treating similar numbers of Medicare beneficiaries. As of June 2017, CMS has not provided any additional information about actions to address this recommendation.
    Recommendation: In order to improve CMS's ability to identify self-referred anatomic pathology services and help CMS avoid unnecessary increases in these services, the Administrator of CMS should develop and implement a payment approach for anatomic pathology services that would limit the financial incentives associated with referring a higher number of specimens--or anatomic pathology services--per biopsy procedure.

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

    Comments: In June 2013, we recommended that the Administrator of the Centers for Medicare & Medicaid Services (CMS) develop and implement a payment approach for anatomic pathology services under the Physician Fee Schedule that would limit the financial incentives associated with referring a higher number of specimens--anatomic pathology services--per biopsy procedure. Although health care providers have discretion in determining the number of tissue samples from biopsy procedures that become specimens (anatomic pathology services), CMS's current payment system under the Physician Fee Schedule provides a financial incentive for providers to refer more specimens per biopsy procedure. Specifically, CMS pays for each specimen that a provider submits to be analyzed. HHS indicated that it concurred with our recommendation and that it had addressed this recommendation by reducing payment for the most commonly furnished anatomic pathology service (Current Procedural Terminology [CPT] code 88305) by approximately 30 percent in calendar year 2013. However, CMS's payment reduction did not change the financial incentive providers have to refer more specimens per biopsy procedure because they will still be paid separately for each specimen submitted. We continue to believe that CMS should develop a payment approach that addresses this incentive. As of June 2017, CMS had not provided any additional information about actions it has taken to address this recommendation.
    Director: Bagdoyan, Seto J
    Phone: (202) 512-4749

    1 open recommendations
    Recommendation: Congress should consider granting Labor the additional authority it is seeking to access wage data to help verify claimants' reported income and help ensure the proper payment of benefits.

    Agency: Congress
    Status: Open

    Comments: No legislation introduced as of February 2017. The Workers' Compensation Reform Act of 2015 (S. 2051, title V) was introduced in the 114th Congress. It would have allowed DOL to access wage data, as GAO suggested in April 2013, from the National Directory of New Hires to improve the integrity of the Federal Employees' Compensation Act program, among other actions. If introduced in the 115th Congress and enacted, this legislation could help to prevent and detect improper payments in the Federal Employees' Compensation Act program.
    Director: Cosgrove, James C
    Phone: (202)512-7029

    3 open recommendations
    including 3 priority recommendations
    Recommendation: In order to improve CMS's ability to identify self-referred advanced imaging services and help CMS address the increases in these services, the Administrator of CMS should insert a self-referral flag on its Medicare Part B claims form and require providers to indicate whether the advanced imaging services for which a provider bills Medicare are self-referred or not.

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

    Comments: HHS did not concur with this recommendation, noting that CMS did not think this recommendation would be effective in addressing overutilization resulting from self-referral and that it would be complex to administer. We continue to believe that such a flag on Part B claims would likely be the easiest and most cost-effective way for CMS to identify self-referred advanced imaging services and monitor the behavior of those providers who self-refer these services even though the agency has no plans to take further action. As of October 2016, CMS has not provided any additional information about actions to address this recommendation.
    Recommendation: In order to improve CMS's ability to identify self-referred advanced imaging services and help CMS address the increases in these services, the Administrator of CMS should determine and implement a payment reduction for self-referred advanced imaging services to recognize efficiencies when the same provider refers and performs a service.

