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Centers for Medicare & Medicaid Services

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Open Recommendations (116 total)

Medicare and Medicaid: CMS Should Assess Documentation Necessary to Identify Improper Payments

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1 Open Recommendations
Agency Affected Recommendation Status Sort descending
Centers for Medicare & Medicaid Services The Administrator of CMS should take steps to ensure that Medicaid medical reviews provide robust information about and result in corrective actions that effectively address the underlying causes of improper payments. Such steps could include adjusting the sampling approach to reflect state-specific program risks, and working with state Medicaid agencies to leverage other sources of information, such as state auditor and the Department of Health and Human Services' Office of the Inspector General findings. (Recommendation 2)
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The Department of Health and Human Services (HHS) did not concur with this recommendation. As of February 2024, HHS has stated that it does not plan to implement this recommendation because the agency believes the resource requirement is not justified based on the potential improper payment findings. HHS further stated that the agency already uses a variety of sources to identify and take corrective actions to address underlying causes of improper Medicaid payments. However, we found that the Centers for Medicare & Medicaid Services (CMS) and state Medicaid agencies are expending time and resources developing and implementing corrective actions that may not be representative of the underlying causes of improper payments in their states. Without robust information to effectively identify the underlying causes of improper payments, CMS and state Medicaid agencies may not develop corrective actions that effectively address Medicaid program risks.

Medicare: Higher Use of Costly Prostate Cancer Treatment by Providers Who Self-Refer Warrants Scrutiny

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1 Open Recommendations
Agency Affected Recommendation Status Sort descending
Centers for Medicare & Medicaid Services 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.
Open
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 agree that this recommendation would not directly address overutilization, but 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 July 2022, CMS has not provided any additional information about actions it has taken to address this recommendation.

Medicare Advantage: Fundamental Improvements Needed in CMS's Effort to Recover Substantial Amounts of Improper Payments

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1 Open Recommendations
Agency Affected Recommendation Status Sort descending
Centers for Medicare & Medicaid Services As CMS continues to implement and refine the contract-level RADV audit process to improve the efficiency and effectiveness of reducing and recovering improper payments. The Administrator should improve the timeliness of CMS's contract-level RADV appeal process by requiring that reconsideration decisions be rendered within a specified number of days comparable to other medical record review and first-level appeal time frames in the Medicare program.
Open
CMS is working to improve the timeliness of the agency's contract-level risk adjustment data validation appeals process, as GAO recommended in April 2016. In January 2023, CMS officials told us they are exploring policy options to standardize the timelines for RADV appeals at the reconsideration level. For example, CMS officials told GAO they are considering using the federal rulemaking process to establish uniform timelines to expedite the appeals process. Specifically, they plan to require that a findings determination be made within 60-90 days of an arbiter's receipt of each party's arguments at each stage of an appeal. As of February 2024, CMS reported it is reviewing and assessing the implementation of this recommendation. Until CMS takes such actions to improve the risk adjustment data validation contract-level audit process, it will fail to recover improper payments of hundreds of millions of dollars annually.

Medicaid Assisted Living Services: Improved Federal Oversight of Beneficiary Health and Welfare is Needed

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1 Open Recommendations
1 Priority
Agency Affected Recommendation Status Sort descending
Centers for Medicare & Medicaid Services
Priority Rec.
The Administrator of CMS should establish standard Medicaid reporting requirements for all states to annually report key information on critical incidents, considering, at a minimum, the type of critical incidents involving Medicaid beneficiaries, and the type of residential facilities, including assisted living facilities, where critical incidents occurred. (Recommendation 2)
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HHS neither agreed nor disagreed with this recommendation. As of January 2023, CMS had provided states with technical assistance on critical incident reporting, including providing training and an optional incident reporting template. CMS published a proposed rule in April 2023 that included provisions to standardize critical incident oversight, including requirements to report data to CMS. As of February 2024, CMS was reviewing public comments on the proposed rule. To fully implement this recommendation, CMS should establish standard Medicaid reporting requirements for all states to report critical incidents annually. If CMS finalizes the proposed rule, GAO will review and determine whether the recommendation has been implemented.

Medicaid: Further Action Needed to Expedite Use of National Data for Program Oversight

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1 Open Recommendations
Agency Affected Recommendation Status Sort descending
Centers for Medicare & Medicaid Services The Administrator of CMS should articulate a specific plan and associated time frames for using T-MSIS data for oversight. (Recommendation 2)
Open
HHS concurred with this recommendation. As of April 2022, CMS has partially addressed this recommendation by using T-MSIS data for program reporting in specific circumstances. For example, CMS has used T-MSIS data to: (1) report on states' participation in Money Follows the Person demonstrations under which states receive enhanced federal matching funds for health and community-based services; (2) monitor the effects of COVID-19 on Medicaid and CHIP enrollment and utilization; (3) replicate claims-based Child and Adult Core Set quality measures for Medicaid, which will help improve the agency's ability to evaluate all states' performance, as only some states report core quality measures; (4) create and publish an annual substance use disorder (SUD) data book, which includes information on the number of Medicaid beneficiaries with SUD and SUD-related services received, as well as assess the accuracy and completeness of state grantees' data regarding SUD provider types and services furnished; (5) populate certain measures in the Medicaid & CHIP Scorecard to increase public transparency about programs' administration and outcomes; and (6) develop a data clearinghouse to support business needs from different divisions of the agency. For example, CMS has used T-MSIS data to report the extent to which certain Medicaid beneficiaries received appropriate services, such as monitoring whether Medicaid beneficiaries aged 20 and under received appropriate services under the Early and Periodic Screening, Diagnostic, and Treatment benefit. Specifically, as of April 2021, states have had the option of having CMS populate their CMS-416 report with T-MSIS data to meet the program's reporting requirement, provided that their T-MSIS data are of sufficient quality. Despite this progress in using T-MSIS data to oversee components of the program, CMS has yet to establish specific plans for using T-MSIS for broader oversight purposes, such as program management and program integrity. Until CMS establishes specific plans and time frames for using T-MSIS for more comprehensive oversight purposes, including program integrity, progress towards T-MSIS' full potential will be limited. We will continue to monitor CMS's actions relevant to this recommendation.

