oversight

Medicaid: Federal Oversight of Payments and Program Integrity Needs Improvement

Published by the Government Accountability Office on 2012-04-25.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                            United States Government Accountability Office

GAO                         Testimony
                            Before the Subcommittees on Health Care, District of Columbia,
                            Census and the National Archives and Regulatory Affairs,
                            Stimulus Oversight and Government Spending, Committee on
                            Oversight and Government Reform, House of Representatives

                            MEDICAID
For Release on Delivery
Expected at 9:30 a.m. EDT
Wednesday, April 25, 2012



                            Federal Oversight of
                            Payments and Program
                            Integrity Needs
                            Improvement
                            Statement of Carolyn L. Yocom
                            Director, Health Care




GAO-12-674T
                                                  April 25, 2012

                                                  MEDICAID
                                                  Federal Oversight of Payments and Program
                                                  Integrity Needs Improvement
Highlights of GAO-12-674T, a testimony before
the Subcommittees on Health Care, District of
Columbia, Census and the National Archives and
Regulatory Affairs, Stimulus Oversight and
Government Spending, Committee on Oversight and
Government Reform, House of Representatives

Why GAO Did This Study                            What GAO Found
Medicaid, a joint federal-state health            Oversight of managed care rate-setting has been inconsistent. In August
care program, financed care for                   2010, GAO reported that the Centers for Medicare & Medicaid Services (CMS)
about 67 million people at a cost of              had not ensured that all states were complying with the managed care actuarial
$401 billion in fiscal year 2010. At the          soundness requirements that rates be developed in accordance with actuarial
federal level, CMS, an agency within              principles, appropriate for the population and services, and certified by actuaries.
the Department of Health and Human                For example, GAO found significant gaps in CMS’s oversight of 2 of the 26 states
Services, is responsible for overseeing           reviewed—CMS had not reviewed one state’s rates in multiple years and had not
the design and operations of states’              completed a full review of another state’s rates since the actuarial soundness
Medicaid programs, while the states
                                                  requirements became effective. Variation in practices across CMS regional
administer their respective programs’
                                                  offices contributed to these gaps and other inconsistencies in the agency’s
day-to-day operations. The shared
financing arrangement between the
                                                  oversight of states’ rate setting. GAO’s previous work also found that CMS’s
federal government and the states                 efforts to ensure the quality of the data used to set rates were generally limited to
presents challenges for program                   requiring assurances from states and health plans—efforts that did not provide
oversight and Medicaid has been on                the agency with enough information to ensure the quality of the data used. With
GAO’s list of high-risk programs since            limited information on data quality, CMS cannot ensure that states’ managed
2003, in part, because of concerns                care rates are appropriate, which places billions of federal and state dollars at
about the fiscal management of the                risk for misspending. GAO made recommendations to improve CMS’s oversight.
program. Our prior work has shown
that CMS continues to face challenges             Oversight of supplemental payments needs improvement. GAO has reported
overseeing the Medicaid program.                  on varied financing arrangements involving supplemental payments—
                                                  disproportionate share hospital (DSH) payments states are required to make to
GAO was asked to testify on CMS’s                 certain hospitals, and other non-DSH supplemental payments—that increase
oversight of Medicaid. GAO’s                      federal funding without a commensurate increase in state funding. GAO’s work
testimony is based on prior work                  has found that while a variety of federal legislative and CMS actions have helped
conducted from June 1993 through                  curb inappropriate financing arrangements, gaps in oversight remain. For
December 2011 related to CMS’s                    example, while there are federal requirements designed to improve transparency
oversight of (1) states’ rate setting             and accountability for state DSH payments, similar requirements are not in
methodologies for certain managed
                                                  place for non-DSH supplemental payments, which may be increasing. From
care arrangements, particularly the
                                                  2006 to 2010, state-reported non-DSH supplemental payments increased from
requirements that rates be actuarially
sound; (2) supplemental payments,                 $6.3 billion to $14 billion; however, according to CMS officials, reporting was
which are payments made to certain                likely incomplete. GAO made numerous recommendations aimed at improving
providers that are separate from and in           oversight of supplemental payments.
addition to standard Medicaid
payments for services; and                        Challenges exist related to CMS’s role ensuring program integrity. In
(3) program integrity, which focuses on           December 2011, GAO testified that the key challenge CMS faced in
ensuring that payments made are in                implementing the statutorily established federal Medicaid Integrity Program was
the correct amount, to the correct                ensuring effective coordination to avoid duplicating state program integrity efforts,
provider, for an eligible beneficiary.            particularly in the area of auditing provider claims. GAO found that overpayments
                                                  identified by its audit contractors since fiscal year 2009 were not commensurate
                                                  with its contractors’ costs, and CMS reported in 2011 that it was redesigning its
                                                  audit program to achieve better results. Data limitations may have hampered the
                                                  contractors’ ability to identify improper claims beyond what states had already
                                                  identified. With regard to CMS’s other core oversight activities—annual
                                                  assessments and triennial comprehensive state program integrity reviews—GAO
                                                  found that much of the information collected from the annual assessments
View GAO-12-674T. For more information,
contact Carolyn L. Yocom at (202) 512-7114
                                                  duplicated information collected during triennial reviews. Finally, CMS’s Medicaid
or yocomc@gao.gov.                                Integrity Institute, a national training program, appears to promote effective state
                                                  coordination and collaboration.
                                                                                           United States Government Accountability Office
Chairmen Gowdy and Jordan, Ranking Members Davis and Kucinich, and
Members of the Subcommittees:

