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    Subject Term: Beneficiaries

    57 publications with a total of 143 open recommendations including 21 priority recommendations
    Director: Seto Bagdoyan
    Phone: (202) 512-6722

    3 open recommendations
    Recommendation: The Administrator of CMS should provide fraud-awareness training relevant to risks facing CMS programs and require new hires to undergo such training and all employees to undergo training on a recurring basis. (Recommendation 1)

    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: The Administrator of CMS should conduct fraud risk assessments for Medicare and Medicaid to include respective fraud risk profiles and plans for regularly updating the assessments and profiles. (Recommendation 2)

    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: The Administrator of CMS should, using the results of the fraud risk assessments for Medicare and Medicaid, create, document, implement, and communicate an antifraud strategy that is aligned with and responsive to regularly assessed fraud risks. This strategy should include an approach for monitoring and evaluation. (Recommendation 3)

    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: Elizabeth H. Curda
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: The Administrator of CMS should gather information over time on the number of beneficiaries at risk of harm from opioids, including those who receive high opioid morphine equivalent doses regardless of the number of pharmacies or providers, as part of assessing progress over time in reaching the agency's goals related to reducing opioid use. (Recommendation 1)

    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: The Administrator of CMS should require its contractor, National Benefit Integrity Medicare Drug Integrity Contractor, to identify and conduct analyses on providers who prescribe high amounts of opioids separately from providers who prescribe high amounts of any Schedule II drug. (Recommendation 2)

    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: The Administrator of CMS should require plan sponsors to report to CMS on investigations and other actions taken related to providers who prescribe high amounts of opioids. (Recommendation 3)

    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: Katherine Iritani
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To improve CMS's oversight of states' MLTSS programs, the Administrator of CMS should take steps to identify and obtain key information needed to oversee states' efforts to monitor beneficiary access to quality services, including, at a minimum, obtaining information specific to network adequacy, critical incidents, and appeals and grievances.

    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

    1 open recommendations
    Recommendation: To strengthen CMS's oversight of MA contracts, the Administrator of CMS should review data on disenrollment by health status and the reasons beneficiaries disenroll as part of the agency's routine monitoring efforts.

    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: Thomas Melito
    Phone: (202) 512-9601

    5 open recommendations
    Recommendation: To enhance USAID's financial oversight of implementing partners' spending to implement and support Title II development and emergency projects, the USAID Administrator should develop, document, and implement a process for periodically conducting systematic, targeted financial reviews of Title II development and emergency projects. Such reviews should include efforts to verify that actual costs incurred for these projects align with planned budgets.

    Agency: United States Agency for International Development
    Status: Open

    Comments: In July 2017, USAID informed us that it is exploring options to develop a new process for conducting systematic, targeted financial reviews. As of September 2017, we will continue to monitor USAID's actions in response to the recommendation.
    Recommendation: To enhance USAID's financial oversight of implementing partners' spending to implement and support Title II development and emergency projects, the USAID Administrator should ensure that its requirements for implementing partners to provide monitoring data on an ongoing basis on the use of 202(e) funding for cash transfers, food vouchers, and local and regional procurement are consistent for Title II development and emergency projects.

    Agency: United States Agency for International Development
    Status: Open

    Comments: In July 2017, USAID informed us that it has updated its Food for Peace development award template, and programs are now required to provide quarterly reports on cash transfers, food vouchers, and local and regional procurement. As of September 2017, we are following up with USAID to confirm the actions taken in response to the recommendation.
    Recommendation: To enhance USAID's financial oversight of implementing partners' spending to implement and support Title II development and emergency projects, the USAID Administrator should take steps to ensure that it collects complete and consistent monitoring data from implementing partners for Title II development and emergency projects on the use of 202(e) funding for cash transfers, food vouchers, and local and regional procurement as well as data on the use of Title II funding for internal transportation, storage, and handling (ITSH) costs, in accordance with established requirements.

    Agency: United States Agency for International Development
    Status: Open

    Comments: In July 2017, USAID informed us that it has taken actions in response to this recommendation including hiring staff and providing training to support adherence to award requirements. As of September 2017, we continue to monitor USAID's actions in response to the recommendation.
    Recommendation: To enhance USAID's financial oversight of implementing partners' spending to implement and support Title II development and emergency projects, the USAID Administrator should update key guidance and systems to consistently reflect allowable uses of ITSH funds in Title II development and emergency projects.

    Agency: United States Agency for International Development
    Status: Open

    Comments: In July 2017, USAID informed us that it is updating guidance and exploring other options to further clarify ITSH and 202(e) funding distinctions, in response to this recommendation. As of September 2017, we will continue to monitor USAID's actions in response to the recommendation.
    Recommendation: To enhance USAID's financial oversight of implementing partners' spending to implement and support Title II development and emergency projects, the USAID Administrator should establish a requirement for Title II development project partners to conduct and document comprehensive risk assessments and mitigation plans for cash transfers and food vouchers funded by 202(e), and take steps to ensure that implementing partners adhere to the requirement.

    Agency: United States Agency for International Development
    Status: Open

    Comments: In July 2017, USAID informed us that it has inserted a requirement for partners to conduct and document comprehensive risk assessments and mitigation plans for activities including cash transfers and food vouchers into its FY 2017 Request for Applications for Food for Peace development activities, and that new Title II development awards will require partners to adhere to the requirement. As of September 2017, we continue to monitor USAID's actions taken in response to this recommendation.
    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: Carolyn L. Yocom
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: To improve oversight of states' payment structures for MLTSS, the Administrator of CMS should require all states to collect and report on progress toward achieving MLTSS program goals, such as whether the program enhances the provision of community-based care.

    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 oversight of states' payment structures for MLTSS, the Administrator of CMS should establish criteria for what situations would warrant exceptions to the federal standards that the data used to set rates be no older than the three most recent and complete years.

    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 oversight of states' payment structures for MLTSS, the Administrator of CMS should provide states with guidance that includes minimum standards for encounter data validation procedures.

    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: Allison Bawden
    Phone: (202) 512-7215

    6 open recommendations
    Recommendation: To preserve the balance between the importance of repaying federal student loan debt and protecting a minimum level of Social Security benefits put in place by the Debt Collection Improvement Act of 1996, Congress should consider modifying Social Security administrative offset provisions, such as by authorizing the Department of the Treasury to annually index the amount of Social Security benefits exempted from administrative offset to reflect changes in the cost of living over time.

    Agency: Congress
    Status: Open

    Comments: As of August 2017, Congress has not yet taken action on this matter.
    Recommendation: To improve program design for Social Security offsets and related relief options, the Secretary of Education should inform affected borrowers of the suspension of offset and potential consequences if the borrower does not take action to apply for a TPD discharge. Such information could include notification that interest continues to accrue and that offsets may resume once their disability benefits are converted to retirement benefits.

    Agency: Department of Education
    Status: Open

    Comments: The Department of Education does not currently notify borrowers of the suspension of offset, but plans to implement a process to do so in the future using a new mailing sent to affected borrowers by their default servicer. The current budget situation does not allow for this type of enhancement, and it is not clear when that will change. In the interim, the agency is exploring alternative notification approaches that could be put in place prior to the implementation of an automated solution. We will monitor the agency's progress.
    Recommendation: To improve program design for Social Security offsets and related relief options, the Secretary of Education should revise forms sent to borrowers already approved for a TPD discharge to clearly and prominently state that failure to provide annual income verification documentation during the 3-year monitoring period will result in loan reinstatement.

    Agency: Department of Education
    Status: Open

    Comments: The Department of Education stated that the current Office of Management and Budget (OMB) TPD-Post discharge forms contain the recommended language in the first bullet of the Earned Income Section. In order to more clearly provide this information they recommended that the new OMB form, which is in its public comment period, (1) use a larger font size for the form and (2) use "plain language." GAO will consider closing this recommendation when the agency has completed this effort.
    Recommendation: To improve program design for Social Security offsets and related relief options, the Secretary of Education should evaluate the feasibility and benefits of implementing an automated income verification process, including determining whether the agency has the necessary legal authority to implement such a process.

    Agency: Department of Education
    Status: Open

    Comments: The Department of Education stated that over the next six months, they are committed to working with SSA to determine the feasibility and benefits of implementing an automated income verification process. The verification will address both the legal authority to implement such a process as well as operational and budgetary feasibility. We will monitor the agency's progress.
    Recommendation: To improve program design for Social Security offsets and related relief options, the Secretary of Education should inform borrowers about the financial hardship exemption option and application process on the agency's website, as well as the notice of offset sent to borrowers.

    Agency: Department of Education
    Status: Open

    Comments: The Department of Education agrees with the recommendation and said that they will include this change in upcoming revisions to the agency's web content. The agency reported that the Notice of Offset to borrowers is sent by Treasury and that they will share this recommendation with Treasury and discuss possible changes to the notice. We will consider closing this recommendation when the agency has completed this effort.
    Recommendation: To improve program design for Social Security offsets and related relief options, the Secretary of Education should implement an annual review process to ensure that only eligible borrowers are exempted from offset for financial hardship on an ongoing basis.

    Agency: Department of Education
    Status: Open

    Comments: The Department of Education reported that it plans plan to fully automate their process for tracking hardships and other exceptions from offset. However, due to competing priorities and funding limitations, full implementation of these improvements have not been scheduled. As they fully implement this process, they will review complementary strategies to assist borrowers in complying with annual reporting requirements. We will monitor the agency's progress.
    Director: Katherine Iritani
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: 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.

    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 achieve a better understanding of the effect of certain PCS services on beneficiaries and a more consistent administration of policies and procedures across PCS programs, the Acting Administrator of CMS should take steps to harmonize requirements, as appropriate, across PCS programs in a way that accounts for common risks faced by beneficiaries and to better ensure that billed services are provided.

    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: Thomas Melito
    Phone: (202) 512-9601

    2 open recommendations
    Recommendation: To strengthen USAID's monitoring and evaluation of cash transfer and food voucher projects and help ensure improved program oversight of these projects, the USAID Administrator should take steps to ensure that final reports submitted for cash transfer and food voucher projects comply with USAID's minimum data requirements.

    Agency: United States Agency for International Development
    Status: Open

    Comments: In June 2017, USAID said it had entered into an institutional support contract in December 2016 to address this recommendation. Support staff under this contract will be responsible for assisting each geographic team to ensure that implementing partners adhere to existing award processes and procedures, including compliance with reporting on minimum data requirements. USAID noted that the revised target completion date is 9/30/2017.
    Recommendation: To strengthen USAID's monitoring and evaluation of cash transfer and food voucher projects and help ensure improved program oversight of these projects, the USAID Administrator should strengthen the indicators USAID uses to measure the timeliness, cost-effectiveness, and appropriateness of Emergency Food Security Program cash transfer and food voucher projects.

