Recommendation: The Administrator of CMS should eliminate impediments to collaborative audits in managed care conducted by audit contractors and states, by ensuring that managed care audits are conducted regardless of which entity--the state or the managed care organization--recoups any identified overpayments. (Recommendation 2)

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

Comments: CMS agreed with and has taken some steps to address this action, as recommended by GAO in July 2018. In September 2019, CMS reported that in July 2019 CMS held a meeting with states and collaborative audit contractors to discuss coordination of managed care audits, including a wide range of challenges with managed care audits. As result of the feedback and recommendations received, CMS is evaluating several process improvements and reiterated that audit contractors will continue to work with states to provide support and assistance in Medicaid managed care, and that Medicaid managed care audits should not be limited by MCO contract language. Although CMS has communicated to states the need to increase audits in managed care and address identified issues, it is unclear if these actions will remove known impediments to managed care audits or result in an increase in the number of collaborative audits. Implementing GAO's July 2018 recommendation is needed because few audits of Medicaid managed care have been conducted and overpayments can be significant based on the findings from federal and state audits and investigations that have been completed. .

Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, the Secretary of Health and Human Services should direct the Administrator of CMS to annually report improper payment estimates and error rates for the advance PTC program.

Agency: Department of Health and Human Services
Status: Open
Priority recommendation

Comments: The Department of Health and Human Services (HHS) concurred with this recommendation. On May 23, 2018, HHS's Centers for Medicare and Medicaid Services (CMS) stated that it is currently in the process of developing an improper payment measurement for the advance premium tax credit (PTC). The development of the measurement methodologies will be a multi-year process which consists of the development of measurement policies, procedures, and tools. It also includes extensive pilot testing to ensure an accurate and efficient improper payment estimate, as well as, acquisition activities for procurement of improper payment measurement contractors. In January 2020, CMS stated that it is still in the process of developing an improper payment measurement for the advance PTC. Further, CMS stated that it provided progress updates in the fiscal year 2019 HHS agency financial report (AFR), and will continue to do so in future AFRs until an improper payment rate is estimated. We will continue to monitor the agency's actions to address this recommendation.

Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, and until annual reporting of improper payment estimates and error rates for the advance PTC program is performed, the Secretary of Health and Human Services should direct the Administrator of CMS to disclose significant matters relating to the Improper Payments Information Act (IPIA) estimation, compliance, and reporting objectives for the advance PTC program in the agency financial report, including CMS's progress and timeline for expediting the achievement of those objectives and the basis for any delays in meeting IPIA requirements.

Agency: Department of Health and Human Services
Status: Open

Comments: HHS concurred with this recommendation. On February 28, 2018, the Department of Health and Human Services's (HHS) Centers for Medicare and Medicaid Services (CMS) stated that updates on the advance premium tax credit (PTC) program improper payment measurement development were provided in the fiscal year (FY) 2017 Agency Financial Report (AFR), which was published in November 2017. In FY 2018, we reviewed the FY 2017 AFR that HHS's CMS cited in support for closing this recommendation. Based on our review, the FY 2017 AFR does not address our recommendation as it does not provide a timeline for reporting an improper payment estimate. In FY 2019, we reviewed HHS's FY 2018 AFR published in November 2018, which includes a statement that HHS will continue to update its annual AFRs on the status of the measurement program development until the improper payment estimate is reported. However, this latest AFR also does not provide a timeline for reporting an improper payment estimate for HHS's PTC program. In January 2020, CMS stated that it is in the process of procuring federal contractors to perform the improper payment measurement. However, CMS further stated that due to uncertainties surrounding the timing of the procurement, CMS does not anticipate publishing a reporting timeline until the contracts have been awarded. We will continue to monitor the agency's actions to address this recommendation.

Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, the Secretary of Health and Human Services should direct the Administrator of CMS to design and implement procedures for verifying the identities of phone and mail applicants to reasonably assure that ineligible individuals are not enrolled in qualified health plans in the marketplaces or provided advance PTC.

Agency: Department of Health and Human Services
Status: Open

Comments: The Department of Health and Human Services (HHS) neither agreed nor disagreed with this recommendation. Regarding verification of filer identity, HHS stated, in response to the draft report, that for individuals starting an application via phone, the call center representatives use verbal attestations for verifications from individuals. HHS stated that for paper applications, individuals must provide names and complete addresses as well as other information. In addition, HHS stated that individuals must attest that the information they provide on all applications is accurate by signing under penalty of perjury. However, these steps do not involve the verification of an applicant's identity to a third-party source. In August 2018, HHS officials stated that they are exploring alternatives for assessing risk and ensuring integrity of applicant information that is provided to the program and ways to ensure personal information provided by an individual is accurate through a variety of means. After this analysis phase, they will assess resource requirements, cost, and operational implications for potential implementation approaches with a target date for completion of 2019. As of December 2018, HHS had not designed and implemented procedures for verifying the identities of phone and mail applicants, as GAO recommended. As of January 2020, HHS indicated that it is developing new policy and guidance which could significantly change potential solutions or requirements. However, HHS did not provide us a time frame for when it plans to finalize the new policy and guidance. We will continue to monitor agency's actions to address the recommendation.

Recommendation: To comply with improper payments reporting requirements and improve procedures related to processing PTC information on tax returns, the Commissioner of Internal Revenue should direct the appropriate officials to assess the program against applicable IPIA-defined thresholds and conclude on its susceptibility to significant improper payments, and revise the scope of its improper payments susceptibility assessment for the PTC program to include instances in which advance PTC is greater than or equal to the amount of PTC claimed on the tax return. If the program meets the IPIA definition for being susceptible to significant improper payments based on this assessment, estimate and report improper payments associated with the PTC program consistent with IPIA requirements.

