Archives: Other GAO Developments

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GAO Calls For Mandatory Medicare Drug ASP Reporting, CMS Verification of Drug Pricing

A recent Government Accountability Office (GAO) report, “Medicare Part B: CMS Should Take Additional Steps to Verify Accuracy of Data Used to Set Payment Rates for Drugs,” questions the reliability of pricing for Medicare Part B drugs reimbursed based on average sales price (ASP). The GAO observes that while CMS performs various electronic checks of … Continue Reading

GAO Faults CMS’s Basis for Payments to Hospitals for Uncompensated Care Costs

The Government Accountability Office (GAO) recently examined the extent to which federal government payments to hospitals for uncompensated care aligned with hospital costs. This federal support, which totaled nearly $50 billion annually in FYs 2013 and 2014, mainly came in the form of Medicare and Medicaid payments to hospitals (about $14 million in Medicare payments … Continue Reading

GAO Highlights Significant Backlog in Medicare Appeals, Routine ALJ Failure to Meet Statutory Deadlines

The Medicare appeals process has not been able to keep up with an explosion in the number of volume, particularly at the administrative law judge (ALJ) level (Level 3), resulting in significant backlogs and widespread failure to meet statutory deadlines, according to a recent Government Accountability Office (GAO) report. Specifically, the GAO determined that Medicare … Continue Reading

GAO Report Shows Medicare Bearing Largest Burden from Sequestration Cuts

Medicare cuts comprised 58% of all sequestration savings in fiscal year (FY) 2014 — $11.3 billion out of $19.4 billion in total sequestration funds — according to a new GAO report. Under current sequestration law, across-the-board cuts to Medicare provider and plan payments are capped at 2%, while other types of federal spending are subject … Continue Reading

GAO Examines Hospital Challenges in Implementing Patient Safety Practices

The Government Accountability Office (GAO) has issued a report focusing on the roadblocks hospitals face in implementing evidence-based patient safety practices, such as the use of antiseptics to reduce Central Line-Associated Bloodstream Infection or administration of anti-clotting medications to higher-risk patients to prevent venous thromboembolism. Based on a review of selected hospitals, the OIG found … Continue Reading

GAO Reviews Safeguards on State Supplemental Medicaid Payments to Hospitals

According to the GAO, 505 hospitals received Medicaid payment surpluses (payments that exceeded the costs of providing services) totaling about $2.7 billion in 2012, resulting in part from lump-sum supplemental payments hospitals above regular payments for individual services. The GAO has conducted a review of states’ basis for distributing these payments and how hospitals use … Continue Reading

GAO Calls for Improvements to HHS Oversight of Health Care Workforce Programs

The GAO has reviewed HHS management of the 72 health care workforce programs administered by HHS and its agencies. The GAO concludes that HHS “lacks comprehensive planning and oversight to ensure that its many workforce efforts address identified national needs.” The GAO recommends that HHS establish a comprehensive and coordinated workplace development program planning approach … Continue Reading

GAO Recommends Equalizing Payment for Evaluation & Management Visits

The Government Accountability Office (GAO) has issued a report examining trends in “vertical consolidation” — hospital acquisition of physician practices or hiring of physicians as salaried employees – and the impact on Medicare spending. According to the GAO, the number of vertically consolidated hospitals increased from about 1,400 to 1,700 from 2007 through 2013, while … Continue Reading

GAO Recommends Improved CMS Nursing Home Quality Oversight

The Government Accountability Office (GAO) recently issued a report, “Nursing Home Quality: CMS Should Continue to Improve Data and Oversight,” examining changes in reported nursing home quality and related CMS oversight activities. According to the GAO, three nursing home data sets—standard survey deficiencies, reported staffing levels, and clinical quality measures—indicate potential improvement in nursing home … Continue Reading

GAO Examines Trends in Medicare Part B Expenditures for New Drugs and Biologicals

The Government Accountability Office (GAO) has issued a report describing trends in Medicare Part B spending and utilization for “new” drugs and biologicals (approved by the FDA from 2006 through 2013). The GAO’s analysis is based on 250 such drugs identified by the FDA, 83 of which had either an associated Medicare billing code or … Continue Reading

GAO Finds Limited Hospital Impact from Hospital Value-Based Purchasing Program

According to a recent Government Accountability Office (GAO) report, bonuses and penalties triggered by the Medicare Hospital Value-based Purchasing (HVBP) program have had no apparent impact on quality measure performance trends to date. The HVBP program, which was established by the Affordable Care Act, adjusts inpatient hospital payments based on individual hospital performance on designated … Continue Reading

GAO Assesses Considerations for Expansion of the Medicare Appropriate Use Criteria Program

