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Open Recommendations (118 total)

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

GAO-18-179
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should ensure that all states submit annual reports for HCBS waivers on time as required. (Recommendation 3)
Open
CMS concurred with this recommendation and stated that it will review and update its communications with states to reaffirm reporting requirements and ensure that all HCBS annual reports are submitted on time. As of January 2024, CMS reported that it has updated the online system that states use to complete and submit their annual HCBS waiver reports to incorporate automatic reminders to states about due dates for submitting their annual reports. CMS indicated that the agency had also completed outreach to states to remind them of annual reporting requirements resuming after the end of the public health emergency, and states had begun submitting outstanding reports. To the extent that automated reminders of due dates are being sent to states and CMS is receiving timely reports from states, GAO will consider closing this recommendation as implemented.

Abuse and Neglect: CMS Should Strengthen Reporting Requirements to Better Protect Individuals Receiving Hospice Care

GAO-23-105463
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The CMS administrator should require, for individuals in hospice care, immediate reporting of all abuse and neglect allegations involving all perpetrators—including those not affiliated with the hospice—to the hospice administrator, a state survey agency, and other appropriate authorities. (Recommendation 1)
Open
In February 2023, CMS issued an update to the State Operations Manual Appendix M, which provides guidance for state survey agencies for hospices. The updated Appendix M includes language about the need for hospice staff to be trained on the reporting requirements for abuse and neglect. In their July 2023 update on their efforts to address our recommendation, CMS officials also noted that an RN is part of a hospice survey review team and would be a mandatory reporter of any abuse or neglect witnessed in a survey. While this is helpful information for survey teams, these edits do not address the substance of our recommendation, which is focused on the need to require all hospice staff to immediately report allegations of abuse or neglect, including actions by individuals not affiliated with the hospice, to appropriate authorities. Therefore this recommendation remains open and we will continue to follow up with CMS regarding future updates.

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

GAO-16-76
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services 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 ensure that CMS develops specific plans and a timetable for incorporating a RAC in the MA program as mandated by the Patient Protection and Affordable Care Act.
Open
CMS has attempted to incorporate recovery audit contractor functions into its RADV program, although it has not developed specific plans and a timetable for incorporating a recovery audit contractor in the Medicare Advantage program as GAO recommended in April 2016. In January 2023, CMS reported in its budget justification that it believes the proposed scope of the contract-level risk adjustment data validation audits satisfies GAO's recommendation. CMS officials noted that RADV audits are the primary corrective action that CMS has to address payments in Part C as these audits verify that diagnoses submitted by Medicare Advantage organizations for risk adjusted payment are supported by medical record documentation. In February 2024, CMS reported that while different in program name, the RADV program conducts the same audits as a RAC, and therefore, it would be duplicative in efforts and results. Until CMS completes efforts to improve the risk adjustment data validation contract-level audit process and demonstrates that the changes made to the RADV program satisfy the requirement to incorporate a recovery audit contractor in the Medicare Advantage program, CMS may fail to recover improper payments of hundreds of millions of dollars annually.

Medicare Advantage: Actions Needed to Enhance CMS Oversight of Provider Network Adequacy

GAO-15-710
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services To improve its oversight of network adequacy in MA, the Administrator of CMS should augment MA network adequacy criteria to address provider availability.
Open
HHS concurred with this recommendation. As of August 2023, CMS has not included provider availability as part of its MA network adequacy criteria. While CMS has not updated these criteria, the agency described the various efforts it has taken related to provider availability, including examining MAO provider directories that document whether a provider is accepting new patients. Specifically, CMS stated in November 2020 that it has reviewed the accuracy of its own tools and MAO provider directories. In those reviews, CMS reported finding a number of variables affecting whether a provider is accepting new patients, noting that it is difficult for an MAO to capture this information in real time. As a result, CMS updated its provider directory policy to allow MAOs to include a notice instructing beneficiaries to contact a provider to determine the provider's status. CMS also stated that it encourages MAOs to use a national system to create and update provider directories but that the system does not include a data field related to whether a provider is accepting new patients. CMS also stated that it monitors complaints to identify access to care issues related to provider availability and that MAOs are provided an incentive by the CMS Star Ratings system to perform well on beneficiary surveys that, in part, ask about getting appointments and care quickly. As CMS has not included provider availability in its MA network adequacy criteria, the agency has not implemented this recommendation as of August 2023.