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

    Comments: HHS did not concur with this recommendation, noting that CMS did not believe that a payment reduction would address overutilization that occurs as a result of self-referral and that the agency's multiple procedure payment reduction policy for advanced imaging already captures efficiencies inhering in providing multiple advanced imaging services by the same physician. Further, CMS officials stated that providers in self-referring arrangements could avoid this reduction by having one provider refer an advanced imaging service while having another perform the service. Finally, CMS questioned whether implementing our recommendation would violate the Medicare statute prohibiting paying a differential by physician specialty for the same service. Our recommendation, however, refers to specific self-referral arrangements in which the same provider refers and performs an imaging service, and therefore would not be addressed by CMS's multiple procedure payment reduction policy. As noted in our report, this payment reduction would affect about 10 percent of advanced imaging services referred by self-referring providers. In addition, while CMS raised questions about whether implementing our recommendation would violate Medicare's prohibition on paying a differential by physician specialty for the same service, the agency did not indicate how it would do so as of October 2016. We continue to believe that CMS should determine and implement a payment reduction to recognize efficiencies for advanced imaging services referred and performed by the same provider even though, as of October 2016, the agency has no plans to take further action.
    Recommendation: In order to improve CMS's ability to identify self-referred advanced imaging services and help CMS address the increases in these services, the Administrator of CMS should determine and implement an approach to ensure the appropriateness of advanced imaging services referred by self-referring providers.

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

    Comments: HHS noted that it would consider this recommendation. The Secretary of HHS has the authority to establish a program to promote the use of appropriate use criteria - criteria that are evidenced-based (to the extent feasible) and that assist professionals to make the most appropriate treatment decisions for a specified clinical condition - for advanced imaging services under the Protecting Access to Medicare Act of 2014. CMS has begun developing its appropriate use criteria program (e.g., in November 2015, CMS established criteria to identify Qualified Provider Led Entities that are responsible for developing appropriate use criteria and has since selected Qualified Provider Led Entities), but full implementation of the program will not occur until at least January 1, 2018. If it - and the subsequent prior authorization program that incorporates appropriate use criteria - are implemented broadly enough (i.e., they ensure the appropriateness of advanced imaging services by all physicians, including those who self-refer), we could close the recommendation.
    Director: White, James
    Phone: (202) 512-3000

    1 open recommendations
    Recommendation: The Congress may wish to consider broadening IRS's ability to use math error authority (MEA), with appropriate safeguards against misuse of that authority.

    Agency: Congress
    Status: Open

    Comments: Congress has expanded IRS's math error authority in certain circumstances, but not as broadly as we suggested in February 2010. Congress enacted legislation in December 2015 that expands the circumstances in which IRS may use math error authority. Section 208 of division Q of the Consolidated Appropriations Act, 2016 (Public Law 114-113) gives IRS the authority to use math error authority if (1) a taxpayer claimed the Earned Income Tax Credit, Child Tax Credit, or the American Opportunity Tax Credit (AOTC) during the period in which a taxpayer is not permitted to claim such credit as a consequence of either having made a prior fraudulent or reckless claim; or (2) a taxpayer omitted information required to be reported because the taxpayer made prior improper claims of the Child Tax Credit or the AOTC. While expanding math error authority is consistent with what we recommended Congress consider, we had suggested that math error authority be authorized on a broader basis with appropriate controls rather than on a piecemeal basis. Our previous work has identified additional tax provisions for which expanded math error authority would be helpful, such as the First-Time Homebuyer Credit, Individual Retirement Accounts, and Residential Energy Property Credit. While Congress expanded math error authority for the First-Time Homebuyer Credit in November 2009 and for other individual credits as previously described, we maintain that a broader authorization of math error authority with appropriate controls would enable IRS to correct obvious noncompliance, would be less intrusive and burdensome to taxpayers than audits, and would potentially help taxpayers who underclaim tax benefits to which they are entitled. If Congress decides to extend broader math error authority to IRS, controls may be needed to ensure that this authority is used properly. Our prior work identified potential controls, such as requiring IRS to report on its use of math error authority. The administration also requested that Congress grant the Department of the Treasury regulatory authority to expand IRS's use of math error authority as part of its budget submission for fiscal year 2017. The 114th Congress did not provide Treasury with such authority. The Joint Committee on Taxation estimated this change could raise $274 million through fiscal years 2018 through 2026.
    Director: White, James R
    Phone: (202) 512-5594

    1 open recommendations
    Recommendation: Given the potential for improving compliance now and in the future, Congress may wish to provide IRS with the authority to use math error checks to identify and correct returns with ineligible (1) IRA "catch-up" contributions, and (2) contributions to traditional IRAs from taxpayers over age 70-1/2.