Agency: Department of the Treasury: Internal Revenue Service
Status: Open
Priority recommendation

Comments: The Internal Revenue Service (IRS) partially agreed with this recommendation. On December 13, 2019, IRS provided us a status update and stated that its Research, Applied Analytics and Statistics division completed an analysis of net premium tax credit (PTC) using National Research Program (NRP) tax years 2015 and 2014 data during the 4th quarter of fiscal year 2019 and developed improper payment estimates using two different methodological approaches. However, IRS indicated that it did not publish these improper payment estimates in Treasury's Agency Financial Report for two reasons: (1) there is as yet insufficient NRP data to develop an estimate that is within the confidence interval and margin of error prescribed by the Office of Management and Budget for improper payments sampling, and (2) the Department of the Treasury (Treasury) wishes to engage with Health and Human Services' Centers for Medicare & Medicaid Services on the potential for developing a joint rate estimate for advance PTC and PTC. In addition, IRS noted that it had not yet determined whether this is even possible from a data compatibility standpoint. Further, IRS stated that while the estimates do not meet the statistical precision requirement, they do suggest that Net PTC would meet the criteria to be considered susceptible to significant improper payments. IRS indicated that when it last discussed this recommendation with GAO, it was suggested this recommendation would be closed once improper payment rates are published. However, IRS would now like GAO to consider closing this recommendation at this time given (1) the IRS's efforts to analyze potential improper payments, (2) Treasury's new approach to reporting, and (3) the need for additional years of data before a statistically valid estimate can be developed. We do not believe the recommendation should be closed at this time based on the three reasons IRS has listed above. However, we credit IRS for exploring ways to meet the intent of the recommendation. We will continue to monitor the agency's actions to address this recommendation.

Recommendation: To comply with improper payments reporting requirements and improve procedures related to processing PTC information on tax returns, the Commissioner of Internal Revenue should direct the appropriate officials to assess and document the feasibility of approaches for incorporating information from the marketplaces on individuals who did not demonstrate that they met the eligibility requirements for citizenship or lawful presence in the tax compliance process. If determined feasible, IRS should work with Treasury to require marketplaces to periodically provide such information on individuals and use such information to recover advance PTC made for those individuals.

Agency: Department of the Treasury: Internal Revenue Service
Status: Open

Comments: The Internal Revenue Service (IRS) agreed with this recommendation. In December 2018, an IRS official indicated that IRS conducted a detailed review of the recommendation. IRS informed GAO that it is internally discussing an alternative way to address the recommendation to prevent premium tax credit to noncitizens. The IRS official indicated that IRS is reviewing this alternative with the Department of the Treasury and the Department of Health and Human Services' Centers for Medicare & Medicaid Services. IRS did not provide GAO with a time frame for its implementation. On December 13, 2019, IRS provided us a status update and stated that it had no new information for this recommendation. We will continue to monitor the agency's actions to address this recommendation.

Recommendation: To allow DOE management to effectively monitor invoice reviews and have assurance that this control activity is operating as intended, the Secretary of Energy should establish a DOE-wide invoice review policy that includes requirements for sites to establish well-documented invoice review operating procedures.

Agency: Department of Energy
Status: Open

Comments: In its comments on a draft of the report in March 2017, DOE concurred in principle with this recommendation, stating that it already had an established, detailed DOE-wide invoice review policy provided in DOE's Financial Management Handbook and in the DOE Acquisition Guide. In February 2020, DOE issued an update to its Financial Management Handbook that included additional procedures to address intra-governmental payment and collection transactions. However, neither the prior version of the Financial Management Handbook nor the additional information includes invoice review procedures. The Financial Management Handbook refers users to the DOE Acquisition Guide for procedures for invoice review. However, the Acquisition Guide states that it is intended to offer general guiding principles for approving officials to consider when reviewing and analyzing cost elements included in contract invoices--as opposed to detailed procedures for invoice review--and does not require sites to establish well-documented invoice review operating procedures, as we recommended.

Recommendation: To help DOE take a more strategic approach to managing improper payments and risk, including fraud risk, the Secretary of Energy should implement leading practices for managing the department's risk of fraud, including creating a structure with a dedicated entity within DOE to design and oversee fraud risk management activities.

Agency: Department of Energy
Status: Open
Priority recommendation

Comments: In its comments on a draft of the report in March 2017, DOE partially agreed with the recommendation. In its written comments on the report, DOE stated that it considered the recommendation to be closed without corrective action and that it would rely on the existing Office of Financial Policy and Internal Controls and on the DOE Office of Inspector General (OIG) to design and oversee financial fraud risk management activities. However, we disagree that relying in part on the OIG to design and oversee fraud risk management activities meets best practices because, according to GAO's Fraud Risk Framework, the dedicated entity should not include the OIG so that the OIG can maintain its independence. In May 2020, DOE officials said they were developing a fraud risk and data analytics framework. Among other steps, DOE expects to establish a new group in fiscal year 2020 that will oversee DOE's fraud risk management activities. We will continue to monitor DOE's progress in implementing this recommendation.

