Recommendation: The Administrator of CMS should ensure that the Medicare & You publication includes explicit information on the services covered by the Medicare program for beneficiaries with a SUD. (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 Commissioner of the Social Security Administration should ensure that (a) the agency's policies and guidance are specific enough so field office staff know how to apply complex suitability criteria for assessing payee suitability, such as by providing a minimum set of specific questions; and (b) additional regional guidance that is made available to staff is centrally reviewed for compliance and completeness. (Recommendation 1)

Agency: Social Security Administration
Status: Open

Comments: SSA agreed with this recommendation but did not specify plans to address it.

Recommendation: The Commissioner of the Social Security Administration should create safeguards in the Electronic Representative Payee System (eRPS) to ensure that field office staff fully document all required information, such as the rationale for their decision, before approving an application. (Recommendation 2)

Agency: Social Security Administration
Status: Open

Comments: SSA agreed with this recommendation and identified actions to address it. Specifically, SSA reported that, as part of implementing the Strengthening Protections for Social Security Beneficiaries Act of 2018, planned changes to eRPS will improve documentation of selection decisions. SSA also reported it will also consider additional enhancements to eRPS in the future. We will consider closing this recommendation when this effort is complete.

Recommendation: The Commissioner of the Social Security Administration should complete a plan, including timeframes, for comprehensively evaluating if and how to leverage external sources of information on organizations' suitability, such as by conducting background checks or credit checks on organizations or key staff that handle beneficiaries' funds or requiring organizations to conduct their own background checks on key staff. (Recommendation 3)

Agency: Social Security Administration
Status: Open

Comments: SSA agreed with this recommendation and identified actions to address it. SSA officials stated that it is first focusing on implementing provisions of the Strengthening Protections for Social Security Beneficiaries Act of 2018 related to background checks for certain individual payees. After completing this work, the agency plans to evaluate conducting criminal background checks and credit checks on organizational payees and their staff. While we agree that implementing background screening pursuant to the law should take precedence, SSA should seek opportunities to implement screening for organizational payees at the earliest opportunity.

Recommendation: The Commissioner of the Social Security Administration should develop and implement mechanisms to systematically obtain and review feedback from organizational payees and communicate findings to SSA management. (Recommendation 4)

Agency: Social Security Administration
Status: Open

Comments: SSA agreed with this recommendation but did not identify plans to address it.

Recommendation: The Commissioner of the Social Security Administration should (a) establish a plan and time frame for periodically reviewing the predictive model's design; (b) consider additional data sources that would allow for additional screening or modeling of potentially high-risk organizational payees; and (c) ensure that subsequent design decisions are documented in sufficient detail so the development process can be more fully understood and replicated, either by SSA or a knowledgeable third party, with minimal further explanation. (Recommendation 5)

Agency: Social Security Administration
Status: Open
Priority recommendation

Comments: SSA agreed with this recommendation in 2019 and identified actions to address it. The agency stated that it would pursue other data sources to develop additional screening tools and models to identify potentially high-risk organizational payees, but that it is unable to incorporate additional data into the existing model. They reported they cannot use new data to modify the existing model, which was built from cases and transactions that occurred many years ago. We recognize that the current model, which focuses on misuse findings and is based on historical data, presents challenges for both updating and including new data sources. Therefore, as SSA considers additional screening tools and models to identify high-risk, low-volume organizational payees, SSA should develop a plan for revising the existing model that allows for more timely updates and results in documentation of related design decisions. In April 2020, SSA officials reported that the agency is finalizing a plan to revise the existing model and would pursue other data sources to develop additional screening tools and models to identify potentially high-risk organizational payees.

Recommendation: The Commissioner of the Social Security Administration should require field offices to contact payees about missing or problematic annual accounting forms within a specific time frame. (Recommendation 6)

Agency: Social Security Administration
Status: Open

Comments: SSA agreed with this recommendation but did not identify plans to address it.

Recommendation: The Commissioner of the Social Security Administration should revise the annual accounting form to enhance its effectiveness. Such revisions could include (but not be limited to) more fully ascertaining the use of collective accounts, adopting stakeholders' recommendations on using the form to collect more meaningful data, and reflecting best practices from behavioral science insights in the design of the form. (Recommendation 7)

Agency: Social Security Administration
Status: Open

Comments: SSA agreed with this recommendation but did not identify plans to address it.

