Recommendation: The Under Secretary for Health should fully define in VHA policy the oversight roles and responsibilities related to ensuring facilities' adherence to disbursement agreement policies, including roles related to ReDPro and the role of VISNs. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should more clearly define in VHA policy the purposes of the periodic independent audits and the ReDPro checklist reviews—including differentiating their purposes from one another and ensuring that they do not unnecessarily overlap. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should ensure that OAA and CBI modify the ReDPro checklist and associated guidance, to include ensuring that checklist items are clearly stated, relevant to the updated purpose of the ReDPro checklist, and not unnecessarily duplicative of items to be addressed by the periodic independent audits. The guidance should also include detailed instruction on what the compliance officers should review, and how they should determine the appropriate response for each checklist item. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should ensure that OAA and CBI develop and provide additional ReDPro training for compliance officers, consistent with the updated checklist and guidance. This training should include general information on GME programs and disbursement agreement oversight, as well as detailed information about how ReDPro reviews should be conducted. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should ensure that OAA implements a standardized independent audit tool that is consistent with the updated purpose of the periodic independent audits, and does not unnecessarily overlap with the ReDPro checklist. This could include modifying its existing recommended checklist, or developing a new tool. (Recommendation 5)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should ensure that OAA develops guidance for periodic independent audits to assist the audit teams and facility management in understanding how audits are to be conducted. (Recommendation 6)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should ensure that OAA develops substantive training for independent audit team members, consistent with the updated audit purpose, guidance, and tools. This training should include general information on GME programs and disbursement agreement oversight, as well as detailed information about how the independent audits should be conducted. (Recommendation 7)

Agency: Department of Veterans Affairs
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 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 Administrator of CMS should determine the extent to which state Medicaid programs are in compliance with federal requirements to cover MAT medications in all formats and take actions to ensure compliance, as appropriate. (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 Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the military departments, collect consistent information on the replacement costs of military physicians and dentists and use this information to inform investment decisions in the package of incentives to recruit and retain military physicians and dentists. (Recommendation 1)

Agency: Department of Defense: Office of the Under Secretary for Personnel and Readiness: Defense Health Agency
Status: Open

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

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the military departments, collect consistent information on current and historical retention data, to include data on the percentage of eligible physicians and dentists who accept retention bonuses, and use this information to inform investment decisions in the package of incentives to retain military physicians and dentists. (Recommendation 2)

Agency: Department of Defense: Office of the Under Secretary for Personnel and Readiness: Defense Health Agency
Status: Open

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

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the military departments, collect consistent information on private sector civilian wages and use this information to help inform investment decisions in the package of incentives to recruit and retain military physicians and dentists. (Recommendation 3)

Agency: Department of Defense: Office of the Under Secretary for Personnel and Readiness: Defense Health Agency
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 clarify policies and procedures to remind staff that a diagnosis of a substance use disorder is not necessary to conduct a Drug Addiction and Alcoholism evaluation. (Recommendation 1)

Agency: Social Security Administration
Status: Open

Comments: SSA agreed with this recommendation. The agency stated that it had revised related policies in February 2020, and had planned to issue guidance and video-on-demand training to further clarify policies and procedures in this area. However, SSA said its efforts to maintain mission critical activities amid the COVID-19 pandemic have delayed further implementation of this recommendation and a specific implementation date could not be provided at this time.

Recommendation: The Commissioner of the Social Security Administration should ensure that staff document their rationale for decisions involving the Drug Addiction and Alcoholism evaluation process. (Recommendation 2)

Agency: Social Security Administration
Status: Open

Comments: SSA agreed with this recommendation. The agency said it had planned to issue guidance reinforcing its policy on properly documenting decisions involving the Drug Addiction and Alcoholism evaluation process. However, SSA said its efforts to maintain mission critical activities amid the COVID-19 pandemic have delayed implementation of this recommendation and a specific implementation date could not be provided at this time.

Recommendation: Congress should consider giving CMS authority to establish additional enforcement remedies for hospices that do not meet federal health and safety requirements. (Matter for Consideration 1)

Agency: Congress
Status: Open

Comments: In October 2019, we suggested that Congress should consider giving CMS authority to establish additional enforcement remedies for hospices that do not meet federal health and safety requirements. As of June 2020, Congress has not implemented this suggestion.

Recommendation: The Administrator of CMS should incorporate the use of additional information, such as quality measures or other information that could identify potential quality of care issues, into its survey process for overseeing hospice providers. (Recommendation 1)

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

Comments: HHS concurred with this recommendation. In May 2020, HHS said CMS is evaluating ways in which the Hospice Consumer Assessment of Health Providers and Systems (CAHPS) survey data can be used to inform surveys of hospice providers. HHS also said CMS intends to incorporate use of the current Hospice Quality Reporting Program (HQRP) measurement data into the survey process to provide additional items that inform a surveyor's evaluation of a hospice provider. HHS noted that these changes would be incorporated into a more comprehensive update to the survey process to target providers and areas where risk of noncompliance is greatest. HHS projected the updated process would be implemented by the end of the first quarter of calendar year 2021. In order for us to close the recommendation, CMS has to implement an updated survey process that incorporates the use of additional information that could identify potential quality of care issues, such as that described above.

Recommendation: The Secretary of Veterans Affairs should develop a department-wide succession plan for leadership and mission-critical occupations that incorporates key leading practices for succession planning. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: As of April 2020, VA reported that it is developing a department-wide succession plan for leadership positions and mission-critical occupations. VA estimated it would complete this plan by September 30, 2020. When VA provides us a copy of the completed plan, we will provide updated information.