    Agency: Congress
    Status: Open

    Comments: As of April 2017, the Congress has not provided IRS with the math error authority to ensure that taxpayers comply with certain catch-up and contributions requirements.
    Director: Shames, Lisa R
    Phone: (202)512-2649

    5 open recommendations
    Recommendation: To better ensure sufficient oversight and management direction are provided to guide USDA's civil rights efforts, to make responsibility for improvement clear, and to make USDA's performance more transparent, Congress may wish to consider making USDA's Assistant Secretary for Civil Rights subject to a statutory performance agreement.

    Agency: Congress
    Status: Open

    Comments: As of September 2013, action on a new farm bill is pending and it is not known whether Congress will make the Assistant Secretary subject to a performance agreement.
    Recommendation: To better ensure sufficient oversight and management direction are provided to guide USDA's civil rights efforts, to make responsibility for improvement clear, and to make USDA's performance more transparent, Congress may wish to consider establishing a USDA civil rights oversight board.

    Agency: Congress
    Status: Open

    Comments: As of September 2013, action on a new farm bill is pending and it is not known whether Congress will establish a USDA civil rights oversight board.
    Recommendation: To improve USDA efforts to address civil rights issues and the participation of minority farmers and ranchers in USDA programs, the Secretary of Agriculture should prepare and implement an improvement plan for resolving discrimination complaints that sets time frame goals and provides management controls for resolving complaints from beginning to end.

    Agency: Department of Agriculture
    Status: Open

    Comments: USDA has not fully implemented this recommendation. As of August 2012, USDA had developed a plan to improve resolution of discrimination complaints, and the Office of the Assistant Secretary for Civil Rights (OASCR) had implemented many of the plan's actions, such as placing priority on processing program complaints facing the statute of limitations. However, USDA had more work to do on (1) establishing an electronic records management system; (2) implementing the Lean Six Sigma (LSS) process; (3) conducting pilot efforts to explore establishing new time frame goals for intake, investigation, and adjudication activities to resolve employee and program complaints; and (4) providing documentation of new policies, procedures, guidance, and training needed to determine if new management controls cover the entire process for resolving complaints. As of September 2013, OASCR's electronic complaints management systems allow OASCR to scan in, store, and retrieve multiple records in a searchable environment. OASCR undertook a review of the program complaint process through LSS, and based on the results, extended the scope of the review to include the employment complaint process. OASCR implemented core changes through LSS that identify efficiencies to reduce time frames. OASCR has established time frame goals for processing program complaints; however, it has yet to establish them for investigating and adjudicating employment complaints. Time frame goals for the entire employment complaint resolution process would have to be final before management controls can be made final.
    Recommendation: To improve USDA efforts to address civil rights issues and the participation of minority farmers and ranchers in USDA programs, the Secretary of Agriculture should develop and implement a plan to ensure the accuracy, completeness and reliability of ASCR's databases on customer and employee complaints, and that provides for independent validation of ASCR's data quality.

    Agency: Department of Agriculture
    Status: Open

    Comments: USDA has not fully implemented this recommendation. As of August 2012, the Office of the Assistant Secretary for Civil Rights' (OASCR) efforts to ensure data reliability of the iComplaints employee complaints database included a comprehensive set of business rules, a data integrity tool, and a quality review management module. Also, OASCR had developed and was implementing a plan to check the accuracy of the data entered for every program complaint in the Program Complaints Management System (PCMS). However, OASCR had not provided all of the documentation needed to assess whether its planned efforts contain key elements to ensure the accuracy, completeness, and reliability of the iComplaints and PCMS databases. For example, OASCR officials had neither provided documentation showing that the office developed departmental policy to ensure the consistent use of iComplaints and PCMS nor training to ensure the completeness of data in PCMS. As of September 2013, OASCR officials provided standard operating procedures (SOPs) for processing program complaints, which include numerous steps to ensure the consistent use of PCMS. OASCR officials also provided SOPs for processing employment complaints; however, the SOPs have not been finalized for the investigation and adjudication phases of the processing and are therefore insufficient to ensure the consistent use of iComplaints. OASCR officials did provide documentation showing that OASCR has established a formal training program to ensure that OASCR and USDA civil rights practitioners are trained in the proper use of PCMS and iComplaints. In addition, the PCMS Data Integrity Team is working to correct discrepancies found as of October 2012. This effort is 85 percent complete.
    Recommendation: To improve USDA efforts to address civil rights issues and the participation of minority farmers and ranchers in USDA programs, the Secretary of Agriculture should develop a results-oriented department-level strategic plan for civil rights at USDA that unifies USDA's departmental approach with that of ASCR and the newly created Office of Advocacy and Outreach and that is transparent about USDA's efforts to address the concerns of stakeholders.

