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Open Recommendations (124 total)

Medicaid Program Integrity: Opportunities Exist for CMS to Strengthen Use of State Auditor Findings and Collaboration

GAO-23-105881
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2 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should annually examine state auditors' Medicaid findings to identify trends across states and use this information to inform oversight activities and audit processes. (Recommendation 1)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
Centers for Medicare & Medicaid Services The Administrator of CMS should build on the agency's efforts to collaborate with state auditors on Medicaid oversight activities. These collaboration efforts should include continuing to identify potential updates to the Compliance Supplement, having regular discussions to address auditor training needs, annually sharing information on trends in audit findings and program risks, and increasing auditor awareness of actions taken to address single audit findings. (Recommendation 2)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Medicare Part D: CMS Should Monitor Effects of Rebates on Plan Formularies and Beneficiary Spending

GAO-23-105270
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should monitor the effect of rebates on plan sponsor formulary design and on Medicare and beneficiary spending to assess whether rebate practices are likely to substantially discourage enrollment by certain beneficiaries.
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Medicaid: CMS Oversight and Guidance Could Improve Recovery Audit Contractor Program

GAO-23-106025
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2 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should conduct a study to determine whether it is cost effective to require states to include payments to managed care organizations and their providers as part of the RAC program. (Recommendation 4)
Open
In its comments on our draft report, CMS said that states are permitted to tailor their Recovery Audit Contractor (RAC) programs to their specific needs and environment. In addition, CMS said states have many other ways to oversee managed care improper payments. While CMS suggested that we remove our recommendation, we stand by our suggested course of action. CMS already has established a framework that allows states to request exemptions from the RAC program to address their specific needs and environment, irrespective of whether managed care is required to be included in Medicaid RAC program. CMS further stated that it must be mindful of time and resources, and that conducting a study regarding the cost-effectiveness of requiring all states to include managed care in their RAC programs may not be the most efficient use of time and resources. CMS stated that many states with large managed care populations have reported that the contingency fee payment methodology is not financially feasible for managed care encounters. While it is important that CMS use its resources efficiently, it is also essential that states use Medicaid funds effectively. CMS plays a key role in helping ensure that states make Medicaid payments appropriately. As part of this role, CMS can determine whether including managed care payments in the RAC program would be cost effective for the overall program. If the RAC scope was to include managed care claims, this could generate sufficient revenue to support a RAC program. Therefore, we continue to believe that our recommendation for CMS to conduct a cost-effectiveness study is valid.
Centers for Medicare & Medicaid Services The Administrator of CMS should establish and implement written policies and procedures to document and communicate an expiration date when approving SPAs that have a full exemption from the RAC program. (Recommendation 1)
Open
In its comments on our draft report, HHS stated that it concurred with the recommendation and that CMS will work to establish and implement written policies and procedures to document and communicate an expiration date to Recovery Audit Contractor (RAC) programs exemption state plan amendments (SPA).

Medicaid: CMS Oversight and Guidance Could Improve Recovery Audit Contractor Program

GAO-23-106025
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2 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should establish and implement written policies and procedures for the agency to monitor SPA expiration dates. (Recommendation 2)
Open
In its comments on our draft report, HHS stated that it concurred with this recommendation and that CMS will work to establish and implement written policies and procedures for the agency to monitor state plan amendment (SPA) expiration dates.
Centers for Medicare & Medicaid Services The Administrator of CMS, in collaboration with the states, should describe the effectiveness of the RAC program and include recommendations, if any, for expanding or improving the program in their annual report to Congress. (Recommendation 3)
Open
In its comments on our draft report, HHS stated that it partially concurred with this recommendation. Specifically, CMS stated that it concurs with the recommendation to make information available to expand or improve the Recovery Audit Contractor (RAC) program. CMS stated it plans to add certain information to the annual Medicare and Medicaid Program Integrity Report to Congress. This added information includes a breakdown of the states with full or partial exemptions, and promising state practices in RAC administration that other states may use when determining if and how to administer a RAC program. CMS further stated its current identification of RAC overpayment recoveries in the report already satisfies the statutory requirement to report on the effectiveness of states' Medicaid RAC programs. We agree that the reporting of RAC overpayment recoveries is important for determining the effectiveness of the Medicaid RAC program. However, Congress and other external stakeholders do not have other important information that would help them monitor how well the Medicaid RAC program is identifying and reducing improper payments. One such metric is a breakout of overpayments collected, underpayments restored, and amounts overturned on appeal. CMS's planned actions would help meet the intent of our recommendation, if effectively implemented.