Medicare: CMS Needs to Address Risks Posed by Provider Enrollment Waivers and Flexibilities

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1 Open Recommendations
Agency Affected Recommendation Status Sort descending
Centers for Medicare & Medicaid Services The Administrator of CMS should conduct fingerprint-based criminal background checks for high-risk provider types who enrolled during the COVID-19 public health emergency, such as when CMS revalidates these providers' information. (Recommendation 1)
Open
CMS issued regulations that became effective January 1, 2024 that authorize the agency to conduct fingerprint-based criminal background checks for providers that were in a high-risk category at the time of initial enrollment when these providers revalidate enrollment. This authority may help CMS detect criminal behavior among high-risk providers who enrolled in Medicare during the COVID-19 public health emergency. When we confirm what actions the agency has taken to conduct these background checks, we will provide updated information.

Health Care Quality: CMS Could More Effectively Ensure Its Quality Measurement Activities Promote Its Objectives

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1 Open Recommendations
Agency Affected Recommendation Status Sort descending
Centers for Medicare & Medicaid Services The Administrator of CMS should develop and use a set of performance indicators to evaluate the agency's progress towards achieving its quality measurement strategic objectives. (Recommendation 3)
Open
As of August 2023, CMS's responses to this recommendation have focused on a series of impact assessments for quality measures, most recently the 2021 National Impact Assessment of CMS Quality Measures Report. That report summarizes trends in the level of performance achieved on CMS's existing quality measures. However, this recommendation called on CMS to develop a separate set of performance indicators to assess the extent to which its quality measurement activities as a whole are achieving its strategic objectives for quality measurement, and to identify any gaps in meeting those goals. Such indicators would help CMS to make adjustments to its set of quality measures in order to more fully meet the strategic objectives it has established.

End-Stage Renal Disease: Medicare Payment Refinements Could Promote Increased Use of Home Dialysis

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1 Open Recommendations
Agency Affected Recommendation Status Sort descending
Centers for Medicare & Medicaid Services To ensure that patients with chronic kidney disease receive objective and timely education related to this condition, the Administrator of CMS should examine the Kidney Disease Education benefit and, if appropriate, seek legislation to revise the categories of providers and patients eligible for the benefit.
Open
As of February 2024, CMS has not implemented this recommendation. HHS did not agree with this recommendation and stated in June 2016 that CMS continuously works to pay appropriately for ESRD services and must prioritize its activities to improve care for dialysis patients. While we acknowledge the need for CMS to prioritize its activities to improve dialysis care, it is important for CMS to help ensure that Medicare patients with chronic kidney disease understand their condition, how to manage it, and the implications of the various treatment options available, particularly given the central role of patient choice in dialysis care. The limited use of the Kidney Disease Education benefit that we noted in our report suggests that it may be difficult for Medicare patients to receive this education and underscores the need for CMS to examine and potentially revise the benefit. We will update the status of this recommendation when we receive additional information.

340B Drug Discount Program: Oversight of the Intersection with the Medicaid Drug Rebate Program Needs Improvement

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1 Open Recommendations
Agency Affected Recommendation Status Sort descending
Centers for Medicare & Medicaid Services The Administrator of CMS should ensure that state Medicaid programs have written policies and procedures that specify the extent to which covered entities can use 340B drugs for Medicaid beneficiaries, are designed to effectively identify if 340B drugs were used, and if so, how they should be excluded from Medicaid rebate requests. The policies and procedures should be made publically available and cover FFS, managed care, and all of the dispensing methods for outpatient drugs. (Recommendation 1)
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HHS concurred with this recommendation. In January 2023, CMS stated that it is developing guidance, which it plans to issue in 2023, to state Medicaid programs directing them to strengthen policies and procedures related to 340B drugs for Medicaid beneficiaries.

Medicaid Managed Care: Rapid Spending Growth in State Directed Payments Needs Enhanced Oversight and Transparency

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1 Open Recommendations
Agency Affected Recommendation Status Sort descending
Centers for Medicare & Medicaid Services The Administrator of CMS should enhance the agency's fiscal guardrails for approving state directed payments by establishing a definition of, and standards for, assessing whether directed payments result in payment rates that are reasonable and appropriate, and communicating those to states; determining whether additional limits are needed; and requiring states to submit data on actual spending amounts at renewal. (Recommendation 1)
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When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.