Recommendation: The Under Secretary for Health should incorporate key leading practices into VHA's succession planning processes, including monitoring and evaluating VHA's succession planning. (Recommendation 2)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: As of April 2020, VHA reported that it is developing guidance and metrics, developing a process to assess field-based succession planning actions, and incorporating evaluations and updates of implementation strategies into its succession plan. VHA also indicated that it is developing a new VHA Executive Succession Plan. VHA plans to complete these actions by December 2021. When we receive VHA's updated plans and guidance, we will provide updated information.

Recommendation: The Under Secretary for Benefits should develop a succession planning process for all leadership positions and incorporate key leading practices into VBA's succession planning for leadership positions and mission-critical occupations. These practices include aligning the plans with strategic goals, identifying strategies to close workforce gaps, and monitoring and evaluating VBA's succession planning. (Recommendation 3)

Agency: Department of Veterans Affairs: Veterans Benefits Administration
Status: Open

Comments: As of April 2020, VBA reported that it is developing succession plans that align with VBA's strategic goals and identify succession planning strategies. VBA also indicated that it plans to review, assess, and update the plans annually. According to VBA, its plans will cover mission-critical occupations as well as leadership positions within those mission-critical occupations. However, VBA stated that VA's Corporate Senior Executive Management Office (CSEMO) is responsible for planning related to VBA's senior executives and that VBA will coordinate with CSEMO on succession planning for senior executives. To implement our recommendation, VBA will need to demonstrate that VBA, or CSEMO in coordination with VBA, has developed succession planning processes that cover all leadership positions (including senior executives) and mission-critical occupations. VBA expects to complete its succession plans by September 30, 2020. When we receive VBA's completed plans, we will provide updated information.

Recommendation: The Secretary of Veterans Affairs should update VA's 2003 directive on workforce and succession planning to incorporate relevant legal requirements, including Office of Personnel Management strategic human capital management regulation requirements. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open

Comments: As of April 2020, VA reported that its updated directive is going through the Department's internal review and concurrence process. VA estimated it would complete the directive by July 31, 2020. When VA provides us a copy of the directive, we will provide updated information.

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 Under Secretary for Health should ensure that facility officials who are responsible for credentialing, reviewing credentials, and hiring receive periodic mandatory training. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: As of March 2020, VA officials told us that they expect to have this recommendation implemented during calendar year 2020.

Recommendation: The Under Secretary for Health should develop policies and guidance regarding DEA registrations, including the circumstances in which Drug Enforcement Administration (DEA) waivers may be required, the process for requesting them, and a mechanism to ensure that facilities follow these policies. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: As of March 2020, this recommendation remains open. VA sent a letter to DEA asking for clarification about DEA employment waivers and received a response from DEA dated November 26, 2019. VA officials told us that they are considering the input from DEA and consulting with relevant stakeholders to determine next steps. To fully implement this recommendation, VA needs to provide evidence of actions taken to ensure that DEA requirements regarding DEA registrations and employment waivers are met. Such actions include developing policies regarding when a DEA employment waiver may be necessary and guidance about how to request such a waiver.

Recommendation: The Under Secretary for Health should identify and review providers whose DEA registrations were revoked or surrendered for cause and determine whether an employment waiver may be needed from DEA. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: As of March 2020, VA has reported important steps toward implementing this recommendation. Specifically, VA officials told us that they reviewed licensed independent practitioners to see if any that are currently employed at VA have a revoked or surrendered DEA registration. They identified at least one provider with a revoked or surrendered DEA registration. To fully implement this recommendation, VA needs to provide evidence that appropriate action was taken for this provider, such as obtaining a DEA waiver if necessary.

Recommendation: The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness, in coordination with the Director, CAPE, the Joint Staff Surgeon, and the secretaries of the military departments, establish joint planning assumptions for developing operational medical and dental personnel requirements, including a definition of what forces should and should not be identified as "operational." (Recommendation 1)

Agency: Department of Defense
Status: Open

Comments: The Department of Defense concurred with this recommendation and said it would take steps to implement it. According to department officials, as of November 2019, they are drafting a report that will address this recommendation. We will continue to monitor DOD's efforts.

Recommendation: The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness, in coordination with the Director of Cost Assessment and Program Evaluation, the Joint Staff Surgeon, and the secretaries of the military departments, establish a method to assess options for achieving joint efficiencies in medical and dental personnel requirements and any associated risks. (Recommendation 2)

Agency: Department of Defense
Status: Open

Comments: The Department of Defense concurred with this recommendation and said it would take steps to implement it. According to department officials, as of November 2019, they are drafting a report that will address this recommendation. We will continue to monitor the department's efforts. .

Recommendation: The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness, in coordination with the Director of Cost Assessment and Program Evaluation, the Joint Staff Surgeon, and the secretaries of the military departments, apply joint planning assumptions and a method for assessing efficiencies and risk, use these to determine operational medical and dental requirements, and report to Congress. (Recommendation 3)

Agency: Department of Defense
Status: Open

Comments: The Department of Defense concurred with this recommendation and said it would take steps to implement it. According to department officials, as of November 2019, they are drafting a report that will address this recommendation. We will continue to monitor DOD's efforts..

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the Surgeons General of the military departments, identify and mitigate limitations in the clinical readiness metric, such as data reliability, a lack of complete information on reserve component providers and patient care workload performed outside of medical treatment facilities (MTFs), and the lack of linkage between the metric and patient care and retention outcomes. (Recommendation 4)

Agency: Department of Defense
Status: Open

Comments: The Department of Defense concurred with this recommendation and said it would take steps to implement it. As of November 2019, DOD has not taken any actions to implement this recommendation.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the Surgeons General of the military departments and the Director of the Defense Health Agency, determines which critical wartime specialties perform high-risk, high-acuity procedures and rely upon perishable skill sets and use this information to prioritize specialties to which the clinical readiness metric could be expanded (Recommendation 5).

