Recommendation: In order to improve CMS's ability to identify self-referred advanced imaging services and help CMS address the increases in these services, the Administrator of CMS should insert a self-referral flag on its Medicare Part B claims form and require providers to indicate whether the advanced imaging services for which a provider bills Medicare are self-referred or not.

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

Comments: HHS did not concur with this recommendation. CMS believes that a new checkbox on the claim form identifying self-referral would be complex to administer and providers may not characterize referrals accurately. 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 advanced imaging services and monitor the behavior of those providers who self-refer these services, even though the agency has no plans to take further action. As of January 2020, CMS continues to indicate it will not take additional actions to address this recommendation.

Recommendation: In order to improve CMS's ability to identify self-referred advanced imaging services and help CMS address the increases in these services, the Administrator of CMS should determine and implement a payment reduction for self-referred advanced imaging services to recognize efficiencies when the same provider refers and performs a service.

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

Comments: HHS did not concur with this recommendation, noting that CMS did not believe that a payment reduction would address overutilization that occurs as a result of self-referral and that the agency's multiple procedure payment reduction policy for advanced imaging already captures efficiencies inherent in providing multiple advanced imaging services by the same physician. Further, CMS does not think a payment reduction for self-referred services would be effective. For example, the agency believes that providers in self-referring arrangements could avoid this reduction by having one provider refer an advanced imaging service while having another perform the service. Finally, CMS questioned whether implementing our recommendation would violate the Medicare statute prohibiting paying a differential by physician specialty for the same service. Our recommendation, however, refers to specific self-referral arrangements in which the same provider refers and performs an imaging service, and therefore would not be addressed by CMS's multiple procedure payment reduction policy. As noted in our report, this payment reduction would affect about 10 percent of advanced imaging services referred by self-referring providers. In addition, while CMS raised questions about whether implementing our recommendation would violate Medicare's prohibition on paying a differential by physician specialty for the same service, our report shows that self-referring providers generally referred more MRI and CT services, regardless of differences in specialties, and CMS did not indicate how this recommendation would implicate the prohibition on paying a differential by specialty. We continue to believe that CMS should determine and implement a payment reduction to recognize efficiencies for advanced imaging services referred and performed by the same provider. As of January 2020, the agency has no plans to take further action regarding this recommendation.

Recommendation: In order to improve CMS's ability to identify self-referred advanced imaging services and help CMS address the increases in these services, the Administrator of CMS should determine and implement an approach to ensure the appropriateness of advanced imaging services referred by self-referring providers.

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

Comments: HHS did not concur with this recommendation, according to its fiscal year 2021 budget justification. To fully implement this recommendation, CMS should determine and implement an approach to ensure the appropriateness of advanced imaging services referred by self-referring providers.

Recommendation: To strengthen NNSA's oversight practices and current and future facility modernization efforts, and to improve the transparency and usefulness of cost analyses prepared for future NNSA nuclear facilities modernization projects, the Secretary of Energy should direct the Administrator of NNSA to ensure that life cycle cost analyses include a thorough and balanced evaluation of short- and long-term construction and financing alternatives. Such analyses should consider the full useful life of the facility rather than the 20-year requirement for GSA leases or any predetermined length of time that might produce results that favor one option over another.

Agency: Department of Energy
Status: Open

Comments: NNSA provided evidence that it requires life cycle cost analyses for projects greater than $20 million. However, this is not fully responsive to GAO's recommendation. For example, the recommendation stated that each life cycle cost analysis performed includes short- and long-term construction and financing alternatives and that these analyses should consider the full life of the facility rather than the 20-year requirements for GSA leases or any predetermined length of time. NNSA's actions do not address this aspect of the life cycle cost analysis. Our work found that facility's life cycle cost analysis only covered 20 years and it failed to reflect cost savings over a longer useful life (possibly over 50 years) that could have been realized if the facility were purchased instead of leased. Nothing in the Order addresses how the life cycle cost period to be analyzed should be established (e.g., 20 years or 50 plus years). Although we requested additional information from NNSA on this recommendation in fiscal year 2019, the agency has not responded. As a result, as of June 2020, the recommendation remains open.

Recommendation: To strengthen NNSA's oversight practices and current and future facility modernization efforts, and because of the importance of mitigating the risks of outsourcing nuclear weapons components and other information that if exported, might allow potential adversaries to develop or advance their nuclear capabilities, the Secretary of Energy should direct the Administrator of NNSA to take immediate action to assess the effectiveness of NNSA's oversight of KCP's current export control and nonproliferation practices and, if appropriate, initiate corrective actions to strengthen that oversight.