On September 30, 2015, the Government Accountability Office (GAO) released a report entitled “Medicare: Considerations for Expansion of the Appropriate Use Criteria Program.”  In addition to describing CMS’s plans for implementing the imaging Appropriate Use Criteria (AUC) program, the GAO provides examples of non-imaging services deemed “questionable- or low-value” by researchers and for which provider-led … Continue Reading

GAO Calls for Expanded State Reporting on Medicaid Prescription Drug Fraud Controls

In light of continuing indicators of potential prescription-medication fraud and abuse in state Medicaid programs, the Government Accountability Office (GAO) has reviewed federal and state pharmacy-related policies and processes to prevent and detect such abuses. The GAO identified two potential controls that are not included in CMS’s current reporting requirements: (1) lock-in programs for noncontrolled … Continue Reading

GAO Examines Medicare Provider Eligibility Verification Safeguards

The Government Accountability Office (GAO) has issued a report examining the extent to which CMS’s enrollment screening procedures are designed and implemented to prevent enrollment of ineligible or potentially fraudulent Medicare providers. The GAO identified weaknesses in CMS’s verification of provider practice location and physician licensure status that have allowed potentially ineligible providers and suppliers to … Continue Reading

GAO Report Examines Hospital Financial Incentives to Prescribe 340B Drugs to Medicare Beneficiaries

The Government Accountability Office (GAO) has issued a report examining financial and other characteristics of hospitals that participate in the 340B Drug Pricing Program, focusing on disproportionate share hospitals (DSH) that account for the majority of 340B Program discount drug purchases.  Based on a review of Health Resources and Services Administration (HRSA) data for 2008 … Continue Reading

GAO Calls for Tighter Medicaid Fraud Controls

A recent GAO review of Medicaid claims in four selected states (Arizona, Florida, Michigan, and New Jersey) discovered that thousands of Medicaid beneficiaries and hundreds of providers were involved in potentially improper or fraudulent payments during FY 2011. Such potentially improper payments involved, among other things, beneficiaries concurrently receiving benefits paid by two or more … Continue Reading

GAO Criticizes Medicare Physician Payment Ratesetting Process

The Government Accountability Office (GAO) has issued a report pointing out potential shortcomings in the data and process used by CMS to establish the relative values (and consequently the reimbursement levels) for Medicare physician services. In particular, the GAO expresses concern that the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) process for … Continue Reading

GAO Report on Oversight of Medicaid Payments to Hospitals

The Government Accountability Office (GAO) has released a report entitled “Medicaid: CMS Oversight of Provider Payments Is Hampered by Limited Data and Unclear Policy.”  The report examines how state Medicaid payments to government hospitals compare to those made to private hospitals in selected states (Illinois, New York, and California) and CMS oversight of such payments. … Continue Reading

GAO Calls for Tighter Reins on Section 1115 Demonstrations

A recent GAO report examined expenditure authorities in “section 1115” demonstrations approved by HHS between June 2012 and October 2013. Section 1115 of the Social Security Act gives HHS broad authority to approve “expenditure authorities” that allow states to receive federal funds for costs that would not otherwise be matchable under Medicaid if the Secretary … Continue Reading

GAO Calls for Changes to Medicare Payments to PPS-Exempt Cancer Hospitals

A recent Government Accountability Office (GAO) report, “Medicare: Payment Methods for Certain Cancer Hospitals Should Be Revised to Promote Efficiency,” examines the Medicare reimbursement methodology for cancer hospitals exempt from the acute inpatient prospective payment systems (PPS). The GAO determined that Medicare payments were substantially higher at PPS-exempt cancer hospitals (PCHs) in 2012 than at … Continue Reading

GAO Calls for Expanded HHS Efforts to Reduce Antipsychotic Drug Use in Community Settings

The Government Accountability Office (GAO) has issued a report examining the extent to which antipsychotic drugs are prescribed for older adults with dementia in nursing homes and other settings. The GAO found that, according to Medicare Part D data, about one-third of older adults with dementia who spent more than 100 days in a nursing … Continue Reading

GAO Seeks Stronger CMS Measurement of State Medicaid Program Integrity System Effectiveness

Based on a review of 10 state Medicaid Management Information Systems (MMIS) used to process claims and support program integrity efforts, the GAO has concluded that the effectiveness of these systems is not known because CMS does not require states to measure results related to detecting and preventing improper payments. The GAO therefore recommends that … Continue Reading

GAO Evaluates CMS Activities to Prepare Health Industry for ICD-10 Launch

According to a recent GAO report, CMS has taken numerous steps to prepare industry for the October 1, 2015 transition to ICD-10 codes, such as developing checklists, timelines, and other educational materials and hosting training sessions for Medicare providers. CMS also has monitored covered entity and vendor readiness through stakeholder collaboration meetings, focus group testing, … Continue Reading
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