Recommendation: To help DOE take a more strategic approach to managing improper payments and risk, including fraud risk, the Secretary of Energy should implement leading practices for managing the department's risk of fraud, including conducting fraud risk assessments that are tailored to each program and use the assessments to develop a fraud risk profile

Agency: Department of Energy
Status: Open

Comments: In its comments on a draft of the report in March 2017, DOE concurred with the substance of the recommendation; however they considered the recommendation to be closed without corrective action because DOE believed that its risk assessments met the requirements of the Improper Payments Elimination and Recovery Improvement Act of 2012, as reported by the Office of Inspector General (OIG), and because it has implemented updates to OMB Circular A-123 that added requirements related to managing fraud risk and adherence to GAO's Fraud Risk Framework. However, we found that DOE has not conducted fraud risk assessments that were tailored to its programs and, therefore, do not allow the department to create a fraud risk profile. We also found that, although DOE updated its internal control assessment tools with a list of fraud risks as required by OMB Circular A-123, the list of risks were the same for all DOE sites and were not tailored to the sites' different programs. In May 2020, DOE officials said they were developing a fraud risk and data analytics framework. Among other steps, the framework is expected to include changes to DOE's process to develop its fraud risk profile, beginning in fiscal year 2020. We will continue to monitor DOE's progress in implementing this recommendation.

Recommendation: To help DOE take a more strategic approach to managing improper payments and risk, including fraud risk, the Secretary of Energy should implement leading practices for managing the department's risk of fraud, including developing and documenting an antifraud strategy that describes the programs' approaches for addressing the prioritized fraud risks identified during the fraud risk assessment.

Agency: Department of Energy
Status: Open

Comments: In its comments on the draft report in March 2017, DOE concurred with this recommendation but considered the recommendation closed without corrective action because DOE had implemented the updated OMB Circular A-123 and because DOE's antifraud strategy was embedded in the DOE internal control program. However, DOE officials told us that they had not developed or documented a DOE-wide antifraud strategy or directed individual programs to develop program-specific strategies. Furthermore, DOE's implementation of OMB Circular A-123 included adding a list of potential risks to their internal control assessment tool that were the same for all DOE sites and were not tailored to the sites' different programs. In May 2020, DOE officials said they were developing a fraud risk and data analytics framework. Among other steps, DOE is planning to develop an antifraud strategy in fiscal year 2021. We will continue to monitor DOE's progress in implementing this recommendation.

Recommendation: To help DOE take a more strategic approach to managing improper payments and risk, including fraud risk, the Secretary of Energy should implement leading practices for managing the department's risk of fraud, including designing and implementing specific control activities, including fraud awareness training and data analytics, to prevent and detect fraud and other improper payments.

Agency: Department of Energy
Status: Open

Comments: In its comments on the draft report in March 2017, DOE stated that it concurred in principle with the recommendation, but that it had implemented the recommendation. In May 2020, DOE officials said they were developing a fraud risk and data analytics framework. Among other steps, DOE is planning to begin in fiscal year 2022 to use data analytics across the agency to prevent fraud. We will continue to monitor DOE's progress in implementing this recommendation.

Recommendation: To help ensure that necessary data are available to employ data analytics as a tool to perform contractor cost-surveillance activities, the Secretary of Energy should require contractors to maintain sufficiently detailed transaction-level cost data that are reconcilable with amounts charged to the government, including (1) cost data that, at a minimum, represent a full data population and (2) the details necessary to determine the nature of each cost transaction, with such identifiers as transaction date, dollar amount, item or service description, and transaction codes to indicate the type of cost represented (e.g., construction materials, property lease, and office supplies).

Agency: Department of Energy
Status: Open

Comments: In its comments on the draft report in March 2017, DOE did not agree to implement this recommendation because officials believe that the recommendation establishes agency-specific requirements for DOE contractors that are more prescriptive than current federal requirements. In May 2020, DOE officials said they were developing a fraud risk and data analytics framework. Among other steps, DOE is planning to begin in fiscal year 2022 to use data analytics across the agency to prevent fraud. We will continue to monitor DOE's progress in implementing this recommendation.

Recommendation: To provide agencies access to SSA's more complete set of death data, Congress should consider amending the Social Security Act to explicitly allow SSA to share its full death file with Treasury for use through the DNP working system.

Agency: Congress
Status: Open

Comments: In fiscal year 2020, the Senate passed S.4104, which included language to address the recommendation. In the context of the Do Not Pay (DNP) working system, the bill, if enacted, would authorize comparison of the Social Security Administration's (SSA) full death file with personally identifiable information reviewed through the working system and would allow redisclosure of such comparison of information to any federal or state agency authorized to use the working system. As of July 15, 2020, the House has not introduced a related bill for fiscal year 2020. Additionally, in February 2020, the administration released its President's 2021 Budget, which proposes legislation to allow the DNP Business Center full access to the SSA full death file. This proposal would include the Department of the Treasury and the SSA working together to determine the most efficient manner to make full death information available for use in preventing improper payment and fraud. We will continue to monitor congressional legislation to address this recommendation. .

Recommendation: To better monitor agency use of the DNP working system once a strategy has been developed, the Director of OMB should develop and implement monitoring mechanisms--such as goals, benchmarks, and performance measures--to evaluate agency use of the DNP working system.

