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Open Recommendations (114 total)

Health Care Quality: CMS Could More Effectively Ensure Its Quality Measurement Activities Promote Its Objectives

GAO-19-628
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should develop and implement procedures to systematically assess the measures it is considering developing, using, or removing in terms of their impact on achieving CMS's strategic objectives and document its compliance with those procedures. (Recommendation 2)
Open – Partially Addressed
As of August 2023, CMS completed initial development of its Quality Measure Index (QMI), which is designed to systematically assess the relative value of quality measures based on key measure characteristics, including the extent to which they address strategic objectives outlined in CMS's National Quality Strategy. This enabled CMS to begin using the QMI in its annual process of selecting new quality measures for its various quality programs. However, as of August 2023, CMS was still in the process of adapting the QMI for use in making decisions regarding which measures it should prioritize that are under development. In addition, based on the information CMS provided, the agency had not yet used the QMI (or any equivalent tool) to inform decisions regarding which measures to remove from its various quality programs.

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

GAO-20-123
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should, in collaboration with OMB, solicit input from FBI, IRS, SSA, and state agency stakeholders on revisions to its security policy to ensure that cybersecurity requirements for state agencies are consistent with other federal agencies and NIST guidance to the greatest extent possible and document CMS's rationale for maintaining any requirements variances.(Recommendation 3)
Open – Partially Addressed
CMS agreed with and has taken steps to partially address this recommendation. As of February 2024, CMS has participated in the FBI's Criminal Justice Information Services Division Modernization Task Force, which includes representatives from the FBI and Internal Revenue Services, to discuss the impact of inconsistent cybersecurity standards. CMS stated that it received a presentation from FBI on its efforts to align with the National Institute of Standards and Technology's (NIST) Special Publication 800-53, Revision 5. Further, CMS is currently developing a new version of its state cybersecurity requirements policy to align with the same NIST publication. It also plans to solicit feedback and concurrence from state agency and federal stakeholders. To fully address this action, CMS needs to complete its efforts to coordinate with the other federal agencies and decide what revisions to make to its cybersecurity requirements for state agencies. We will continue to monitor the agency's progress in implementing this recommendation.

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 formula for the calculation of hospitals' total performance score or take other actions so that the efficiency score does not have a disproportionate effect on the total performance score.
Open – Partially Addressed
HHS indicated that it would examine the formula used for calculating hospitals' total performance scores and consider revisions, which would be subject to notice and comment rulemaking. In September 2018, HHS indicated that it had been examining alternatives and considering revising the formula for the calculation of hospitals' total performance scores (TPS) consistent with relevant statutory guidance, and in a way to reduce the effect of the efficiency domain on the TPS. In the Fiscal Year 2019 Inpatient Prospective Payment System proposed rule, CMS proposed to remove the safety domain weighted at 25 percent of the TPS and, in connection, increase the weight of the clinical care domain from 25 percent to 50 percent, which was estimated to reduce the effect of the efficiency domain on the TPS. According to CMS, stakeholders were concerned about the safety domain removal and adverse impacts to rural and smaller hospitals due to increasing outcome measure relative weights. CMS indicated that it analyzed current data in the fall of 2018 and found a similar trend, where rural and small hospitals' payment would be adversely impacted from increasing outcome measure weights. CMS decided to keep measure weights to avoid adversely impacting rural and small hospitals. However, CMS did not take actions so that the efficiency score would not have a disproportionate effect on the total performance score and bonus payments 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. In January 2023, CMS indicated that the agency had revised the Medicare spending per beneficiary measure-part of the HVBP efficiency domain-with the intent of using it for the HVBP program once it meets its statutory requirement of being publicly reported for a year in the Hospital Inpatient Quality Reporting (IQR) Program. CMS provided documentation of the analyses conducted. Our review of the documentation supports that the measure was revised, tested, and adopted. We will close the recommendation once the revisions are incorporated into the HVBP program. As of July 2023, no additional action has been taken.