    Agency: United States Agency for International Development
    Status: Open

    Comments: In June 2017, USAID stated that it released an updated Annual Program Statement for Emergency Food Assistance Programs in December 2016, which addresses this recommendation. As implementation provides data to support a closure request, USAID anticipates completing this recommendation in Fiscal Year 2017. The revised target completion date is 9/30/2017.
    Director: Brenda S. Farrell
    Phone: (202) 512-3604

    1 open recommendations
    Recommendation: To help support DOD management of its FECA responsibilities, the Secretary of Defense should direct the Office of the Under Secretary of Defense for Personnel and Readiness, in collaboration with the Secretaries of the military departments and other defense agency leaders, to monitor timelines associated with significant FECA claims-management actions in order to identify the extent to which delays or inefficiencies may be occurring and at what points in the process; to identify any known reasons for the delays; and to communicate this information to DOL as appropriate for consideration and action.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Jeszeck, Charles A
    Phone: (202) 512-7215

    6 open recommendations
    including 1 priority recommendation
    Recommendation: To ensure that key information provided by claims specialists to potential claimants of Social Security retirement benefits is clear and consistent with POMS, the Commissioner of the SSA should take steps to ensure when applicable, claims specialists inform that delaying claiming will result in permanently higher monthly benefit amounts, and at least offer to provide claimants their estimated benefits at their current age, at full retirement age (FRA) (unless the claimant is already older than FRA), and age 70.

    Agency: Social Security Administration
    Status: Open
    Priority recommendation

    Comments: On 10/19/16, SSA sent a message to technicians (including claims representatives who discuss claiming with clients in field offices or over the phone) reminding them to 1) inform claimants that delaying results in permanently higher benefits; and 2) provide estimated benefits at different claiming ages. While the reminder message to claims specialists is a positive step by the agency, SSA should continue to send periodic messages about these requirements to claims specialists. Further, SSA should have field office managers periodically discuss best practices for providing this information to potential claimants at office training sessions.
    Recommendation: To ensure that key information provided by claims specialists to potential claimants of Social Security retirement benefits is clear and consistent with POMS, the Commissioner of the SSA should take steps to ensure claims specialists understand that they should avoid the use of breakeven analysis to compare benefits at different claiming ages.

    Agency: Social Security Administration
    Status: Open

    Comments: On 10/19/16, SSA sent a message to technicians (including claims representatives who discuss claiming with clients in field offices or over the phone) reminding them not to use breakeven analysis or discuss breakeven points with claimants to compare benefits at different claiming ages. While the reminder message to claims specialists is a positive step by the agency, SSA should continue to send periodic messages to claims specialist to ensure that they understand the requirement to avoid use of breakeven analysis to compare benefits at different claiming ages.
    Recommendation: To ensure potential claimants are consistently provided with key information during the claiming process to help them make informed decisions about when to claim benefits, SSA should take steps to ensure that when applicable, claims specialists inform claimants that monthly benefit amounts are determined by the highest (indexed) 35 years of earnings, and that in some cases, additional work could increase benefits.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA reported that, as appropriate, it will issue a reminder to technicians or include instructions in SSA's Program and Operations Manual System (POMS) to reinforce the instructions. The agency did not provide information on how it plans to include this information in the online claims process.
    Recommendation: To ensure potential claimants are consistently provided with key information during the claiming process to help them make informed decisions about when to claim benefits, SSA should take steps to ensure that when appropriate, claims specialists clearly explain the retirement earnings test and inform claimants that any benefits withheld because of earnings above the earnings limit will result in higher monthly benefits starting at FRA.

    Agency: Social Security Administration
    Status: Open

    Comments: On 10/19/16, SSA sent a message to technicians (including claims representatives who discuss claiming with clients in field offices or over the phone) reminding them to inform claimants that any amounts withheld due to earnings (over limits) will result in higher benefits later on. While the reminder message to claims specialists is a positive step by the agency, SSA should continue to send periodic messages to claims specialist reinforcing the importance of explaining the earnings test, and informing potential claimants that any benefits withheld due to earnings will result in higher benefits starting at FRA. Further, SSA should have field office managers periodically discuss best practices for providing this information to potential claimants at office training sessions.
    Recommendation: To ensure potential claimants are consistently provided with key information during the claiming process to help them make informed decisions about when to claim benefits, SSA should take steps to ensure that claims specialists explain that lump sum retroactive benefits will result in a permanent reduction of monthly benefits. For the online claiming process, SSA should evaluate removing or revising the online question that asks claimants to provide a reason for not choosing retroactive benefits.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA stated that it will issue a reminder to technicians, instructing them to explain that a lump sum retroactive benefit would result in a permanent reduction in monthly benefits; or include instructions in SSA's Program and Operations Manual System (POMS). As for the question included in the online process, SSA said it will explore the underlying rationale for this question and consider modifying the question.
    Recommendation: To ensure potential claimants are consistently provided with key information during the claiming process to help them make informed decisions about when to claim benefits, SSA should take steps to ensure that the claims process include basic information on how life expectancy and longevity risk may affect the decision to claim benefits.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA updated Pub No. 05-10147 to mention that: 1) monthly benefits are higher for the rest of one's life the longer one delays claiming; 2) retirement may be longer than you think; and 3) for married couples, delaying claiming may increase survivor benefits. SSA also added a new question on this topic to its frequently asked questions (FAQ) page, "At what age should I start receiving my Social Security Retirement benefits?" The answer provides key information for individuals to consider, and links to the newly updated publication, the Retirement Estimator tool, and other resources that SSA offers. Updating and improving a key publication on this topic is a positive step by the agency. However, it is not clear if claimants will be able to access this information while they are applying for retirement benefits online. Further, SSA did not specify how it plans to instruct claims specialists to provide information on life expectancy and longevity risk during the in-person claims process.
    Director: James Cosgrove
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To improve the accessibility and reliability of SNF expenditure data, the Acting Administrator of CMS should take steps to improve the accessibility of SNF expenditure data, making it easier for public stakeholders to locate and use the data.

    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 accessibility and reliability of SNF expenditure data, the Acting Administrator of CMS should take steps to ensure the accuracy and completeness of SNF expenditure data.

    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: Thomas Melito
    Phone: (202) 512-9601

    4 open recommendations
    including 4 priority recommendations
    Recommendation: To improve the financial oversight of U.S. programs to provide humanitarian assistance to people inside Syria, the USAID Administrator should update guidance to require non-governmental organizations to conduct risk assessments addressing the risk of fraud.

    Agency: United States Agency for International Development
    Status: Open
    Priority recommendation

    Comments: USAID concurred with our recommendation; however, as of November 2017, it has yet to fully implement this recommendation. In December 2016, the Office of Food for Peace updated its annual program statement to include language requiring organizations to complete an analysis of risks related to fraud, corruption, and mismanagement, with relevant mitigation measures. However, the Office of U.S. Foreign Disaster Assistance (OFDA) has yet to officially update its guidance, although USAID has previously noted that OFDA will require all organizations seeking funding to address fraud risks and submit a detailed mitigation plan in their proposal package. We will continue to update the status of this recommendation as we receive information.
    Recommendation: To improve the financial oversight of U.S. programs to provide humanitarian assistance to people inside Syria, the USAID Administrator should use risk assessments submitted by implementing partners to inform USAID oversight activities, for example, using information from assessments to ensure that control activities for programs are designed to mitigate identified risks.

    Agency: United States Agency for International Development
    Status: Open
    Priority recommendation

    Comments: USAID concurred with our recommendation, stating that they plan to tailor their oversight activities to mitigate risks identified in the fraud risk mitigation plans that organizations will submit as part of their funding proposal packages in the future. In addition, USAID noted that it planned to hire a compliance officer by October 2016 to manage fraud mitigation and other compliance issues for OFDA and FFP's Syria and Iraq portfolios. However, as of November 2017, USAID has yet to fill this position. We will continue to track the status of this recommendation.
    Recommendation: To improve the financial oversight of U.S. programs to provide humanitarian assistance to people inside Syria, the USAID Administrator should ensure that field monitors in Syria are trained on assessing and identifying potential fraud risks.

    Agency: United States Agency for International Development
    Status: Open
    Priority recommendation

    Comments: USAID concurred with our recommendation, but has yet to implement this recommendation, as of November 2017. USAID has previously stated that it would work to provide the third-party monitoring organization with information specific to the Syria context that identifies methods to detect fraud. USAID also stated that it would work with the third-party monitoring organization to ensure that data collectors are trained on fraud risks and methods for identifying fraud. We will continue to track the status of this recommendation.
    Recommendation: To improve the financial oversight of U.S. programs to provide humanitarian assistance to people inside Syria, the USAID Administrator should instruct the third party monitoring organization monitoring Office of U.S. Foreign Disaster Assistance programs in Syria to modify the site visit forms to include specific guidance for documenting incidents of potential fraud.

    Agency: United States Agency for International Development
    Status: Open
    Priority recommendation

    Comments: USAID concurred with this recommendation, stating that it would seek to have site visit forms revised to include indications of fraud, waste, and abuse. However, as of November 2017, USAID has yet to implement the recommendation. We will continue to track the status of this recommendation.
    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: Randall B. Williamson
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To enhance oversight of access to mental health care and help ensure that servicemembers have timely access to mental health care, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to establish an access standard for mental health follow-up appointments and regularly monitor data on these appointments.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Michelle Sager
    Phone: (202) 512-6806

    2 open recommendations
    Recommendation: To increase the transparency to Congress about the total amount of funds agencies have available in a given year, the Director of the Office of Management and Budget should identify and publicly report the total amount of actual budget authority government-wide that is temporarily sequestered and "pops up," or becomes available again to agencies for obligation in the subsequent fiscal year.

    Agency: Executive Office of the President: Office of Management and Budget
    Status: Open

    Comments: In February 2017, OMB staff told us they will consider additional options for reporting a government-wide total amount of actual budget authority that is temporarily sequestered during preparation of the full 2018 President's Budget.
    Recommendation: To promote further transparency in measuring the federal government's progress against deficit reduction targets required under current law, the Director of the Office of Management of Budget should identify and publicly report the total amount of actual reductions in budget authority government-wide each year as a result of sequestration or the reduction of discretionary spending limits under BBEDCA.

    Agency: Executive Office of the President: Office of Management and Budget
    Status: Open

    Comments: In February 2017, OMB staff maintained their position of disagreement with this recommendation as summarized in our April 2016 report.
    Director: bertonid@gao.gov
    Phone: (202) 512-7215

    8 open recommendations
    including 1 priority recommendation
    Recommendation: To ensure effective and appropriate recovery of DI overpayments and administration of penalties and sanctions, the Acting Commissioner of the Social Security Administration should clarify its policy for assessing the reasonableness of expenses used in determining beneficiaries' repayment amounts to help ensure that withholding plans are consistently established across the agency and accurately reflect individuals' ability to pay.