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

Comments: OMB agreed with the concept of monitoring mechanisms and will continue to work with agencies to reduce improper payments and encourage agencies to establish goals to improve payment accuracy that will be monitored and evaluated by OMB. In fiscal year 2019, OMB provided us a status update on July 31, 2019, stating that Treasury does this monitoring and reports updates to OMB on a quarterly basis and that monitoring will occur in conjunction with the President's Management Agenda. In August 2020, Treasury provided us examples of reports that it provides to OMB to assist OMB with evaluating agency use of the DNP working system. We plan to meet with OMB to discuss how it uses these reports and will continue to monitor OMB's actions to address this recommendation.

Recommendation: To reasonably assure that agency-reported information on use of the DNP working system is reliable, the Director of OMB should develop a process for comparing agency reporting on the use of the DNP working system to available sources, such as OMB guidance and DNP working system adjudication reports.

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

Comments: The Office of Management and Budget (OMB) agreed with the concept of ensuring that data are reliable and will consider the feasibility of a process to compare agency submissions to available sources to reasonably assure that agency-reported information on use of the Do Not Pay working system is reliable. OMB provided us a status update on July 1, 2019, stating that OMB will work with Treasury to determine feasibility of doing this review and establishing a process during fiscal year 2019. As of February 2020, OMB has not provided any new status updates for this recommendation. We will continue to monitor the agency's actions to address this recommendation.

Recommendation: To reasonably assure that agency-reported information on use of the DNP working system is complete, the Director of OMB should revise its guidance to clarify whether agencies should report on their uses of all of the functionalities of the DNP working system in their agency financial reports.

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

Comments: The Office of Management and Budget (OMB) agreed with ensuring the completeness of data and will continue to work with agencies and the Chief Financial Officer community to ensure that agency-reported information on the use of the Do Not Pay (DNP) working system is complete. In fiscal year 2019, OMB provided us a status update on July 1, 2019, stating that this recommendation was addressed in OMB's Circular A-136. Additionally, we met with OMB officials on July 31, 2019. During the meeting, OMB officials informed us that the OMB Circular A-136, Section II.4.5 (bullet 3) (dated June 28, 2019) states that "Agencies should provide a brief narrative of the reduction in improper payments that is attributable to the DNP Initiative, as applicable. See OMB Circular A-123, Appendix C, Part V for a thorough overview of the roles and responsibilities of agencies to use centralized data sources such as the Treasury Working System and other government databases to prevent improper payments." We have reviewed OMB Circular A-136 and confirmed that the circular does contain the statements above. However, we do not believe that the OMB Circular A-136 meets the intent of our recommendation. GAO issued its recommendation, in part, because GAO found that OMB guidance does not indicate whether agencies should report on all uses of the DNP working system, including those outside payment integration that the DNP working system does not track. For this reason, GAO report concluded that without complete and reliable data and clear guidance on what information agencies should report, OMB cannot effectively monitor and evaluate the use of the DNP working system. Therefore, we do not believe that the OMB Circular A-136 sufficiently clarifies whether agencies should report on their uses of all of the functionalities of the DNP working system in their agency financial reports. As of February 2020, OMB has not provided any new status updates for this recommendation. We will continue to monitor OMB's actions to address this recommendation.

Recommendation: To strengthen efforts to identify and address noncompliance with the EITC, ACTC, and AOTC, the Commissioner of Internal Revenue should direct Refundable Credits Policy and Program Management (RCPPM) to take necessary steps to ensure the reliability of collections data and periodically review that data to (a) compute a collections rate for post-refund enforcement activities and (b) determine what additional analyses would provide useful information about compliance results and costs of post-refund audits and document-matching reviews.

Agency: Department of the Treasury: Internal Revenue Service
Status: Open

Comments: No executive action taken as of December 2019. The Internal Revenue Service (IRS) disagreed with this May 2016 recommendation. IRS raised concerns about the cost of studying collections data for post-refund enforcement activities. GAO recognizes that gathering collections data has costs and the data have limitations, notably that not all recommended taxes are collected. However, use of these data -- once IRS is able to verify their reliability -- could better inform resource allocation decisions and improve the overall efficiency of enforcement efforts. By not taking necessary steps to ensure the reliability of that data and to link them to tax assessments to calculate a collections rate, IRS lacks critical information. Periodic reviews of collections data and analyses could help IRS officials more efficiently allocate limited enforcement resources by providing a more complete picture about compliance results and costs.

Recommendation: In order to better ensure proper Medicare payments and protect Medicare funds, CMS should seek legislative authority to allow the RAs to conduct prepayment claim reviews.

Agency: Department of Health and Human Services
Status: Open
Priority recommendation

Comments: In April 2016, we recommended that the Centers for Medicare and Medicaid Services (CMS) should seek legislative authority to allow the Recovery Auditors (RAs) to conduct prepayment claim reviews. The Department of Health and Human Services did not concur with this recommendation, and the President's fiscal year 2021 budget did not include a proposal for such authority. We continue to believe CMS should seek legislative authority to allow RAs to conduct these reviews. Until CMS seeks and implements this authority, it will be missing an opportunity to help identify improper payments before they are made.

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: CMS is working to improve the accuracy of its calculation of coding intensity, as GAO recommended in April 2016. In October 2017, CMS officials told GAO that the agency is reevaluating the design of the risk adjustment data validation audits to ensure their rigor in the context of all the payment error data acquired since the original design of the audits. As part of this work, CMS officials told GAO that the agency will examine whether coding intensity is the best criterion to use to select contracts for audit. As a result, in October 2018, CMS told GAO that rather than coding intensity, it plans to implement a new methodology using payment error as the key sampling driver beginning with audits for payment year 2014. Additionally, CMS was taking steps to modernize its audit system to improve reliability. For example, it initiated a project to explore how to directly receive electronic medical record documentation. As of January 2020, the agency is continuing to reevaluate the design of these audits. Unless CMS takes this and other actions to improve the risk adjustment data validation contract-level audit process, it will fail to recover improper payments of hundreds of millions of dollars annually.

