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Open Recommendations (114 total)

Medicaid Long-Term Services and Supports: Access and Quality Problems in Managed Care Demand Improved Oversight

GAO-21-49
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1 Open Recommendations
1 Priority
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services
Priority Rec.
The Administrator of CMS should develop and implement a national strategy for monitoring MLTSS programs and ensuring that states and MCOs resolve identified problems. Among other things, this strategy should address state implementation of beneficiary protection and monitoring requirements. (Recommendation 1)
Open – Partially Addressed
CMS did not concur with our recommendation. However, in June 2022 CMS took a number of steps to enhance oversight. CMS issued a new technical assistance toolkit for states to use in overseeing MLTSS programs, as well as an updated Managed Care Program Annual Report template, which requires states to report a number of different data on MLTSS, including on beneficiary protection systems and on certain appeals and grievances. As of February 2024, CMS reported that it continues to assess states' submission of the annual reports for completeness and reasonableness. Once CMS finds that data is sufficiently complete it will establish a strategy for analyzing and following up on specific information and for assessing the nature of access and quality issues identified. The agency indicated that it is reassessing the use of the appeals and grievance reporting template and may combine it with another template being tested to produce a more effective single data collection tool. We will continue to monitor CMS actions on this recommendation, including any evidence of a strategy for resolving identified problems with state MLTSS programs.

Medicare Advantage: CMS Should Fully Develop Plans for Encounter Data and Assess Data Quality before Use

GAO-14-571
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1 Open Recommendations
1 Priority
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services
Priority Rec.
To ensure that MA encounter data are of sufficient quality for their intended purposes, the Administrator of CMS should complete all the steps necessary to validate the data, including performing statistical analyses, reviewing medical records, and providing MAOs with summary reports on CMS's findings, before using the data to risk adjust payments or for other intended purposes.
Open – Partially Addressed
HHS generally agreed with this recommendation. As of February 2024, CMS has made progress in examining the completeness and accuracy of Medicare Advantage encounter data, but more work remains to fully validate these data. For example, CMS has established some performance metrics for MA encounter data completeness and accuracy and conducted associated analyses. CMS has communicated findings from these analyses to MAOs, with the expectation that MAOs provide plans within 60 days to address identified concerns. In addition, CMS stated in February 2024 that the agency has conducted various analyses of encounter data completeness for internal purposes. We requested detailed descriptions and documentation of those analyses and will review any information CMS submits to determine whether they are consistent with the requirements specified in CMS's protocol for assessing the completeness and accuracy of Medicaid data. Despite this progress, CMS has not yet taken the steps necessary to fully validate these data. Although CMS has established performance metrics for completeness and accuracy for some encounter data elements, these metrics are not sufficiently detailed or do not address all data elements. In addition, CMS has not demonstrated that it verifies encounter data by systematically reviewing medical records in a timely manner. Until CMS fully validates the completeness and accuracy of MA encounter data, the soundness of adjustments to payments to MA organizations remains unsubstantiated.

Medicaid Long-Term Services and Supports: Access and Quality Problems in Managed Care Demand Improved Oversight

GAO-21-49
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should assess the nature and prevalence of MLTSS access and quality problems across states. (Recommendation 2)
Open – Partially Addressed
CMS did not concur with our recommendation. However, in June 2022 CMS issued an updated Managed Care Program Annual Report template that required states to report on the performance of managed care organizations and any sanctions or corrective actions issued. As of February 2024, CMS reported that it continues to assess states' submission of the annual reports for completeness and reasonableness. Once CMS finds that data is sufficiently complete it will establish a strategy for analyzing and following up on specific information and for assessing the nature of access and quality issues identified. The agency indicated that it is reassessing the use of the appeals and grievance reporting template and may combine it with another template being tested to produce a more effective single data collection tool. We will continue to monitor CMS actions on this recommendation, including any evidence of a strategy for resolving identified problems with state MLTSS programs. 2/23/24

Medicare Advantage: CMS Should Improve the Accuracy of Risk Score Adjustments for Diagnostic Coding Practices

GAO-12-51
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1 Open Recommendations
1 Priority
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services
Priority Rec.
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.
Open – Partially Addressed
CMS indicated in March 2021 that, given the complexity of measuring coding changes attributable to plan behavior and the difficulty of measuring countervailing factors, there is not a single correct factor within the viable range of adjustment factors. In addition, the agency noted that there is policy discretion with respect to the appropriate adjustment factor for the payment year. CMS applied the statutory minimum adjustment of 5.90 for calendar year 2023. As of February 2024, CMS had not provided any documentation of its analysis and the basis for its determination. Although the application of the 5.90 percent adjustment and other changes CMS has made to its methodology for calculating risk scores (i.e., the exclusion of diagnosis codes that were differentially reported in Medicare fee-for-service and Medicare Advantage) likely brings CMS's adjustment closer to what GAO's analysis would project to be an accurate adjustment, a modified methodology for calculating the diagnostic coding adjustment that incorporates more recent data, accounts for all relevant years of coding differences, and incorporates the effect of coding difference trends would better ensure an accurate adjustment in future years. Until CMS shows the sufficiency of the diagnostic coding adjustment or implements an adjustment based on analysis using an updated methodology, payments to Medicare Advantage plans may not accurately account for differences in diagnostic coding between these plans and traditional Medicare providers.

