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 assist states that rely on or are planning to contract with an MCO to administer Medicaid prescription benefits, and to help provide effective oversight of psychotropic medications prescribed to children in foster care, the Secretary of Health and Human Services should issue guidance to state Medicaid, child-welfare, and mental-health officials regarding prescription-drug monitoring and oversight for children in foster care receiving psychotropic medications through MCOs.

Agency: Department of Health and Human Services
Status: Open

Comments: In an October 2018 written response, Health and Human Services (HHS) noted that they released 2017-2018 Drug Utilization Review Summaries for Prescription Drug Fee-For-Service Programs as it relates to national statistics on state oversight of psychotropic medications, as well as new state requirements to report on their Medicaid managed care organizations. However, as of August 2019, HHS confirmed they have not issued any guidance to state Medicaid, child-welfare, and mental-health officials regarding prescription-drug monitoring and oversight for children in foster care receiving psychotropic medications through MCOs, as we recommended. We continue to believe that additional HHS guidance that helps states implement oversight strategies within the context of a managed-care environment is needed to help ensure appropriate monitoring of psychotropic medications prescribed to children in foster care.

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 2020, 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 2020, CMS has not provided any additional information about actions it has taken to address this recommendation.

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.