    Agency: Social Security Administration
    Status: Open

    Comments: As a result of the Bipartisan Budget Act of 2015, SSA gained the ability to use the Access to Financial Information (AFI) system to verify information about the assets of beneficiaries. In February 2017, the agency reported it is continuing to work on clarifying its policy for assessing the reasonableness of expenses used in determining repayment amounts, including guidance on using the new AFI process. As part of this effort, SSA is also reviewing the Internal Revenue Service's (IRS) Collection Financial Standards and determining whether it can incorporate these or similar standards in its policies for determining reasonable repayment amounts. We will continue to track SSA's efforts to clarify its policies, including efforts to incorporate IRS standards.
    Recommendation: To ensure effective and appropriate recovery of DI overpayments and administration of penalties and sanctions, the Acting Commissioner of the Social Security Administration should improve oversight of DI benefit withholding agreements to ensure that they are completed appropriately. This could include requiring supervisory review of repayment plans or sampling plans as part of a quality control process, and requiring that supporting documentation for all withholding plans be retained to enable the agency to perform such oversight.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA agreed with this recommendation, but does not believe that it is necessary to conduct supervisory reviews. As of February 2017, SSA reported that it is exploring system, policy, and training opportunities to better ensure staff appropriately complete benefit withholding agreements. We will continue to track SSA's efforts to improve oversight in this area.
    Recommendation: To ensure effective and appropriate recovery of DI overpayments and administration of penalties and sanctions, the Acting Commissioner of the Social Security Administration should explore the feasibility of using additional methods to independently verify financial information provided by beneficiaries to ensure that complete and reliable information is used when determining repayment amounts. These additional tools could include those already being used by the agency for other purposes.

    Agency: Social Security Administration
    Status: Open

    Comments: According to SSA, Section 834 of the Bipartisan Budget Act of 2015 gave the agency the authority to use the Access to Financial Information system as part of the agency's waiver determination process. SSA reported that, as of February 2017, it also considered using the National Directory of New Hires Query for verifying an overpaid beneficiary's financial information, but preliminarily determined that the information in this system would be of limited value since it is a quarterly report of past earnings. SSA states that it continues to explore other options to verify financial information such as The Work Number and the Interstate Benefit Inquiry. We will monitor SSA's efforts to explore additional options for verifying financial information.
    Recommendation: To ensure effective and appropriate recovery of DI overpayments and administration of penalties and sanctions, the Acting Commissioner of the Social Security Administration should adjust the minimum withholding rate to 10 percent of monthly DI benefits to allow quicker recovery of debt.

    Agency: Social Security Administration
    Status: Open
    Priority recommendation

    Comments: SSA agreed with this recommendation and as of April 2017, it estimated that this would result in an additional $213 million in collections over a 5-year period. The fiscal year 2017 President's budget submission contained a legislative proposal to make this change, but has not yet been enacted. In April 2017, the agency reported that, in the third quarter of fiscal year 2017, it intends to resubmit a regulatory change to establish the minimum withholding rate to 10 percent in the event that its legislative proposal is not included in the fiscal year 2017 budget.
    Recommendation: To ensure effective and appropriate recovery of DI overpayments and administration of penalties and sanctions, the Acting Commissioner of the Social Security Administration should consider adjusting monthly withholding amounts according to cost of living adjustments or charging interest on debts being collected by withholding benefits. Should SSA determine that it is necessary to do so, it could pursue legislative authority to use recovery tools that it is currently unable to use.

    Agency: Social Security Administration
    Status: Open

    Comments: As of February 2017, SSA continued to disagree with this recommendation. For debt subject to benefit withholding, which is not considered delinquent debt, SSA asserted that these measures would not have a significant effect on the amount of debt recovered, especially compared to the option of changing the minimum withholding rate to 10 percent of monthly benefits. For delinquent debt, SSA stated charging interest on debts would require substantial changes to multiple systems that affect its overpayment businesses processes, and would require extensive training to its employees. We continue to believe there is merit in further consideration of these measures. While SSA reported it has studied the potential changes needed to charge interest on debt, without further consideration of, for example, the costs and benefits of charging interest or adjusting withholding amounts according to cost of living adjustments, SSA cannot know the extent to which these options would improve debt recovery efforts or help protect the value of debts against the effects of inflation, which can be substantial given that withholding plans can take decades to complete.
    Recommendation: To ensure effective and appropriate recovery of DI overpayments and administration of penalties and sanctions, the Acting Commissioner of the Social Security Administration should pursue additional debt collection tools for collecting delinquent penalties. This includes taking steps to implement tools within its existing authority and exploring the use of those not within its authority, and seeking legislative authority if necessary.

    Agency: Social Security Administration
    Status: Open

    Comments: In June 2016, SSA reported that: it had drafted regulations to use existing external debt collection tools for penalties, was developing a legislative proposal to allow the use of additional debt collection tools such as Federal salary offset and credit bureau reporting, and had started planning for a multi-activity, multi-year administrative sanctions project. In February 2017, SSA reported that, as part of its administrative sanctions project, the agency revised policy guidance on factors significant to OCIG's civil monetary penalty determinations. We will track SSA's progress in applying new tools to collecting penalties.
    Recommendation: To ensure effective and appropriate recovery of DI overpayments and administration of penalties and sanctions, the Acting Commissioner of the Social Security Administration should take steps to collect complete, accurate, and timely data on, and thereby improve its ability to track civil monetary penalties and their disposition.

    Agency: Social Security Administration
    Status: Open

    Comments: As of February 2017, SSA reported that it is developing a workload tracking tool for penalties to provide accurate management information on cases. SSA expects to implement this tool by September 2017, and have the first full year of management information available in fiscal year 2018. We will close this recommendation once SSA implements and begins using this tool.
    Recommendation: To ensure effective and appropriate recovery of DI overpayments and administration of penalties and sanctions, the Acting Commissioner of the Social Security Administration should take steps to collect complete, accurate, and timely data on, and thereby improve its ability to track administrative sanctions and their disposition.

    Agency: Social Security Administration
    Status: Open

    Comments: As of February 2017, SSA reported that it has been developing a new workload tracking tool for administrative sanctions. The first phase of this tool was implemented in December 2016 and allows SSA to track administrative sanction cases throughout the development process. The second phase, expected to be implemented by September 2017, will provide SSA with management information on sanctions cases. We will continue to monitor SSA's process in developing this tool. We will close this recommendation once the tool is implemented.
    Director: James Cosgrove
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: The Secretary of Health and Human Services should direct the Administrator of CMS to assess the feasibility of updating the agency's study on the effect of VA-provided Medicare-covered services on per capita county Medicare FFS spending rates by obtaining VA utilization and diagnosis data for veterans enrolled in Medicare FFS under its existing data use agreement or by other means as necessary.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In July 2016, the U.S. Department of Health and Human Services (HHS) reiterated its disagreement with our recommendation. HHS stated that the Centers for Medicare & Medicaid Services (CMS) uses Medicare fee-or-service(FFS) spending rates when setting the benchmark, which excludes services provided by Department of Veterans Affairs (VA) facilities. In addition, HHS stated that incorporating VA utilization and diagnosis data into CMS's analysis may not materially improve the analysis and the resulting adjustment. HHS indicated that it will continue to review the need for incorporating additional data or for methodology changes in the future. As we note in the report, only VA's utilization and diagnosis data can account for services provided by and diagnoses made by VA. Depending on the number and mix of services provided by and the diagnoses made by VA, risk-adjusted Medicare FFS spending for veterans may either be higher or lower than it would be if CMS accounted for VA-provided services and diagnoses. Therefore, relying exclusively on Medicare FFS spending to estimate the effect of VA spending on Medicare FFS-enrolled veterans could result in an inaccurate estimate of how VA spending on services for Medicare FFS-enrolled veterans affects per capita county Medicare FFS spending. While there may be challenges associated with incorporating VA utilization and diagnosis data into CMS's analysis, we maintain that CMS should work to do so given the implications that not incorporating the data may have on the accuracy of payment to MA plans.
    Recommendation: If CMS makes an adjustment to the benchmark to account for VA spending on Medicare-covered services, the Secretary of Health and Human Services should direct the Administrator of CMS to assess whether an additional adjustment to MA payments is needed to ensure that payments to MA plans are equitable for veterans and nonveterans.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: The Department of Health and Human Services (HHS)has proposed adjusting the benchmark for 2017 to account for the Department of Veterans Affairs (VA) spending on Medicare-covered services. As of July 2016, HHS had not yet completed its assessment of whether an additional adjustment to MA payments is needed to ensure that payment to Medicare Advantage (MA) plans are equitable for veterans and nonveterans. In order to close this recommendation, CMS will need to complete its assessment.
    Director: James Cosgrove
    Phone: (202) 512-7114

    5 open recommendations
    including 1 priority recommendation
    Recommendation: 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 and to improve the accuracy of CMS's calculation of coding intensity, the Administrator should modify that calculation by taking actions such as the following: (1) including only the three most recent pair-years of risk score data for all contracts; (2) standardizing the changes in disease risk scores to account for the expected increase in risk scores for all MA contracts; (3) developing a method of accounting for diagnostic errors not coded by providers, such as requiring that diagnoses added by MA organizations be flagged as supplemental diagnoses in the agency's Encounter Data System to separately calculate coding intensity scores related only to diagnoses that were added through MA organizations' supplemental record review (that is, were not coded by providers); and (4) including MA beneficiaries enrolled in contracts that were renewed from a different contract under the same MA organization during the pair-year period.

    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: 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 modify CMS's selection of contracts for contract-level RADV audits to focus on those contracts most likely to have high rates of improper payments by taking actions such as the following: (1) selecting more contracts with the highest coding intensity scores; (2) excluding contracts with low coding intensity scores; (3) selecting contracts with high rates of unsupported diagnoses in prior contract-level RADV audits; (4) if a contract with a high rate of unsupported diagnoses is no longer in operation, selecting a contract under the same MA organization that includes the service area of the prior contract; and (5) selecting some contracts with high enrollment that also have either high rates of unsupported diagnoses in prior contract-level RADV audits or high coding intensity scores.

    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: 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 enhance the timeliness of CMS's contract-level RADV process by taking actions such as the following: (1) closely aligning the time frames in CMS's contract-level RADV audits with those of the national RADV audits the agency uses to estimate the MA improper payment rate; (2) reducing the time between notifying MA organizations of contract audit selection and notifying them about the beneficiaries and diagnoses that will be audited; (3) improving the reliability and performance of the agency's process for transferring medical records from MA organizations, including assessing the feasibility of updating Electronic Submission of Medical Documentation for use in transferring medical records in contract-level RADV audits; and (4) requiring that CMS contract-level RADV auditors complete their medical record reviews within a specific number of days comparable to other medical record review time frames in the Medicare program.

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

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: 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.

    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: 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.

    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: Daniel Bertoni
    Phone: (202) 512-7215

    6 open recommendations
    Recommendation: The Acting Commissioner of Social Security should direct the Deputy Commissioner of Operations to further consider cost savings as part of its prioritization of full medical reviews. Such options could include considering the feasibility of prioritizing different types of beneficiaries on the basis of their estimated average savings and, as appropriate, integrating case-specific indicators of potential cost savings, such as beneficiary age and benefit amount, into its modeling or prioritization process.

