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Open Recommendations (114 total)

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

GAO-19-481
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should develop a plan with time frames and interim milestones for using T-MSIS data to generate the necessary data from the Child Core Set to improve EPSDT oversight and streamline state reporting. (Recommendation 6)
Open
As of February 2024, CMS stated the agency continues to assess the feasibility of extracting Core Set data for select quality measures using T-MSIS data, in order to reduce the administrative burden on states. CMS previously stated that it was conducting a pilot to explore the feasibility of using T-MSIS data to generate certain Child Core Set measures. GAO will continue to follow the agency's progress on this activity.

Medicaid Personal Care Services: CMS Could Do More to Harmonize Requirements across Programs

GAO-17-28
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services To achieve a better understanding of the effect of certain Personal care services (PCS) services on beneficiaries and a more consistent administration of policies and procedures across PCS programs, the Acting Administrator of CMS should collect and analyze states' required information on the impact of the Participant-Directed Option and Community First Choice programs on the health and welfare of beneficiaries as well as the state quality measures for the Participant-Directed Option and Community First Choice programs.
Open
The Centers for Medicare & Medicaid Services (CMS) concurred with GAO's recommendation. On December 30, 2016, the agency issued guidance on the Community First Choice program to assist states in submitting information to CMS on the health and welfare of beneficiaries. In March 2019, CMS officials stated that the agency is currently developing the process for states to report this information to CMS. Agency officials also stated they are exploring the value of collecting this information for the Participant-Directed Option program given the limited number of states currently operating under this authority. In February 2020, CMS officials stated that the agency continues to develop policy related to this recommendation. In March 2022, CMS officials stated that CMS's work on Community First Choice data collection and development of a plan for the Participant-Directed Option program had been interrupted by the COVID-19 pandemic. In March 2023, CMS officials stated that the agency has requested funding in fiscal year 2023 to secure a contractor to develop reporting requirements, standards, and templates that CMS can distribute to states to meet this requirement. Officials said work on this task is paused until contract resources can procured. In addition, officials said potential amendments to Community First Choice program reporting requirements are under development as part of a larger initiative to standardize reporting across home- and community-based services authorities. In September 2023, CMS officials stated that the agency has included provisions in the Ensuring Access to Medicaid Services (CMS 2442-P) Notice of Proposed Rulemaking to standardize data collection across all 1915 authorities, including the Participant-Directed Option and Community First Choice programs. The regulation is expected to be finalized in spring 2024 with sub-regulatory guidance issued throughout 2024 and possibly 2025. CMS officials provided an estimated completion date of December 31, 2024. GAO will continue to monitor the implementation of this recommendation.

Nursing Homes: Consumers Could Benefit from Improvements to the Nursing Home Compare Website and Five-Star Quality Rating System

GAO-17-61
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services To help improve the Five-Star System's ability to enable consumers to understand nursing home quality and make distinctions between high- and low- performing homes, the Administrator of CMS should add information to the Five-Star System that allows consumers to compare nursing homes nationally.
Open
HHS did not concur with this recommendation. CMS officials told us in July 2019 that they do not plan to implement this recommendation. We maintain that adding national comparison information is important. As of September 2021 CMS has not informed us of steps taken to address this recommendation.

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

GAO-16-76
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1 Open Recommendations
Agency Affected Recommendation Status
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.

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

GAO-16-76
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1 Open Recommendations
Agency Affected Recommendation Status
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 ensure that CMS develops specific plans and a timetable for incorporating a RAC in the MA program as mandated by the Patient Protection and Affordable Care Act.
Open
CMS has attempted to incorporate recovery audit contractor functions into its RADV program, although it has not developed specific plans and a timetable for incorporating a recovery audit contractor in the Medicare Advantage program as GAO recommended in April 2016. In January 2023, CMS reported in its budget justification that it believes the proposed scope of the contract-level risk adjustment data validation audits satisfies GAO's recommendation. CMS officials noted that RADV audits are the primary corrective action that CMS has to address payments in Part C as these audits verify that diagnoses submitted by Medicare Advantage organizations for risk adjusted payment are supported by medical record documentation. In February 2024, CMS reported that while different in program name, the RADV program conducts the same audits as a RAC, and therefore, it would be duplicative in efforts and results. Until CMS completes efforts to improve the risk adjustment data validation contract-level audit process and demonstrates that the changes made to the RADV program satisfy the requirement to incorporate a recovery audit contractor in the Medicare Advantage program, CMS may fail to recover improper payments of hundreds of millions of dollars annually.