Agency: Department of Energy
Status: Open

Comments: As of August 2020, there has been no change in the status of this recommendation. While NNSA/contractor actions are commendable and appear to be beneficial, such as adding performance-based incentives, training 950 employees, and including new contract clauses in its supplier purchase orders, these actions do not fully satisfy the recommendation. GAO's recommendation was specifically directed at the effectiveness of NNSA's oversight of the KCP contractor's export control and nonproliferation practices and to initiate corrective actions to strengthen that NNSA oversight. While the Kansas City Site Office's addition of a performance based incentive seems to be a good improvement, NNSA has not demonstrated its own oversight effectiveness. Our review of NNSA's response provided in March 2014 was not persuasive. In addition, GAO-16-710 found that as of May 2016, the Secretary of Energy had not used the enhanced procurement authority to ensure supply chain integrity, and the Department of Energy (DOE) had not developed processes for using the authority, as it had not fully assessed the circumstances under which the authority might be useful. Although NNSA provided additional information on this recommendation in August 2019, these actions relied primarily on contractor self assessments and not on independent federal oversight. As a result, this recommendation will continue to remain open.

Recommendation: To improve the management of the stockpile life extension program, the Administrator of NNSA should direct the Deputy Administrator for Defense Programs to develop a realistic schedule for the W76 warhead and future life extension programs that allows NNSA to (1) address technical challenges while meeting all military requirements and (2) build in time for unexpected technical challenges that may delay the program.

Agency: Department of Energy: National Nuclear Security Administration
Status: Open

Comments: In past and ongoing work, GAO has identified areas where NNSA's modernization plans may not align with planned funding requests over the Future Years Nuclear Security Plan (FYNSP) and post-FYNSP periods. Based on the FY 2014 Stockpile Stewardship and Management Plan (SSMP), (GAO-14-45) NNSA plans to work on five life extension programs (LEP) or major alterations through 2038. The FY 2014 SSMP states that the LEP workload represents a resource and production throughput challenge that requires improvements in LEP planning and execution. GAO's analysis indicates there is limited contingency time built into the LEP schedules, all of which are technically ambitious. Any delays in schedules could lead to an increase in program costs or a reduction in the number built for any of the LEPs, both of which have occurred in prior and ongoing LEPs. While NNSA has acknowledged issues and identified some steps to improve the LEP process, this recommendation will remain open and unimplemented until NNSA demonstrates successful LEP and refurbishment execution. We reconfirmed this finding in GAO-17-341 where we found the following: In some cases, NNSA's FY 2017 nuclear security budget materials do not align with the agency's modernization plans, both within the 5-year FYNSP for fiscal years 2017 through 2021 and beyond, raising concerns about the affordability of NNSA's planned portfolio of modernization programs. As of June 2020, this situation has not been fully addressed as evidenced by cost increases and likely delays in the B61-12 and W88 ALTV programs; an aggressive schedule in the W80-4 program, and a large scope in the W87-1 warhead replacement. In addition, new programs contained in the 2018 Nuclear Posture Review and the announcement of a new development effort, the W93, may further stress NNSA's program.

Recommendation: To improve the management of the stockpile life extension program, the Administrator of NNSA should direct the Deputy Administrator for Defense Programs to ensure that the program managers responsible for overseeing the construction of new facilities directly related to future life extension programs coordinate with the program managers of such future programs to avoid the types of delays and problems faced with the construction and operation of the Fogbank manufacturing facility for the W76 program.

Agency: Department of Energy: National Nuclear Security Administration
Status: Open

Comments: A number of Stockpile Stewardship and Management Plans (SSMP) state that the life extension program (LEP) workload represents a resource and production throughput challenge that requires improvements in LEP planning and execution. The officials elaborated that the main area that will be strained is pit production. NNSA's plutonium strategy needs to be resourced fully and implemented successfully by 2030 to support the W87 warhead replacement. Additionally, the officials said that the UPF project and an arrange of associated programmatic efforts need to be operational by 2025 or there will be challenges in completing all of the planned LEPs. In addition, NNSA needs to re-establish depleted uranium operations, construct a new lithium facility and establish a domestic uranium enrichment function for tritium production by the late 2020s to meet stockpile needs. As such, this recommendation remains open and, given the aggressive warhead and bomb modernization efforts proceeding in parallel with infrastructure modernization efforts, will likely remain open for some time.

Recommendation: To improve the management of the stockpile life extension program, the Administrator of NNSA should direct the Deputy Administrator for Defense Programs to ensure that program managers for the construction of new facilities for future life extensions base their schedule for the construction and start-up of a facility on the life extension program managers' needs identified in their risk mitigation strategies.

Agency: Department of Energy: National Nuclear Security Administration
Status: Open

Comments: NNSA has generally improved its management of construction projects, to include requirements setting, Analysis of Alternatives, and independent cost estimates, among other items. However, it is too soon to tell if these positive developments will help--or hinder--LEPs that are underway or are being conducted. Key uranium activities, to include construction and operating funds will not be complete until 2025; key tritium and lithium programs and facilities will not complete until the 2030s; key plutonium activities are underway as well, but will not be complete until the late 2020s. As of June 2020, there are no significant changes related to this recommendation, and it will continue to remain open.