Recommendations Database

GAO’s recommendations database contains report recommendations that still need to be addressed. GAO’s priority recommendations are those that we believe warrant priority attention. We sent letters to the heads of key departments and agencies, urging them to continue focusing on these issues. Below you can search only priority recommendations, or search all recommendations.

Our recommendations help congressional and agency leaders prepare for appropriations and oversight activities, as well as help improve government operations. Moreover, when implemented, some of our priority recommendations can save large amounts of money, help Congress make decisions on major issues, and substantially improve or transform major government programs or agencies, among other benefits.

As of December 1, 2021, there are 4659 open recommendations, of which 482 are priority recommendations. Recommendations remain open until they are designated as Closed-implemented or Closed-not implemented.

Search Open Recommendations

1 - 20 of 22 Recommendations
Download CSV Download XLS

Medicaid: CMS Needs More Information on States' Financing and Payment Arrangements to Improve Oversight

Show
1 Open Recommendations
1 Priority
Agency Recommendation Status
Centers for Medicare and Medicaid Services
Priority Rec.
This is a priority recommendation.
The Administrator of CMS should collect and document complete and consistent provider-specific information about Medicaid payments to providers, including new state-directed managed care payments, and states' sources of funding for the nonfederal share of these payments. (Recommendation 1)
Open

HHS neither agreed nor disagreed with our recommendation but acknowledged the need for additional state Medicaid financing and payment data to oversee the Medicaid program. HHS also noted that CMS has begun work to improve the collection of financing and payment information through a revised data collection form and that CMS would explore additional actions to do so. In addition, Congress passed and the President signed into law requirements in December 2020 for additional state reporting on Medicaid supplemental payments. To fully implement our recommendation, HHS needs to demonstrate how its

Medicaid Providers: CMS Oversight Should Ensure State Implementation of Screening and Enrollment Requirements

Show
1 Open Recommendations
1 Priority
Agency Recommendation Status
Centers for Medicare and Medicaid Services
Priority Rec.
This is a priority recommendation.
The Administrator of CMS should expand its review of states' implementation of the provider screening and enrollment requirements to include states that have not made use of CMS's optional consultations. Similar to CMS's contractor site visits, such reviews should include any necessary steps to address areas of noncompliance for all types of enrolled providers, including those under contract with managed care organizations. (Recommendation 1)
Open

CMS concurred with our recommendation. In June 2020, CMS told us that it plans to reach out to states that have not yet participated in its optional consultations to discuss their progress towards implementing provider screening and enrollment requirements, and outline steps that the states should take to come into full compliance with them. However, in February 2021, CMS noted that all states opted to waive certain provider screening and enrollment requirements in an effort to help providers contain the spread of the 2019 Novel Coronavirus Disease. CMS will recognize these waivers until the

Medicaid: Additional CMS Data and Oversight Needed to Help Ensure Children Receive Recommended Screenings

Show
1 Open Recommendations
1 Priority
Agency Recommendation Status
Centers for Medicare and Medicaid Services
Priority Rec.
This is a priority recommendation.
The Administrator of CMS should work with states and relevant federal agencies to collect accurate and complete data on blood lead screening for Medicaid beneficiaries in order to ensure that CMS is able to monitor state compliance with its blood lead screening policy, and assist states with planning improvements to address states' compliance as needed. (Recommendation 1)
Open

In January 2021, CMS provided states with the option to use a new data system-as states meet certain data quality and completeness benchmarks for the system-to generate the report that includes states' blood lead screening data. CMS stated that this will improve the agency's and states' ability to assess gaps in blood lead screening data. This is a positive step, yet any new data system will also need to consider how to help address known limitations in the current blood lead screening data, such as the under-counting of blood lead screening tests not paid for by Medicaid. To implement this

Nursing Homes: Improved Oversight Needed to Better Protect Residents from Abuse

Show
2 Open Recommendations
2 Priority
Agency Recommendation Status
Centers for Medicare and Medicaid Services
Priority Rec.
This is a priority recommendation.
The administrator of CMS should require state survey agencies to immediately refer complaints and surveys to law enforcement (and, when applicable, to Medicaid Fraud Control Units (MFCU)) if they have a reasonable suspicion that a crime against a resident has occurred when the complaint is received. (Recommendation 3)
Open

HHS concurred with this recommendation. In February 2020, HHS said CMS will require state survey agencies to immediately refer complaints upon receipt and surveys to law enforcement (and, when applicable, to Medicaid Fraud Control Units) if they have a reasonable suspicion that a crime against a resident has occurred and aims to implement this requirement by December 2020. In March 2021, HHS said that, due to the 2019 Novel Coronavirus pandemic, much of the regulatory work related to nursing homes that was being undertaken by CMS has had to slow down due to shifting priorities in responding to