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: CMS is working to modify the selection of MA contracts for audit, as GAO recommended in April 2016. In October 2017, CMS officials told GAO that the initial RADV audit design was based on a limited set of payment error data available at the time. As part of efforts to improve the audits, CMS officials told GAO that the agency will examine whether coding intensity is the best criterion to select contracts for audit. In October 2018, CMS told GAO that it plans to implement a new methodology using payment error as the key sampling driver-rather than coding intensity-beginning with audits for payment year 2014. As of January 2020, the agency is using the revised methodology on the 2014 and 2015 payment year audits. They expect to conclude this process in late fiscal year 2020 and 2021, respectively. Unless CMS completes actions to improve the RADV contract-level audit process, it will fail to recover improper payments of hundreds of millions of dollars annually.

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: HHS concurred with this recommendation in its fiscal year 2021 budget justification. HHS reaffirmed its commitment to identifying and correcting improper payments in the MA program. It has begun taking steps to improve the timeliness of the contract-level RADV audit process, such as aligning the time frames in CMS's contract-level RADV audits with those of the national RADV audits. Once completed, CMS needs to provide evidence that the actions taken by the agency have enhanced the timeliness of CMS's contract-level RADV process.

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: CMS is working to improve the timeliness of the agency's contract-level risk adjustment data validation appeals process, as GAO recommended in April 2016. In October 2017, CMS officials told GAO that the agency is actively considering options for expediting the appeals process. For example, CMS is considering the appropriate number of days for rendering reconsideration decisions while allowing for a complete and thorough adjudication. In December 2019, CMS officials told GAO they expect to issue a final rule in January 2021 that will establish uniform timelines to expedite the appeals process. Specifically, they plan to require that a findings determination be made within 60-90 days of an arbiter's receipt of each party's arguments at each stage of an appeal. Unless CMS takes such actions to improve the risk adjustment data validation contract-level audit process, it will fail to recover improper payments of hundreds of millions of dollars annually.

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: CMS has attempted to incorporate a recovery audit contractor in the Medicare Advantage program, as GAO recommended in April 2016. After failing to receive any proposals when CMS first issued a request for proposals (RFP) in 2014, CMS issued a request for information to industry in December 2015, which included a draft Statement of Work to solicit feedback, gauge interest, and conduct market research regarding CMS entering into a contract with a recovery audit contractor to identify underpayments and overpayments associated with diagnosis data submitted to CMS by Medicare Advantage Organizations. CMS reported that it subsequently issued another RFP in 2016 and did not receive any proposals for a second time. In December 2019, CMS officials told GAO that the functions of the Part C recovery Audit programs are being performed through other program integrity mechanisms. CMS subsequently reported in its fiscal year 2021 budget justification that CMS believes the proposed scope of the Part C RAC has been subsumed by RADV and CMS will demonstrate that the RADV program satisfies this recommendation. Until CMS completes efforts to improve the risk adjustment data validation contract-level audit process and demonstrates that it has satisfied the requirement to incorporate a recovery audit contractor in the MA program, CMS will fail to recover improper payments of hundreds of millions of dollars annually.

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: SSA continues to disagree with this recommendation as of December 2019. As we reported, when SSA accepts a beneficiary's return to work allegation (work report), staff have 30 days to determine whether additional action is needed, such as a continuing disability review (CDR) to assess continued eligibility and determine whether benefits should be adjusted. However, not all work reports result in a CDR, and GAO reported that SSA lacks an oversight process to help determine whether work reports are not resulting in CDRs when they should. SSA continues to maintain that its staff carefully review work reports and make independent determinations on the need for a CDR. Absent an oversight process to ensure that work reports are properly screened, SSA may be missing opportunities to prevent overpayments for unreported work. SSA further reported that it may decide to complete a CDR through alternative approaches, such as its Continuing Disability Review Enforcement Operation process using Internal Revenue Service data, its Quarterly Earnings Project using Office of Child Support Enforcement data, or its analysis of electronically reported wages. However, SSA did not indicate whether these alternative avenues for conducting CDRs could identify errors made by its staff handling work reports and result in feedback. Implementing this recommendation will help ensure that SSA staff appropriately take action on work reports.

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: As of December 2019, SSA reported taking several steps to clarify work reporting requirements. For instance, SSA reported it has developed outreach materials to share information with beneficiaries and advocacy groups. However, SSA has not provided sufficient documentation for GAO to determine if it has clarified issues identified in GAO's 2015 report, such as how and when to report work, and that beneficiaries may have to repay overpayments that occur even when they report work. Finally, SSA has not indicated whether it has assessed options for increasing the frequency of reporting reminders to DI beneficiaries. Until SSA can demonstrate that it has improved the clarity of its work reporting requirements and frequency of its work reporting reminders, DI beneficiaries may continue to incur overpayments, or be required to repay overpayments that occurred even though they reported work.

Recommendation: To improve the effectiveness of its oversight of eligibility determinations, the Administrator of CMS should conduct reviews of federal Medicaid eligibility determinations to ascertain the accuracy of these determinations and institute corrective action plans where necessary.