Medicaid: CMS Needs to Implement Risk-Based Oversight of Puerto Rico's Procurement Process

GAO-21-229
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should take steps to implement ongoing, risk-based oversight of Medicaid procurement processes in Puerto Rico; such actions could include performing an assessment of competitive and noncompetitive procurement processes to identify risks and address them by promoting competition, as appropriate for the efficient operation of the Medicaid program. (Recommendation 1)
Open – Partially Addressed
CMS concurred with our recommendation and indicated a commitment to work with Puerto Rico to improve its procurement processes. As of December 2022, CMS provided evidence of feedback and technical assistance it had provided on Medicaid procurement processes in Puerto Rico. At this time, CMS was reviewing documentation of the Puerto Rico Medicaid Program's reformed procurement process and was awaiting similar documentation from Puerto Rico's Administracion de Seguros de Salud (Health Insurance Administration). In March 2024, CMS reported the agency would begin a risk-based assessment of Puerto Rico's reformed procurement process once implemented. When we confirm additional actions the agency has taken in response to this recommendation, we will provide updated information.

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

GAO-19-628
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should develop and implement procedures to systematically assess the measures it is considering developing, using, or removing in terms of their impact on achieving CMS's strategic objectives and document its compliance with those procedures. (Recommendation 2)
Open – Partially Addressed
As of August 2023, CMS completed initial development of its Quality Measure Index (QMI), which is designed to systematically assess the relative value of quality measures based on key measure characteristics, including the extent to which they address strategic objectives outlined in CMS's National Quality Strategy. This enabled CMS to begin using the QMI in its annual process of selecting new quality measures for its various quality programs. However, as of August 2023, CMS was still in the process of adapting the QMI for use in making decisions regarding which measures it should prioritize that are under development. In addition, based on the information CMS provided, the agency had not yet used the QMI (or any equivalent tool) to inform decisions regarding which measures to remove from its various quality programs.

Cybersecurity: Selected Federal Agencies Need to Coordinate on Requirements and Assessments of States

GAO-20-123
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should, in collaboration with OMB, solicit input from FBI, IRS, SSA, and state agency stakeholders on revisions to its security policy to ensure that cybersecurity requirements for state agencies are consistent with other federal agencies and NIST guidance to the greatest extent possible and document CMS's rationale for maintaining any requirements variances.(Recommendation 3)
Open – Partially Addressed
CMS agreed with and has taken steps to partially address this recommendation. As of February 2024, CMS has participated in the FBI's Criminal Justice Information Services Division Modernization Task Force, which includes representatives from the FBI and Internal Revenue Services, to discuss the impact of inconsistent cybersecurity standards. CMS stated that it received a presentation from FBI on its efforts to align with the National Institute of Standards and Technology's (NIST) Special Publication 800-53, Revision 5. Further, CMS is currently developing a new version of its state cybersecurity requirements policy to align with the same NIST publication. It also plans to solicit feedback and concurrence from state agency and federal stakeholders. To fully address this action, CMS needs to complete its efforts to coordinate with the other federal agencies and decide what revisions to make to its cybersecurity requirements for state agencies. We will continue to monitor the agency's progress in implementing this recommendation.

Hospital Value-Based Purchasing: CMS Should Take Steps to Ensure Lower Quality Hospitals Do Not Qualify for Bonuses