Agency: Department of Defense
Status: Open

Comments: The Department of Defense concurred with this recommendation and said it would take steps to implement it. As of November 2019, DOD has not implemented this recommendation.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with each of the Surgeons General of the military departments and the Director of the Defense Health Agency, estimates the cost and benefits, by specialty, of implementing a clinical readiness metric and use that information to determine whether DODs approach should be revised. Costs to be considered should include those needed to provide additional training for medical personnel to achieve clinical readiness thresholds and to hire additional civilian personnel in MTFs to backfill military providers who leave to attend training. (Recommendation 6)

Agency: Department of Defense
Status: Open

Comments: The Department of Defense concurred with this recommendation and said it would take steps to implement it. As of November 2019, DOD has not implemented this recommendation.

Recommendation: The Director of IHS should obtain, on an agency-wide basis, information on temporary provider contractors, including their associated cost and number of full-time equivalents, and use this information to inform decisions about resource allocation and provider staffing. (Recommendation 1)

Agency: Indian Health Service
Status: Open

Comments: In February 2020, IHS reported that challenges in rolling-up contractor information on a national level stem from the fact that the agency often uses single contract vehicles, such as staffing companies, to hire multiple providers for temporary periods of time. IHS's contract databases do not centrally track the numbers of individual providers through such staffing contracts. The ability to analyze and compare detailed actual costs of federal hires vs. contract hires is currently limited to local information sources and on a narrow area of focus, such as one provider category or one facility at a time. IHS reported that the agency is implementing a monthly reporting requirement for IHS Areas and plans to use this information to inform decisions about resource allocation and provider staffing. We will review these reporting requirements when they have been fully implemented.

Recommendation: The Secretary of HHS should coordinate with federal agencies, including VA, that fund GME training to identify information needed to evaluate the performance of federal programs that fund GME training, including the extent to which these programs are efficient and cost-effective and are meeting the nation's health care workforce needs. (Recommendation 1)

Agency: Department of Health and Human Services
Status: Open

Comments: In January 2020, HHS indicated that the agency had not yet taken steps to identify information needed to evaluate the performance of federal programs that fund GME training, including the extent to which these programs are efficient and cost-effective and are meeting the nation's health care workforce needs. HHS reiterated its comments on GAO's report, noting that the President's fiscal year 2020 budget for HHS proposed consolidating federal spending from Medicare, Medicaid, the Teaching Health Center Graduate Medical Education Program, and the Children's Hospitals Graduate Medical Education Payment Program into a single grant program for teaching hospitals. The President's fiscal year 2021 budget for HHS also included this proposal. It noted that such a restructuring would allow the Department to set expectations for program performance in Medicare and Medicaid GME programs and allow the kind of tracking HRSA has been able to implement in the Children's Hospital GME program and its Teaching Hospital GME program. It noted that Congress had not responded to this request. As GAO noted in its 2018 report, this recommendation stands on its own and is separate from any legislative efforts to modify how federal GME funds are distributed. Whether or not legislation is enacted to implement a consolidated federal GME grant program, HHS should take action to identify information needed to evaluate the performance of federal programs that fund GME training. Such action is important for HHS to assure that federal programs fully meet workforce needs. However, HHS did not otherwise indicate whether it had coordinated with federal agencies that fund GME training. As of January 2020, this proposal had not been adopted.

Recommendation: The Secretary of HHS should coordinate with federal agencies to identify opportunities to improve the quality and consistency of the information collected within and across federal programs, and implement these improvements. (Recommendation 2)

Agency: Department of Health and Human Services
Status: Open

Comments: In January 2020, HHS indicated that the agency had not yet taken steps to identify opportunities to improve the quality and consistency of the information collected within and across federal programs, and implement these improvements. HHS reiterated its comments on GAO's report, noting that the President's fiscal year 2020 budget for HHS proposed consolidating federal spending from Medicare, Medicaid, the Teaching Health Center Graduate Medical Education Program, and the Children's Hospitals Graduate Medical Education Payment Program into a single grant program for teaching hospitals. The President's fiscal year 2021 budget for HHS also included this proposal. It noted that such a restructuring would allow the Department to set expectations for program performance in Medicare and Medicaid GME programs and allow the kind of tracking HRSA has been able to implement in the Children's Hospital GME program and its Teaching Hospital GME program. It noted that Congress had not responded to this request. As GAO noted in its 2018 report, this recommendation stands on its own and is separate from any legislative efforts to modify how federal GME funds are distributed. Whether or not legislation is enacted to implement a consolidated federal GME grant program, HHS should take action to identify information needed to evaluate the performance of federal programs that fund GME training. Such action is important for HHS to assure that federal programs fully meet workforce needs. However, HHS did not otherwise indicate whether it had coordinated with federal agencies that fund GME training. As of February 2020, this proposal had not been adopted.

Recommendation: The Undersecretary for Health should develop and implement a process to accurately count all physicians providing care at each medical center, including physicians who are not employed by VHA. (Recommendation 1)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open
Priority recommendation

Comments: As of January 2020, VHA continues to disagree with the recommendation and has not taken any action. Although VA responded to our report by stating that the ability to count physicians does not affect its ability to assess workload, we maintain that an accurate count of all physicians providing care at each medical center is necessary for accurate workforce planning. To implement the first recommendation, VHA needs to develop a system-wide process to collect information on all physicians providing care at VAMCs, including physicians that are not employed by VHA. This information should be available at the local level for workforce planning purposes.

