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    Results:

    Subject Term: Fee-for-service

    10 publications with a total of 21 open recommendations including 4 priority recommendations
    Director: King, Kathleen M
    Phone: (202) 512-7114

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

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

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

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

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

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

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

    4 open recommendations
    Recommendation: To improve the collection of complete and consistent personal care services data and better ensure CMS can effectively monitor the states' provision of and spending on Medicaid personal care services, CMS should establish standard reporting guidance for personal care services collected through Transformed-MSIS (T-MSIS) to ensure that key data reported by states, such as procedure codes, provider identification numbers, units of service, and dates of service, are complete and consistent.

    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 improve the collection of complete and consistent personal care services data and better ensure CMS can effectively monitor the states' provision of and spending on Medicaid personal care services, CMS should better ensure, for all types of personal care services programs, that data on provision of personal care services and other home-and community-based services (HCBS) collected through T-MSIS claims can be specifically linked to the expenditure lines on the CMS-64 that correspond with those particular types of HCBS services.

    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 improve the collection of complete and consistent personal care services data and better ensure CMS can effectively monitor the states' provision of and spending on Medicaid personal care services, CMS should better ensure that personal care services data collected from states through T-MSIS and MBES comply with CMS reporting requirements.

    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 improve the collection of complete and consistent personal care services data and better ensure CMS can effectively monitor the states' provision of and spending on Medicaid personal care services, CMS should develop plans for analyzing and using personal care services data for program management and oversight.

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

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

    2 open recommendations
    Recommendation: To help the Department of Health and Human Services ensure accuracy in Part B drug payment rates, Congress should consider requiring all manufacturers of Part B drugs paid at ASP, not only those with Medicaid drug rebate agreements, to submit sales price data to CMS, and ensure that CMS has authority to request source documentation to periodically validate all such data.

    Agency: Congress
    Status: Open

    Comments: As of August 2017, no action has been taken on this Matter for Congressional Consideration.
    Recommendation: CMS should periodically verify the sales price data submitted by a sample of drug manufacturers by requesting source documentation from manufacturers to corroborate the reported data, either directly or by working with the HHS Office of Inspector General as necessary.

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

    Comments: In its comments on a draft of this report, HHS concurred with this recommendation. HHS stated that it will continue to work with the Office of Inspector General (OIG) as appropriate to collect source documentation from drug manufacturers and take action as may be warranted. HHS also stated that OIG reviews and compares the submitted average sales price (ASP) to the average manufacturer price (AMP) for Medicare Part B drugs and CMS has the authority to adjust ASP-based payment amounts when the difference between the two rates reaches a certain threshold. We do not consider this recommendation closed because CMS only collects source documentation from manufacturers under very limited circumstances (e.g., when there are obvious inconsistencies in the data submitted by manufacturers). CMS does not periodically request source documentation, such as sales invoices, from a sample of drug manufacturers to verify that the reported data reflect actual sales prices. As of August 17, 2017, CMS has not provided any additional information about actions to address this recommendation.
    Director: Kathleen King
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: To reduce the number of Medicare appeals and to strengthen oversight of the Medicare FFS appeals process, the Secretary of Health and Human Services should direct CMS, Office of Medicare Hearings and Appeals (OMHA), or Departmental Appeals Board (DAB) to modify the various Medicare appeals data systems to collect information on the reasons for appeal decisions at Level 3.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: According to HHS as of August 2016, OMHA and DAB were considering the cost and technical feasibility of collecting this information within their appeals data systems. As of September 2017, HHS officials have not implemented this recommendation. We will update the status of this recommendation when we receive additional information.
    Recommendation: To reduce the number of Medicare appeals and to strengthen oversight of the Medicare FFS appeals process, the Secretary of Health and Human Services should direct CMS, OMHA, or DAB to modify the various Medicare appeals data systems to capture the amount, or an estimate, of Medicare allowed charges at stake in appeals in Medicare Appeals System (MAS) and Medicare Operations Division Automated Case Tracking System (MODACTS).