    Agency: Social Security Administration
    Status: Open

    Comments: In July 2017, SSA stated that there is no accepted way to accurately predict future benefit payments at the individual level and that any improvement from implementing this recommendation would be minimal - and would be reduced over time as the continuing disability review (CDR) backlog diminishes - because SSA already considers expected return on investment by cohort in its overall approach to releasing CDRs. It is unclear whether SSA will be able to achieve and sustain currency in its CDR workloads. Even if SSA were to eliminate the backlog of full medical reviews, refining its prioritization process would enable the agency to more efficiently use its resources with any future backlogs. SSA could use actuarial considerations to prioritize refined cohorts of beneficiaries (e.g., types of DI beneficiaries) on the basis of their estimated average savings. SSA Operations could collaborate with SSA's Office of the Actuary on this work as needed. SSA previously agreed that it could look for ways to improve its return on conducting CDRs, but also stated that its statistical models and prioritization process already do much of what we recommend. For example, SSA stated that age is already a strong variable in its statistical models. However, these models predict medical improvement and are not designed to take expected cost savings into account. We continue to believe that to maximize expected cost savings SSA could refine its prioritization process by factoring in additional actuarial considerations.
    Recommendation: The Acting Commissioner of Social Security should direct the Deputy Commissioner of Budget, Finance, Quality, and Management to complete a re-estimation of the statistical models that are used to prioritize CDRs and determine a plan for re-estimating these models on a regular basis to ensure that they reflect current conditions.

    Agency: Social Security Administration
    Status: Open

    Comments: In July 2016, SSA re-estimated the statistical models that it uses to prioritize CDRs. However, as of October 2017, SSA has not yet produced a plan for re-estimating the models on a regular basis to ensure that they continually reflect current conditions.
    Recommendation: The Acting Commissioner of Social Security should direct the Deputy Commissioner of Budget, Finance, Quality, and Management to monitor the characteristics of CDR errors to identify potential root causes and report results to the Disability Determination Services. For example, SSA could analyze CDRs with and without errors to identify trends by impairment, beneficiary type, or other characteristics.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA agreed with this recommendation and stated that it reports all errors to the relevant DDS for corrective action. SSA further stated that its identification of root causes is limited by the relatively few reviewed CDRs that have errors. However, in fiscal year 2014 as an example, SSA identified over 600 CDRs with errors. Although these CDRs make up a small percentage of the CDRs reviewed by SSA that year, the agency could analyze the characteristics of CDRs with errors by comparing relevant percentages without modeling. In addition, SSA could combine data from multiple years if it determined that considering more CDRs with errors would be helpful. There is no change in the status of this recommendation for 2017.
    Recommendation: The Acting Commissioner of Social Security should direct the Deputy Commissioner of Budget, Finance, Quality, and Management to regularly track the number and rate of date errors, which can affect benefit payments (e.g., incorrect cessation dates), and consider including those errors in its reported CDR accuracy rates.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA disagreed with this recommendation and stated that, per SSA regulation, the agency does not consider date errors when calculating accuracy rates because date errors do not affect the decision to cease or continue benefits. SSA also stated its stewardship reviews examine the non-medical quality of benefit payment decisions. However, these reviews are not focused on CDRs, and SSA does not report results from them for CDRs specifically. SSA also explained that it does not track the number and rate of date errors because they are infrequent. However, SSA's regulations do not prevent the agency from tracking date errors, and until it does, SSA cannot definitively determine the frequency of these errors. In addition, we found that considering date errors substantially reduced some states' estimated CDR accuracy rates. Without tracking these errors, SSA cannot assess their effect and consider whether including them in its reported CDR accuracy rates has merit. There is no change in the status of this recommendation for 2017.
    Recommendation: The Acting Commissioner of Social Security should direct the Deputy Commissioner of Budget, Finance, Quality, and Management to adjust its approach to sampling CDRs to efficiently produce reliable accuracy rate estimates for continuances and cessations separately in each state.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA disagreed with this recommendation and stated that some states do not generate enough CDR decisions, particularly cessations, to generate statistically valid samples. However, for states with CDR samples that are consistently too small to produce reliable results, SSA could, for example, pool decisions from more months than it currently does to generate statistically valid samples by state. Conversely, for states with CDR samples that are consistently larger than necessary to efficiently achieve reliable results, SSA could, for example, reduce sample sizes. Because CDR accuracy rates vary by state and cessations are consistently less accurate than continuances, we maintain that SSA should adjust its approach to sampling CDRs. There is no change in the status of this recommendation for 2017.
    Recommendation: The Acting Commissioner of Social Security should direct the Chief Actuary to better document the methods including data sources, assumptions, and limitations that factor into its estimates of CDR cost savings.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA agreed with this recommendation and stated that it will improve and expand its existing documentation as time and resources permit. As of July 2017, SSA had begun to improve documentation of its OASDI estimates and plans further enhancements including documenting the methods of its SSI estimates.
    Director: Katherine Iritani
    Phone: (202) 512-7114

    2 open recommendations
    including 2 priority recommendations
    Recommendation: To promote consistency in the distribution of supplemental payments among states and with CMS policy, the Administrator of CMS should issue written guidance clarifying its policy that requires a link between the distribution of supplemental payments and the provision of Medicaid-covered services.

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

    Comments: CMS plans to publish a proposed rule for public comment in the summer of 2017 to improve the oversight of supplemental payments, including a proposal to require that supplemental payments be distributed proportional to the volume or cost of services delivered or be tied to meeting performance benchmarks. To the extent the agency issues a final rule that results in states distributing supplemental payments in a manner that aligns their distribution with individual facilities' Medicaid workloads, CMS's ability to ensure that state Medicaid payments are not excessive and are used for Medicaid purposes will improve.
    Recommendation: To promote consistency in the distribution of supplemental payments among states and with CMS policy, the Administrator of CMS should issue written guidance clarifying its policy that payments should not be made contingent on the availability of local funding.

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

    Comments: CMS plans to publish a proposed rule for public comment in the summer of 2017 to improve the oversight of supplemental payments, including a proposal to require that supplemental payments be distributed proportional to the volume or cost of services delivered or be tied to meeting performance benchmarksTo the extent the agency issues a final rule that results in states distributing supplemental payments in a manner that aligns their distribution with individual facilities' Medicaid workloads, CMS's ability to ensure that state Medicaid payments are not excessive and are used for Medicaid purposes will improve.
    Director: Carolyn L. Yocom
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To ensure states have appropriate and current guidance to assist them in designing and administering Medicaid NEMT, the Secretary of HHS should direct CMS to assess current Medicaid NEMT guidance and update that guidance as needed.

    Agency: Department of Health and Human 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

    1 open recommendations
    Recommendation: In order to prevent the shift of services from physician offices to HOPDs from increasing costs for the Medicare program and beneficiaries, Congress should consider directing the Secretary of HHS to equalize payment rates between settings for E/M office visits--and other services that the Secretary deems appropriate--and to return the associated savings to the Medicare program.

    Agency: Congress
    Status: Open

    Comments: When we determine what steps the Congress has taken, we will provide updated 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: Daniel Bertoni
    Phone: (202) 512-7215

    7 open recommendations
    including 1 priority recommendation
    Recommendation: To improve transparency in reporting processing errors, SSA should provide additional information on the margins of error or confidence intervals, and clearly identify any limitations in its findings on overpayment information provided to Congress and the public.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA agreed with this recommendation and reported in January 2016 that it would include a discussion about the limitations of error deficiencies data in future reports. To help close this recommendation, SSA will need to report any limitations, such as small sample sizes, that would affect the reliability of its estimates of DI improper payments due to specific types and causes of errors. Although SSA provided recommendation updates on this report in April 2017, it did not comment on this particular recommendation.
    Recommendation: To minimize the potential effect of vulnerabilities in the work reporting process, SSA should take steps to help ensure that work information is entered directly into eWork, the system of record for work information, and issue required receipts. Such steps could include: (a) Improving and issuing guidance and training to field and 800- number staff to help ensure they log information into eWork and issue required receipts. (b) Establishing policies to monitor alerts to help ensure that work information for concurrent beneficiaries is reflected in SSI and DI systems, and take steps to monitor and make enhancements to systems or guidance, as needed.

    Agency: Social Security Administration
    Status: Open

    Comments: In April 2017, SSA reported that it updated training to Field and Processing Center staff and issued an administrative message to staff to remind them about issues related to overpayments and waivers. SSA also reported that, as part of its implementation of Section 826 of the Bipartisan Budget Act of 2015 (P.L.114-74), it is creating a business process and building an internet work reporting system that will allow both SSDI beneficiaries and SSI recipients to report work and earnings electronically. According to SSA, this system will determine the individual's entitlement and automatically forward the work report to the appropriate staff for processing CDR decisions. To close this recommendation, SSA will need to provide documentation that shows the agency provided training and reminders to staff, and that the agency implemented a mechanism that ensures work information for concurrent beneficiaries is reflected in both SSI and DI systems.
    Recommendation: To further ensure the effective screening of work reports, SSA should monitor its process for handling work reports to determine whether staff are taking action on work reports in accordance with proper procedures, and provide feedback to staff as needed.

    Agency: Social Security Administration
    Status: Open

    Comments: In its April 2017 update, SSA continued to disagree with this recommendation. SSA stated that the outcome of a work continuing disability review (CDR) is not dependent on the accuracy of the work report. However, as we noted in our report, inaccurate work reports may result in overpayments or work receipts (which are required by law) to not be issued. Further, pending work reports may be closed inappropriately without resulting in a work CDR. To help close this recommendation, SSA will need to show how it plans to monitor its process for handling work reports to determine compliance with agency procedures, and how feedback, if any, will be provided to staff.
    Recommendation: To enhance the ease and integrity of the work reporting process, SSA should study the costs and benefits of automated reporting options, including options similar to those currently available for SSI recipients, but that do not go as far as automating the continuing disability review process.

    Agency: Social Security Administration
    Status: Open

    Comments: In April 2017, SSA reported that the agency has made progress on two fronts, which could enhance the ease and integrity of its work reporting process, both pursuant to the Bipartisan Budget Act of 2015 (BBA). In response to Section 826 of BBA, which requires SSA to permit Disability Insurance (DI) beneficiaries to report their earnings via electronic means similar to what is available for SSI recipients, SSA reported that it has drafted a business process to build an Internet and wage reporting system for SSDI beneficiaries. SSA also noted that this business process contains plans for an Internet work reporting system that will allow both SSDI and SSI recipients to report work and earnings electronically and will automatically forward the work report to either SSI or eWork (for DI beneficiaries), and will automatically generate a receipt to the beneficiary. SSA has also completed a business process for Section 824 of the BBA, which allows SSA to contract with third party payroll providers to receive earnings in a monthly file. SSA reported that these data will allow SSI to automate benefit adjustments based on the monthly earnings report, and for DI, the information will be incorporated into the agency's Work Smart process--a new technique that combines several business processes into one unified approach to identify cases in need of a work continuing disability review. To help close this recommendation, SSA will need to provide documentation of its proposed business process for building Internet and telephone wage reporting systems for DI beneficiaries.
    Recommendation: To enhance beneficiary understanding of work reporting requirements, SSA should: (a) Clarify work reporting requirements provided to beneficiaries. (b) Explore options for increasing the frequency of reporting reminders to DI beneficiaries, similar to those currently available to SSI recipients.

