Skip to main content

Centers for Medicare & Medicaid Services

Jump To:

Open Recommendations (116 total)

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

Show
1 Open Recommendations
Agency Affected Recommendation Status Sort descending
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.

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

Show
1 Open Recommendations
Agency Affected Recommendation Status Sort descending
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.

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

Show
1 Open Recommendations
Agency Affected Recommendation Status Sort descending
Centers for Medicare & Medicaid Services The Administrator of CMS should conduct regular evaluations of state performance by comparing states' performance measurement data with CMS's EPSDT targets to identify gaps in states' performance and areas for improvement. (Recommendation 3)
Open
As of February 2024, CMS reports the agency does not concur with this recommendation. CMS has previously noted this is in part because the agency provides states with information about their performance on ESPDT measures reported on the Child Core Set, including a state's performance relative to other states' performance. We noted the limitations of this approach in our report; descriptions of a state's performance relative to other states is subject to change over time. For example, because the median is the midpoint of all states' performance, it ensures that half of states will not meet it, regardless of their individual performance. A fixed target--or targeted improvement goal, such as the one developed as part of the Oral Health Initiative--would provide states with the opportunity to measure performance over prior years' results, which is a more meaningful measure that all states can strive to achieve.

Medicare Physician Payment Rates: Better Data and Greater Transparency Could Improve Accuracy

Show
1 Open Recommendations
Agency Affected Recommendation Status Sort descending
Centers for Medicare & Medicaid Services 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.
Open
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 February 2024, 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.

Medicaid Information Technology: Effective CMS Oversight and States' Sharing of Claims Processing and Information Retrieval Systems Can Reduce Costs

Show
1 Open Recommendations
Agency Affected Recommendation Status Sort descending
Centers for Medicare & Medicaid Services The Administrator of CMS should, in consultation with the HHS and CMS CIOs, develop a documented, comprehensive, and risk-based process for how CMS will select IT projects for technical assistance and provide recommendations to states to assist them in improving the performance of the systems, with consideration to those that are high-cost and performing poorly. (Recommendation 5)
Open
As of January 2024, CMS officials stated that the agency is pursuing the development of a risk-based approach to Medicaid Enterprise System oversight. According to CMS, this approach will be a process for Medicaid IT investments to help optimize the level of oversight CMS applies to state systems development projects. This process will be integrated into the system advanced planning document review as well. According to CMS officials, they plan to have the process finalized by July 2025. As of February 2024, CMS officials stated that the proposed draft regulation that will include this process remains on hold due to the pandemic. GAO will continue to monitor the implementation of this recommendation.

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

Show
1 Open Recommendations
Agency Affected Recommendation Status Sort descending
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
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Medicare Laboratory Tests: Implementation of New Rates May Lead to Billions in Excess Payments

Show
1 Open Recommendations
Agency Affected Recommendation Status Sort descending
Centers for Medicare & Medicaid Services The Administrator of CMS should take steps to collect all of the data from all laboratories that are required to report. If only partial data can be collected, CMS should estimate how incomplete data would affect Medicare payment rates and address any significant challenges to setting accurate Medicare rates. (Recommendation 1)
Open
As of December 2023, CMS explained the Further Continuing Appropriations and Other Extensions Act of 2024 extended the time frame for collecting data from laboratories (Pub. L. No. 118-22, 137 Stat. 112, 123 (Nov. 17, 2023)). When we confirm whether CMS has procedures in place to collect all of the data that laboratories are required to report or estimate and address the effects of incomplete data, we will provide updated information.

Medicaid: CMS Should Assess Effect of Increased Telehealth Use on Beneficiaries' Quality of Care

Show
1 Open Recommendations
Agency Affected Recommendation Status Sort descending
Centers for Medicare & Medicaid Services The Administrator of CMS should collect and analyze the information needed to assess the effect delivering services via telehealth has on the quality of care Medicaid beneficiaries receive. (Recommendation 1)
Open
As of April 2023, this recommendation remains unimplemented. In October 2022, CMS said information is not available to carry out an assessment and reiterated the agency does not have the authority to modify the specifications of Core Sets' measures for which it is not the measurement steward. As we noted in our report, this is not the only approach that CMS could take. In particular, CMS could develop a plan for reporting a measure for which it is the steward; for example, reporting on any effect that service delivery (for example, in-person or via telehealth) has on the quality of care Medicaid beneficiaries receive. Additionally, where CMS is not the measure steward, CMS could assess the feasibility of alternatives to current reporting of these measures. GAO maintains it is crucial for CMS to collect and analyze information to assess telehealth's effect on the quality of care Medicaid beneficiaries receive, through the Core Sets or through other means.

Medicare: Action Needed to Address Higher Use of Anatomic Pathology Services by Providers Who Self-Refer

Show
1 Open Recommendations
Agency Affected Recommendation Status Sort descending
Centers for Medicare & Medicaid Services In order to improve CMS's ability to identify self-referred anatomic pathology services and help CMS avoid unnecessary increases in these services, the Administrator of CMS should determine and implement an approach to ensure the appropriateness of biopsy procedures performed by self-referring providers.
Open
In June 2013, we recommended that the Administrator of the Centers for Medicare & Medicaid Services (CMS) implement an approach to ensure the appropriateness of biopsy procedures performed by self-referring providers. The Department of Health and Human Services (HHS) did not concur with this recommendation and does not believe it would address overutilization that occurs as a result of self-referral. In November 2017, CMS officials noted that the agency does not have the ability to identify self-referred anatomic pathology services during medical reviews. As of March 2023, CMS has not provided any additional information about actions it has taken to address the recommendation. We continue to believe that it is important for CMS to monitor the self-referral of anatomic pathology services on an ongoing basis and determine if those services are inappropriate or unnecessary.

Medicaid Managed Care: Improved Oversight Needed of Payment Rates for Long-Term Services and Supports

Show
1 Open Recommendations
Agency Affected Recommendation Status Sort descending
Centers for Medicare & Medicaid Services To improve oversight of states' payment structures for MLTSS, the Administrator of CMS should provide states with guidance that includes minimum standards for encounter data validation procedures.
Open
As of March 2023, CMS has not implemented this recommendation. CMS issued an updated state toolkit for validating Medicaid managed care encounter data in December 2019. This toolkit provides information on steps for states to take to validate and improve the Medicaid encounter data they receive from managed care plans. Among other things, the toolkit outlines specific techniques states could use to validate encounter data, including validating specific data fields related to ratesetting. The toolkit categorizes the techniques into four tiers-each of which involves an increasing level of complexity and sources of data-and encourages states to incorporate techniques from all four tiers. However, the toolkit remains voluntary, and therefore does not establish minimum standards. Further, CMS's efforts to enhance the quality of data submitted by states to T-MSIS have identified numerous issues with state encounter data. We will continue to monitor CMS's work in response to this recommendation, including the agency's assessment of the quality of encounter data reported to T-MSIS.