Recommendation: The Undersecretary for Health should develop and issue guidance to the VAMCs on determining appropriate staffing levels for all mission-critical physician occupations. (Recommendation 2)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VHA concurred with this recommendation. In November 2017, VHA's Executive in Charge chartered the Specialty Care Provider Staffing and Network Model Workgroup to develop a methodology for determining the scope and complexity of specialty care services. The Workgroup also developed an analytical tool to support local decision-making around specialty staffing levels. According to VHA, the Specialty Care Services Staffing model has been validated across some VHA regions. The Workgroup was directed to develop an Executive Decision Memorandum for an official determination as to implementation of the model. As of January 2020, VHA was awaiting the results of the Governing Board's decision on the Executive Decision Memorandum, the guidance documents, and analytical template. VHA reported the target date for completion is March 2020.

Recommendation: The Undersecretary for Health should establish a system-wide method to share information about physician trainees to help fill vacancies across VAMCs. (Recommendation 4)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VHA concurred with this recommendation. VHA is working to develop the necessary capacity to enable a system-wide method for sharing information about physician trainees to help fill vacancies. In April 2019, VHA anticipated having this system in place by the end of fiscal year 2019. However, VHA has not submitted any additional information since April 2019. VHA has also created a VHA-Trainee Recruitment and Hiring Workgroup (the Workgroup). The Workgroup serves as the advisory group on trainee recruitment and hiring, for the purpose of developing a permanent Trainee Recruitment and Hiring Function. The Workgroup is holding Virtual Trainee Recruitment Events for critical occupations. Until GAO sees evidence of a system-wide method for sharing information about physician trainees, this recommendation will remain open.

Recommendation: To help ensure that its efforts to increase patients' electronic access to health information are successful, the Secretary of HHS should direct ONC to use the information these performance measures provide to make program adjustments, as appropriate. Such actions may include, for example, assessing the status of program operations or identifying areas that need improvement in order to help achieve program goals related to increasing patients' ability to access their health information electronically.

Agency: Department of Health and Human Services
Status: Open

Comments: As of May 2019, ONC is collecting and evaluating information from national surveys, program data, and third-party data sources. As ONC works to implement its evaluations, it should identify how evidence collected from national surveys, program data and third-party data sources has been used to assess the outcomes of key efforts and adjust programs accordingly.

Recommendation: To determine the suitability of Medicare's Part B drug payment rate methodology for drugs with coupon programs, Congress should consider (1) granting CMS the authority to collect data from drug manufacturers on coupon discounts for Part B drugs paid based on ASP, and (2) requiring the agency to periodically collect these data and report on the implications that coupon programs may have for this methodology.

Agency: Congress
Status: Open

Comments: As of August 2020, Congress had not passed legislation to address this Matter for Congressional Consideration. We will update the status of this Matter if such action occurs.

Recommendation: To help the Department of Health and Human Services ensure accuracy in Part B drug payment rates, Congress should consider requiring all manufacturers of Part B drugs paid at ASP, not only those with Medicaid drug rebate agreements, to submit sales price data to CMS, and ensure that CMS has authority to request source documentation to periodically validate all such data.

Agency: Congress
Status: Open

Comments: As of June 2020, no action has been taken on this Matter for Congressional Consideration.

Recommendation: CMS should periodically verify the sales price data submitted by a sample of drug manufacturers by requesting source documentation from manufacturers to corroborate the reported data, either directly or by working with the HHS Office of Inspector General as necessary.

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

Comments: In September 2018, HHS officials reiterated that they believe the agency has addressed our recommendation because CMS works with HHS's Office of Inspector General (OIG) as appropriate to collect source documentation from drug manufacturers and takes action as warranted. HHS stated that CMS has continued to provide information regarding problematic ASP submissions to OIG for evaluation of misreporting and continues to use AMP and other benchmarks as comparisons for pricing determinations. They further stated that they do not believe that additional collection of detailed sales information about ASP, such as invoices, is authorized under Part B drug payment provisions in section 1847A or under section 1927(b). As of June 2020, CMS did not provide any additional updates. While we recognize that CMS conducts routine checks to assess the completeness of ASP data submitted by drug manufacturers, we do not believe these activities are enough to close the recommendation. Specifically, CMS only collects source documentation from manufacturers under very limited circumstances (e.g., when there are obvious inconsistencies in the data submitted by manufacturers). CMS does not periodically verify the accuracy of ASP data for a sample of manufacturers by tracing the data to and from drug manufacturers' source documents, such as sales invoices. Because CMS does not routinely verify the accuracy of the underlying data used to determine Medicare payment rates, the resulting payment rates may be inaccurate if drug manufacturers do not report accurate data. With regards to CMS's authority to collect additional information, such as invoices, we believe the agency could work through OIG to collect such information.

Recommendation: In order to prevent the shift of services from physician offices to HOPDs from increasing costs for the Medicare program and beneficiaries, Congress should consider directing the Secretary of HHS to equalize payment rates between settings for E/M office visits--and other services that the Secretary deems appropriate--and to return the associated savings to the Medicare program.