    Agency: Department of Health and Human Services
    Status: Open

    Comments: According to HHS as of August 2016, this information was not captured in any CMS system, including MAS. HHS reported that if MAS is modified to capture the amount of Medicare allowed charges at stake, OMHA will consider modifying its Electronic Case Adjudication and Processing Environment (ECAPE) to include this information as well, and DAB can capture it in a new case management system currently being developed by the agency. As of September 2017, HHS officials have not implemented this recommendation. We will update the status of this recommendation when we receive additional information.
    Recommendation: To reduce the number of Medicare appeals and to strengthen oversight of the Medicare FFS appeals process, the Secretary of Health and Human Services should direct CMS, OMHA, or DAB to modify the various Medicare appeals data systems to collect consistent data across systems, including appeal categories and appeal decisions across MAS and MODACTS.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: According to HHS as of August 2016, HHS reported taking several initial steps to standardize data across Medicare appeals systems. Specifically, HHS stated that, in November 2016, CMS will modify MAS to standardize appeal categories between Levels 1 through 3 and that OMHA will incorporate the standardized MAS appeal categories for Levels 1 and 2 into ECAPE in its next release. DAB will also work to incorporate these standardized categories into its new appeals data system. In addition, HHS reported that CMS is working to modify MAS to collect additional information related to appeal decisions. As of September 2017, HHS officials have not implemented this recommendation. We will update the status of this recommendation when we receive additional information.
    Director: Kathleen M. King
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To strengthen oversight of the provision of care coordination services in the Financial Alignment Demonstration, the Secretary of Health and Human Services should direct the Administrator of CMS to expediently develop and require organizations in the capitated model, and the states in the MFFS model, to report comparable core data measures across the demonstration that measure the following: (1) the extent to which interdisciplinary care team meetings are occurring, and (2) for MFFS states, the extent to which health risk assessments are completed.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In April 2016, CMS officials told us they are exploring whether it would be feasible to identify and develop additional measures related to interdisciplinary care team meetings and health risk assessment completion within the demonstration period. For the first part of our recommendation, CMS officials said that they did not believe it was feasible to implement a care team measure during the demonstration period. For the second part of our recommendation, CMS officials said they had begun discussions with their existing CMS contractor about the level of effort required to develop and implement a health risk assessment measure in the Managed-Fee-For-Service (MFFS) demonstrations. CMS also planned to have discussions with the MFFS model states about the feasibility of collecting and reporting this type of data. As of June 2017, HHS officials have not informed us of any actions taken to implement this recommendation. We will update the status of this recommendation when we receive additional information.
    Recommendation: To strengthen oversight of the provision of care coordination services in the Financial Alignment Demonstration, the Secretary of Health and Human Services should direct the Administrator of CMS to align CMS's existing state-specific measures regarding the extent to which individualized care plans are being developed across the capitated and MFFS states to make them comparable and designate them as a core reporting requirement.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In April 2016, CMS officials said they planned to use an existing CMS contractor to develop a care plan measure that more closely aligns the specifications across demonstrations. As of June 2017, HHS officials have not informed us of any actions taken to implement this recommendation. We will update the status of this recommendation when we receive additional information.
    Director: Williamson, Randall B
    Phone: (202) 512-7114

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

    Agency: Department of Veterans Affairs
    Status: Open

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

    Agency: Department of Veterans Affairs
    Status: Open
    Priority recommendation

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

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: As of September 2015, VA has taken some actions to address this recommendation, but additional actions are needed to fully implement it. We will update the status of this recommendation when we receive additional information from VA.
    Director: King, Kathleen M
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To improve the effectiveness of the unpublished MUEs and better ensure Medicare program integrity, the CMS Administrator should consider periodically reviewing claims to identify the providers exceeding the unpublished MUE limits and determine whether their billing was proper.

