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 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 February 2018 update that CMS requires MAOs to identify provider availability in certain circumstances, such as in granting exceptions to the agency's network adequacy criteria. CMS also stated that it would consider augmenting MA network adequacy criteria to address provider availability in future years. However, CMS's 2018 MA network adequacy guidance stated that the agency does not currently consider provider availability when reviewing an organization's network adequacy, and this guidance was not updated in 2019. As a result, as of September 2019, 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 February 2018 update that the agency has standardized 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, CMS's 2018 MA network adequacy guidance stated that MAOs remain responsible for conducting validation of Health Services Delivery data. Unless CMS verifies provider information submitted by MAOs, the agency cannot be confident that MAOs are meeting network adequacy criteria. As of September 2019, 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 September 2017 update, the agency stated that it had met the spirit of our recommendation by adding its best practice suggestions of what should be included in the written termination notice to the Medicare Managed Care Manual. However, as we noted in our report, those practices are not required, nor are the letters regularly reviewed. As of September 2019, agency officials have not yet implemented this recommendation.

Recommendation: To improve the military whistleblower reprisal investigation process and oversight of such investigations, the Secretary of Defense should work in coordination with the Department of Defense Inspector General (DODIG) to direct the services to follow standardized investigation stages and issue guidance clarifying how the stages are defined.

Agency: Department of Defense
Status: Open

Comments: DOD officials concurred with this recommendation and provided an update in May 2019, in which they stated that the office was preparing an issuance for coordination that will direct the services to follow standardized investigation stages and guidance clarifying how the stages are defined. DOD officials estimated that the issuance would be completed by December 31, 2019.

Recommendation: To improve CMS's oversight of Medicaid payments, the Administrator of CMS should take steps to ensure that states report accurate provider-specific payment data that include accurate unique national provider identifiers (NPI).

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

Comments: In November 2019, CMS issued a proposed rule that the agency said would promote state accountability, improve federal oversight, and strengthen the fiscal integrity of the Medicaid program. Among other things, the proposed rule would require states to report supplemental payments made to individual providers; furthermore, it would require states to include the National Provider Identifier (NPI) number-a unique 10-digit identification number assigned to health care providers. GAO will continue to monitor the status of the proposed rule and will review a final rule, if one is issued, to determine the extent it addresses the recommendation.

Recommendation: To improve CMS's oversight of Medicaid payments, the Administrator of CMS should develop a policy establishing criteria for when such payments at the provider level are economical and efficient.

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

Comments: In November 2019, CMS issued a proposed rule that the agency said would require states to demonstrate to CMS that supplemental payments to individual providers are economical and efficient and also require states to end and then seek CMS approval to renew supplemental payments every three years. GAO will monitor the status of the proposed rule and will review a final rule, if one is issued, to determine the extent to which it addresses the recommendation.

Recommendation: To improve CMS's oversight of Medicaid payments, the Administrator of CMS should, once criteria are developed, develop a process for identifying and reviewing payments to individual providers in order to determine whether they are economical and efficient.

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

Comments: In November 2019, CMS issued a proposed rule that the agency said would require states to demonstrate to CMS that supplemental payments to individual providers are economical and efficient and also require states to end and then seek CMS approval to renew supplemental payments every three years. GAO will monitor the status of the proposed rule and will review a final rule, if one is issued, to determine the extent to which it addresses the recommendation.

Recommendation: To enhance State's efforts to protect SWT participants from abuse and the SWT program from misuse, the Secretary of State should direct the Bureau of Education and Cultural Affairs to establish a mechanism to ensure that sponsors provide complete and consistent lists of fees that participants must pay.

Agency: Department of State
Status: Open

Comments: In response to our recommendation that the State Department (State) establish a mechanism to ensure that sponsor provide complete and consistent lists of fees that exchange visitors on the Summer Work Travel program must pay, State acknowledged it collected such fee information in 2016. As July 18, 2018, we are awaiting State's review and analysis of this information to ensure the price lists are consistent and comprehensive, as well as published guidance it is sending to sponsors on how fee and cost information must be listed on their websites so that there will be consistency among sponsors. State indicated its fee study will take place in 2019 to cover the period of 2018. As of August 2020, State indicated that it planned to complete the fee study following final Summer Work Travel rule, pending OMB approval.

Recommendation: To enhance State's efforts to protect SWT participants from abuse and the SWT program from misuse, the Secretary of State should direct the Bureau of Education and Cultural Affairs to establish a mechanism to ensure that information about these participant fees is made publicly available.