I am pleased to be here today as you explore oversight of Medicaid—a
joint federal-state program that in 2010 financed health care for about
67 million people. Given the size and complexity of this $401 billion
program, the federal government and its state partners continue to face
challenges finding the proper balance between states’ flexibility to
administer their Medicaid programs and the shared federal-state
responsibility to manage program finances efficiently and economically.
Ensuring the program’s long-term sustainability is critical as Medicaid
plays a crucial and growing role in providing health care coverage for a
variety of vulnerable populations, including certain low-income children,
families, and individuals who are aged or disabled.

Medicaid is jointly funded by the federal and state governments. At the
federal level, the Centers for Medicare & Medicaid Services (CMS), an
agency within the Department of Health and Human Services (HHS), is
responsible for overseeing the design and operations of states’ Medicaid
programs, while the states administer their respective programs’ day-to-
day operations. Within broad federal requirements, states have some
flexibility in deciding the range of medical services to provide, which
individuals to cover, and the amount to pay providers. The federal
government matches state expenditures for most Medicaid services using
the Federal Medical Assistance Percentage, a statutory formula that is
based, in part, on each state’s per capita income. 1

The shared financing arrangement between the federal government and
the states, however, presents challenges for program oversight and
requires sustained vigilance on the part of CMS and the Congress. Our
prior work has shown that CMS continues to face challenges overseeing
the fiscal management of the Medicaid program. Because of concerns
about the program’s fiscal management, size, growth, and diversity,
Medicaid has been on GAO’s list of high-risk programs since 2003. 2




1
 Under this statutory formula, the federal government’s share of Medicaid expenditures
can range from 50 to 83 percent.
2
See GAO, High-Risk Series: An Update, GAO-11-278 (Washington, D. C.: Feb. 2011).




Page 1                                                                      GAO-12-674T
             You asked GAO to testify today on our previous work related to CMS’s
             oversight of the Medicaid program. My remarks will focus on our findings
             related to CMS’s oversight of the following three areas of the Medicaid
             program:

             1. states’ rate-setting methodologies for capitated managed care
                arrangements, particularly the statutory and regulatory requirements
                that rates be actuarially sound; 3

             2. supplemental payments, which are payments made to certain
                providers that are separate from and in addition to standard Medicaid
                payments for services; and

             3. program integrity, which focuses on ensuring that payments made are
                in the correct amount, to the correct provider, for an eligible
                beneficiary.

             My testimony is based on our previous work assessing federal oversight
             of Medicaid managed care rate-setting, and supplemental payment
             arrangements, as well as our work assessing CMS’s program integrity
             activities. We conducted this body of work from June 1993 through
             December 2011 in accordance with generally accepted government
             auditing standards. Those standards require that we plan and perform the
             audit to obtain sufficient, appropriate evidence to provide a reasonable
             basis for our findings and conclusions based on our audit objectives.