    Agency: Social Security Administration
    Status: Open

    Comments: SSA agreed with this recommendation and noted in January 2016 that it plans to assess its method of communication and explore options to strengthen its message to Disability Insurance (DI) beneficiaries regarding the importance of consistent wage reporting. The agency also plans to consider whether direct phone outreach, currently being piloted to improve wage reporting for SSI recipients, would be appropriate for the DI program. In its April 2017 update, SSA indicated progress toward: updating policies and procedures related to "treatment of earnings derived from services," implementing a commercial payroll data exchange pursuant to section 824 of the BBA, and implementing electronic reporting of earnings pursuant to section 826 of the BBA. While the agency's actions to implement BBA requirements may improve program administration, SSA did not explain how these actions or its efforts to update to policies and procedures related to "treatment of earnings derived from services" would clarify work reporting requirements for or increase the frequency of reporting reminders to DI beneficiaries. SSA also did not provide an update on its plans to assess communication and explore options, as it reported in January 2016. To help close this recommendation, SSA will need to show how these or other actions taken clarify work reporting requirements for and increase reporting reminders for DI beneficiaries.
    Recommendation: improve compliance with waiver policies, SSA should develop a timetable for implementing updates to its Debt Management System to: (a) Align system controls with SSA policy, so that waivers over $1,000 cannot be administratively waived. (b) Ensure that evidence supporting waiver decisions is sufficiently maintained to allow for subsequent monitoring and oversight.

    Agency: Social Security Administration
    Status: Open
    Priority recommendation

    Comments: According to SSA, in February 2016, the agency implemented an edit to the Debt Management System remarks that amended a deficiency in the system that prevented system remarks from being deleted after a case is closed. The edit locks Debt Management System remarks to prevent technicians from overwriting existing remarks in closed cases. With respect to ensuring that overpayments over $1,000 cannot be administratively waived, SSA reported in November 2016 that it will provide a timeline for and take steps to update the Debt Management System when the agency obtains resources to fund the update. SSA reported in April 2017 that its ability to update system controls to align with SSA policy was dependent on resources. To help close this recommendation, SSA will need to show its plans and time frames for updating system controls to align them with SSA policy.
    Recommendation: To improve compliance with waiver policies, SSA should take steps to regularly assess the accuracy of DI waiver decisions, particularly for administrative waivers and for some waivers under $2,000. This could include periodically reviewing approved and denied DI waivers through its continuous quality initiative.

    Agency: Social Security Administration
    Status: Open

    Comments: In August 2016, the agency reported that it had taken several actions, including producing a comprehensive training series on overpayment and waiver policy and procedures, building a policy cluster to serve as a "one-stop resource shop" of policy references and tools for technicians, and clarifying agency policies including the Administrative Tolerance Decision Tree to assist technicians with making appropriate low-dollar overpayment waiver decisions. The agency also reported that its Continuous Quality work group continues to review the accuracy of waivers under Title II of the Social Security Act. Based on these efforts, in November 2016, SSA reported that it has closed this recommendation. However, as of April 2017, SSA did not specifically report that its review of Title II waivers will target DI waivers, including administrative waivers and waivers less than $2,000, or that such review will be an ongoing effort. To close this recommendation, SSA will need to show its plans for periodically assessing the accuracy of DI waiver decisions--particularly for administrative waivers and waivers under $2,000--through its continuous quality initiative or other means.
    Director: Debra A. Draper
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To be able to identify and address problems that may occur and thus help ensure a smooth transition, the Secretary of Defense should require the Defense Health Agency ensure that planning documents for the expansion include specific requirements to continuously monitor affected beneficiaries, including whether (1) covered medications are available and filled in a timely and accurate manner through mail order and across MTF pharmacies; and (2) beneficiaries are satisfied with the transition to mail order and MTF pharmacies.

    Agency: Department of Defense
    Status: Open

    Comments: As of April 2016, DOD has not provided information that it plans to separately track through mail order and military treatment facilities the availability, timeliness, and accuracy of prescriptions filled by beneficiaries affected by the expansion of the TRICARE pharmacy pilot. Similarly, DOD has not provided information that it plans to separately track through mail order and military treatment facilities the satisfaction of beneficiaries affected by the expansion of the TRICARE pharmacy pilot.
    Director: Thomas Melito
    Phone: (202) 512-9601

    2 open recommendations
    Recommendation: To strengthen USAID's ability to monitor Title II conditional food aid and evaluate food-for-assets activities' impact on reducing food insecurity, the USAID Administrator should establish a mechanism to readily identify all Title II projects that include conditional food aid activities and systematically collect information about the type of conditional activity included in each project.

    Agency: United States Agency for International Development
    Status: Open

    Comments: In written comments on our draft report, USAID concurred with the recommendation and stated its intention to establish a mechanism to readily identify all Title II projects that include conditional food aid activities and to collect information about the type of conditional activity in each project through the Food for Peace Management Information System. USAID also noted that it is already collecting such information for the Emergency Food Security Program, another food assistance program. As of November 2017, GAO continues to monitor USAID's efforts to fully address the recommendation.
    Recommendation: To strengthen USAID's ability to monitor Title II conditional food aid and evaluate food-for-assets activities' impact on reducing food insecurity, the USAID Administrator should systematically assess the effectiveness of food-for-assets activities in development projects in achieving project goals and objectives.

    Agency: United States Agency for International Development
    Status: Open

    Comments: In written comments on our draft report, USAID concurred with the recommendation. In September 2016, USAID stated that it had undertaken relevant reviews of the effectiveness and sustainability of Title II development projects and that it is considering expanding evaluations of completed projects to assess sustainability of results over time. As of November 2017, GAO continues to monitor USAID's efforts to fully address the recommendation.
    Director: James Cosgrove
    Phone: (202) 512-7114

    4 open recommendations
    Recommendation: To improve its oversight of network adequacy in MA, the Administrator of CMS should augment MA network adequacy criteria to address provider availability.

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

    Comments: HHS concurred with this recommendation, and noted in a January 2016 update that CMS will review how to augment the MA network adequacy criteria to address provider availability in future years. As of September 2016, agency officials have not implemented this recommendation.
    Recommendation: To improve its oversight of network adequacy in MA, the Administrator of CMS should verify provider information submitted by MAOs to ensure validity of the Health Services Delivery data.

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

    Comments: HHS concurred with this recommendation, and noted in a January 2016 update that the agency is working to standardize existing protocols to ensure the validity of the Health Services Delivery data submitted by MAOs with regards to exceptions requests and partial county justifications. However, unless CMS verifies provider information submitted by MAOs, the agency cannot be confident that MAOs are meeting network adequacy criteria. As of September 2016, agency officials have not implemented this recommendation.
    Recommendation: To improve its oversight of network adequacy in MA, the Administrator of CMS should expand network adequacy reviews by requiring that all MAOs periodically submit their networks for assessment against current Medicare requirements.

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

    Comments: HHS concurred with this recommendation. In a January 2016 update, the agency noted that CMS has expanded its reviews to include both existing and new service areas for network adequacy when MAOs apply for a service area expansion, However, unless CMS periodically requires evidence of compliance of all existing MAO networks, the agency cannot be confident that MAOs are meeting network adequacy criteria. As of September 2016, agency officials have not implemented this recommendation.
    Recommendation: 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.

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

    Comments: HHS concurred with this recommendation. In a January 2016 update, the agency noted that the Medicare Marketing Guidelines contain best practice suggestions of what should be included in the written termination notice; however, we note in our report those practices are not required, nor are the letters regularly reviewed. The agency also noted that it was considering rulemaking to require that MAOs submit sample written notices of termination to HHS for review and approval. As of September 2016, agency officials have not implemented this recommendation.
    Director: Seto Bagdoyan
    Phone: (202) 512-6722

    4 open recommendations
    including 2 priority recommendations
    Recommendation: To improve SSA's ability to detect, prevent, and recover potential DI benefit overpayments due to the concurrent receipt of FECA benefits, the Commissioner of Social Security should review the potential DI overpayments resulting from FECA benefits identified in our case studies, as well as any indicators of fraudulent activity related to FECA benefits that were not self-reported by DI beneficiaries, and establish debt-collection efforts and fraud-related penalties, as appropriate.

    Agency: Social Security Administration
    Status: Open

    Comments: As of January 2017, SSA stated that it will continue reviewing the potential DI overpayments resulting from FECA benefits identified in GAO's case studies, as GAO recommended in July 2015, and that actions are due to be completed by the end of April 2017. GAO will continue to monitor SSA's efforts in this area.
    Recommendation: To improve SSA's ability to detect, prevent, and recover potential DI benefit overpayments due to the concurrent receipt of FECA benefits, the Commissioner of Social Security should review the instances described in our report in which SSA staff did not obtain proof of FECA benefits that were reported by DI beneficiaries and (1) determine the reasons for these occurrences and whether this is a pervasive problem; and (2) if necessary, design appropriate controls or make other efforts, such as staff training, to help ensure SSA staff obtain proof of workers' compensation payments, as required by SSA policy.

    Agency: Social Security Administration
    Status: Open

    Comments: As of February 2017, SSA stated that it will continue reviewing the instances described in GAO's report in which SSA staff did not obtain proof of FECA benefits that DI beneficiaries reported nor took follow-up actions as needed, as GAO recommended in July 2015. SSA expected to complete its analysis by the end of April 2017. SSA also stated that it has published an administrative message to remind staff of correct development and processing procedures for FECA claims. GAO will continue to monitor SSA's efforts in this area.
    Recommendation: To improve SSA's ability to detect, prevent, and recover potential DI benefit overpayments due to the concurrent receipt of FECA benefits, the Commissioner of Social Security should, in accordance with OMB guidance, compare the costs and benefits of alternatives to SSA's current approach for reducing the potential for overpayments that result from the concurrent receipt of FECA benefits, which relies on beneficiaries to self-report any FECA benefits they receive. These alternatives could include, among others, routinely matching DOL's FECA program data with DI program data to detect potential DI overpayments.

    Agency: Social Security Administration
    Status: Open
    Priority recommendation

    Comments: SSA has taken steps to address this recommendation, but it has not completed its efforts. Specifically, in February 2017, SSA told GAO that the agency continues to discuss with DOL a data-matching agreement to obtain FECA payment data for offsetting DI benefits in accordance with federal law, as GAO recommended in July 2015. SSA also stated that it has reviewed its internal controls, policies, and workflow processes related to DI beneficiaries who receive concurrent FECA payments. Because SSA has not completed its work in this area, it is too early to determine whether these actions will address the problems GAO identified. GAO will continue to monitor SSA's work in this area.
    Recommendation: To improve SSA's ability to detect, prevent, and recover potential DI benefit overpayments due to the concurrent receipt of FECA benefits, the Commissioner of Social Security should strengthen internal controls designed to prevent DI overpayments due to the concurrent receipt of FECA benefits by implementing the alternative that provides the greatest net benefits.

