Recommendation: The Administrator of FNS should develop and implement a process, documented in policies and procedures, to analyze SNAP state-level root causes to identify potential similarities among the states and develop and implement SNAP agency-level corrective actions, if appropriate, to help address them. (Recommendation 1)

Agency: Department of Agriculture: Office of the Secretary: Food, Nutrition and Consumer Services: Food and Nutrition Service
Status: Open

Comments: In commenting on our draft report, USDA stated that the Food and Nutrition Service should formalize its existing processes into a standard operating procedure to analyze the Supplemental Nutrition Assistance Programs (SNAP) state-level root causes to identify potential similarities among states, in order to improve development and implementation of SNAP agency-level corrective actions, if appropriate.

Recommendation: The Secretary of Agriculture should revise USDA's procedures to include processes for monitoring the progress and measuring the effectiveness of improper payment corrective actions. The process for measuring the effectiveness of corrective actions should clearly demonstrate the effect USDA's corrective actions have on reducing improper payments. (Recommendation 2)

Agency: Department of Agriculture
Status: Open

Comments: In commenting on our draft report, USDA stated that a proposed action plan will be developed to revise USDA's procedures for monitoring the progress and measuring the effectiveness of improper payment corrective actions. Processes will focus on the impact corrective actions have on the root causes of improper payments.

Recommendation: The Secretary of Education should revise and document Education's process for measuring the effectiveness of its corrective actions based on its new statistical estimation methodology for Direct Loan and Pell Grant improper payments. This process should clearly demonstrate the effect Education's corrective actions have on reducing improper payments. (Recommendation 3)

Agency: Department of Education: Office of the Secretary
Status: Open

Comments: In commenting on our draft report, Education stated that Federal Student Aid (FSA) will continue to evaluate and refine its processes to measure corrective actions and the effectiveness of these actions. Further, Education stated that FSA's measurement of corrective action effectiveness and root cause identification will gain additional precision as FSA collects annual improper payment data and builds upon the new baseline of statistically valid improper payment estimates. Education stated that FSA annually measures the overall effectiveness of its corrective action plans collectively against the improper payment reduction targets, rather than measuring the effectiveness of each individual corrective action. However, OMB guidance directs agencies to measure the effectiveness of each individual corrective action annually.

Recommendation: The Secretary of Health and Human Services should document in policies and procedures HHS's improper payment corrective action plan process. As part of these procedures, HHS should include processes for (1) establishing planned completion dates, (2) monitoring the progress of implementing corrective actions, and (3) measuring the effectiveness of improper payment corrective actions. The process for measuring the effectiveness of corrective actions should clearly demonstrate the effect HHS's corrective actions have on reducing improper payments. (Recommendation 4)

Agency: Department of Health and Human Services: Office of the Secretary
Status: Open

Comments: In commenting on our draft report, HHS elaborated on the improper payment corrective action plan process that is called for in OMB guidance. HHS stated that OMB guidance provides agencies the flexibility to measure the effectiveness of corrective actions and believes that this flexibility is vital to its oversight processes to reduce improper payments.

Recommendation: The Secretary of the Treasury should determine whether Treasury's current improper payment root cause analysis provides sufficiently relevant information that can be used as a basis for proposed corrective actions in reducing EITC improper payments and, if not, update the analysis using more timely data to ensure their reliability for identifying root causes of EITC improper payments. (Recommendation 5)

Agency: Department of the Treasury: Office of the Secretary
Status: Open

Comments: In commenting on our draft report, Treasury stated that each year it indicates in its corrective action plan that IRS will continue to work with Treasury to develop legislative proposals that will improve refundable credit compliance and reduce erroneous payments.

Recommendation: The Secretary of the Treasury should update Treasury's strategy for addressing the root causes of EITC improper payments to include (1) coordinating with other agencies to identify potential strategies and data sources that may help in determining EITC eligibility and (2) determining whether legislative changes are needed, and developing proposals as appropriate, to help reduce EITC improper payments, such as those related to the inability to authenticate taxpayer eligibility. (Recommendation 6)

Agency: Department of the Treasury: Office of the Secretary
Status: Open

Comments: In commenting on our draft report, Treasury stated that each year it indicates in its corrective action plan that IRS will continue to work with Treasury to develop legislative proposals that will improve refundable credit compliance and reduce erroneous payments. Although Treasury has made certain legislative proposals, it has not made proposals to specifically help address EITC eligibility criteria issues. Additionally, Treasury's strategy does not include identifying and proposing additional legislative changes needed to help reduce EITC improper payments.