Payment Integrity: Additional Coordination Is Needed for Assessing Risks in the Improper Payment Estimation Process for Advance Premium Tax Credits

GAO-23-105577
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator for CMS should, in coordination with the states, assess and identify residual risks to which the SBMs may be vulnerable related to eligibility determinations and take these risks into account when developing and implementing the improper APTC payment estimation methodology for the SBMs. (Recommendation 1)
Open
The Department of Health and Human Services (HHS) disagreed with our recommendation. HHS stated that in 2019 HHS developed an initiative to provide state-based marketplaces (SBM) with an opportunity to voluntarily engage with HHS to prepare for future measurement of improper advance premium tax credit payments. However, we found that HHS's Centers for Medicare & Medicaid Services' (CMS) initiative did not include a process to identify and consider residual risks that may result from SBMs' eligibility determinations. In September 2023, HHS indicated it continues to non-concur with this recommendation and considers it closed - not implemented. In addition, HHS stated that the Payment Integrity Information Act of 2019 and the Office of Management and Budget (OMB) guidance in Appendix C to Circular A-123 do not reference any requirements related to the assessment of residual risk. Further, HHS stated the recommendation to assess and identify residual risks would be redundant with CMS's existing approach to developing the improper payment measurement methodology. However, as discussed in our report, OMB guidance states management must perform an assessment to identify and evaluate the potential payment integrity risks that the agency faces and that the identification of payment integrity risks should be a continuous process. Further, OMB encourages agencies to ensure that significant payment integrity risks are part of the estimation methodology so that estimates can be used to assist in identifying root causes. Without first identifying residual risks, there is an increased likelihood that CMS's estimation methodology may not address key risks of improper payments, such as those related to eligibility determinations. Therefore, we continue to believe that our recommendation is valid.

Payment Integrity: Additional Coordination Is Needed for Assessing Risks in the Improper Payment Estimation Process for Advance Premium Tax Credits

GAO-23-105577
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator for CMS should, in coordination with the states, assess and identify residual risks to which the SBMs may be vulnerable related to eligibility determinations and identify any additional guidance or other actions, as needed, to mitigate any residual risks within the SBMs. (Recommendation 2)
Open
The Department of Health and Human Services (HHS) disagreed with our recommendation. In September 2023, HHS indicated it considers this recommendation to be closed - not implemented. HHS stated that the Patient Protection and Affordable Care Act (PPACA) provides states with flexibility in the design and operation of their marketplaces, within federal rules, to best meet the unique needs of their residents and insurance markets. HHS further stated that Centers for Medicare & Medicaid Services (CMS) regulations specify a set of eligibility verification requirements that all marketplaces, including state-based marketplaces (SBM), must follow and allow flexibility for how certain eligibility verification requirements should be met. We acknowledge in the report that PPACA and CMS regulations provide flexibilities related to certain eligibility verification requirements, in part due to whether reliable data sources are available that would allow a marketplace to verify eligibility criteria. However, with such flexibilities, we believe it is important that CMS, in coordination with SBMs, evaluates the risks in making improper eligibility determinations and identifies any additional guidance or actions, if needed, to mitigate those risks. Therefore, we continue to believe that our recommendation is valid.

Medicare Advantage: Plans Generally Offered Some Supplemental Benefits, but CMS Has Limited Data on Utilization

GAO-23-105527
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should clarify guidance to MA plans on the extent to which encounter data submissions must include data on the utilization of supplemental benefits. (Recommendation 1)
Open
HHS concurred with this recommendation. As of July 2023, HHS reported that it was working to issue guidance on the inclusion of supplemental benefits in encounter data submissions. HHS noted that, under federal regulations, each MA plan must submit to CMS the data necessary to characterize the context and purposes of each item and services provided to a Medicare enrollee by a provider, supplier, physician, or other practitioner. HHS indicated that it planned to send updated guidance to remind MA plans of this regulatory obligation and to clarify that this obligation extends to supplemental benefits. We will update the status of this recommendation when we receive additional information.
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