Recommendation: The Commissioner of the Social Security Administration should enhance the eRPS system to ensure that field offices are (a) alerted when collective accounts are due to be reviewed; and (b) able to take action on expired collective account information and thereby avoid payees' continued use of these accounts without oversight. (Recommendation 8)

Agency: Social Security Administration
Status: Open

Comments: SSA agreed with this recommendation and identified actions to address it. SSA officials reported that they would work with staff to ensure staff know where to find alerts for expiring accounts and enhance how eRPS displays information on collective accounts that have already expired. We agree with SSA's proposed actions. However, we adjusted our recommendation to clarify that SSA should enhance eRPS in a manner that ensures staff take action on expired accounts and that payees do not continue to use expired accounts without oversight.

Recommendation: The Commissioner of the Social Security Administration should, as it carries through with its plan to develop a risk assessment for the organizational payee program, ensure that that the plan reflects periodic consideration of findings from onsite reviews and audits. (Recommendation 9)

Agency: Social Security Administration
Status: Open
Priority recommendation

Comments: SSA agreed with this recommendation. In April 2020, SSA officials reported starting its Representative Payee Fraud Risk Assessment. We will consider closing this recommendation when SSA ensures that its risk assessment plan reflects periodic consideration of findings from onsite reviews and audits.

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 Director of OMB should develop guidance on how agencies test to identify improper payments, such as using a risk-based approach to help ensure that key risks of improper payments, such as eligibility, are addressed through testing processes. (Recommendation 1)

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

Comments: OMB partially concurred with this recommendation. On July 31, 2019, we met with the Office of Management and Budget (OMB). At the meeting, OMB officials indicated that OMB's position has not changed since the issuance of the GAO report and what OMB had already communicated to GAO at the exit conference. Specifically, OMB stated that it should not have to develop more specific guidance as each program and activity has its own risks. Instead, inspectors general are better equipped and positioned to review the sampling and estimation plans as part of their annual Improper Payments Elimination and Recovery Act of 2010 compliance audits and that agencies, their statisticians, and inspectors general should work out the best testing procedures for their agencies. We continue to believe that OMB could provide suggestions during OMB's annual town meeting related to improper payments for areas that inspectors general may consider. Further, although we agree that programs and activities may face different risks of improper payment, we continue to believe that guidance from OMB on how agencies test to identify improper payments, such as using a risk-based approach, could help ensure that agencies address the specific risks they identify when developing improper payment estimates. In February 2020, OMB informed us that it had no status updates to provide at this time. We will continue to monitor agency's actions to address this recommendation.

Recommendation: The Director of OMB should develop guidance clarifying the appropriate treatment of nonresponse cases during improper payment testing. (Recommendation 2)

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

Comments: OMB concurred with this recommendation. On July 31, 2019, we met with the Office of Management and Budget (OMB). At the meeting, OMB officials indicated that OMB's position has not changed since the issuance of the GAO report and what OMB had already communicated to GAO at the exit conference. At the meeting, OMB officials stated that OMB will "consider" updating guidance in OMB Circular A-123, Appendix C, to direct agencies to treat nonresponse cases such as improper payments and to include a new category for tracking such cases but only after assessing the impact such guidance would have on the agencies testing and reporting of improper payments. OMB has not taken action to develop this guidance. In February 2020, OMB informed us that it had no status updates to provide at this time. We will continue to monitor agency's actions to address this recommendation.

Recommendation: The Director of OPM should assess the processes to estimate Retirement improper payments to determine whether they effectively address key risks of improper payments--including eligibility and whether older claims face different risks of improper payments than new claims--and take steps to update the processes to incorporate key risks that are not currently addressed. (Recommendation 4)