Recommendation: The Commissioner of SSA should develop and implement a process, documented in policies and procedures, to measure the effectiveness of SSA's corrective actions for OASDI and SSI improper payments. This process should clearly demonstrate the effect SSA's corrective actions have on reducing improper payments. (Recommendation 7)

Agency: Social Security Administration
Status: Open

Comments: In commenting on our draft report, SSA stated that it will determine the most cost-effective strategies to remediate the underlying causes of payment errors and monitor, measure, and revise the strategies as needed.

Recommendation: The Administrator of the Food and Nutrition Service should establish a process to plan and conduct regular fraud risk assessments for the school meals programs that align with the leading practices in the Fraud Risk Framework. (Recommendation 1)

Agency: Department of Agriculture: Office of the Secretary: Food, Nutrition and Consumer Services: Food and Nutrition Service
Status: Open

Comments: As of September 12, 2019, USDA stated that it will undertake, over the course of the next year, a re-evaluation of its existing research and oversight activity to measure and assess fraud risk, its efforts to manage that risk, and its work to minimize the occurrence and impact of fraudulent activity on the school meal programs. USDA also stated that it will look to GAO's Fraud Risk Framework as a model for this effort. USDA expects this effort to include some new activity, such as a deeper examination of the underlying causes of program error in the agency's periodic studies of improper payments. USDA also views this as an opportunity to clarify and highlight how the agency's existing approach to risk management currently addresses fraud risk. USDA agrees that it is appropriate to review and refine its existing controls on a regular basis and recognizes that a more formalized assessment of fraud risk is likely to uncover gaps in existing activity that point to opportunities for further agency action. USDA commits to the development of a response to the effort that is appropriate to the scale of the identified risk and the broader mission of the school meal programs. In September 2020, USDA stated that it has been reviewing agency research and administrative data, as well as conducting new analysis. USDA is concluding work on its risk assessment and plans to circulate it within the agency for review soon. We will continue to monitor USDA's progress in this area.

Recommendation: The Administrator of CMS should institute a process to routinely assess, and take steps to ensure, as appropriate, that Medicare and Medicaid documentation requirements are necessary and effective at demonstrating compliance with coverage policies while appropriately addressing program risks. (Recommendation 1)

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

Comments: The Department of Health and Human Services concurred with this recommendation. In February 2020, the Centers for Medicare & Medicaid Services (CMS) noted that it had clarified and amended several Medicare documentation requirements as part of an agency initiative to assess such requirements. CMS further stated that Medicaid documentation requirements are generally established at the state level, and that the agency has taken steps to identify best practices for documentation requirements and share them with states. However, we believe that CMS still needs to take steps to assess documentation requirements in both programs to better understand how the variation in the programs' requirements affects estimated improper payment rates. Without an assessment of how the programs' documentation requirements affect estimates of improper payments, CMS may not have the information it needs to ensure that Medicare and Medicaid documentation requirements are effective at demonstrating compliance and appropriately address program risks.

Recommendation: The Administrator of CMS should take steps to ensure that Medicaid medical reviews provide robust information about and result in corrective actions that effectively address the underlying causes of improper payments. Such steps could include adjusting the sampling approach to reflect state-specific program risks, and working with state Medicaid agencies to leverage other sources of information, such as state auditor and the Department of Health and Human Services' Office of the Inspector General findings. (Recommendation 2)

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

Comments: The Department of Health and Human Services (HHS) did not concur with this recommendation. As of September 2020, HHS has stated that it does not plan to implement this recommendation because the agency believes the resource requirement is not justified based on the potential improper payment findings. HHS further stated that the agency already uses a variety of sources to identify and take corrective actions to address underlying causes of improper Medicaid payments. However, we found that the Centers for Medicare & Medicaid Services (CMS) and state Medicaid agencies are expending time and resources developing and implementing corrective actions that may not be representative of the underlying causes of improper payments in their states. Without robust information to effectively identify the underlying causes of improper payments, CMS and state Medicaid agencies may not develop corrective actions that effectively address Medicaid program risks.