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

GAO-19-481
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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 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 – Partially Addressed
In February 2024, CMS stated that it continues to remind states of Medicaid's universal blood lead screening and has encouraged state Medicaid agencies and health departments to establish data sharing agreements with other state agencies, in order to have more complete data. In addition, CMS added a lead screening measure to the Child Core Set, which is a set of quality measures reported by states that is used, among other things, to monitor performance at the state level. States began reporting this measure in late 2023 and CMS expects these data to be available in late 2024. CMS also said it expects to release updated guidance on blood lead screening by the end of 2024. CMS has previously said the updated guidance will emphasize the importance of complete and accurate data. These are positive steps that can assist CMS as it continues 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 (and therefore which are not included in the current data). We will continue to monitor CMS's issuing of the guidance and update its status accordingly. To implement this recommendation, CMS should fully address limitations in blood lead screening data to better monitor compliance with the agency's blood lead screening policy.

Medicaid: CMS Should Take Additional Steps to Improve Assessments of Individuals' Needs for Home- and Community-Based Services

GAO-18-103
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should ensure that all types of Medicaid HCBS programs have requirements for states to avoid or mitigate potential conflicts of interest on the part of entities that conduct needs assessments that are used to determine eligibility for HCBS and to develop HCBS plans of service. These requirements should address both service providers and managed care plans conducting such assessments. (Recommendation 1)
Open – Partially Addressed
HHS initially concurred with our recommendation. However, in an April 2018 update, HHS noted that the recommendation should be closed based on existing Medicaid regulations, and in subsequent updates, reported that it does not plan to implement additional conflict of interest requirements applicable to entities conducting needs assessments. GAO continues to maintain that additional steps to avoid or mitigate potential conflict of interest in HBCS needs assessments are warranted, as the existing regulations--which GAO reviewed at the time of this study--do not address all types of Medicaid HCBS programs. For example, specific conflict of interest requirements are generally not in place for needs assessments that are used to inform HCBS eligibility determinations. Similarly, managed care plans may have a financial interest in the outcome of HCBS assessments used for both determining eligibility and service amounts. GAO notes, however, that the agency has taken action to improve oversight of managed care plans that partially addresses this recommendation. In particular, CMS issued guidance to states in June 2021 that triggered the requirement for states to submit annual reports on their Medicaid managed care programs, including on the beneficiary support system for managed care HCBS programs referenced in the report. GAO noted in the report that taking this action would help to address concerns regarding managed care plans' potential for conflicts of interest in conducting needs assessments for service planning purposes. CMS could take additional steps to address remaining gaps such as working with states to address potential conflict of interest in needs assessments used to inform HCBS eligibility determinations or for state plan personal care services that are not covered by conflict of interest requirements that apply to service planning for other types of HCBS programs. As of September 2023, CMS reported that the agency continues to enforce existing conflict of interest provisions and that no further actions are planned.

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

GAO-15-434
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services 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.
Open – Partially Addressed
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 provided a copy of the final rulemaking for the 2017 Physician Fee Schedule, which described 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. We acknowledge that CMS has made progress towards meeting our recommendation 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 February 2024, we had not received this documentation.

Medicaid: CMS Needs Better Data to Monitor the Provision of and Spending on Personal Care Services

GAO-17-169
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services To improve the collection of complete and consistent personal care services data and better ensure CMS can effectively monitor the states' provision of and spending on Medicaid personal care services, CMS should better ensure that personal care services data collected from states through T-MSIS and MBES comply with CMS reporting requirements.
Open – Partially Addressed
The Centers for Medicare & Medicaid Services (CMS) concurs with GAO's recommendation. In December 2017, CMS cited ongoing efforts related to claims data submitted by states through T-MSIS, CMS's new claims reporting system. Efforts included validation checks of personal care service claims to ensure that key data are not missing or incorrect. In addition, CMS issued technical guidance in February 2018 directing states to fill out claims for personal care services accurately and completely, including the type, amount, and dates of services. In contrast, as of February 2024, CMS has not reported implementing systems to identify inaccurate state reporting of personal care expenditures through CMS's expenditure reporting system, Medicaid Budget and Expenditure System (MBES). Complete implementation of the recommended action will better ensure state reporting of claims and expenditures is accurate and will allow CMS to effectively perform key management functions.