Agency: Office of Personnel Management
Status: Open

Comments: The Office of Personnel Management (OPM) partially concurred with this recommendation. Prior to 2006, the improper payment estimate sampling methodology used by OPM included both new and old adjudicated claims. After analyzing several years of data using this methodology, OPM found that including older claims in the sample could result in claimant's records being sampled multiple times. In addition, OPM also found that the variance in the number of errors detected in new claims versus old claims was very low. OPM also looked at the resources used in performing the audit of old and new claims and based on these factors, management determined that it was not an efficient use of resources to include both old and new claims in the review. The methodology was updated to make the process more efficient. By using new claims only, OPM was able to provide feedback to program managers more timely. As a result, management can address issues negatively impacting the improper payment rate and prevent improper payments promptly. OPM agrees with the intent of our recommendation; however, OPM does not agree with our recommendation regarding a risk assessment on eligibility. Eligibility is determined before annuity/survivor benefits are fully adjudicated. As part of its correction plan, OPM stated that it will conduct an audit of older claims to determine if there are different risks to new claims. In February 2020, OPM indicated that it is currently in the process of pulling/gathering the cases that should be in the universe of this audit. OPM plans to complete the corrective action by end of 4th quarter of fiscal year 2020. We will continue to monitor the agency's actions to address this recommendation.

Recommendation: To improve the collection of complete and consistent personal care services data and better ensure CMS can effectively monitor the states' provision of and spending on Medicaid personal care services, CMS should better ensure that personal care services data collected from states through T-MSIS and MBES comply with CMS reporting requirements.

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

Comments: The Centers for Medicare & Medicaid Services (CMS) concurs with GAO's recommendation. In December 2017, CMS cited ongoing efforts related to claims data submitted by states through T-MSIS, CMS's new claims reporting system. Efforts included validation checks of personal care service claims to ensure that key data are not missing or incorrect. In addition, CMS stated it was working with the states to address concerns that are identified with the quality of claims data submitted. However, as of March 2020, CMS had not reported that it had addressed inaccurate state reporting of expenditures through CMS's expenditure reporting system, Medicaid Budget and Expenditure System (MBES). Complete implementation of the recommended action will better ensure state reporting of claims and expenditures is accurate and will allow CMS to effectively perform key management functions.

Recommendation: To improve the collection of complete and consistent personal care services data and better ensure CMS can effectively monitor the states' provision of and spending on Medicaid personal care services, CMS should develop plans for analyzing and using personal care services data for program management and oversight.

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

Comments: The Centers for Medicare & Medicaid Services (CMS) concurred with this recommendation. However, as of March 2020, CMS had not developed a plan for analyzing and using personal care services data as GAO recommended in January 2017. Developing a plan for analyzing and using personal care services data for program management and oversight is an important step CMS needs to take to improve the oversight and management of personal care services.

Recommendation: To reduce the number of Medicare appeals and to strengthen oversight of the Medicare FFS appeals process, the Secretary of Health and Human Services should direct CMS, Office of Medicare Hearings and Appeals (OMHA), or Departmental Appeals Board (DAB) to modify the various Medicare appeals data systems to collect information on the reasons for appeal decisions at Level 3.

Agency: Department of Health and Human Services
Status: Open

Comments: According to HHS as of August 2016, OMHA and DAB were considering the cost and technical feasibility of collecting this information within their appeals data systems. As of August 2018, OMHA has begun to take action on this recommendation. Specifically, in the July 2017 interim release of the Electronic Case Adjudication and Processing Environment (ECAPE) system, OMHA added a "Reason for Disposition" data field. However, the "Reason for Disposition" data field is currently limited in the number of reasons that can be selected, and ECAPE has not yet been rolled out to all OMHA offices. In May 2019, HHS reported that OMHA had modified the "Reason for Disposition" data field to capture more categories, and that DAB had modified its case management system to capture the reasons for appeal decisions at Level 3 and was working to develop system interoperability with ECAPE. In August 2019, OMHA officials noted that ECAPE had been implemented in 6 of OMHA's 10 field offices and was on track to implement ECAPE in all 10 field offices and its satellite office by the end of 2019. We will update the status of this recommendation when we receive additional information regarding DAB's efforts to implement this recommendation.

Recommendation: To reduce the number of Medicare appeals and to strengthen oversight of the Medicare FFS appeals process, the Secretary of Health and Human Services should direct CMS, OMHA, or DAB to modify the various Medicare appeals data systems to capture the amount, or an estimate, of Medicare allowed charges at stake in appeals in Medicare Appeals System (MAS) and Medicare Operations Division Automated Case Tracking System (MODACTS).

