Other GAO Developments

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The Government Accountability Office (GAO) has identified shortcomings in CMS’s implementation of accreditation requirements for suppliers of advanced diagnostic imaging (ADI) services under the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). For instance, the GAO found significant differences among the accrediting organizations arising from the lack of minimum national standards, rendering it…

The Government Accountability Office (GAO) has provided a status report on seven states’ efforts to establish health insurance exchanges — online marketplaces mandated by the ACA to enable eligible individuals and small business employers to compare and select health insurance coverage offered by qualified health plans. States can establish and operate an exchange themselves or…

A recent GAO report found that CMS’s Medicare low-volume payment adjustment (LVPA) for dialysis facilities has not been effectively targeted at low-volume facilities with high costs. Specifically, based on a review of claims and cost reports, the GAO estimates that Medicare overpaid about $5.3 million in 2011 to dialysis facilities that were ineligible for the…

In response to a request from Rep. Henry Waxman, Ranking Member of the House Committee on Energy and Commerce, the GAO has issued a report examining Pharmacy Services Administrative Organizations (PSAOs), which are used primarily by independent pharmacies to interact with drug wholesalers, third-party payers, and other entities. The report includes data from 2011…

The GAO has examined how private-sector efforts to adjust physician payments to reflect quality and efficiency could be applied successfully to the Medicare program.  As previously reported, CMS developing a physician value-based payment modifier (Value Modifier), which was mandated by the ACA as a way to reward physicians for providing higher quality and more…

A recent GAO report, “Medicaid: More Transparency of and Accountability for Supplemental Payments Are Needed,” reviews federal oversight of supplemental Medicaid payments, including how information in required disproportionate share hospital (DSH) audits and reports facilitates CMS’s oversight of DSH payments. The report also discusses the lack of similar information for non-DSH payments (such…

The GAO has issued a report examining selected consumer protection requirements for dual eligible beneficiaries — low-income seniors and individuals with disabilities enrolled in both Medicare and Medicaid. The report summarizes such consumer protections for dual eligible beneficiaries (e.g., access to primary care providers, appeals processes) in the Medicare fee-for-service (FFS) and Medicare Advantage programs…

In light of a continued high rate of Medicare fee-for-service improper payments (8.6% in FY 2011), the GAO recently assessed the use of Medicare prepayment edits and CMS’s oversight of Medicare Administrative Contractors (MACs) that process claims.  In the report, "Medicare Program Integrity: Greater Prepayment Control Efforts Could Increase Savings and Better Ensure Proper Payment," the…

A recent GAO report, “Medicaid Integrity Program: CMS Should Take Steps to Eliminate Duplication and Improve Efficiency,” points to a number of shortcomings in CMS Medicaid program integrity efforts. Among other things, the GAO found that Medicaid Integrity Group’s (MIG) oversight and support activities had mixed results in achieving the goal of enhancing…

The Health Information Technology for Economic and Clinical Health (HITECH) Act provided funding to promote the adoption and meaningful use of certified EHR technology, including a Medicaid EHR program. In 2011, the first year of the Medicaid EHR program, 1,964 hospitals and 45,962 professionals were awarded a total of approximately $2.7 billion in Medicaid EHR…

The OIG’s December 2012 Compendium of Unimplemented Recommendations highlights unimplemented OIG recommendations that the OIG believes represent significant opportunities for action in FY 2013. The report includes recommendations made through FY 2011 that were not fully implemented as of December 2012. The OIG’s priority open recommendations, which in the OIG’s view represent the most significant opportunities to positively impact HHS’s programs, include the following:
Continue Reading OIG Releases 2012 Compendium of Unimplemented Recommendations

A recent Government Accountability Office (GAO) report reviews CMS efforts to implement the Fraud Prevention System (FPS), which uses predictive analytics technologies to identify fraudulent claims before they are paid. CMS and its program integrity contractors began using the FPS in July 2011 in compliance with the Small Business Jobs Act. According to the…

The GAO has issued a report analyzing trends related to high-expenditure Medicare Part B drugs, which are drug commonly administered by a physician or under a physician’s close supervision in physicians’ offices and hospital outpatient departments. The report provides data on: (1) the highest-expenditure Medicare Part B drugs in 2010 and utilization and spending…

A recent GAO report examines the growing prevalence of physician self-referral (referral to the physician’s own practice) for advanced imaging services (e.g., magnetic resonance imaging (MRI) and computed tomography (CT) services) and its effect on Medicare spending. The GAO reports that while the number of both self-referred and non-self-referred advanced imaging services increased from 2004…

The GAO has issued a report that responds to concerns raised by certain Democratic lawmakers that manufacturers participating in the Medicare Part D drug “Coverage Gap Discount Program” would raise prices for brand-name drugs used by beneficiaries in the coverage gap to offset the 50% discount that manufacturers must provide under the Affordable Care Act.

A new Government Accountability Office (GAO) report breaks down the provider types most frequently involved with Medicare, Medicaid, and Children’s Health Insurance Program fraud cases in 2010.  Highlights include the following: 

  • Medical facilities (including medical centers, clinics, or practices) and DME suppliers were the most-frequent subjects of criminal health care fraud investigations, comprising about 40%

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A recent GAO report warns of information security risks – such as unauthorized changes of device settings resulting from a lack of appropriate access controls — associated with the growing use of wireless technology in certain active implantable medical devices (e.g., implantable cardioverter defibrillators and insulin pumps). On the other hand, officials and technology experts…