Agency: Congress
Status: Open

Comments: The Bipartisan Budget Act of 2015, enacted in November 2015, partially addressed our recommendation as it limits certain providers from billing at higher hospital outpatient department payment rates. Specifically, the legislation excludes services furnished by off-campus hospital outpatient departments from reimbursement under Medicare's hospital outpatient prospective payment system, effective January 1, 2017. According to the Congressional Budget Office, this action saves the Medicare program $9.3 billion over 10 years. However, the Act does not apply to services furnished by providers billing as hospital outpatient departments prior to enactment of the legislation-which includes providers billing as hospital outpatient departments during the study period in our report-as well as hospital outpatient departments located on hospital campuses. This means that, even in 2017 and beyond, many providers will not be affected by the Act, and Medicare will continue to pay more than necessary for certain services. In November 2018, CMS issued a final rule adopting payment changes-that have since been partially overturned under a decision by a federal district court, which CMS has appealed-capping payment rates for certain services furnished by the off-campus hospital outpatient departments that existed or were under construction in 2015 at the physician fee schedule rate. Since these services furnished by these off-campus hospital outpatient departments were paid under a higher rate, the payment cap, which was to be implemented over 2 years, was intended to equalize payment rates for certain clinical visits between settings. In 2019, CMS applied 50 percent of the payment reduction and in 2020 and subsequent years planned to apply 100 percent of the payment reduction. The rule applied to specific clinical visits; and other services would continue to be paid at the higher rate. However, a federal district court overturned the payment cap in September 2019. CMS has appealed that ruling and adopted a final rule in November 2019 that will implement the payment reduction in 2020. A lawsuit challenging the November 2019 final rule has been filed.

Recommendation: To ensure that HHS workforce efforts meet national needs, the Secretary of Health and Human Services should develop a comprehensive and coordinated planning approach to guide HHS's health care workforce development programs--including education, training, and payment programs--that (1) includes performance measures to more clearly determine the extent to which these programs are meeting the department's strategic goal of strengthening health care; (2) identifies and communicates to stakeholders any gaps between existing programs and future health care workforce needs identified in the Health Resources and Services Administration's workforce projection reports; (3) identifies actions needed to address identified gaps; and (4) identifies and communicates to Congress the legislative authority, if any, the Department needs to implement the identified actions.

Agency: Department of Health and Human Services
Status: Open

Comments: In December 2016, HHS indicated that the agency had not yet taken steps to implement a comprehensive workforce planning effort. Officials said that for the FY2018 cycle, HHS had planned to expand its group developing legislative proposals to include budget issues and gaps that warrant attention. While it did not do so during that cycle, officials indicated that they would recommend this broader approach to workforce planning for future budget and legislative cycles. In an update presented in HHS's FY2021 budget justification, HHS did not address efforts to develop a comprehensive and coordinated planning approach to guide HHS's health care workforce development programs. Instead, it described its current legislative and budget development effort and proposal to restructure CMS Graduate Medical Education (GME) programs into a discretionary grant program. It noted that such a restructuring would allow the Department to set expectations for program performance in CMS GME and allow the kind of tracking HRSA has been able to implement in the Children's Hospital GME program and its Teaching Hospital GME program. It noted that Congress had not responded to this request. However, this recommendation stands on its own and is separate from any legislative efforts to modify how federal GME funds are distributed. Whether or not legislation is enacted to implement a consolidated federal GME grant program, HHS should take action to develop a comprehensive and coordinated planning approach. Such action is important for HHS to assure that federal programs fully meet workforce needs. Further, the CARES Act of 2020 requires HHS to develop a comprehensive and coordinated strategic plan for HHS health workforce programs. We will be monitoring HHS's implementation of this requirement to determine if it satisfies the intent of this recommendation.

Recommendation: To determine the extent to which Medicare payments are aligned with costs for specific types of dialysis treatment and training, the Administrator of CMS should take steps to improve the reliability of the cost report data for treatment and training associated with specific types of dialysis.

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

Comments: As of February 2020, CMS has not implemented this recommendation. HHS agreed with this recommendation and stated in February 2020 that CMS was exploring ways to clarify the cost report instructions in an effort to improve the accuracy of the information submitted. We will update the status of this recommendation when we receive additional information.

Recommendation: To ensure that patients with chronic kidney disease receive objective and timely education related to this condition, the Administrator of CMS should examine the Kidney Disease Education benefit and, if appropriate, seek legislation to revise the categories of providers and patients eligible for the benefit.

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

Comments: As of February 2020, CMS has not implemented this recommendation. HHS did not agree with this recommendation and stated in June 2016 that CMS continuously works to pay appropriately for ESRD services and must prioritize its activities to improve care for dialysis patients. While we acknowledge the need for CMS to prioritize its activities to improve dialysis care, it is important for CMS to help ensure that Medicare patients with chronic kidney disease understand their condition, how to manage it, and the implications of the various treatment options available, particularly given the central role of patient choice in dialysis care. The limited use of the Kidney Disease Education benefit that we noted in our report suggests that it may be difficult for Medicare patients to receive this education and underscores the need for CMS to examine and potentially revise the benefit. We will update the status of this recommendation when we receive additional information.

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 help improve CMS's process for establishing relative values for Medicare physicians' services, the Administrator of CMS should better document the process for establishing relative values for Medicare physicians' services, including the methods used to review RUC recommendations and the rationale for final relative value decisions.

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

Comments: To help improve the Centers for Medicare & Medicaid Service's (CMS) process for establishing relative values for Medicare physicians' services, in May 2015 we recommended that the Administrator of CMS better document the process, including the methods used to review recommendations from the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) and the rationale for final relative value decisions. CMS concurred with this recommendation, stating that CMS establishes relative values for new, revised, and potentially misvalued physicians' services based on its review of a variety of sources of information, including the RUC. At that time, CMS officials told us the agency was working to improve the transparency of its process by proposing and finalizing changes to the process in the annual rule for the Physician Fee Schedule. Officials estimated that this process would take several years to complete. In order to close this recommendation as implemented, CMS will need to demonstrate that it has improved its internal and external documentation of its process for establishing relative values. As of June 2020, GAO was still waiting on confirmation from CMS that it had completed its enhancement process for establishing relative values for Medicare physicians' services in a way that would allow for greater transparency and documentation. CMS will need to demonstrate that it has improved its internal and external documentation for establishing relative values in order for GAO to close the recommendation. CMS officials agreed the recommendation should remain open as progress continues.