             The federal government and the states share responsibilities for financing
Background   and administering Medicaid. As a result of flexibility in the program’s
             design, Medicaid consists of 56 distinct state-based programs. 4 The
             challenges inherent in overseeing a program of Medicaid’s size and
             diversity make the program vulnerable to inappropriate program
             spending. CMS is responsible for overseeing state Medicaid programs.
             For example, CMS is responsible for ensuring that states’ capitated
             managed care payments meet actuarial soundness requirements, that
             supplemental payments are appropriate, and for supporting and


             3
             See 42 U.S.C. § 1396b(m)(2)(A)(iii), 42 C.F.R. 438.6(c).
             4
              The 56 Medicaid programs include 1 for each of the 50 states, the District of Columbia,
             Puerto Rico, Samoa, Guam, the Commonwealth of the Northern Mariana Islands, and the
             United States Virgin Islands.




             Page 2                                                                      GAO-12-674T
                            overseeing state program integrity activities—activities intended to
                            address Medicaid fraud, waste, and abuse. 5


Managed Care Rate Setting   Managed care is a significant component of the Medicaid program, with
and Actuarial Soundness     nearly half of all Medicaid enrollees—approximately 20.7 million
                            individuals—enrolled in capitated managed care in 2008. 6 In 2007, there
                            was a total of over $62 billion in federal and state spending for managed
                            care. Under managed care, states use capitation payments to
                            prospectively pay health plans to provide or arrange for services for
                            Medicaid enrollees. Such capitation payments are required by federal law
                            to be actuarially sound. 7 CMS regulations, first issued in 2002, define
                            actuarially sound rates as those that are (1) developed in accordance with
                            generally accepted actuarial principles and practices, (2) appropriate for
                            the populations to be covered and the services to be furnished, and
                            (3) certified as meeting applicable regulatory requirements by qualified
                            actuaries. 8 In order to receive federal funds for their managed care
                            programs, states must submit documentation to CMS regional offices for
                            review, including a description of their rate-setting methodology and data
                            used to set rates. This review, completed by CMS regional office staff, is
                            designed to ensure that a state complies with the regulatory requirements
                            for setting actuarially sound rates.




                            5
                             Fraud involves an intentional act or representation to deceive with the knowledge that the
                            action or representation could result in gain. Waste results from clerical errors or the
                            provision of medically unnecessary services. Abuse typically involves actions that are
                            inconsistent with acceptable business and medical practices that result in unnecessary
                            program costs.
                            6
                             Throughout this report, the term managed care refers only to capitated managed care
                            arrangements, which are arrangements through which a health plan is prospectively paid
                            a fixed monthly rate per enrollee to provide or arrange for most health services. States
                            may also have primary care case management (PCCM) programs under which a primary
                            care provider is paid a nominal monthly, per person, case management fee to coordinate
                            care for beneficiaries, in addition to fee-for-service (FFS) reimbursement for any health
                            care services they provide. While some consider PCCM programs to be managed care,
                            we consider those programs to be FFS-based arrangements because participating
                            providers are predominately paid on a FFS basis.
                            7
                            See 42 U.S.C. § 1396b(m)(2)(A)(iii).
                            8
                            See 42 CFR §438.6(c)(1)(i).




                            Page 3                                                                        GAO-12-674T
Supplemental Payments   Most state Medicaid programs make supplemental payments to certain
                        providers in addition to the standard payments states make to these
                        providers for Medicaid services. For purposes of this testimony, we
                        have grouped supplemental payments into two broad categories:
                        (1) Disproportionate Share Hospital (DSH) payments, which states are
                        required to make to hospitals that treat large numbers of low-income
                        uninsured people and Medicaid patients; 9 and (2) non-DSH supplemental
                        payments, which are not required by statute or regulation. In fiscal year
                        2010, states made more than $31 billion in supplemental payments; the
                        federal share was more than $19 billion. CMS is responsible for
                        overseeing these payment arrangements to ensure the propriety of
                        expenditures for which states seek federal reimbursement, including
                        whether states were appropriately financing their share.