Recommendation: The Administrator of CMS should take steps to minimize the potential for Payment Error Rate Measurement (PERM) medical reviews to compromise fraud investigations, such as by directing states to determine whether providers selected for PERM medical reviews are also under fraud investigation and to assess whether such reviews could compromise investigations. (Recommendation 3)

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

Comments: The Department of Health and Human Services (HHS) concurred with this recommendation. In October 2019, the Centers for Medicare & Medicaid Services (CMS) updated Medicaid Payment Error Rate Measurement (PERM) program guidance to strongly encourage state Medicaid agencies to proactively review providers selected for the state's PERM review; determine whether any of the selected providers are subjects of current or impending fraud investigations; and assess whether a PERM review could compromise the fraud investigation. CMS included this clarification in updated contractor guidance and in information provided to state Medicaid agencies. CMS plans to include the updated guidance in the fiscal year 2019 PERM program manual, which CMS anticipates completing by the end of 2019. Such revisions to the PERM manual will further codify and encourage state efforts to prevent PERM reviews from potentially compromising ongoing fraud investigations. As of September 2020, CMS has not informed us of any additional actions taken to implement this recommendation, including of any revisions to the PERM manual; we will update the status of this recommendation when we receive additional information.

Recommendation: The Administrator of CMS should address disincentives for state Medicaid agencies to notify the PERM contractor of providers under fraud investigation. This could include educating state officials about the benefits of reporting providers under fraud investigation, and taking actions such as revising how claims from providers under fraud investigation are accounted for in state-specific FFS improper payment rates, or the need for corrective actions in such cases. (Recommendation 4)

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

Comments: The Department of Health and Human Services (HHS) concurred with this recommendation. In October 2019, the Centers for Medicare & Medicaid Services (CMS) noted that the agency updated Medicaid Payment Error Rate Measurement (PERM) guidance regarding state Medicaid agencies' corrective action plans for providers under fraud investigation. If a state Medicaid agency opts to remove a provider from the state's PERM review due to a fraud investigation, claims associated with the provider are determined to be improper, due to no documentation. Under the updated guidance, states are no longer required to develop a corrective action plan for such claims, since the state is already addressing the issue through a fraud investigation. CMS included this updated guidance in the fiscal year 2017 PERM corrective action plan template, and plans to include the updated guidance in the fiscal year 2019 PERM program manual, which CMS anticipates completing by the end of 2019. Such revisions to the PERM manual will remove a disincentive for state Medicaid agencies to notify the PERM contractor of providers under fraud investigation. As of September 2020, CMS has not informed us of any additional actions taken to implement this recommendation, including of any revisions to the PERM manual; we will update the status of this recommendation when we receive additional information.

Recommendation: The Administrator of CMS should take steps to collect all of the data from all laboratories that are required to report. If only partial data can be collected, CMS should estimate how incomplete data would affect Medicare payment rates and address any significant challenges to setting accurate Medicare rates. (Recommendation 1)

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

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

Recommendation: The Administrator of CMS should phase in payment-rate reductions that start from the actual payment rates Medicare paid prior to 2018 rather than the national limitation amounts. CMS should revise these rates as soon as practicable to prevent paying more than necessary. (Recommendation 2)

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

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

Recommendation: The Administrator of CMS should use bundled rates for panel tests, consistent with its practice prior to 2018, rather than paying for them individually; if necessary, the Administrator of CMS should seek legislative authority to do so. (Recommendation 3)

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

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

Recommendation: The Administrator of CMS should consider and take steps to mitigate the program risks that are not measured in the PERM, such as overpayments and unallowable costs; such an effort could include actions such as revising the PERM methodology or focusing additional audit resources on managed care. (Recommendation 1)

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

Comments: CMS concurred with this recommendation. In October 2018, it reported that it was developing a plan to address the recommendation. CMS also reported that it has published several guidance documents and is in the process of finalizing others. In addition, it reported that it continues to develop educational strategies (such as a recent course managed care offered by CMS' Medicaid Integrity Institute) and oversight and audit strategies and mechanisms related to managed care. CMS communicated that it initiated 32 audits involving Medicaid managed care network providers in 6 states and an audit of a managed care plan in another state in FY 2018. For FY 2019, CMS stated that it will be establishing a medical loss ratio examination process and initiating such audits of managed care organizations in California. CMS also stated that it will be developing guidance for states and managed care plans on managed care delivery and oversight to develop program integrity capacity and reduce program risks. As of December 2019, CMS has not taken any additional steps; we will continue to monitor CMS's progress to mitigate the managed care program risks not measured in the PERM.