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

Comments: The Department of Health and Human Services (HHS) has taken some steps to improve the accuracy of Medicaid eligibility determinations, as GAO recommended in October 2015, but has not yet conducted a systematic review of federal eligibility determinations. In July 2017, HHS issued its final rule on the Payment Error Rate Measurement (PERM) program, and stated that it would include reviews of federal eligibility determinations in states that have delegated that authority. In December 2017, HHS provided information noting that the first cycle of the revised PERM includes two states where there were federal eligibility determinations. However, as HHS confirmed in December 2019, the random sample of eligibility determinations reviewed in the first cycle of the revised PERM did not include any federal eligibility determinations. As such, the PERM has not systematically reviewed federal determinations, and we maintain that further reviews are needed to help ensure that only individuals eligible for Medicaid are receiving benefits. We will continue to monitor HHS to determine if HHS is ascertaining the accuracy of federal eligibility determinations and taking corrective action where necessary.

Recommendation: To better assess and address the full extent of improper payments in the TRICARE program, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to implement a more comprehensive TRICARE improper payment measurement methodology that includes medical record reviews, as done in other parts of its existing postpayment claims review programs.

Agency: Department of Defense
Status: Open
Priority recommendation

Comments: The Department of Defense (DOD) concurred with our recommendation. As of November 2019, the DOD's Defense Health Agency (DHA) has taken some action to incorporate medical record reviews in its improper payment estimate, as GAO recommended in February 2015. In June 2017, DHA awarded a contract for TRICARE claims review services which, according to DHA officials, will allow the agency to implement a more comprehensive improper payment measurement methodology using retrospective medical records reviews. As of November 2019, the agency reported to Congress that its managed care support contracts now included medical record reviews. It also expected to include payment error results from medical record reviews in its improper payment calculation for fiscal year 2020. DOD also planned to report the effect of medical record reviews on its improper payment rate in a report to Congress in March 2020. Once DHA incorporates medical record reviews in its improper payment rate calculation methodology, GAO will be able to close this recommendation.

Recommendation: To better assess and address the full extent of improper payments in the TRICARE program, and once a more comprehensive improper payment methodology is implemented, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to develop more robust corrective action plans that address underlying causes of improper payments, as determined by the medical record reviews.

Agency: Department of Defense
Status: Open
Priority recommendation

Comments: The Department of Defense concurred with our recommendation. As of November 2019, the Department of Defense's Defense Health Agency (DHA) has taken steps to implement a more comprehensive TRICARE improper payment measurement methodology. Until the department fully implements the new methodology and identifies the underlying causes of improper payments, the full extent of improper payments in the TRICARE program will likely not be identified and addressed. As of November 2019, the DHA has not yet fully implemented a more comprehensive measurement methodology, and has, therefore, not developed more robust corrective action plans.

Recommendation: To promote and enhance federal, state, and local NEMT coordination activities, the Secretary of Transportation, as the chair of the Coordinating Council, should convene a meeting of the member agencies of the Coordinating Council and complete and publish a new or updated strategic plan that, among other things, clearly outlines a strategy for addressing NEMT and how it can be coordinated across federal agencies that fund NEMT service.

Agency: Department of Transportation
Status: Open

Comments: The Federal Transit Administration (FTA) concurred with this recommendation. The Department of Transportation (DOT), which chairs the Coordinating Council on Access and Mobility (Coordinating Council) and provides administrative support and staff, has made some progress to enhance coordination of NEMT programs through the development of a new or updated strategic plan, as GAO recommended in December 2014, but coordination at the federal level remains limited. In October 2019, the Coordinating Council adopted a new strategic plan as recommended by GAO. However, DOT indicated that strategies for coordinating NEMT across federal agencies would not be fully articulated until November 2020 when it plans to issue a report to the President and Congress. Until the report is finalized, the Coordinating Council may be missing an opportunity to identify and align goals and strategies for increased NEMT coordination with the benefits of coordination, such as increased program efficiency or reduced costs.

Recommendation: To promote and enhance federal, state, and local NEMT coordination activities, the Secretary of Transportation, as the chair of the Coordinating Council, should convene a meeting of the member agencies of the Coordinating Council and finalize and issue a cost-sharing policy and clearly identify how it can be applied to programs under the purview of member agencies of the Coordinating Council that provide funding for NEMT.

Agency: Department of Transportation
Status: Open

Comments: FTA concurred with this recommendation. The Department of Transportation (DOT), which chairs the Coordinating Council and provides administrative support and staff, has made minimal progress to develop and issue a cost-sharing policy, as GAO recommended in December 2014, which would allow agencies to identify and allocate costs among programs. In October 2019, the Coordinating Council adopted a new strategic plan. DOT plans to include a cost sharing policy as part of a report to the President and Congress in September 2020. According to DOT officials, they have begun the process of soliciting and including input from Coordinating Council agencies to develop the elements of the report, including the cost sharing policy, as of December 2019. The development of a cost sharing policy would provide federal guidance on how to address cost sharing issues across agencies and help facilitate ride and vehicle sharing. Until the Coordinating Council develops federal cost allocation principles for transportation providers, federal agencies may be unable to address cost-sharing issues across agencies such as ride and vehicle sharing.

Recommendation: To promote and enhance federal, state, and local NEMT coordination activities, the Secretary of Transportation, as the chair of the Coordinating Council, should convene a meeting of the member agencies of the Coordinating Council and using the on-going work of the Health, Wellness, and Transportation working group and other appropriate resources, (1) identify the challenges associated with coordinating Medicaid and VA NEMT programs with other federal programs that fund NEMT, (2) develop recommendations for how these challenges can be addressed while still maintaining program integrity and fraud prevention, and (3) report these recommendations to appropriate committees of Congress. To the extent feasible, the Coordinating Council should implement those recommendations that are within its legal authority.

