The Government Accountability Office (GAO) is out with the latest installment of its “High-Risk Series,” which identifies federal programs “that are especially vulnerable to waste, fraud, abuse, and mismanagement, or that need transformative change.” Once again, GAO flags Medicare and Medicaid as high-risk programs.

With regard to Medicare, GAO notes that while Congress, HHS, and CMS have taken steps to improve the fiscal integrity of Medicare over the years, “continued federal improvements to the oversight of Medicare are warranted given the size and complexity of the program as well as the number and scope of ongoing changes to the program.” Specific Medicare program integrity recommendations for Congress include:

  • Directing the HHS Secretary to require providers who self-refer intensity-modulated radiation therapy services to disclose to their patients that they have a financial interest in the service.
  • Paying for cancer hospitals exempt from the inpatient prospective payment system (PPS) on the same basis as teaching hospitals or otherwise modifying how Medicare pays these providers.
  • Directing the HHS Secretary to equalize payment rates for evaluation and management visits between physician office and hospital outpatient settings.
  • Requiring all Part B drug manufacturers paid at average sales price (ASP) to submit data to CMS and authorizing CMS to collect data from drug manufacturers on coupon discounts for Part B drugs paid based on ASP.
  • Increasing cost-sharing for services that are not recommended by the US Preventive Task Force..

GAO also offers Medicare program management recommendations to CMS and HHS, including:

  • Establishing a self-referral flag for advanced imaging services claims and reducing payments for self-referred advanced imaging services.
  • Improving Medicare Advantage (MA) data review and adjustments for differences in diagnostic coding practices between MA and Medicare fee-for-services.
  • Reforming dialysis facility low-volume payment adjustment policies.

In terms of Medicaid, the GAO identified as an “overarching challenge” CMS’s lack of accurate and timely data to oversee diverse and complex state Medicaid programs. To that end, GAO recommends that HHS take steps to improve reporting and oversight of supplemental payments, Section 1115 Medicaid demonstrations, and personal care services programs. GAO also recommends that CMS establishing criteria for determining when provider payments are “economical and efficient,” along with a process for identifying and reviewing payments to individual providers to determine if they meet that standard. Finally, to ensure “federal funding efficiently and effectively responds to the countercyclical nature of the Medicaid program,” Congress should consider federal matching formula changes to target variable state Medicaid needs and provide temporary increased federal assistance in response to national economic downturns.