Recommendation: The Secretary of Defense should direct the Under Secretary of Defense (Comptroller), with regard to estimating improper payments, to establish and implement key quality assurance procedures, such as reconciliations, to ensure the completeness and accuracy of the sampled populations.

Agency: Department of Defense
Status: Open
Priority recommendation

Comments: The Department of Defense (DOD), in concurring with this recommendation, stated that DOD will work with the Defense Finance and Accounting Service (DFAS) to implement key quality assurance procedures, such as reconciliations, to ensure the completeness and accuracy of sampled populations. In August 2017, DOD officials stated that its Office of the Under Secretary of Defense (Comptroller) will continue its work with DFAS to annually reconcile gross outlays (as stated on its Statement of Budgetary Resources) with outlays as reported in its Agency Financial Report. These reconciliations are currently done only on a summary level. In the future, DOD's validation of its universe of transactions combined with planned reconciliations with the Defense Departmental Reporting System trial balance and transaction data from DOD's entitlement systems will provide more complete reconciliations. As of December 2019, DOD officials stated that DOD needs to resolve its material weakness relating to the universe of transactions. This material weakness is preventing the department from performing the reconciliations necessary to ensure that the populations, from which the samples are drawn to estimate improper payments, are complete and accurate. As of May 2020, DOD had developed a spreadsheet including over 80 financial management and disbursing systems. The Office of the Under Secretary of Defense, OUSD(C), is planning to review and analyze these systems to (1) determine the types of payments and lists of systems used to process the types of payments; (2) confirm if reconciliations are done to verify the total outlays; and (3) determine the testing status of the universe of payments. As of September 30, 2020, this recommendation remains open.

Recommendation: The Secretary of Defense should direct the Under Secretary of Defense (Comptroller), with regard to implementing recovery audits, to monitor the implementation of the revised FMR chapter on recovery audits to ensure that the components either develop recovery audits or demonstrate that it is not cost effective to do so.

Agency: Department of Defense
Status: Open
Priority recommendation

Comments: Department of Defense (DOD) officials, in concurring with this recommendation, stated that DOD would work with the applicable components to monitor the implementation of the revised Financial Management Regulation (FMR) chapter on recovery audits (subsequently renamed as payment recapture audits). According to DOD officials, this action would help to ensure that recovery audits are developed, or will demonstrate that it is not cost-effective to do these audits. In July 2015, DOD was working to update the FMR chapter on recovery audits to reflect revised Office of Management and Budget (OMB) guidance issued in October 2014. DOD issued its revised FMR chapter in November 2015. This chapter requires components to develop cost-effective payment recapture audits or to submit a quantitative justification to the Office of the Under Secretary (Comptroller) for approval. However, we consider this recommendation to be open because DOD did not provide documentation demonstrating that the Office of the Under Secretary of Defense (Comptroller) is monitoring component implementation of recovery auditing. Further, as of April 2017, DOD's efforts to develop cost-estimates for recovery audits were still under way. As of October 2018, this recommendation remains open. As of December 2019, DOD stated that in FY 2020, the Office of the Under Secretary (Comptroller) will coordinate with the DOD improper payment reporting components to analyze whether it would be cost effective to implement payment recapture audit programs for their payments. In a March 20, 2020 memorandum, the Deputy CFO asked DOD components, programs, or activities with annual payments exceeding $1 million to submit a payment recapture plan by June 30, 2020. If a component determines that payment recapture audits are not cost-effective, then the plan must provide the specific analysis and documentation used to reach that conclusion. When completed, the results of the evaluation will serve the Department's final position on payment recapture audit programs. As of September 30, 2020, this recommendation remains open as this evaluation was not yet complete.