Recommendation: To help improve CMS's process for establishing relative values for Medicare physicians' services, the Administrator of CMS should develop a process for informing the public of potentially misvalued services identified by the RUC, as CMS already does for potentially misvalued services identified by CMS or other stakeholders.

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

Comments: To help improve the Centers for Medicare & Medicaid Service's (CMS) process for establishing relative values for Medicare physicians' services, in May 2015 we recommended that the Administrator of CMS develop a process for informing the public of potentially misvalued services identified by the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC), as CMS already does for potentially misvalued services identified by CMS or other stakeholders. CMS did not concur with this recommendation, asserting that the RUC is completely independent of CMS, and as such CMS has no authority to set the RUC's agenda for which services are reviewed. As of June 2020, CMS had not changed its position on the recommendation. We continue to believe that CMS needs to inform the public of potentially misvalued services identified by the RUC, as it does for potentially misvalued services identified by other stakeholders. We acknowledge that in 2017 CMS changed its process for establishing relative values by including proposed values for almost all services in the annual proposed rulemaking for the Physician Fee Schedule, which means that the changes in values for potentially misvalued services identified by the RUC are open for public comment before they become effective. However, we continue to believe CMS should inform stakeholders of these potentially misvalued services before CMS receives RUC recommendations for them and subsequently publishes the values in the proposed rule. Doing so would give stakeholders the same amount of time they have to provide input on potentially misvalued services identified by other stakeholders.

Recommendation: To help improve CMS's process for establishing relative values for Medicare physicians' services, the Administrator of CMS should incorporate data and expertise from physicians and other relevant stakeholders into the process as well as develop a timeline and plan for using the funds appropriated by the Protecting Access to Medicare Act of 2014.

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

Comments: To help improve the Centers for Medicare & Medicaid Service's (CMS) process for establishing relative values for Medicare physicians' services, in May 2015 we recommended that the Administrator of CMS incorporate data and expertise from physicians and other relevant stakeholders into the process, as well as develop a timeline and plan for using the funds appropriated by the Protecting Access to Medicare Act of 2014 (PAMA). CMS concurred with this recommendation, stating that stakeholders have the opportunity each year to nominate potentially misvalued services for review through a public nomination process. In August 2017, CMS officials reported that the final rulemaking for the 2017 Physician Fee Schedule included a data collection effort using PAMA funds and other authorities that will help furnish data to help in valuations for more than half of physician services. However, this effort pertains to global services, which are a specific type of service under the Physician Fee Schedule that include global, professional, and technical components, and does not apply to non-global services, which encompass almost half of physician services. Officials also reported that they had awarded a contract to explore data collection on practice expense and methodologies for using such data when valuing services in the Physician Fee Schedule. However, CMS did not indicate a specific timeline and plan for using the PAMA funds, just that the agency would continue to use these funds to explore more ways to gain improved data. In March 2018, CMS reported that it now incorporates data and expertise from relevant stakeholders-apart from the RUC-into its process for establishing relative values by including any new, revised, or potentially misvalued values in the annual proposed rulemaking, instead of establishing them on an interim final basis in the final rule. This means that the changes in values for services will be open for public comment prior to the implementation of changes to payment. We acknowledge that CMS has made progress towards meeting our recommendation by changing its process to allow for public comments on proposed changes to relative values before they go into effect. CMS has also made progress by beginning to use PAMA funds to assist with valuing global services and exploring avenues for collecting practice expense data. To close this recommendation, we need documentation that CMS has started to incorporate data more broadly into its process for establishing relative values and that it has a documented timeline and plan for how it will use the funds appropriated by the Protecting Access to Medicare Act of 2014. As of June 2020, we had not received this documentation.

Recommendation: To ensure that CMS and ONC can effectively monitor the effect of the EHR programs and progress made toward goals, the Secretary of Health and Human Services should direct the agencies to develop performance measures to assess outcomes of the EHR programs--including any effects on health care quality, efficiency, and patient safety and other health care reform efforts that are intended to work toward similar outcomes.

Agency: Department of Health and Human Services
Status: Open

Comments: HHS neither agreed nor disagreed with our recommendation. In July 2015, CMS noted that the agency is working to align the programs to better enable monitoring using outcome-oriented performance measures and noted that the agency is collecting data that will help them to develop such measures. CMS did not indicate when HHS plans to develop such measures as GAO recommended. In June 2016, CMS also noted that it analyzed the results of the EHR programs as of October 2015, but did not indicate that it used performance measures that assess outcomes. In September 2017, HHS officials provided us a variety of publically available reports, which they indicated show how program participants are progressing in the EHR programs and the related impacts. In 2018, CMS changed the name of these programs to the Promoting Interoperability programs to focus on improving interoperability and patients' access to health information, and officials noted that the agency is working to develop related outcome-based measures. To fully implement this recommendation, CMS needs to develop performance measures that enable the agency to assess whether the Promoting Interoperability programs are improving outcomes, such as health care quality, efficiency, and patient safety, as we recommended.

Recommendation: To ensure that CMS and ONC can effectively monitor the effect of the EHR programs and progress made toward goals, the Secretary of Health and Human Services should direct the agencies to use the information these performance measures provide to make program adjustments, as appropriate, to better achieve program goals.