Agency: Department of State
Status: Open

Comments: In response to our recommendation that the State Department (State) establish a mechanism to ensure that information about Summer Work Travel participant fees is made publicly available, State noted that it had published a notice for proposed rulemaking on January 12, 2017. When finalized, this would require each sponsor to include in its recruiting material, and post on its main Web site (e.g., with a visible link to such a page on the sponsors homepage), examples of the typical monthly budgets of exchange visitors placed in various regions of the United States to illustrate wages (based on the required weekly minimum of 32-hours of work at a typical host placement) balanced against itemized fees and estimated costs. Until State finalizes this rule, they cannot enforce this requirement. State anticipated releasing the final rule in the middle of 2019, pending OMB approval. As of August 2020 State has not issued a final rule; and OMB approval is still pending.

Recommendation: To enhance State's efforts to protect SWT participants from abuse and the SWT program from misuse, the Secretary of State should direct the Bureau of Education and Cultural Affairs to establish detailed criteria that will allow State to assess the sufficiency and appropriateness of opportunities for cultural activities outside the workplace that sponsors provide to SWT participants.

Agency: Department of State
Status: Open

Comments: In response to our recommendation that the State Department (State) establish detailed criteria that will allow it to assess the sufficiency and appropriateness of opportunities for cultural activities outside the workplace that sponsors provide to Summer Work Travel participants, State published a notice for proposed rulemaking on January 12, 2017. When finalized, this would require sponsors and their host entities to create cultural opportunities at least once per month. The proposed rule also notes that State will issue guidance outlining best practices for cross-cultural programming. As of August 2020 this is not finalized.

Recommendation: To strengthen federal oversight of facilities with ammonium nitrate, the Secretary of Labor and the Administrator of EPA should direct OSHA and EPA, respectively, to consider revising their related regulations to cover ammonium nitrate and jointly develop a plan to require high risk facilities with ammonium nitrate to assess the risks and implement safeguards to prevent accidents involving this chemical.

Agency: Department of Labor
Status: Open

Comments: On December 9, 2013, OSHA issued a Request for Information seeking, among other things, comments on potential revisions to its Process Safety Management standard and its Explosives and Blasting Agents Standard. The Request for Information specifically invited comments on safe work practices for storing, handling, and managing ammonium nitrate and on regulatory requirements to improve its approach to preventing the hazards associated with ammonium nitrate. As of July 2017, OSHA reports it has completed a Small Business Regulatory Flexibility Review Act panel to gather feedback from small businesses on updating its Process Safety Management (PSM) regulation. During the panel, the agency discussed the option of adding ammonium nitrate to the list of chemicals covered by PSM and collected comments. As of June 2018, the PSM rulemaking is on the regulatory agenda under Long Term Action. According to OSHA officials, the agency will continue to collect comments on the option of adding ammonium nitrate to the list of highly hazardous chemicals covered by the PSM regulations as dictated by the rulemaking process. We will close this recommendation when OSHA decides what action to take as a result of the rulemaking process.

Recommendation: To strengthen federal oversight of facilities with ammonium nitrate, the Secretary of Labor and the Administrator of EPA should direct OSHA and EPA, respectively, to consider revising their related regulations to cover ammonium nitrate and jointly develop a plan to require high risk facilities with ammonium nitrate to assess the risks and implement safeguards to prevent accidents involving this chemical.

Agency: Environmental Protection Agency
Status: Open

Comments: In January 2017, EPA issued a final rule to modify its Risk Management Program (RMP) regulations. The agency decided not to propose any revisions to the list of regulated substances and therefore, did not address ammonium nitrate in the revised regulations.

Recommendation: The Secretary of Labor should direct the Assistant Secretary for Occupational Safety and Health to consider updating regulations for the storage of ammonium nitrate taking into consideration, as appropriate, other related standards and current practices.

Agency: Department of Labor
Status: Open

Comments: OSHA previously (December 3, 2014) issued guidance to Regional Administrators to assist OSHA officials in enforcing the ammonium nitrate storage requirements in the Explosives and Blasting Agents Standard. In addition, on December 9, 2013, OSHA issued a Request for Information (RFI) seeking, among other things, comments on potential revisions to the Explosives and Blasting Agents Standard, which includes ammonium nitrate storage requirements. According to OSHA officials, the agency discussed the option of adding ammonium nitrate to the list of chemicals covered by the Process Safety Management (PSM) regulations and collected comments. As of June 2018, the PSM rulemaking is on the regulatory agenda under Long-Term Action. We will close this recommendation when the agency decides what action to take as a result of the rulemaking process.

Recommendation: In order to improve NMB's planning and make the most effective use of its limited resources, the Chairman of the National Mediation Board should develop and fully implement key components of an information security program in accordance with the Federal Information Security Management Act of 2002.