Centers for Medicare and Medicaid Services
Priority Rec.
This is a priority recommendation.
The administrator of CMS should require that abuse and perpetrator type be submitted by state survey agencies in CMS's databases for deficiency, complaint, and facility-reported incident data, and that CMS systematically assess trends in these data. (Recommendation 1)
Open

HHS concurred with this recommendation. In February 2020, HHS said CMS is developing the ability to review survey trends related to alleged perpetrator and alleged abuse types and aims to implement this recommendation by December 2020. In March 2021, HHS said that, due to the 2019 Novel Coronavirus pandemic, much of the regulatory work related to nursing homes that was being undertaken by CMS has had to slow down due to shifting priorities in responding to the pandemic. HHS identified a target date of June 2021.

Medicaid Demonstrations: Approvals of Major Changes Need Increased Transparency

Show
1 Open Recommendations
1 Priority
Agency Recommendation Status
Centers for Medicare and Medicaid Services
Priority Rec.
This is a priority recommendation.
The Administrator of CMS should develop and communicate a policy whereby applications for section 1115 demonstration amendments that may have significant impact are subject to transparency requirements comparable to those for new demonstrations and extensions. (Recommendation 2)
Open

HHS stated that it plans to implement a policy applying state public input processes and application criteria to amendments proposing significant or substantial changes in the same manner as for new demonstrations. In December 2020, CMS reiterated that the agency plans to develop criteria for determining whether an amendment application proposes a substantial change to an existing demonstration and to include this in guidance by early 2021. As of March 2021, HHS officials have not informed us of any additional actions taken to implement this recommendation. We will continue to monitor CMS's

Medicare and Medicaid: CMS Should Assess Documentation Necessary to Identify Improper Payments

Show
1 Open Recommendations
1 Priority
Agency Recommendation Status
Centers for Medicare and Medicaid Services
Priority Rec.
This is a priority 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)
Open

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

Medicaid: CMS Needs to Better Target Risks to Improve Oversight of Expenditures

Show
1 Open Recommendations
1 Priority
Agency Recommendation Status
Centers for Medicare and Medicaid Services
Priority Rec.
This is a priority recommendation.
The Administrator of CMS should complete a comprehensive, national risk assessment and take steps, as needed, to assure that resources to oversee expenditures reported by states are adequate and allocated based on areas of highest risk. (Recommendation 1)
Open

CMS has suspended steps to conduct a comprehensive national risk assessment. CMS developed a standard tool to assess risk and staff capacity in October 2019, but the implementation of this tool was suspended in November 2019 when the agency initiated a reorganization of its regional office functions, including financial oversight. According to CMS, the reorganization is intended to improve coordination between central and regional offices so that financial operations are consistent across the nation. As of March 2021, the tool remains suspended. HHS officials have not informed us of any

Medicaid Managed Care: Improvements Needed to Better Oversee Payment Risks

Show
1 Open Recommendations
1 Priority
Agency Recommendation Status
Centers for Medicare and Medicaid Services
Priority Rec.
This is a priority recommendation.
The Administrator of CMS should eliminate impediments to collaborative audits in managed care conducted by audit contractors and states, by ensuring that managed care audits are conducted regardless of which entity--the state or the managed care organization--recoups any identified overpayments. (Recommendation 2)
Open

CMS agreed with and has taken some steps to address this action, as recommended by GAO in July 2018. In September 2019, CMS reported that in July 2019 CMS held a meeting with states and collaborative audit contractors to discuss coordination of managed care audits, including a wide range of challenges with managed care audits. As result of the feedback and recommendations received, CMS is evaluating several process improvements and reiterated that audit contractors will continue to work with states to provide support and assistance in Medicaid managed care, and that Medicaid managed care

Medicaid: CMS Should Take Steps to Mitigate Program Risks in Managed Care

Show
1 Open Recommendations
1 Priority
Agency Recommendation Status
Centers for Medicare and Medicaid Services
Priority Rec.
This is a priority recommendation.
The Administrator of CMS should consider and take steps to mitigate the program risks that are not measured in the PERM, such as overpayments and unallowable costs; such an effort could include actions such as revising the PERM methodology or focusing additional audit resources on managed care. (Recommendation 1)
Open