    Agency: Social Security Administration
    Status: Open
    Priority recommendation

    Comments: SSA has taken steps to address this recommendation, but it has not completed its efforts. Specifically, in February 2017, SSA told GAO that the agency was negotiating with DOL to enter into a data matching agreement to obtain FECA payment data for offsetting DI benefits in accordance with federal law, as GAO recommended in July 2015. SSA also stated that it was reviewing its internal controls related to DI beneficiaries who receive concurrent FECA payments and is in the process of considering the best options for strengthening these internal controls. SSA further stated that in August 2016, it issued reminders to technicians regarding developing and processing DI cases when an individual is concurrently receiving FECA benefits. Because SSA has not completed its work in this area, it is too early to determine whether these actions will address the problems GAO identified. GAO will continue to monitor SSA's work in this area.
    Director: James Cosgrove
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To help ensure the financial sustainability of the Medicare program, protect beneficiaries from unwarranted financial burden, and address potential concerns about the appropriateness of the health care provided to Part B beneficiaries, Congress should consider eliminating the incentive to prescribe more drugs or more expensive drugs than necessary to treat Medicare Part B beneficiaries at 340B hospitals.

    Agency: Congress
    Status: Open

    Comments: As of February 2017, no action had been taken on this Matter for Congressional Consideration.
    Director: Bertoni, Daniel
    Phone: (202) 512-7215

    3 open recommendations
    including 1 priority recommendation
    Recommendation: To help ensure that Total Disability Individual Unemployability (TDIU) decisions are well supported and TDIU benefits are provided only to veterans whose service-connected disabilities prevent them from obtaining or retaining substantially gainful employment, the Secretary of Veterans Affairs should direct the Under Secretary for Benefits to update the TDIU guidance to clarify how rating specialists should determine unemployability when making TDIU benefit decisions. This updated guidance could clarify whether factors such as enrollment in school, education level, and prior work history should be used and if so, how to consider them; and whether or not to assign more weight to certain factors than others. Updating the guidance would also give VBA the opportunity to re-examine the applicability, if at all, of other factors it has identified as extraneous.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: VA reported in March 2017 that an internal workgroup is in the final stage of collecting and analyzing the data to determine if age should be a factor in deciding Total Disability Individual Unemployability (TDIU), and whether or not to use positive vocational assessments to disallow TDIU claims. VA reported that the workgroup is also in the process of completing an Inter-Rater Variability Assessment (IRVA) to examine the disparity in rating decisions involving entitlement to TDIU and service connection. After completion of the internal study on TDIU and the IRVA, targeted for September 30, 2017, the workgroup will submit its preliminary analysis and recommendations to VBA leadership for a decision on the next courses of action for future policy decisions and will then update any related guidance, as appropriate.
    Recommendation: To help ensure that TDIU decisions are well supported and TDIU benefits are provided only to veterans whose service-connected disabilities prevent them from obtaining or retaining substantially gainful employment, the Secretary of Veterans Affairs should direct the Under Secretary for Benefits to verify the self-reported income provided by veterans (a) applying for TDIU benefits and (b) undergoing the annual eligibility review process by comparing such information against IRS earnings data, which VBA currently has access to for this purpose. VA could also explore options to obtain more timely earnings data from other sources to ensure that claimants are working within allowable eligibility limits

    Agency: Department of Veterans Affairs
    Status: Open
    Priority recommendation

    Comments: VA is developing an upfront verification process by expanding the data sharing agreement with Social Security Administration (SSA), which enables VA to receive federal tax information via an encrypted electronic transmission through a secure portal. Once a Total Disability Individual Unemployability (TDIU) claim is received, VA will request the reported income through the secured SSA portal and receive a response within 10-16 days. VA reported that process will serve as a more efficient way to receive income data in a timely manner and maintain the integrity of the TDIU benefit while reducing improper payments. The development and implementation of the upfront verification process for TDIU claimants is anticipated to be completed by July 21, 2017. Meanwhile, VA has reinstituted the data match agreement with SSA through December 2017, which collects earned income (employment wages). The agreement allows VBA to compare reported income earnings of TDIU beneficiaries to earnings actually received. In addition, VA completed the upfront income verification manual guidance and is planning to pilot the guidance prior to implementation. VA also has drafted new manual guidance for the annual eligibility review process and the documents are currently under review. As of March 2017, VA reported delays and stated it planned to fully implement the annual eligibility review process by June 30, 2017.
    Recommendation: To help ensure that TDIU decisions are well supported and TDIU benefits are provided only to veterans whose service-connected disabilities prevent them from obtaining or retaining substantially gainful employment, in light of VA's agreement with the recommendations made by the Advisory Committee on Disability Compensation, the Secretary of Veterans Affairs should direct the Under Secretary for Benefits to develop a plan to study the complex TDIU policy questions on (1) whether age should be considered when deciding if veterans are unemployable and (2) whether it is possible to disallow TDIU benefits for veterans whose vocational assessment indicated they would be employable after rehabilitation.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: As of March 2017, a VA workgroup is in the final stages of collecting and analyzing the data to determine if age should be a factor in deciding TDIU, and whether or not the agency will use positive vocational assessments to disallow TDIU claims. Additionally, the workgroup is in the process of completing an Inter-Rather Variability Study (IRVA) to examine the disparity in rating decisions involving entitlement to TDIU and service connection. After completion of the internal study on TDIU and the IRVA, targeted for September 30, 2017, he workgroup will submit its preliminary analysis and recommendations and VA will then decide on the next courses of action for future policy decisions. Due to VA's earlier conclusions, in April 2015, that no immediate changes to its current guidance were necessary, and in the spirit of this recommendation, the status will remain open until the completion of these ongoing efforts.
    Director: Seto J. Bagdoyan
    Phone: (202) 512-6722

    1 open recommendations
    Recommendation: To further improve efforts to limit improper payments, including fraud, in the Medicaid program, the Acting Administrator of CMS should provide guidance to states on the availability of automated information through Medicare's enrollment database--the Provider Enrollment, Chain and Ownership System (PECOS)--and full access to all pertinent PECOS information, such as ownership information, to help screen Medicaid providers more efficiently and effectively.

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

    Comments: HHS considers this recommendation closed because they provide states with training and direct access to PECOS on an ongoing basis. Additionally, CMS also makes Medicare Enrollment data available to states through custom data extracts. We do not consider this action sufficient to close the recommendation, to provide states information on the availability of automated information through PECOS. For example, custom extracts do not constitute automated information containing all information in PECOS states need to screen providers in Medicaid. Additionally, the states the we interviewed for our study were not aware that custom extracts were available. CMS should provide guidance to state Medicaid programs that this information is available until fully automated access to PECOS is available. We reached out to CMS about the status of this recommendation. As of May 2017, we have not received a response. We will continue to monitor progress on this recommendation.
    Director: Thomas Melito
    Phone: (202) 512-9601

    2 open recommendations
    including 2 priority recommendations
    Recommendation: To strengthen its management of cash-based food assistance projects and help ensure improved oversight of these projects, the USAID Administrator should develop policy and comprehensive guidance for USAID staff and implementing partners for financial oversight of cash-based food assistance projects.

    Agency: United States Agency for International Development
    Status: Open
    Priority recommendation

    Comments: USAID concurred with this recommendation in its comments to the March 2015 GAO report. In June 2016, USAID reported that it would work with the Cash Learning Partnership (CaLP) on the development and dissemination of policy and guidance related to financial oversight of cash-based food assistance projects. In April 2017, USAID stated that it is continuing to work with CaLP and provide training for FFP staff and implementing partners for the oversight and management of cash-based food assistance programs, including courses related to the financial oversight. However, as of April 2017, USAID had not completed any guidance for USAID staff and implementing partners for financial oversight of cash-based food assistance projects.
    Recommendation: To strengthen its management of cash-based food assistance projects and help ensure improved oversight of these projects, the USAID Administrator should require USAID staff to conduct systematic financial oversight of USAID's cash-based food assistance projects in the field.

    Agency: United States Agency for International Development
    Status: Open
    Priority recommendation

    Comments: USAID concurred with this recommendation in its comments to the March 2015 GAO report. In January 2017, USAID stated that it was continuing to pursue training opportunities for staff in response to this recommendation. However, USAID, as of April 2017, had not completed efforts to address the recommendation. GAO will continue to monitor USAID's efforts to require staff to conduct systematic financial oversight and determine the extent to which the training and third monitoring will address this issue.
    Director: James Cosgrove
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To help the Department of Health and Human Services better control spending and encourage efficient delivery of care, Congress should consider requiring Medicare to pay PCHs as it pays PPS teaching hospitals, or provide the Secretary with the authority to otherwise modify how Medicare pays PCHs. To generate cost savings from any reduction in outpatient payments to PCHs, Congress should also provide that all forgone outpatient payment adjustment amounts be returned to the Supplementary Medical Insurance Trust Fund.

    Agency: Congress
    Status: Open

    Comments: The 21st Century Cures Act enacted in December 2016 slightly reduces the additional payments to PCHs for outpatient services furnished on or after January 1, 2018, and returns savings to the Supplementary Medical Insurance Trust Fund. However, the law does not substantively change how PCHs are paid for outpatient services, which differs from how Medicare pays PPS teaching hospitals. In addition, as of March 1, 2017, no legislative action had been identified that changes how PCHs are paid for inpatient services, as GAO suggested in February 2015. Until Medicare pays these cancer hospitals in a way that encourages greater efficiency, Medicare remains at risk for overspending.
    Director: Randall B. Williamson
    Phone: (202) 512-7114

    4 open recommendations
    Recommendation: To ensure DHA can accurately and consistently assess mental health provider staffing needs across each of the military services, the Secretary of Defense should direct the Secretaries of the Army, Air Force, and Navy to require the medical commands of each military service to include its estimated mental health provider staffing needs generated through PHRAMS in the requirements fields of DHA's quarterly mental health staffing reports.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: The Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to ensure DHA, through the PHRAMS contractor, continue to refine PHRAMS to incorporate the needs of the military services to reduce the need for additional service-specific methods of determining mental health provider staffing needs.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: To ensure the Defense Health Agency (DHA) can accurately and consistently assess mental health provider staffing needs across each of the military services, the Secretary of Defense should direct the Secretaries of the Army, Air Force, and Navy to require the medical commands of each military service to report any additional service-specific methods they use to determine their final estimates of mental health provider staffing needs.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Recommendation: The Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to require the National Capital Region Medical Directorate to include its estimated mental health provider staffing needs generated through PHRAMS in the requirements fields of DHA's quarterly mental health staffing reports.

    Agency: Department of Defense
    Status: Open

    Comments: As of July 2017, DOD officials have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Director: Rebecca Gambler
    Phone: (202) 512-8777

    1 open recommendations
    Recommendation: To ensure data required by IMBRA are collected, maintained, and reliable, the Director of USCIS should ensure that IMBRA-required data elements will be collected in an automated manner with the release of the electronic I-129F petition.