Cybersecurity: Selected Federal Agencies Need to Coordinate on Requirements and Assessments of States

GAO-20-123
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1 Open Recommendations
1 Priority
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services
Priority Rec.
The Administrator of CMS should revise its assessment policies to maximize coordination with other federal agencies to the greatest extent practicable. (Recommendation 4)
Open
CMS agreed with this recommendation. As of February 2024, CMS stated that it would accept results of a recent, independent, third-party assessment conducted for another federal agency. CMS also stated that it would work to revise its assessment policies to maximize coordination with other federal agencies to the greatest extent possible but has not yet provided documentation. In addition, CMS stated that the Office of Management and Budget would need to be involved in developing a standardized process for sharing independent security assessments performed by the states with other federal agencies. To fully implement this recommendation, CMS needs to determine what changes it can make to its assessment policies and implement those changes. Maximizing coordination with other federal agencies would help provide reasonable assurance that CMS is leveraging compatible assessments with other agencies and may help reduce federal resources associated with their implementation. We will continue to monitor the agency's progress in implementing this recommendation.

Medicaid Managed Care: Rapid Spending Growth in State Directed Payments Needs Enhanced Oversight and Transparency

GAO-24-106202
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should make publicly available all approval documents related to new and renewed state directed payments, including application attachments, state evaluation plans, and evaluation results. (Recommendation 4)
Open
As of April, GAO continues to monitor CMS progress toward implementing this recommendation.

Medicaid: CMS Action Needed to Ensure Compliance with Abortion Coverage Requirements

GAO-19-159
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services CMS should determine the extent to which state Medicaid programs are in compliance with federal requirements regarding coverage of Mifeprex and take actions to ensure compliance, as appropriate. (Recommendation 2)
Open
In June 2019, HHS officials reported they were reviewing agency processes and would determine the best course of action moving forward. Officials said they would provide an update on actions by 12/20/2019. In May 2022, CMS officials reported that this topic is of significant importance and they were continuing to actively determine strategies to ensure the availability of covered services in the Medicaid program, but provided no further details. Additionally, HHS leadership reported that they decided not to take action at this time.. As of August 2023, CMS had not provided additional information on steps it had taken to address this recommendation. As such, this recommendation remains open.

Medicare Imaging Accreditation: Establishing Minimum National Standards and an Oversight Framework Would Help Ensure Quality and Safety of Advanced Diagnostic Imaging Services

GAO-13-246
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services 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.
Open
CMS concurred with this recommendation. However, as of September 2022, CMS has not established health and safety standards for the accreditation of ADI suppliers. Until CMS establishes minimum national standards for the accreditation of ADI supplies, it cannot ensure that ADI suppliers provide consistent, safe, and high-quality imaging to Medicare beneficiaries.

Medicaid Home- and Community-Based Services: Evaluating COVID-19 Response Could Help CMS Prepare for Future Emergencies

GAO-21-104401
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The CMS Administrator should evaluate the temporary changes to Medicaid HCBS programs after the COVID-19 emergency and develop corrective action plans to address any opportunities for improvement it identifies. (Recommendation 2)
Open
As of April 2024, HHS reported that CMS is evaluating temporary changes to Medicaid HCBS programs after the COVID-19 public health emergency. The agency also noted CMS's efforts to revise templates and instructions for requesting temporary changes. When we confirm CMS has conducted this evaluation, we will provide updated information.

Hospital Value-Based Purchasing: CMS Should Take Steps to Ensure Lower Quality Hospitals Do Not Qualify for Bonuses

GAO-17-551
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services To ensure that the HVBP program accomplishes its goal to balance quality and efficiency and to ensure that it minimizes the payment of bonuses to hospitals with lower quality scores, the Administrator of CMS should revise the practice of proportional redistribution used to correct for missing domain scores so that it no longer facilitates the awarding of bonuses to hospitals with lower quality scores.
Open
HHS indicated that it would explore alternatives to the practice of proportional redistribution, and any changes to the distribution of weights for missing domains would be evaluated for potential negative impacts and would be subject to notice and comment rulemaking. In September 2018, HHS indicated that it was exploring alternatives and considering revising the practice of proportional redistribution used to correct for missing domain scores while also being mindful of any potential unintended consequences. In the Fiscal Year 2019 Inpatient Prospective Payment System proposed rule, CMS proposed to remove the safety domain and, in connection, to require scores for the remaining three domains in order to calculate the total performance score, but CMS did not finalize the weighting revision. CMS reported that stakeholders were concerned about the safety domain removal and any adverse impact to rural and smaller hospitals due to increasing outcome measure relative weights. CMS reported that it analyzed data and found that rural and small hospitals' payment would be adversely impacted from changing proportional redistribution to assign greater relative weight to outcomes. As a result, CMS decided to keep proportional redistribution. However, CMS's actions did not revise the practice of proportional redistribution, and, as a result, the practice may continue to facilitate the awarding of bonuses to hospitals with lower quality scores. In December 2020, CMS indicated that it is exploring additional options that may require significant changes to the program's scoring methodology. The agency is researching how it could make changes via rulemaking and is conducting analyses to ensure that these options do not have unintended consequences for small and rural facilities. As of July 2023, the recommendation remains open.
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