Agency: Department of Transportation
Status: Open

Comments: FTA said they concurred in part with this recommendation. The Fixing America's Surface Transportation (FAST) Act requires the Coordinating Council on Access and Mobility (Coordinating Council) to develop and publish a strategic plan. The Department of Transportation (DOT), which chairs the Coordinating Council and provides administrative support and staff, has made some but minimal progress to address the challenges associated with coordinating Medicaid and VA NEMT programs and other federal programs, as GAO recommended in December 2014. In October 2019, the Coordinating Council adopted a new strategic plan. According to DOT, it has made progress identifying challenges associated with coordinating Medicaid and VA NEMT programs, in part through the use of focus groups and a survey conducted by the National Center for Mobility Management. DOT expects it will include recommendations for addressing the challenges identified in a November 2020 report to the President and Congress. As of December 2019, DOT had begun the process of soliciting input from Coordinating Council agencies into these recommendations. Until DOT's assessment to identify and address coordination challenges is completed, agencies will be limited in coordinating Medicaid and VA NEMT programs with other federal programs that fund NEMT.

Recommendation: If Congress agrees that significant paid preparer errors exist, it should consider legislation granting IRS the authority to regulate paid tax preparers.

Agency: Congress
Status: Open

Comments: Multiple bills have been introduced in the Congress that would authorize the Department of Treasury to regulate paid tax preparers, as GAO recommended in April 2014. The most recent bills include: H.R. 3157, H.R. 3330, S. 1192, and Section 5 of S. 1138. As of August 2020, no action has been taken on any of these bills. In addition, multiple other bills were introduced in both the House and Senate between 2014 and 2018 to regulate paid tax preparers. GAO testified on October 1, 2015 on improper payments and the tax gap before Senate Finance and on December 10, 2015 on GAO recommendations before the Subcommittee on Regulatory Affairs and Federal Management, Committee on Homeland Security and Governmental Affairs, US Senate. Both hearings increased attention to GAO's matter to Congress that tax preparers be regulated. Paid preparer regulation may increase the accuracy of tax returns and potentially reduce the tax gap.

Recommendation: To improve the implementation of the act, the Secretary of Agriculture should develop and implement policies and procedures for cost-benefit analyses related to computer matching agreements to include key elements such as personnel and computer costs, as well as avoidance of future improper payments and recovery of improper payments and debts.

Agency: Department of Agriculture
Status: Open

Comments: Although department officials have stated that they plan to take actions to address this recommendation, as of July 2019 we have not yet received information to validate agency actions. Subsequent to the agency sending documentation, we plan to verify whether implementation has occurred.

Recommendation: To improve the implementation of the act, the Secretary of Labor should develop and implement policies and procedures for cost-benefit analyses related to computer matching agreements to include key elements such as personnel and computer costs, as well as avoidance of future improper payments and recovery of improper payments and debts.

Agency: Department of Labor
Status: Open

Comments: Although department officials have stated that they are taking actions to address this recommendation, as of August 2020, we have not yet received information to validate agency actions. Subsequent to the agency sending documentation, we plan to verify whether implementation has occurred.

Recommendation: To improve the implementation of the act, the Secretary of Labor should ensure the DIB reviews cost-benefit analyses to make certain cost savings information for the computer matching program is included before approving CMAs.

Agency: Department of Labor
Status: Open

Comments: Although department officials have stated that they are taking actions to address this recommendation, as of August 2020, we have not yet received information to validate agency actions. Subsequent to the agency sending documentation, we plan to verify whether implementation has occurred.

Recommendation: To improve the implementation of the act, the Secretary of Labor should ensure the DIB performs annual reviews and submits annual reports on agency computer matching activities, as required by the act.

Agency: Department of Labor
Status: Open

Comments: Although department officials have stated that they are taking actions to address this recommendation, as of August 2020, we have not yet received information to validate agency actions. Subsequent to the agency sending documentation, we plan to verify whether implementation has occurred

Recommendation: To proactively prepare for oversight of future disaster relief funding, the Director of OMB should develop standard guidance for federal agencies to use in designing internal control plans for disaster relief funding. Such guidance could leverage existing internal control review processes and should include, at a minimum, the following elements: (1) robust criteria for identifying and documenting incremental risks and mitigating controls related to the funding and (2) requirements for documenting the linkage between the incremental risks related to disaster funding and efforts to address known internal control risks.