Agency: Department of Health and Human Services
Status: Open

Comments: In written responses provided by HHS in February 2014, on a draft of the report, the agency indicated that it agrees that outcome-oriented performance measures will be useful to evaluating the extent that the EHR programs--enacted through legislation--achieve the expected results. However, HHS did not identify any specific actions that it might undertake to address our recommendation. In July 2015, CMS indicated that the agency is still working to develop additional performance measures, which is a necessary first step towards implementing our recommendation to HHS that CMS and ONC use the outcome-oriented performance measures to make program adjustments, as appropriate. In September 2017 and March 2018, HHS officials provided us documents, which they indicated show how information gathered through monitoring activities was used to inform the EHR programs. In November 2018, HHS officials noted that CMS is actively working to use data submitted for the Promoting Interoperability Programs to improve upon the outcomes of patients, and also indicated (as noted above) that CMS is collaborating with stakeholders to develop outcome-based measures for the Promoting Interoperability Programs. To fully implement this recommendation, CMS needs to develop outcome-oriented performance measures and then demonstrate it is using them to make appropriate program adjustments. We will update the status of this recommendation when we receive additional information.

Recommendation: To help ensure that qualified CDRs promote improved quality and efficiency of physician care for Medicare beneficiaries, the Secretary of Health and Human Services should direct CMS to establish a requirement for qualified CDRs to demonstrate improvement on key measures of quality and efficiency for their target populations.

Agency: Department of Health and Human Services
Status: Open

Comments: As of April 2019, HHS officials reported that they were implementing new requirements for qualified CDRs, but these requirements were not related to demonstrating improvement on the measures of quality and efficiency, as GAO recommended. We will update the status of this recommendation when we receive additional information.

Recommendation: To help ensure that qualified CDRs promote improved quality and efficiency of physician care for Medicare beneficiaries, the Secretary of Health and Human Services should direct CMS to establish a process for monitoring compliance with requirements for qualified CDRs that draws on relevant expert judgment. This process should assess CDR performance on each requirement in a way that takes into account the varying circumstances of CDRs and their available opportunities to promote quality and efficiency improvement for their target populations.

Agency: Department of Health and Human Services
Status: Open

Comments: As of April 2019, HHS officials have not informed us of any actions taken to implement this recommendation. We will update the status of this recommendation when we receive additional information.

Recommendation: To help ensure that qualified CDRs promote improved quality and efficiency of physician care for Medicare beneficiaries, the Secretary of Health and Human Services should determine and implement actions to reduce barriers to the development of qualified CDRs, such as (1) developing guidance that clarifies Health Insurance Portability and Accountability Act requirements to promote participation in qualified CDRs; (2) working with private sector entities to make relevant multipayer cost data available to qualified CDRs; (3) testing one or more models of shared savings between Medicare and qualified CDRs that achieve reduced Medicare expenditures with improved quality of care, and (4) providing technical assistance to qualified CDRs.

Agency: Department of Health and Human Services
Status: Open

Comments: As of April 2019, HHS officials have not informed us of any actions taken to implement this recommendation beyond providing limited technical assistance to qualified CDRs through monthly support calls and an annual kick-off meeting. We will update the status of this recommendation when we receive additional information.

Recommendation: To help ensure that qualified CDRs promote improved quality and efficiency of physician care for Medicare beneficiaries, the Secretary of Health and Human Services should determine key data elements needed by qualified CDRs--such as those relevant for a required core set of measures--and direct Office of the National Coordinator for Health Information Technology and CMS to include these data elements, if feasible, in the requirements for certification of EHRs under the EHR incentive programs.

Agency: Department of Health and Human Services
Status: Open

Comments: As of April 2019, HHS officials have not informed us of any actions taken to implement this recommendation. We will update the status of this recommendation when we receive additional information.

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 help ensure that ADI suppliers provide consistent, safe, and high-quality imaging to Medicare beneficiaries, the Administrator of CMS should determine the content of and publish minimum national standards for the accreditation of ADI suppliers, which could include specific qualifications for supplier personnel and requiring accrediting organization review of clinical images.

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

Comments: In June 2019, HHS officials informed us that they plan to implement this recommendation in March 2020. We will update the status of this recommendation when we receive additional information.

Recommendation: To help ensure that ADI suppliers provide consistent, safe, and high-quality imaging to Medicare beneficiaries, the Administrator of CMS should develop an oversight framework for evaluating accrediting organization performance, which could include collecting and analyzing information on accreditation results and conducting validation audits.

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

Comments: In June 2019, HHS officials informed us that they plan to implement this recommendation in March 2020. We will update the status of this recommendation when we receive additional information.

Recommendation: To help ensure that ADI suppliers provide consistent, safe, and high-quality imaging to Medicare beneficiaries, the Administrator of CMS should develop more specific requirements for accrediting organization mid-cycle audit procedures and clarify guidance on immediate-jeopardy deficiencies to ensure consistent identification and timely correction of serious care problems for the duration of accreditation.

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

Comments: In June 2019, HHS officials informed us that they plan to implement this recommendation in March 2020. We will update the status of this recommendation when we receive additional information.

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 help ensure that the military services' requirements for physician credentialing and privileging are consistent across the MHS, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Surgeons General of the military services to establish a DOD-wide process to identify and address existing inconsistencies between DOD's and the military services' physician credentialing and privileging requirements, including those inconsistencies we identified in this report.

Agency: Department of Defense
Status: Open

Comments: We will update the status of this recommendation when we receive additional information. As of September 2019, DOD has not provided information or documentation to address this recommendation.