Agency: Department of Health and Human Services
Status: Open

Comments: According to HHS as of August 2016, this information was not captured in any CMS system, including MAS. HHS reported that if MAS is modified to capture the amount of Medicare allowed charges at stake, OMHA will consider modifying its Electronic Case Adjudication and Processing Environment (ECAPE) to include this information as well, and DAB can capture it in a new case management system currently being developed by the agency. As of August 2019, HHS officials stated that developing a methodology to estimate the amount that CMS would have paid providers is complex and would not be appropriate for use in determining whether the appeal meets the amount in controversy requirements for a Level 3 appeal. The basis for our recommendation was also so that HHS could better monitor important appeal trends. Additionally, without this information, HHS does not know the actual amount of Medicare reimbursement at issue in the appeals process. We will update the status of this recommendation when we receive additional information regarding HHS's efforts to implement it.

Recommendation: To reduce the number of Medicare appeals and to strengthen oversight of the Medicare FFS appeals process, the Secretary of Health and Human Services should direct CMS, OMHA, or DAB to modify the various Medicare appeals data systems to collect consistent data across systems, including appeal categories and appeal decisions across MAS and MODACTS.

Agency: Department of Health and Human Services
Status: Open

Comments: According to HHS as of August 2016, HHS reported taking several initial steps to standardize data across Medicare appeals systems. As of August 2018, HHS was continuing to take steps to implement GAO's recommendation to standardize data collection on appeals across its multiple data systems. Specifically, HHS stated that, in November 2016, CMS and OMHA modified the MAS system to standardize appeal categories between Levels 1 through 3, which will help to facilitate more accurate trending analyses across appeal levels. Further, as of April 2017, all Part A Medicare Administrative Contractors (MAC), who are responsible for Part A Level 1 appeals, were successfully processing appeals in MAS, according to HHS. In August 2019, OMHA officials noted that the ECAPE system, which will interact with MAS for reporting purposes, had been implemented in 6 of OMHA's 10 field offices and would be implemented in all 10 field offices and its satellite office by the end of 2019. However, Part B and DME MACs, which are responsible for Part B and DME Level 1 appeals, have not been fully transitioned to MAS. Therefore, appeals categories are still inconsistent for these claims. According to HHS, CMS has not received funding to transition the remaining Level 1 appeals contractors to MAS. Additionally, HHS reported that DAB continues to explore ways to develop interoperability between MODACTS and OMHA's ECAPE system. Therefore, we will continue to monitor progress on the implementation of this recommendation.

Recommendation: To help ensure appropriate payments to MA plans, the Administrator of CMS should take steps to improve the accuracy of the adjustment made for differences in diagnostic coding practices between MA and Medicare FFS. Such steps could include, for example, accounting for additional beneficiary characteristics, including the most current data available, identifying and accounting for all years of coding differences that could affect the payment year for which an adjustment is made, and incorporating the trend of the impact of coding differences on risk scores.

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

Comments: CMS indicated in January 2020 that it has no plans to take further action regarding our recommendation. CMS stated that, given the complexity of measuring coding changes attributable to plan behavior and the difficulty of measuring countervailing factors, there is not a single correct factor within the viable range of adjustment factors. In addition, the agency noted that there is policy discretion with respect to the appropriate adjustment factor for the payment year. In the Medicare Advantage Call Letter of April 2019, CMS stated that it will apply the statutory minimum adjustment of 5.90 percent for calendar year 2020. As of February 2020, CMS had not provided any documentation of its analysis and the basis for its determination. Although the application of the 5.90 percent adjustment and other recent changes CMS has made to its methodology for calculating the diagnostic coding adjustment (i.e., the exclusion of diagnosis codes that were differentially reported in Medicare fee-for-service and Medicare Advantage) likely brings CMS's adjustment closer to what GAO's analysis projects to be an accurate adjustment, a modified methodology that incorporates more recent data, accounts for all relevant years of coding differences, and incorporates the effect of coding difference trends would better ensure an accurate adjustment in future years. Until CMS shows the sufficiency of the diagnostic coding adjustment or implements an adjustment based on analysis using an updated methodology, payments to Medicare Advantage plans may not accurately account for differences in diagnostic coding between these plans and traditional Medicare providers.