Agency: National Mediation Board
Status: Open

Comments: In February 2020, we determined that NMB had taken some steps to further implement key information security practices, but had not fully implemented this recommendation. We reported in GAO-20-236 that NMB continued to only partially follow the eight key information security practices in accordance with the Federal Information Security Management Act (FISMA). NMB must take other steps, such as providing risk assessment documentation of its enterprise network for fiscal year 2019. NMB officials stated that the agency plans to address several of these practices by the end of fiscal year 2020. They further noted that they hired a Chief Information Officer and planned to hire additional staff and employ contractors to aid in these efforts.

Recommendation: In order to improve NMB's planning and make the most effective use of its limited resources, the Chairman of the National Mediation Board should establish a privacy program that includes conducting privacy impact assessments and issuing system of record notices for systems that contain personally identifiable information.

Agency: National Mediation Board
Status: Open

Comments: In February 2020, we reported in GAO-20-236 that NMB had taken some steps to implement information privacy practices, such as designating a privacy officer. However, NMB must take additional steps, such as specifying whether a system of records notice would be developed, as required by the Office of Management and Budget.

Recommendation: To help improve the oversight and accountability of the military services' ROTC programs, the Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to coordinate with the military services to ensure that service ROTC guidance aligns with the updated DOD instruction.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation in written comments on our report. An April 2016 letter from the Director of Accession Policy, MPP, ASD(M&RA) to the DOD OIG states that the services reviewed and adjusted their current procedures and metrics in advance of the projected DODI publication date. However, in August 2018, we requested documentation of the services' efforts outlined in the letter to the DOD OIG and to verify that the services had taken the requisite steps to address our recommendation--namely, that their ROTC guidance aligned with the updated DODI. As of June 2020, DOD had provided documentation of updated service ROTC guidance, aligning with the updated DODI, for the Department of the Navy and the Air Force. However, according to DOD, the relevant Army Regulation update remains in draft, and thus the recommendation remains open. We will continue to monitor DOD's efforts to implement this recommendation and will update it as more information becomes available.

Recommendation: To help improve the oversight and accountability of the military services' ROTC programs, the Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to develop and implement, in conjunction with the Secretaries of the military services, a strategy to periodically communicate with Congress and other key stakeholders on ROTC program performance.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation in written comments on our report. The March 2018 version of DODI 1215.08 directs the services to provide criteria, annual assessments, and decisions about establishment/disestablishment of ROTC units to institution presidents. It also states that the ROTC resources summary report will be the basis for responding to congressional and public inquiries. In addition, updated service guidance from the Department of Navy includes a provision for annual communication with host institutions. The DODI did not include and DOD has not developed a strategy to periodically communicate with Congress on ROTC program performance, as we recommended. According to DOD, as of July 2020, a congressional communication plan has been developed for the ROTC program, including dates and topics for discussion. However, DOD has not yet provided documentation of this plan, and, thus, the recommendation remains open. We will continue to monitor DOD's efforts to implement this recommendation and will update it as more information becomes available.

Recommendation: To help states identify and address quality-of-care concerns among individuals with developmental disabilities receiving Medicaid HCBS waiver services, the Administrator of CMS should encourage states to (1) include death as a critical incident and conduct mortality reviews if they do not already do so and (2) broaden their mortality review processes if they already include death as a critical incident and conduct mortality reviews.

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

Comments: As of August 2020, CMS had taken some steps to address this recommendation but additional actions are needed to fully implement it. In June 2018 CMS issued a Medicaid update to states explaining that CMS strongly encourages them to include unexpected deaths in their definition of reportable critical incidents. CMS also stated in the update that states should conduct a preliminary review of all beneficiary deaths and investigations should focus on those deaths determined to be unexpected. Further, CMS has shared with states best practices for state mortality reviews that include, for example, the use of an interdisciplinary review committee and taking actions to address identified quality of care problems. CMS also developed a webinar training (Incident Management 101) to help states improve their incident management systems for the Medicaid HCBS waiver. The webinar outlines the key elements of building a comprehensive incident management system (e.g., establishing a process for conducting investigations of incidents, tracking and trending incidents to help prevent and mitigate incidents from occurring) and reiterates CMS's expectation that states identify and address unexplained deaths on an ongoing basis in order to meet the waiver's health and welfare assurance. In late 2018, CMS planned to include in its revised waiver application questions to determine practices regarding states' review and evaluation of unexpected deaths. In September 2019, CMS officials notified us that it will provide an updated status report on this recommendation in November 2019. As of August 2020, CMS officials have not provided us information regarding its revised waiver application and technical guide. We will update the status of this recommendation when we receive this information.