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

    Comments: In its comments on a draft of this report, HHS concurred with this recommendation and indicated that CMS would conduct further analysis to determine the most appropriate way to respond. In July 2015, HHS told us that CMS has established a process to identify providers exceeding the unpublished MUE limits and determine whether their billing was proper. In August 2016, CMS informed us that the agency is developing a process to review provider level data to determine potential improper billing that exceeds unpublished MUE limits. However, as of September 2016, CMS has not yet implemented this process. We requested that CMS provide documentation of the process once it has been implemented. With this documentary support, we hope to close the recommendation.
    Director: King, Kathleen M
    Phone: (202) 512-7114

    1 open recommendations
    including 1 priority recommendation
    Recommendation: In order to promote greater use of effective prepayment edits and better ensure proper payment, and to promote implementation of effective edits based on national policies, the CMS Administrator should develop written procedures to provide guidance to agency staff on all steps in the processes for developing and implementing edits based on national policies, including (1) time frames for taking corrective actions, (2) methods for assessing the effects of corrective actions, and (3) procedures for ensuring consideration of automated edits whenever possible, including for all existing NCDs and other national policies.

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

    Comments: HHS concurred with this recommendation. CMS developed written procedures in November 2012 to provide guidance to agency staff on procedures for ensuring consideration of automated edits whenever possible, as GAO recommended in November 2012, but these procedures do not include several key elements of GAO's recommendation. For example, the written procedures do not include time frames for making decisions on whether an edit will be developed for all existing National Coverage Determinations (NCD) and national policies. The written procedures also do not include requirements for methods to assess the effects of corrective actions taken. Implementing a comprehensive written process for developing edits for national policies could help ensure that edits are implemented whenever possible to reduce improper payments. As of September 2017, CMS had not provided us updated documentation that addressed these aspects of our recommendation. Once received, we will review the information and update this recommendation accordingly.
    Director: Cosgrove, James C
    Phone: (202)512-7029

    1 open recommendations
    including 1 priority recommendation
    Recommendation: To increase D-SNPs' accountability and ensure that CMS has the information it needs to determine whether D-SNPs are providing the services needed by dual-eligible beneficiaries, especially those who are most vulnerable, the Administrator of CMS should conduct an evaluation of the extent to which D-SNPs have provided sufficient and appropriate care to the population they serve, and report the results in a timely manner.

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

    Comments: As of October 2016, HHS has not implemented this recommendation. CMS noted that, in 2012, they conducted two independent reviews to evaluate how well SNPs, including D-SNPs, developed and implemented a quality improvement tool used to ensure that the unique needs of SNP enrollees are identified and addressed through the plan's care management practices. However, CMS has not conducted an evaluation of the extent to which D-SNPs have provided sufficient and appropriate care to the population they serve. In prior updates, CMS officials said that they were uncertain whether an evaluation of D-SNPs would be conducted in the future, since the likelihood of an evaluation would be dependent on availability of funding for an independent contract. However, they noted that, to the extent that CMS is able to develop solid care coordination outcome measures (which would be incorporated into the HEDIS requirements), that they expect these measures will serve as key indicators of D-SNP performance. For this recommendation to be closed as implemented, CMS will need to conduct an evaluation of the extent to which D-SNPs have provided sufficient and appropriate care to the population they serve.
    Director: Cosgrove, James C
    Phone: (202) 512-7114

    1 open recommendations
    including 1 priority recommendation
    Recommendation: To help ensure appropriate payments to MA plans, the Administrator of CMS should take steps to improve the accuracy of the adjustment made for differences in diagnostic coding practices between MA and Medicare FFS. Such steps could include, for example, accounting for additional beneficiary characteristics, including the most current data available, identifying and accounting for all years of coding differences that could affect the payment year for which an adjustment is made, and incorporating the trend of the impact of coding differences on risk scores.

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

    Comments: CMS noted in the Medicaid Advantage Call Letter of April 2016 that it has extensively analyzed the MA data and determined that the optimal way to apply the adjustment is to do so using the statutory minimum adjustment level of 5.66 percent. However, as of October 2016, CMS had not provided any documentation of its analysis and the basis for its determination. CMS has requested a meeting with GAO to discuss the issues and GAO will meet with CMS. However, until we receive additional information about the actions CMS has taken, this recommendation remains open.