    Agency: Department of Homeland Security: United States Citizenship and Immigration Services
    Status: Open

    Comments: In January 2015, USCIS reported that it expected to start development for the electronic I-129F petition in March 2016. As of March 2016, USCIS officials confirmed that the electronic I-129F petition is tied to the Family-Based Adjustment of Status (AOS) product line for USCIS ELIS. USCIS officials stated that, as of March 2016, the requirements-gathering phase for this product line is underway and, as of June 2016, USCIS began the requirements-gathering phase. In October 2016, the Office of Transformation Coordination reported that there have been some delays in the product line that includes the I-129F petition and the tentative expected completion date is the second quarter of fiscal year 2018. To fully implement this recommendation, USCIS should ensure that IMBRA-required data elements are collected in an automated manner with the release of the electronic I-129F petition.
    Director: Linda T. Kohn
    Phone: (202) 512-7114

    4 open recommendations
    Recommendation: To improve consumers' access to relevant and understandable information on the cost and quality of health care services, the Secretary of HHS should direct the Administrator of CMS to include in the CMS Compare websites, to the extent feasible, estimated out-of-pocket costs for Medicare beneficiaries for common treatments that can be planned in advance.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of July 2015 CMS indicated that it is working to implement this recommendation. Specifically, it is actively investigating options for allowing a more targeted and consumer-centric individual user experience on Physician Compare. We will follow up to gather additional information from CMS officials as they continue their work.
    Recommendation: To improve consumers' access to relevant and understandable information on the cost and quality of health care services, the Secretary of HHS should direct the Administrator of CMS to organize cost and quality information in the CMS Compare websites to facilitate consumer identification of the highest-performing providers, such as by listing providers in order based on their performance.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of July 2015, CMS indicated that it is working to implement this recommendation. We will follow up to gather additional information from CMS officials as they continue their work.
    Recommendation: To improve consumers' access to relevant and understandable information on the cost and quality of health care services, the Secretary of HHS should direct the Administrator of CMS to include in the CMS Compare websites the capability for consumers to customize the information presented, to better focus on information relevant to them.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of July 2015, CMS indicated that it is working to implement this recommendation. Specifically, it is evaluating feasibility of including estimated out-of-pocket costs on physician compare. We will follow up to gather additional information from CMS officials as they continue their work.
    Recommendation: To improve consumers' access to relevant and understandable information on the cost and quality of health care services, the Secretary of HHS should direct the Administrator of CMS to develop specific procedures and performance metrics to ensure that CMS's efforts to promote the development and use of its own and others' transparency tools adequately address the needs of consumers.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As of July 2015, CMS indicated that it is working to implement this recommendation. CMS also noted that Physician Compare is in the early stages of public reporting, and is evaluating the feasibility of listing providers based on their performance in the new carefinder.gov project. We will follow up to gather additional information from CMS officials as they continue their work.
    Director: Debra A. Draper
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To eliminate unnecessary program duplication and to achieve increased efficiencies and potential savings within the integrated MHS, Congress should terminate the Secretary of Defense's authority to contract with the USFHP designated providers in a manner consistent with a reasonable transition of affected USFHP enrollees into TRICARE's regional managed care program or other health care programs, as appropriate.

    Agency: Congress
    Status: Open

    Comments: As of April 2017, no actions have been taken.
    Director: James Cosgrove
    Phone: (202) 512-7114

    2 open recommendations
    including 2 priority recommendations
    Recommendation: To ensure that MA encounter data are of sufficient quality for their intended purposes, the Administrator of CMS should establish specific plans and time frames for using the data for all intended purposes in addition to risk adjusting payments to MAOs.

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

    Comments: HHS was in general agreement with this recommendation. In January 2017 we reported that CMS had made progress in defining its objectives for using MA encounter data for risk adjustment and in communicating its plans and time frames to MAOs. However, although CMS had formed general ideas of how it would use MA encounter data for purposes other than risk adjustment, it had not specified plans and time frames for most of the additional purposes for which encounter data may be used. These other purposes include activities to support program integrity. As of July 2017, CMS officials told us that the agency had not taken any further actions in response to this July 2014 recommendation.
    Recommendation: 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.

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

    Comments: While in general agreement with this recommendation, HHS did not commit to completing data validation before using MA encounter data for risk adjustment. In January 2017 we reported that CMS had made limited progress toward validating encounter data by having begun compiling basic statistics on the volume and consistency of data submissions and preparing automated summary reports for MAOs indicating the diagnosis information used for risk adjustment. However the agency had not yet taken other important steps identified in its Medicaid encounter data validation protocol, such as establishing benchmarks for completeness and accuracy. In July 2017, CMS officials told us that the agency had not taken any further actions in response to this July 2014 recommendation.
    Director: Debra Draper
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: The Secretary of Defense should require the Director of the Defense Health Agency to enhance existing guidance for the TROs to include more specificity on assessing nonenrolled beneficiaries' access to care. Specifically, the guidance should contain criteria for analyzing and interpreting the nonenrolled beneficiary and civilian provider surveys' results and the beneficiary population sizing model to facilitate a more rigorous and consistent approach across regions for identifying locations with potential access problems and determining whether actions should be taken.

    Agency: Department of Defense
    Status: Open

    Comments: In April 2016, DHA informed us that it has taken action to ensure a consistent approach across the regions for identifying locations with potential access problems and determining whether actions should be taken. Specifically, the TROs agreed in April 2014 to utilize the congressionally directed Survey of Civilian Provider Acceptance of, and Beneficiary Access to TRICARE Standard and Extra survey results as the source to identify areas of low awareness, acceptance and access scores. Once an area has been confirmed as an area of low awareness, acceptance and access, the SME will work with the respective managed care support contractor to develop an improvement action plan. In addition, to standardize analysis and provide for more specificity, in May 2014 the three TROs agreed upon a standardized Beneficiary Population Sizing Model (BPSM), an analytical tool to monitor access to care and beneficiary satisfaction for Standard beneficiaries outside PSAs. The standardized BPSM was implemented in the last TRO TRICARE Standard annual brief to the DHA Deputy Director in January 2016. DHA has noted that they took these actions as a result of our recommendation. Although they have taken these actions, we are awaiting further information regarding whether they enhanced existing guidance for the TROs to include this additional specificity on assessing nonenrolled beneficiaries' access to care. We will update this recommendation once we obtain additional information from DHA.
    Director: Dicken, John E
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: The Secretary of HHS should direct the Administrator of CMS to monitor the relationship between PPACA-based FULs and the NADACs on an ongoing basis to help determine whether PPACA-based FULs effectively control federal Medicaid expenditures without reducing beneficiary access to drugs subject to FULs over time.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: As part of the final rule implementing the PPACA-based FUL formula, CMS monitors the relationship between the FUL and the NADAC for individual drugs on an ongoing basis and ensures that the FUL does not fall below the NADAC. CMS, however, does not monitor the relationship between the FUL and NADAC in aggregate. This monitoring would provide CMS information on the extent to which the FUL effectively controls federal Medicaid expenditures, particularly in cases where there may be potential for over-reimbursement. CMS officials expect that, by mid-2017, many states will determine reimbursement using an average acquisition cost based on the NADAC. As a result, any potential variation between the FUL and NADAC would be reduced according to CMS officials. We plan to obtain state plan amendments from CMS to confirm whether states are reimbursing at an average acquisition cost or using some other methodology to control Medicaid expenditures.
    Director: Bertoni, Daniel
    Phone: (202) 512-7215

    2 open recommendations
    Recommendation: In order to enhance the accuracy of and ensure appropriate agency access to SSA's death data, and to clarify how SSA applies the eligibility requirements of the Social Security Act and enhance agencies' awareness of how to obtain access, the Social Security Administration's Acting Commissioner should direct the Deputy Commissioner of Operations to develop and publicize guidance it will use to determine whether agencies are eligible to receive SSA's full death file.

    Agency: Social Security Administration
    Status: Open

    Comments: The Social Security Administration (SSA) disagreed with this recommendation, stating that each request to obtain the full death file is unique, and that officials must review them on a case-by-case basis to ensure compliance with various legal requirements. It also expressed concern that developing this guidance as we recommended would require agency expenditures unrelated to its mission in an already fiscally constrained environment. SSA noted that any federal agency that would like to explore accessing the full death master file (which includes state death records) should submit a request to SSA. SSA will review the file and, if satisfactory, enter into an Information Exchange Agreement covering terms, conditions and reimbursement for the exchange. As of April 2017, SSA reports that it is continuing its efforts and there is no change in status. GAO appreciates that agencies may base their request for the full death file on different intended uses, and supports SSA's efforts to ensure compliance with all applicable legal requirements. However, developing such guidance could help to ensure consistency in SSA's future decision making by the new Office of Data Exchange, and enhance agencies' ability to obtain the data in a timely and efficient manner.
    Recommendation: In order to enhance the accuracy of and ensure appropriate agency access to SSA's death data, and to increase transparency among recipient agencies, the Social Security Administration's Acting Commissioner should direct the Deputy Commissioner of Operations to share a more detailed explanation of how it determines reimbursement amounts for providing agencies with death information.

    Agency: Social Security Administration
    Status: Open

    Comments: The Social Security Administration (SSA) reported that it has implemented improvements in its estimating procedures for future reimbursable agreements to ensure consistent estimates for all customers. It reviews all reimbursable requests on a case-by-case basis to determine full costs (including direct and indirect expenses) to provide goods, resources, or services. However, the agency stated that it is not a typical government business practice to share these detailed costs for reimbursable agreements. As of April 2017, SSA reports that it is continuing its efforts and there is no change in status. We are encouraged that SSA has made efforts to standardize the estimates it shares with its federal partners. While we recognize that there may be limitations on the type of cost details SSA can provide to recipient agencies, we continue to believe that more transparency in conveying the factors that lead to the estimated and final reimbursement amounts recipient agencies are charged could help them make more informed decisions.
    Director: Bagdoyan, Seto J
    Phone: (202) 512-4749

    1 open recommendations
    including 1 priority recommendation
    Recommendation: To improve SSA's ability to detect and prevent potential DI cash benefit overpayments due to work activity during the 5-month waiting period, the Commissioner of Social Security should assess the costs and feasibility of establishing a mechanism to detect potentially disqualifying earnings during all months of the waiting period, including those months of earnings that the agency's enforcement operation does not currently detect and implement this mechanism, to the extent that an analysis determines it is cost-effective and feasible.

    Agency: Social Security Administration
    Status: Open
    Priority recommendation

    Comments: While the Social Security Administration (SSA) initially concurred with our August 2013 recommendation, as of February 2017, SSA has not assessed costs and feasibility of establishing a mechanism to detect potentially disqualifying earnings during all months of the waiting period. Instead, SSA concluded that conducting a study at this time would yield unreliable information because the agency's ability to obtain and track earnings from alternative sources is changing due to several requirements of the Bipartisan Budget Act of 2016, which SSA believes will likely affect GAO's concerns. GAO continues to believe that undertaking an analysis to assess costs and feasibility could provide SSA with more comprehensive information with which to decide on potential revisions to its enforcement operation. We will continue to monitor SSA's efforts in this area.
    Director: Cosgrove, James C
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To increase beneficiaries' awareness of providers' financial interest in a particular treatment, Congress should consider directing the Secretary of Health and Human Services to require providers who self-refer IMRT services to disclose to their patients that they have a financial interest in the service.

    Agency: Congress
    Status: Open

    Comments: In August 2013, to increase beneficiaries' awareness of providers' financial interest in a particular treatment, we suggested that Congress should consider directing the Secretary of Health and Human Services to require providers who self-refer IMRT services to disclose to their patients that they have a financial interest in the service. As of June 2017, Congress has not implemented this suggestion.
    Recommendation: 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.

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

    Comments: 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 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 June 2017, CMS has not provided any additional information about actions it has taken to address this recommendation.
    Director: Cosgrove, James C
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: 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 insert a self-referral flag on Medicare Part B claim forms and require providers to indicate whether the anatomic pathology services for which the provider bills Medicare are self-referred or not.