GAO-17-551
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services To ensure that the HVBP program accomplishes its goal to balance quality and efficiency and to ensure that it minimizes the payment of bonuses to hospitals with lower quality scores, the Administrator of CMS should revise the formula for the calculation of hospitals' total performance score or take other actions so that the efficiency score does not have a disproportionate effect on the total performance score.
Open – Partially Addressed
HHS indicated that it would examine the formula used for calculating hospitals' total performance scores and consider revisions, which would be subject to notice and comment rulemaking. In September 2018, HHS indicated that it had been examining alternatives and considering revising the formula for the calculation of hospitals' total performance scores (TPS) consistent with relevant statutory guidance, and in a way to reduce the effect of the efficiency domain on the TPS. In the Fiscal Year 2019 Inpatient Prospective Payment System proposed rule, CMS proposed to remove the safety domain weighted at 25 percent of the TPS and, in connection, increase the weight of the clinical care domain from 25 percent to 50 percent, which was estimated to reduce the effect of the efficiency domain on the TPS. According to CMS, stakeholders were concerned about the safety domain removal and adverse impacts to rural and smaller hospitals due to increasing outcome measure relative weights. CMS indicated that it analyzed current data in the fall of 2018 and found a similar trend, where rural and small hospitals' payment would be adversely impacted from increasing outcome measure weights. CMS decided to keep measure weights to avoid adversely impacting rural and small hospitals. However, CMS did not take actions so that the efficiency score would not have a disproportionate effect on the total performance score and bonus payments to hospitals with lower quality scores. In December 2020, CMS indicated that it is exploring additional options that may require significant changes to the program's scoring methodology. In January 2023, CMS indicated that the agency had revised the Medicare spending per beneficiary measure-part of the HVBP efficiency domain-with the intent of using it for the HVBP program once it meets its statutory requirement of being publicly reported for a year in the Hospital Inpatient Quality Reporting (IQR) Program. CMS provided documentation of the analyses conducted. Our review of the documentation supports that the measure was revised, tested, and adopted. We will close the recommendation once the revisions are incorporated into the HVBP program. As of July 2023, no additional action has been taken.

Medicaid: Additional CMS Data and Oversight Needed to Help Ensure Children Receive Recommended Screenings

GAO-19-481
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1 Open Recommendations
1 Priority
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services
Priority Rec.
The Administrator of CMS should work with states and relevant federal agencies to collect accurate and complete data on blood lead screening for Medicaid beneficiaries in order to ensure that CMS is able to monitor state compliance with its blood lead screening policy, and assist states with planning improvements to address states' compliance as needed. (Recommendation 1)
Open – Partially Addressed
In February 2024, CMS stated that it continues to remind states of Medicaid's universal blood lead screening and has encouraged state Medicaid agencies and health departments to establish data sharing agreements with other state agencies, in order to have more complete data. In addition, CMS added a lead screening measure to the Child Core Set, which is a set of quality measures reported by states that is used, among other things, to monitor performance at the state level. States began reporting this measure in late 2023 and CMS expects these data to be available in late 2024. CMS also said it expects to release updated guidance on blood lead screening by the end of 2024. CMS has previously said the updated guidance will emphasize the importance of complete and accurate data. These are positive steps that can assist CMS as it continues to consider how to help address known limitations in the current blood lead screening data, such as the under-counting of blood lead screening tests not paid for by Medicaid (and therefore which are not included in the current data). We will continue to monitor CMS's issuing of the guidance and update its status accordingly. To implement this recommendation, CMS should fully address limitations in blood lead screening data to better monitor compliance with the agency's blood lead screening policy.

Medicaid: CMS Should Take Additional Steps to Improve Assessments of Individuals' Needs for Home- and Community-Based Services

GAO-18-103
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should ensure that all types of Medicaid HCBS programs have requirements for states to avoid or mitigate potential conflicts of interest on the part of entities that conduct needs assessments that are used to determine eligibility for HCBS and to develop HCBS plans of service. These requirements should address both service providers and managed care plans conducting such assessments. (Recommendation 1)
Open – Partially Addressed
HHS initially concurred with our recommendation. However, in an April 2018 update, HHS noted that the recommendation should be closed based on existing Medicaid regulations, and in subsequent updates, reported that it does not plan to implement additional conflict of interest requirements applicable to entities conducting needs assessments. GAO continues to maintain that additional steps to avoid or mitigate potential conflict of interest in HBCS needs assessments are warranted, as the existing regulations--which GAO reviewed at the time of this study--do not address all types of Medicaid HCBS programs. For example, specific conflict of interest requirements are generally not in place for needs assessments that are used to inform HCBS eligibility determinations. Similarly, managed care plans may have a financial interest in the outcome of HCBS assessments used for both determining eligibility and service amounts. GAO notes, however, that the agency has taken action to improve oversight of managed care plans that partially addresses this recommendation. In particular, CMS issued guidance to states in June 2021 that triggered the requirement for states to submit annual reports on their Medicaid managed care programs, including on the beneficiary support system for managed care HCBS programs referenced in the report. GAO noted in the report that taking this action would help to address concerns regarding managed care plans' potential for conflicts of interest in conducting needs assessments for service planning purposes. CMS could take additional steps to address remaining gaps such as working with states to address potential conflict of interest in needs assessments used to inform HCBS eligibility determinations or for state plan personal care services that are not covered by conflict of interest requirements that apply to service planning for other types of HCBS programs. As of September 2023, CMS reported that the agency continues to enforce existing conflict of interest provisions and that no further actions are planned.
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