Recommendation: The Secretary of Defense should direct the Under Secretary of Defense (Comptroller), with regard to implementing recovery audits, to develop and submit to OMB for approval a payment recapture audit plan that fully complies with OMB guidance.

Agency: Department of Defense
Status: Open
Priority recommendation

Comments: Department of Defense (DOD) officials, in concurring with this recommendation, stated that DOD would develop and submit to the Office of Management and Budget (OMB) a payment recapture plan that fully complies with OMB guidance and is informed by a cost-effectiveness analysis. In July 2015, DOD's Office of the Under Secretary of Defense (Comptroller) efforts to develop a payment recapture audit plan to ensure cost-effectiveness were ongoing and these efforts must be completed before a plan can be submitted to the OMB. In June 2016, DOD officials stated that the Comptroller's efforts to develop a payment recapture audit plan to ensure cost-effectiveness were ongoing. As of August 28, 2017, DOD officials stated that the Office of the Under Secretary of Defense (Comptroller) will determine if a payment recapture audit plan was developed and submitted to OMB for approval in the previous fiscal years. If so, the Office of the Under Secretary of Defense (Comptroller) will determine its relevance and significance (i.e. cost effectiveness)to the improper payments program. If the payment recapture audit plan is considered to be applicable, the Office of the Under Secretary of Defense (Comptroller) will update the previous plan to comply with current OMB guidance. As of October 2018, this recommendation remains open. As of December 2019, DOD stated that in FY 2020, the Office of the Under Secretary (Comptroller) will coordinate with the DOD improper payment reporting components to analyze whether it would be cost effective to implement payment recapture audit programs for their payments. In a March 20, 2020 memorandum, the Deputy CFO asked DOD components, programs, or activities with annual payments exceeding $1 million to submit a payment recapture plan by June 30, 2020. If a component determines that payment recapture audits are not cost-effective, then the plan must provide the specific analysis and documentation used to reach that conclusion. When completed, the results of the evaluation will serve the Department's final position on payment recapture audit programs. As of September 30, 2020, this recommendation remains open as this evaluation was not yet complete..

Recommendation: The Secretary of Defense should direct the Under Secretary of Defense (Comptroller), with regard to reporting, to design and implement procedures to ensure that the department's annual improper payment and recovery audit reporting is complete, accurate, and in compliance with IPERA and OMB guidance.

Agency: Department of Defense
Status: Open
Priority recommendation

Comments: Department of Defense (DOD) officials, in concurring with this recommendation, stated that DOD would design and implement procedures to further ensure that its annual improper payment and recovery audit reporting is complete, accurate, and in compliance with the Improper Payments Elimination and Recovery Act (IPERA) requirements and Office of Management and Budget (OMB) guidance. In June 2015, DOD revised its FMR chapter on improper payments to require components to provide information needed to report on improper payment and recovery audit activities in its annual financial report (AFR) in accordance with IPERA requirements and OMB guidance. DOD's fiscal year 2015 AFR reflected its implementation of the revised FMR. We found that DOD's improper payment reporting in its fiscal year 2015 AFR had improved. However, we were not provided with evidence that Office of the Under Secretary of Defense (Comptroller) is performing oversight and monitoring activities to ensure the accuracy and completeness of the improper payment and recovery audit data submitted by DOD components for inclusion in the AFR. DOD is continuing to work on procedures for ensuring that its reporting on improper payment and recovery audits is accurate, complete, and in compliance with IPERA and OMB guidance. The Office of the Under Secretary of Defense (Comptroller) has developed and implemented a Payment Integrity Checklist to ensure that the department's annual improper payment and recovery audit reporting was complete, accurate, and in compliance with IPERA and OMB guidance. However, the DOD Inspector General in its May 2020 report, stated that while DOD published improper payment estimates for all eight programs for fiscal year 2019, it did not publish reliable estimates for five of the eight programs: Military Health Benefits, Civilian Pay, Military Retirement, DOD Travel Pay, and Commercial Pay. Moreover, DOD did not use accurate populations in calculating the improper payment estimates for the Military Retirement, Commercial Pay, and DOD Travel Pay programs. Based on these issues affecting improper payment reporting, we consider this recommendation to be open as of September 30, 2020.