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

GAO-13-287
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1 Open Recommendations
1 Priority
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services
Priority Rec.
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 – Partially Addressed
CMS concurred with this recommendation and has taken some steps to implement it. For example, CMS obtained input on the LVPA from sources such as Technical Expert Panels that the agency convened as well as responses to a Request for Information as part of the CY 2022 rulemaking process. CMS stated that the agency planned to use this input to inform potential proposals for refining the LVPA through the rulemaking process. CMS also stated that, as of February 2024, the agency's plan was to issue a proposed and final rule in CY 2024 to revise the LVPA. Once CMS has issued the final rule to revise the LVPA, we will review it to determine whether it fully implements this recommendation.

Medicaid: CMS Oversight and Guidance Could Improve Recovery Audit Contractor Program

GAO-23-106025
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS, in collaboration with the states, should describe the effectiveness of the RAC program and include recommendations, if any, for expanding or improving the program in their annual report to Congress. (Recommendation 3)
Open – Partially Addressed
In its comments on our draft report, HHS stated that it partially concurred with this recommendation. Specifically, CMS stated that it concurs with the recommendation to make information available to expand or improve the Recovery Audit Contractor (RAC) program. CMS stated it plans to add certain information to the annual Medicare and Medicaid Program Integrity Report to Congress. This added information includes a breakdown of the states with full or partial exemptions, and promising state practices in RAC administration that other states may use when determining if and how to administer a RAC program. CMS further stated its current identification of RAC overpayment recoveries in the report already satisfies the statutory requirement to report on the effectiveness of states' Medicaid RAC programs. We agree that the reporting of RAC overpayment recoveries is important for determining the effectiveness of the Medicaid RAC program. However, Congress and other external stakeholders do not have other important information that would help them monitor how well the Medicaid RAC program is identifying and reducing improper payments. One such metric is a breakout of overpayments collected, underpayments restored, and amounts overturned on appeal. CMS's planned actions would help meet the intent of our recommendation, if effectively implemented. In November 2023, CMS issued its fiscal year 2022 report to Congress that included information on the number of states with CMS approved exceptions to Medicaid RAC implementation as well as information on the recovery of overpayments. Additionally, in January 2024, HHS stated that beginning with the fiscal year 2023 report to Congress, CMS is planning to include a breakdown of the states with full or partial exemptions, and promising state practices, if any. HHS stated that CMS is tentatively targeting to release the fiscal year 2023 report to Congress in fall of 2024. We will continue to monitor CMS's actions to address this recommendation.

Medicaid and CHIP: Reports for Monitoring Children's Health Care Services Need Improvement

GAO-11-293R
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services In light of the need for accurate and complete information on children's access to health services under Medicaid and CHIP, the requirement that states report information to CMS on certain aspects of their Medicaid and CHIP programs, and problems with accuracy and completeness in this state reporting, the Administrator of CMS should work with states to identify additional improvements that could be made to the CMS 416 and CHIP annual reports, including options for reporting on the receipt of services separately for children in managed care and fee-for-service delivery models, while minimizing reporting burden, and for capturing information on the CMS 416 relating to children's receipt of treatment services for which they are referred.
Open – Partially Addressed
In August 2019, CMS stated that the agency's long-term plan is to use the Transformed Medicaid Statistical Information System (T-MSIS) to analyze information on children's receipt of Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services. Starting with the submission of FY 2020 data, the CMS-416 was updated to provide an option for states that meet T-MSIS data quality and completeness criteria to have CMS complete the form on their behalf using T-MSIS data. As of December 2023, CMS officials said that they were still exploring the feasibility of using T-MSIS data to generate measures from the Core Set of Children's Health Care Quality Measures for Medicaid and CHIP, some of which are included in the CHIP annual report. GAO considers this recommendation open and will continue to monitor CMS's progress towards its long-term goal of using T-MSIS to monitor children's receipt of EPSDT services in Medicaid and CHIP.
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