Medicare Advantage: Actions Needed to Enhance CMS Oversight of Provider Network Adequacy

GAO-15-710
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services To improve its oversight of network adequacy in MA, the Administrator of CMS should set minimum requirements for MAO letters notifying enrollees of provider terminations and require MAOs to submit sample letters to CMS for review.
Open
HHS concurred with this recommendation. In a September 2017 update, the agency stated that it had met the spirit of our recommendation by adding its best practice suggestions of what should be included in the written termination notice to the Medicare Managed Care Manual. However, as we noted in our report, those practices are not required, nor are the letters regularly reviewed. CMS reiterated its position in a November 2020 update, stating that MAOs have the knowledge and experience to notify enrollees without needing minimum requirements. CMS also stated that it does not have a process in place to routinely review sample letters but MAO letters it has received in the past have incorporated CMS's suggestions for making information clearer to enrollees. In October 2021, CMS provided documentation of the five MAO letters related to significant provider terminations it had examined in the 1-year period from August 2020 to August 2021. For three of the five letters, CMS required the MAO to make changes to its letter, in some cases to avoid potentially confusing information. Because CMS has not set minimum requirements or routinely required MAOs to submit sample provider termination letters, the agency has not implemented this recommendation as of August 2023.

Medicare Physician Payment Rates: Better Data and Greater Transparency Could Improve Accuracy

GAO-15-434
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services To help improve CMS's process for establishing relative values for Medicare physicians' services, the Administrator of CMS should incorporate data and expertise from physicians and other relevant stakeholders into the process as well as develop a timeline and plan for using the funds appropriated by the Protecting Access to Medicare Act of 2014.
Open – Partially Addressed
To help improve the Centers for Medicare & Medicaid Service's (CMS) process for establishing relative values for Medicare physicians' services, in May 2015 we recommended that the Administrator of CMS incorporate data and expertise from physicians and other relevant stakeholders into the process, as well as develop a timeline and plan for using the funds appropriated by the Protecting Access to Medicare Act of 2014 (PAMA). CMS concurred with this recommendation, stating that stakeholders have the opportunity each year to nominate potentially misvalued services for review through a public nomination process. In August 2017, CMS officials provided a copy of the final rulemaking for the 2017 Physician Fee Schedule, which described a data collection effort using PAMA funds and other authorities that will help furnish data to help in valuations for more than half of physician services. However, this effort pertains to global services, which are a specific type of service under the Physician Fee Schedule that include global, professional, and technical components, and does not apply to non-global services, which encompass almost half of physician services. Officials also reported that they had awarded a contract to explore data collection on practice expense and methodologies for using such data when valuing services in the Physician Fee Schedule. However, CMS did not indicate a specific timeline and plan for using the PAMA funds, just that the agency would continue to use these funds to explore more ways to gain improved data. We acknowledge that CMS has made progress towards meeting our recommendation by beginning to use PAMA funds to assist with valuing global services and exploring avenues for collecting practice expense data. To close this recommendation, we need documentation that CMS has started to incorporate data more broadly into its process for establishing relative values and that it has a documented timeline and plan for how it will use the funds appropriated by the Protecting Access to Medicare Act of 2014. As of February 2024, we had not received this documentation.

Medicare: Action Needed to Address Higher Use of Anatomic Pathology Services by Providers Who Self-Refer

GAO-13-445
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services 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.
Open
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) did not concur with this recommendation and does not believe it would address overutilization that occurs as a result of self-referral. In November 2017, CMS officials noted that the agency does not have the ability to identify self-referred anatomic pathology services during medical reviews. As of March 2023, CMS has not provided any additional information about actions it has taken to address the recommendation. 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.

Medicare: Action Needed to Address Higher Use of Anatomic Pathology Services by Providers Who Self-Refer

GAO-13-445
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services 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.
Open
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. As of March 2023, CMS has not provided any additional information about actions it has taken to limit the financial incentives associated with referring a higher number of specimens. We continue to believe that CMS should develop a payment approach that addresses this incentive.

Medicaid Demonstrations: Actions Needed to Address Weaknesses in Oversight of Costs to Administer Work Requirements

GAO-20-149
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should require states to submit and make public projections of administrative costs when seeking approval of demonstrations, including those with work requirements and all other demonstrations. (Recommendation 1)
Open
HHS did not concur with this recommendation and, as of March 2024, HHS officials have not provided information on any actions taken to implement this recommendation. We maintain that the recommendation is valid because requiring states to make public information about administrative costs would help to ensure that demonstration proposals provide sufficient information to ensure meaningful public input.
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