Recommendation: To help ensure that the military services' requirements for physician credentialing and privileging are consistent across the MHS, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Surgeons General of the military services to establish a DOD-wide process to coordinate all current and future efforts to revise physician credentialing and privileging requirements.

Agency: Department of Defense
Status: Open

Comments: We will update the status of this recommendation when we receive additional information. As of September 2019, DOD has not provided information or documentation to address this recommendation.

Recommendation: To assure that information on a physician's clinical competence and practice history is documented and available to support credentialing and privileging decisions by Army MTFs, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Army Surgeon General to coordinate individual MTFs' efforts to establish mechanisms to collect and analyze data to evaluate physician performance and support performance assessments.

Agency: Department of Defense
Status: Open

Comments: We will update the status of this recommendation when we receive additional information. As of September 2019, DOD has not provided information or documentation to address this recommendation.

Recommendation: To assure that information on a physician's clinical competence and practice history is documented and available to support credentialing and privileging decisions by Army MTFs, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Army Surgeon General to clarify requirements for how MTFs document follow-up on peer recommendations, including who is responsible for documenting follow-up and where that documentation should be filed.

Agency: Department of Defense
Status: Open

Comments: We will update the status of this recommendation when we receive additional information. As of September 2019, DOD has not provided information or documentation to address this recommendation.

Recommendation: To assure that information on a physician's clinical competence and practice history is documented and available to support credentialing and privileging decisions by Army MTFs, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Army Surgeon General to clarify requirements for the information that physicians need to provide in their curriculum vitae (CV) so that MTFs can identify unaccounted for periods in practice history, as well as how MTFs should document explanations of any unaccounted for periods.

Agency: Department of Defense
Status: Open

Comments: We will update the status of this recommendation when we receive additional information. As of September 2019, DOD has not provided information or documentation to address this recommendation.

Recommendation: To assure that information on a physician's clinical competence and practice history is documented and available to support credentialing and privileging decisions by Army MTFs, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Army Surgeon General to establish requirements for MTFs to document significant events that occur during the review of a credentials file, including which types of significant events should be documented, who is responsible for documenting significant events, and where that documentation should be filed.

Agency: Department of Defense
Status: Open

Comments: We will update the status of this recommendation when we receive additional information. As of September 2019, DOD has not provided information or documentation to address this recommendation.

Recommendation: To assure that information on a physician's clinical competence and practice history is documented and available to support credentialing and privileging decisions by Army MTFs, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs and the Army Surgeon General to establish a process to ensure that relevant information from the DPDB is documented in the credentials file.

Agency: Department of Defense
Status: Open

Comments: We will update the status of this recommendation when we receive additional information. As of September 2019, DOD has not provided information or documentation to address this recommendation.

Recommendation: To assure that MTFs are fully complying with DOD's and the military services' requirements for physician credentialing and privileging and implementing these requirements appropriately, the Secretary of Defense should direct the Surgeons General of the military services to establish and implement an oversight process to conduct reviews of a sample of credentials files to identify and address areas of noncompliance and incomplete documentation.

Agency: Department of Defense
Status: Open

Comments: We will update the status of this recommendation when we receive additional information. As of September 2019, DOD has not provided information or documentation to address this recommendation.

Recommendation: To ensure that savings are realized from the implementation of an MPPR or other policies that reflect efficiencies occurring when services are furnished together, Congress may wish to consider exempting these savings from budget neutrality.

Agency: Congress
Status: Open

Comments: Congress has exempted savings from the implementation of multiple procedure payment reductions (MPPR) for certain diagnostic imaging and therapy services from the budget neutrality requirement, as GAO suggested in July 2009. However, as of January 2020, other policies that may result in a reduction in payments for the professional component for imaging services remained subject to budget neutrality; "savings" from these services are redistributed to other services and do not accrue to the Medicare program. The Consolidated Appropriations Act of 2016 revised the payment reduction for the professional component of multiple diagnostic imaging services from 25 percent to 5 percent beginning on January 1, 2017, and exempted the reduced expenditures attributable to this MPPR from the budget neutrality provision. MPPRs or other policies that may result in a reduction to payments for the technical component for diagnostic cardiovascular and ophthalmology services continue to be subject to budget neutrality for 2020. Unless Congress exempts from the budget neutrality requirement savings realized from the implementation of all MPPRs or other policies that reflect efficiencies occurring when services are furnished together, these savings will not accrue to the Medicare program.

Recommendation: To better account for physicians practicing in underserved areas through the use of J-1 visa waivers, the Secretary of Health and Human Services should collect and maintain data on waiver physicians--including information on their numbers, practice locations, and practice specialties--and use this information when identifying areas experiencing physician shortages and placing physicians in these areas.

Agency: Department of Health and Human Services
Status: Open

Comments: HHS concurred with our recommendation, commenting that the department's goal was to assure that the limited resources of the J-1 visa waiver program and other programs addressing areas and populations with limited access to health care professionals are targeted most effectively. In 2013, HHS indicated that it was considering the best approach to collect information to identify J-1 visa physicians practicing in underserved areas. As of February 2018, however, HHS reported that it does not have the capacity to track physicians practicing in underserved areas through the use of J-1 visa waivers, citing reasons such as the number of federal entities and states involved in the process. While we recognize that collecting and maintaining these data requires coordination with other agencies, we continue to believe that without data on waiver physicians, HHS--the federal agency with primary responsibility for addressing physician shortages--will lack the information needed to consider waiver physicians working in underserved areas when placing providers in these areas under other programs. As of August 2019, HHS officials have not informed us of actions taken to implement this recommendation. We are leaving this recommendation open until the department collects and maintains data on waiver physicians and considers those physicians in its efforts to address physician shortages.