    Agency: Department of Agriculture
    Status: Open

    Comments: USDA has not fully implemented this recommendation. As of August 2012, the Office of the Assistant Secretary for Civil Rights (OASCR) had not updated its strategic plan since our report was issued in October 2008. From October 1, 2009, to November 20, 2011, OASCR was placed under Departmental Management and during that time was not required to develop or update its own strategic plan, according to OASCR officials. Since November 20, 2011, OASCR has reported directly to the Secretary and has been working to develop its own strategic plan. On July 31, 2012, we obtained a revised draft of OASCR's strategic plan that covers fiscal years 2011-2015. This draft still has a number of shortcomings. For example, it (1) focuses primarily on the activities OASCR plans and does not unify OASCR's approach with the Office of Advocacy and Outreach, other USDA agencies, or the department as a whole; (2) does not describe the viewpoints and interests of USDA's external stakeholders, such as community-based organizations; and (3) does not fully address other key issues identified in our report, such as measuring performance to gauge progress, using performance information for identifying performance gaps and making program improvements, and identifying external and internal factors that can influence the achievement of its long-term goals. As of September 2013, OASCR had, by November 2012, finalized and published its strategic plan for fiscal years 2011-2015. The published plan includes some time frame goals for processing program and employment complaints, but these goals are incomplete. The published plan also includes some minor editorial changes, but otherwise, it was almost identical to the draft plan we reviewed in July 2012 and still has the same shortcomings that we identified at that time.
    Director: Aronovitz, Leslie G
    Phone: (312)220-7767

    1 open recommendations
    Recommendation: The Administrator of CMS should require the PSCs to develop thresholds for unexplained increases in billing--and use them to develop automated prepayment controls as one component of their manual medical review strategies.

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

    Comments: Despite progress in identifying potentially improper groups of claims by provider, CMS has not developed thresholds for unexplained increases in billing by providers and used them to develop automated prepayment controls, as GAO recommended in January 2007. CMS took action in July 2011 to improve Medicare payment accuracy by introducing predictive analytics to help identify patterns of potentially improper claims and has some other prepayment controls in place. Specifically, the Small Business Jobs Act of 2010 requires CMS to use predictive modeling and other analytic techniques?known as predictive analytic technologies?to identify improper claims and prevent improper payments under the Medicare fee-for-service program. CMS is streaming every Medicare fee-for-service claim through a predictive modeling technology system, known as the Fraud Prevention System (FPS), prior to payment. The FPS uses a series of algorithms to identify potentially fraudulent claims. As each claim streams through the FPS, the system builds profiles of providers, networks, and billing patterns. Using these profiles, CMS estimates a claim's likelihood of being fraudulent and prioritizes providers with the most suspicious groups of claims for further investigation. CMS also has other prepayment controls in place, for example, to identify duplicate billing. As of December 2015, CMS did have algorithms in FPS to flag providers with unexpected increases in billings for investigation. CMS also instituted prepayment controls that can deny a claim before payment, however these controls are related to Medicare coverage requirements and do not address the issue of large increases in provider billing. Prepayment controls can suspend claims processing or deny claims before claims are paid, which would provide a greater assurance that Medicare funds are not going to potentially fraudulent providers. As of August 2016, HHS officials reported that they have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.