CMS concurred with this recommendation. In October 2018, it reported that it was developing a plan to address the recommendation. CMS also reported that it has published several guidance documents and is in the process of finalizing others. In addition, it reported that it continues to develop educational strategies (such as a recent course managed care offered by CMS' Medicaid Integrity Institute) and oversight and audit strategies and mechanisms related to managed care. CMS communicated that it initiated 32 audits involving Medicaid managed care network providers in 6 states and an audit of

Medicaid Assisted Living Services: Improved Federal Oversight of Beneficiary Health and Welfare is Needed

Show
1 Open Recommendations
1 Priority
Agency Recommendation Status
Centers for Medicare and Medicaid Services
Priority Rec.
This is a priority recommendation.
The Administrator of CMS should establish standard Medicaid reporting requirements for all states to annually report key information on critical incidents, considering, at a minimum, the type of critical incidents involving Medicaid beneficiaries, and the type of residential facilities, including assisted living facilities, where critical incidents occurred. (Recommendation 2)
Open

HHS neither agreed nor disagreed with this recommendation. As of March 2021, CMS completed a three part national training course for state officials on incident management reporting. Through the training CMS shared the results of its survey of states' incident management systems that found wide variations in state systems, including the types of incidents that are identified as critical. CMS developed a proposed incident reporting template, but converted it to an optional incident reporting tool that CMS may share with states in providing technical assistance. To fully implement this

Hospital Uncompensated Care: Federal Action Needed to Better Align Payments with Costs

Show
1 Open Recommendations
1 Priority
Agency Recommendation Status
Centers for Medicare and Medicaid Services
Priority Rec.
This is a priority recommendation.
To ensure efficient use of federal resources, the Administrator of CMS should account for Medicaid payments a hospital has received that offset uncompensated care costs when determining hospital uncompensated care costs for the purposes of making Medicare UC payments to individual hospitals.
Open

No executive action taken as of March 2021. HHS initially concurred with our recommendation. However, in 2018 and again in March 2021, HHS indicated it was reconsidering whether to implement our recommendation because officials stated that it may not be appropriate to offset Medicare UC payments by Medicaid payments that help offset UC costs . We maintain that CMS should implement our recommendation, because it would (i) ensure that Medicare UC payments are based on accurate levels of UC costs, (ii) result in CMS better targeting billions of dollars in Medicare UC payments to hospitals with

Medicare Advantage: Fundamental Improvements Needed in CMS's Effort to Recover Substantial Amounts of Improper Payments

Show
1 Open Recommendations
1 Priority
Agency Recommendation Status
Centers for Medicare and Medicaid Services
Priority Rec.
This is a priority recommendation.
As CMS continues to implement and refine the contract-level RADV audit process to improve the efficiency and effectiveness of reducing and recovering improper payments. The Administrator should enhance the timeliness of CMS's contract-level RADV process by taking actions such as the following: (1) closely aligning the time frames in CMS's contract-level RADV audits with those of the national RADV audits the agency uses to estimate the MA improper payment rate; (2) reducing the time between notifying MA organizations of contract audit selection and notifying them about the beneficiaries and diagnoses that will be audited; (3) improving the reliability and performance of the agency's process for transferring medical records from MA organizations, including assessing the feasibility of updating Electronic Submission of Medical Documentation for use in transferring medical records in contract-level RADV audits; and (4) requiring that CMS contract-level RADV auditors complete their medical record reviews within a specific number of days comparable to other medical record review time frames in the Medicare program.
Open

CMS is working to enhance the timeliness of the agency's contract-level RADV process, as GAO recommended in April 2016. In October 2017, CMS officials told GAO that, as part of the agency's efforts to consolidate program integrity initiatives into one center, the decision was made to transition RADV contract-level audits to the CMS Center for Program Integrity at the end of 2016. As part of this transition, CMS officials told GAO that the agency is beginning to implement a formal project management structure to facilitate the timeliness of the audit process. As of May 2021, CMS had begun

Medicaid: Federal Guidance Needed to Address Concerns About Distribution of Supplemental Payments

Show
1 Open Recommendations
1 Priority
Agency Recommendation Status
Centers for Medicare and Medicaid Services
Priority Rec.
This is a priority recommendation.
To promote consistency in the distribution of supplemental payments among states and with CMS policy, the Administrator of CMS should issue written guidance clarifying its policy that payments should not be made contingent on the availability of local funding.
Open

In December 2020, Congress passed and the President signed into law legislation requiring additional state reporting on Medicaid supplemental payments that may address this recommendation. The new law includes a requirement for states to report the criteria used to determine which providers are eligible to receive the supplemental payments. Per CMS policy, the receipt of payments cannot be contingent on the availability of local funding. The effectiveness of the new requirement will depend on how CMS implements it. GAO plans to continue to monitor the implementation of the new reporting