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

    Comments: In June 2013, we recommended that the Administrator of the Centers for Medicare & Medicaid Services (CMS) insert a self-referral flag on Medicare Part B claim forms and require providers to indicate whether the anatomic pathology services for which the provider bills Medicare are self-referred or not. 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. We 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 anatomic pathology services and monitor the behavior of those providers who self-refer these services. As of June 2017, CMS has not provided any additional information about actions to address this recommendation.
    Recommendation: 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.

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

    Comments: 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) does not concur with this recommendation and does not believe it would address overutilization that occurs as a result of self-referral. HHS noted that it would be difficult to make recommendations regarding whether anatomic pathology services are appropriate without reviewing a large number of claims. 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. We also continue to believe this can be achieved without reviewing a large number of claims. CMS could, for example, consider performing targeted audits of providers that perform a higher average number of biopsy procedures compared to providers of the same specialty treating similar numbers of Medicare beneficiaries. As of June 2017, CMS has not provided any additional information about actions to address this recommendation.
    Recommendation: 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.

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

    Comments: 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. We continue to believe that CMS should develop a payment approach that addresses this incentive. As of June 2017, CMS had not provided any additional information about actions it has taken to address this recommendation.
    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: Jeszeck, Charles A
    Phone: (202) 512-7215

    4 open recommendations
    Recommendation: To enhance understanding and better inform debate on the possible effects of moving to a more risk-based premium structure, during consideration of various redesign options and after a redesign may be authorized, the Director of PBGC should continue to develop PBGC's hypothetical model, analyzing various premium redesign options and their impacts on sponsors, and report the results to Congress. As part of these analyses, PBGC should evaluate the potential effects on sponsors of incorporating additional risk factors, such as company financial health and plan investment mix, and include an assessment to identify any potentially disproportional hardships on smaller companies that may result from the redistribution of higher rates to riskier sponsors.

    Agency: Pension Benefit Guaranty Corporation
    Status: Open

    Comments: PBGC agreed with this recommendation. The agency is committed to continued development of the databases, models, and analyses of various premium redesign options and their impacts on sponsors, and to report the results of these analyses to Congress. In April 2014, PBGC noted that its efforts are still in process. As of August 2015, PBGC had provided no additional updates on actions taken on this recommendation.
    Recommendation: To help strengthen the PBGC insurance program, Congress should authorize redesign of PBGC's premium structure to more fully reflect the risk posed by plans and sponsors to the agency, such as by providing for the incorporation of additional risk factors.

    Agency: Congress
    Status: Open

    Comments: In July 2012 and December 2013, Congress passed premium increases (P.L. No. 112-141 and P.L. 113-67, respectively) to better reflect the risk posed to the Pension Benefit Guaranty Corporation by certain defined benefit pension plans and plan sponsors. Nevertheless, As of September 2015, Congress had yet to authorize a redesign of PBGC's premium structure.
    Recommendation: In addition, to improve PBGC's ability to collect key information that may be necessary to help the agency estimate its risk exposure to future claims and strengthen implementation of any changes to the premium structure, Congress should provide PBGC with access to additional information needed to assess risk and assist in setting premiums, such as by expanding the criteria requiring plan sponsors to report under section 4010 of ERISA.

    Agency: Congress
    Status: Open

    Comments: As of September 2015, Congress has taken no action related to this matter.
    Recommendation: Moreover, to better understand the mechanics of how best to incorporate additional risk factors, improve transparency, and help inform the evaluation of the various redesign options, Congress should establish an independent premiums advisory committee reflecting a range of perspectives--including, for example, representatives from federal agencies, sponsors, actuaries, private insurers, and labor groups--to assist with such activities as developing the mechanics for incorporating additional risk factors and implementing new rates, as well as delineating a variety of alternative methods to address PBGC's deficit.

    Agency: Congress
    Status: Open

    Comments: As of September 2015, Congress has taken no action related to this matter.
    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.
    Director: Yocom, Carolyn L
    Phone: (202)512-4931

    1 open recommendations
    Recommendation: To ensure that federal funding efficiently and effectively responds to the countercyclical nature of the Medicaid program, Congress may wish to consider enacting an FMAP formula that is targeted for variable state Medicaid needs and provides automatic, timely, and temporary increased FMAP assistance in response to national economic downturns.

    Agency: Congress
    Status: Open

    Comments: On February 10, 2016, GAO testified on considerations related to the Medicaid funding formula. See Medicaid: Changes to Funding Formula Could Improve Allocation of Funds to States GAO-16-377T January 26, 2016. We also cited this report in our discussion on Medicaid funding during economic downturns in Medicaid: Key Policy and Data Considerations for Designing a Per Capita Cap on Federal Funding(GAO-16-726).
    Director: Cosgrove, James C
    Phone: (202)512-7029

    2 open recommendations
    Recommendation: To help ensure that Medicare beneficiaries have access to high-quality dialysis care, the Administrator of CMS should assess the extent to which the bundled payment for dialysis care will be sufficient to cover an efficient dialysis organization's costs to provide such care when the bundled payment expands to cover oral-only ESRD drugs. The Administrator should conduct this assessment before implementing this expanded bundled payment.

    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: In order to ensure effective monitoring of treatment of mineral and bone disorder, the Administrator of CMS should continue collecting data for quality measures related to this condition from sources such as the Elab Project until CROWNWeb is fully implemented and concerns about its data reliability have been adequately addressed.

    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: Cosgrove, James C
    Phone: (202)512-7029

    2 open recommendations
    Recommendation: Congress may wish to consider reducing home oxygen payment rates to better align them with home oxygen suppliers' costs.

    Agency: Congress
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To establish rates that more accurately reflect the distinct costs of providing each type of home oxygen equipment, the Administrator of CMS should restructure Medicare's home oxygen payment methodology. This should include removing the payment for portable oxygen refills from that for stationary equipment and paying for refills only for the equipment types that require them.

    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: Goldstein, Mark L
    Phone: (202)512-3000

    3 open recommendations
    Recommendation: To improve internal controls over the E-rate program, the Federal Communications Commission should, based on the findings of the risk assessment, conduct a thorough examination of the overall design of E-rate's internal control structure to ensure that the procedures and administrative resources related to internal controls are aligned to provide reasonable assurance that program risks are appropriately targeted and addressed.

    Agency: Federal Communications Commission
    Status: Open

    Comments: In April 2014, FCC approved USAC's hiring of a contractor to conduct a risk assessment of the E-rate program. FCC plans to implement this recommendation after the risk assessment is completed and the results of the risk assessment can be used to inform the examination of the internal control structure.
    Recommendation: To improve internal controls over the E-rate program, the Federal Communications Commission should implement a systematic approach to assess internal controls that appropriately considers the results of beneficiary audits and that is supported by a documented and approved set of policies and procedures.

    Agency: Federal Communications Commission
    Status: Open

    Comments: In April 2014, FCC approved the hiring of a contractor to conduct a risk assessment of the E-rate program. In July 2014, an FCC official said that the agency planning to take action on this recommendation before the risk assessment is completed.
    Recommendation: To improve internal controls over the E-rate program, the Federal Communications Commission should develop policies and procedures to periodically monitor the internal control structure of the E-rate program, including evaluating the costs and benefits of internal controls, to provide continued reasonable assurance that program risks are targeted and addressed.

    Agency: Federal Communications Commission
    Status: Open

    Comments: In April 2014, FCC approved the hiring of a contractor to conduct a risk assessment of the E-rate program. In July 2014, an FCC official said that the agency planning to take action on this recommendation before the risk assessment is completed.
    Director: Cosgrove, James C
    Phone: (202)512-7029

    1 open recommendations
    Recommendation: To help ensure that changes in Medicare payment methods for dialysis care do not adversely affect beneficiaries, the Administrator of CMS should monitor the access to and quality of dialysis care for groups of beneficiaries, particularly those with above average costs of dialysis care, under the new bundled payment system. Such monitoring should begin as soon as possible once the new bundled payment system is implemented and be used to inform potential refinements to the payment system.

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

    Comments: In March 2010, we recommended that the Administrator of CMS monitor the access to and quality of dialysis care for groups of beneficiaries, particularly those with above average costs, under the new bundled payment system to help ensure that changes in the Medicare payment methods for dialysis care do not adversely affect. We further specified that such monitoring begin as soon as possible once the new bundled payment system is implemented. CMS implemented the expanded bundled payment system for dialysis care in January 2011. As of August 2011, CMS is collecting data on dialysis care utilization that could be used to examine access to and quality of dialysis care by groups of beneficiaries. Although CMS anticipates using these data to identify potential problems in dialysis care, the agency has not begun using these data to examine access to and quality of care by groups of beneficiaries, nor has finalized plans to do so.
    Director: Cosgrove, James C
    Phone: (202)512-7029

    1 open recommendations
    Recommendation: To ensure that savings are realized from the implementation of an MPPR or other policies that reflect efficiencies occurring when services are furnished together, Congress may wish to consider exempting these savings from budget neutrality.

    Agency: Congress
    Status: Open

    Comments: As of May 2017, we are awaiting an update from HHS on the status of this recommendation. We will update the status of this recommendation when we receive additional information.
    Director: Steinwald, Alan Bruce
    Phone: (202)512-3000

    1 open recommendations
    Recommendation: Given the contribution of physicians to Medicare spending in total, the Administrator of CMS should develop a profiling system that identifies individual physicians with inefficient practice patterns and, seeking legislative changes as necessary, use the results to improve the efficiency of care financed by Medicare. The profiling system should include methods for measuring the impact of physician profiling on program spending and physician behavior.

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

    Comments: Physician feedback reporting was initiated under section 131(c) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), and was expanded by section 3003 of the Patient Protection and Affordable Care Act (PPACA). In addition, PPACA required the Department of Health and Human Services to coordinate the physician feedback program with a Value Modifier (VM) that will adjust fee-for-service physician payments for the relative quality and cost of care provided to beneficiaries. In 2012, CMS provided Quality and Resource Use Reports (QRUR) to large providers nationwide and physician-focused QRURs to groups with 25 or more eligible providers in 9 states; by 2014, CMS sent QRURs to all group practices and solo practitioners. Also, as required in the act, CMS applied the VM to select physicians in 2015, with all physicians being subject to VM by 2017. The Act requires the VM to be implemented in a budget neutral manner, meaning that any upward payment adjustments for high performance must balance the downward payment adjustments applied for poor performance. CMS officials said they develop and will continue to develop experience reports related to each year's QRUR/VM cycle. In 2015, CMS used VM results for physicians in groups of 100 or more in public engagement of stakeholders, encouraging them to report quality, because quality performance was the driver of the payment adjustments in 2015. CMS is working with its Center for Clinical Standards and Quality to think of how to better engage physicians and groups in reporting, to avoid the automatic downward adjustment. As the program gains experience, CMS will use the experience reports to examine the impact of QRURs and VM on the Medicare program. In order for this recommendation to be closed as implemented, CMS will need to expand its efforts to measure the impact of QRURs and VM on program spending and physician behavior.