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

Comments: To address the recommendation, OMB should issue guidance on internal control for disaster relief funding, including criteria for identifying additional risks and mitigating controls related to the funding and a requirement to link these incremental risks to ongoing efforts to address known internal control risks. On July 15, 2016, OMB issued the revised Circular No. A-123, Management's Responsibility for Enterprise Risk Management and Internal Control. The Circular requires agencies to implement enterprise risk management, which includes the development of a risk profile that analyzes the risks faced in achieving strategic objectives and identifies options for addressing them. In April 2017, OMB staff stated that they believe that the implementation of enterprise risk management through Circular No. A-123 satisfies the intent our recommendation. Because the responsibility for implementing enterprise risk management lies with agency management, Circular No. A-123 does not include specific guidance for identifying risks related to disaster funding. Further discussion and documentation to support OMB's position that the revised Circular addresses our recommendation will be necessary. The Bipartisan Budget Act of 2018, Sec. 21208(c) requires OMB to issue standard guidance for Federal agencies to use in designing internal control plans for disaster relief funding in order to proactively prepare for oversight of future disaster relief funds. The Act states this guidance shall leverage existing internal control review processes and shall include, at a minimum, (1) robust criteria for identifying and documenting incremental risks and mitigating controls related to the funding, and (2) guidance for documenting the linkage between the incremental risks related to disaster funding and efforts to address known internal control risks. GAO reviewed OMB's actions to implement the law. On June 28, 2019, GAO, 2017 Disaster Relief Oversight: Strategy Needed to Ensure Agencies' Internal Control Plans Provide Sufficient Information, GAO-19-479 (Washington, D.C.: Jun 28, 2019) reported the 2013 recommendation remains open and that we plan to continue monitoring OMB's progress in implementing this priority recommendation. Further, the report stated that OMB did not have an effective strategy to ensure that agencies timely submitted internal control plans; and OMB's Memorandum M-18-14, Implementation of Internal Controls and Grant Expenditures for the Disaster-Related Appropriations lacked specific instructions to agencies on what to include in their internal control plans. As such, a new recommendation was warranted. As of February 2020, OMB has not provided any new status updates for this recommendation.

Recommendation: To further improve agency controls that help prevent payments to participants whose incomes exceed eligibility limits, the Secretary of Agriculture should direct the Administrator of FSA to implement a process to verify that accountants' and attorneys' statements accurately reflect participants' incomes as reported on income tax returns and supporting documentation or other equivalent documents.

Agency: Department of Agriculture
Status: Open
Priority recommendation

Comments: The U.S. Department of Agriculture agreed with this recommendation at the time of our report but, as of April 2020, has not acted to implement it because of the sensitive nature of questioning accountants' and attorneys' professional judgment. However, we believe doing so would reduce the potential for improper payments supported by taxpayers and would be an appropriate action for the agency to take.

Recommendation: Congress should consider granting Labor the additional authority it is seeking to access wage data to help verify claimants' reported income and help ensure the proper payment of benefits.

Agency: Congress
Status: Open

Comments: No legislation introduced as of March 20120. The Workers' Compensation Reform Act of 2015 (S. 2051, title V) was introduced in the 114th Congress. It would have allowed DOL to access wage data, as GAO suggested in April 2013, from the National Directory of New Hires to improve the integrity of the Federal Employees' Compensation Act program, among other actions. If similar legislation were introduced in the 116th Congress and enacted, this legislation could help to prevent and detect improper payments in the Federal Employees' Compensation Act program.

Recommendation: To reduce the incentive for facilities to restrict their service provision to avoid reaching the LVPA treatment threshold, the Administrator of CMS should consider revisions such as changing the LVPA to a tiered adjustment.

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

Comments: As of February 2020, CMS had not implemented this recommendation. CMS stated in February 2020 that the agency had extensive discussions with the Medicare Payment Advisory Commission regarding the Commission's suggestions for modifying the LVPA. CMS also stated that the agency was analyzing the design of the LVPA as part of its evaluation of the ESRD Prospective Payment System. This recommendation remains open because CMS has not provided documentation of steps such as those described above that the agency has taken to consider revisions to the LVPA. We will update the status of this recommendation upon receipt of additional information from CMS.

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: Congress has exempted savings from the implementation of multiple procedure payment reductions (MPPR) for certain diagnostic imaging and therapy services from the budget neutrality requirement, as GAO suggested in July 2009. However, as of January 2020, other policies that may result in a reduction in payments for the professional component for imaging services remained subject to budget neutrality; "savings" from these services are redistributed to other services and do not accrue to the Medicare program. The Consolidated Appropriations Act of 2016 revised the payment reduction for the professional component of multiple diagnostic imaging services from 25 percent to 5 percent beginning on January 1, 2017, and exempted the reduced expenditures attributable to this MPPR from the budget neutrality provision. MPPRs or other policies that may result in a reduction to payments for the technical component for diagnostic cardiovascular and ophthalmology services continue to be subject to budget neutrality for 2020. Unless Congress exempts from the budget neutrality requirement savings realized from the implementation of all MPPRs or other policies that reflect efficiencies occurring when services are furnished together, these savings will not accrue to the Medicare program.

Recommendation: To help further the progress toward meeting the goals of IPIA and determining states' role in assisting federal agencies to report a national improper payment estimate on federal programs, the Director, Office of Management and Budget, should expand IPIA guidance to provide criteria that federal agencies should consider when developing a plan or methodology for estimating a national improper payment estimate for state-administered programs, such as criteria that address the nature and extent of data and documentation needed from the states to calculate a national improper payment estimate.

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

Comments: The Office of Management and Budget (OMB) concurred with this recommendation. Since the issuance of the GAO report, OMB has made several revisions to its OMB Circular No. A-123, Appendix C "Requirements for Effective Measurement and Remediation of Improper Payments." The latest revision is dated June 26, 2018. The intent of OMB Circular No. A-123, Appendix C, is to ensure that federal agencies focus on prevention and have the proper incentives to improve their improper payment rates. In August 2020, OMB provided us its improper payment guidance on sampling and estimation in place at the time of the GAO audit. Based on this documentation, we sent a follow-up request to OMB for additional information. We are currently waiting to hear back from OMB so we can continue with our review. We will continue to monitor the agency's actions to address this recommendation.