Medicaid: CMS Oversight of Provider Payments Is Hampered by Limited Data and Unclear Policy

Show
1 Open Recommendations
1 Priority
Agency Recommendation Status
Centers for Medicare and Medicaid Services
Priority Rec.
This is a priority recommendation.
To improve CMS's oversight of Medicaid payments, the Administrator of CMS should develop a policy establishing criteria for when such payments at the provider level are economical and efficient.
Open

In December 2020, Congress passed and the President signed into law legislation requiring additional state reporting on Medicaid supplemental payments, including requiring states to describe how these payments are consistent with economy and efficiency. The effectiveness of these new reporting requirements will depend on how CMS implements them. GAO will monitor the implementation of these new reporting requirements to determine the extent to which it establishes criteria for when such Medicaid payments at the provider level are economical and efficient.

Medicare Advantage: CMS Should Fully Develop Plans for Encounter Data and Assess Data Quality before Use

Show
2 Open Recommendations
2 Priority
Agency Recommendation Status
Centers for Medicare and Medicaid Services
Priority Rec.
This is a priority recommendation.
To ensure that MA encounter data are of sufficient quality for their intended purposes, the Administrator of CMS should establish specific plans and time frames for using the data for all intended purposes in addition to risk adjusting payments to MAOs.
Open

HHS generally agreed with this recommendation. As of March 2021, CMS is using MA encounter data for purposes other than risk adjustment, such as quality measurement and program integrity, and continues to develop additional uses, but has not established specific plans and time frames for all uses. Quality measurement - CMS uses MA encounter data to obtain diagnoses for Part D Medicaid Adherence measures and reports using encounter data for other Part D measures. CMS has also used MA encounter data as part of evaluating the first 3 years of MA's Value-Based Insurance Design Model-health

Centers for Medicare and Medicaid Services
Priority Rec.
This is a priority recommendation.
To ensure that MA encounter data are of sufficient quality for their intended purposes, the Administrator of CMS should complete all the steps necessary to validate the data, including performing statistical analyses, reviewing medical records, and providing MAOs with summary reports on CMS's findings, before using the data to risk adjust payments or for other intended purposes.
Open

HHS generally agreed with this recommendation, however, HHS did not commit to completing data validation before using MA encounter data for risk adjustment. As of March 2021, CMS has made additional progress in examining the completeness and accuracy of Medicare Advantage encounter data, but more work remains to fully validate these data. CMS has developed and is implementing a Medicare Advantage Encounter Data Integrity and Monitoring plan, which describes the key activities of evaluating and improving encounter data, including outreach, data analysis, and monitoring completeness and accuracy

End-Stage Renal Disease: CMS Should Improve Design and Strengthen Monitoring of Low-Volume Adjustment

Show
1 Open Recommendations
1 Priority
Agency Recommendation Status
Centers for Medicare and Medicaid Services
Priority Rec.
This is a priority recommendation.
To reduce the incentive for facilities to restrict their service provision to avoid reaching the LVPA treatment threshold, the Administrator of CMS should consider revisions such as changing the LVPA to a tiered adjustment.
Open

CMS concurred with this recommendation and stated in March 2021 that the agency had extensive discussions with the Medicare Payment Advisory Commission regarding the Commission's suggestions for modifying the LVPA. CMS also stated in March 2021 that the agency was analyzing the design of the LVPA as part of its evaluation of the ESRD Prospective Payment System. To fully implement this recommendation, CMS needs to provide documentation of the steps such as those described above that the agency has taken to consider revisions to the LVPA. We will update the status of this recommendation upon

Medicare: Higher Use of Advanced Imaging Services by Providers Who Self-Refer Costing Medicare Millions

Show
2 Open Recommendations
2 Priority
Agency Recommendation Status
Centers for Medicare and Medicaid Services
Priority Rec.
This is a priority 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.
Open

HHS disagreed with our recommendation and, as of March 2021, had no plans to take further action. CMS believes that a new checkbox on the claim form identifying self-referral would be complex to administer and that providers may not characterize referrals accurately. We maintain 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.

Centers for Medicare and Medicaid Services
Priority Rec.
This is a priority 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.
Open

HHS disagreed with our recommendation and, as of March 2021, had no plans to take further action. 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. We maintain that CMS should determine and implement a payment reduction to recognize

Have a Question about a Recommendation?

For questions about a specific recommendation, contact the person or office listed with the recommendation. For general information about recommendations, contact GAO's Audit Policy and Quality Assurance office at (202) 512-6100 or apqa@gao.gov.