Program Integrity       Program integrity activities are designed to prevent, or detect and
                        recover, improper payments throughout the Medicaid program. The
                        Deficit Reduction Act of 2005 expanded CMS’s role regarding Medicaid
                        program integrity, establishing the Medicaid Integrity Program to provide
                        effective federal support and assistance to states to combat fraud, waste,
                        and abuse. 10 CMS’s core program integrity activities include:

                        •     National Provider Audit Program—a program through which separate
                              CMS contractors analyze claims data to identify aberrant claims and
                              potential billing vulnerabilities, and conduct postpayment audits based
                              on data analysis leads in order to identify overpayments to Medicaid
                              providers.

                        •     Comprehensive program integrity reviews—comprehensive
                              management reviews that are conducted every 3 years to assess the
                              effectiveness of each state’s program integrity efforts and determine
                              whether the state’s policies and procedures comply with federal law
                              and regulations.




                        9
                         See 42 U.S.C. §§ 1396a(13)(A)(iv), 1396r-4. States’ DSH programs are subject to limits
                        on overall annual federal expenditures, on the amount of DSH payments a state may
                        make, and on the DSH payments individual hospitals may receive.
                        10
                            See Pub. L. No. 109-171, § 6034, 120 Stat. 4, 74-78 (2006).




                        Page 4                                                                      GAO-12-674T
                       •    State program integrity assessments—annual assessments in which
                            CMS collects data on state Medicaid integrity activities—including
                            program integrity staffing and expenditures, audits, fraud referrals,
                            and recoveries—for the purposes of program evaluation and technical
                            assistance support.

                       CMS also provides training and technical assistance to states. For
                       example, CMS’s Medicaid Integrity Institute is the first national Medicaid
                       integrity training program and offers state officials training and
                       opportunities to develop relationships with program integrity staff from
                       other states.


                       We found that CMS had not ensured that all states were complying with
CMS’s Oversight of     the actuarial soundness requirements and did not have sufficient efforts in
Managed Care Rate      place to ensure that states were using reliable data to set managed care
                       rates. 11 Specifically, in August 2010, we reported that there were
Setting Was            significant gaps in CMS’s oversight of 2 of the 26 states included in our
Inconsistent and Did   review.
Not Ensure the         •    First, CMS had not reviewed one state’s rate setting for multiple years
Quality of the Data         and only determined that the state was not in compliance with the
                            requirements through the course of our work.
Used to Set Rates
                       •    Second, at the time of our work, CMS had not completed a full review
                            of a second state’s rate setting since the actuarial soundness
                            requirements became effective in August 2002, and therefore may
                            have provided federal funds for managed care rates that were not in
                            compliance with all of the requirements.

                       In addition to these gaps in oversight, we found inconsistencies in the
                       reviews CMS completed. For example, the extent to which CMS ensured
                       state compliance with some of the actuarial soundness requirements was
                       unclear because CMS officials did not always document their review or
                       cite evidence of the state’s compliance. When officials did cite evidence,
                       the evidence did not always appear to meet the actuarial soundness
                       requirements. Variation in practices across CMS regional offices
                       contributed to these gaps and other inconsistencies in the agency’s


                       11
                         See GAO, Medicaid Managed Care: CMS’s Oversight of States’ Rate Setting Needs
                       Improvement, GAO-10-810 (Washington D.C.: Aug. 4, 2010).




                       Page 5                                                                 GAO-12-674T
oversight of states’ rate setting. For example, regional offices varied in the
extent to which they tracked state compliance with the actuarial
soundness requirements, their interpretations of how extensive a review
of a state’s rate setting was needed, and their determinations regarding
sufficient evidence for meeting the actuarial soundness requirements.

We also reported in 2010 that CMS’s efforts to ensure the quality of the
data used to set rates were generally limited to requiring assurances from
states and health plans—efforts that did not provide the agency with
enough information to ensure the quality of the data used. CMS
regulations require states to describe the data used as the basis for rates
and provide assurances from their actuaries that the data were
appropriate for rate setting. The regulations do not include requirements
for the type, amount, or age of the data used to set rates, and states are
not required to report to CMS on the quality of the data. When reviewing
states’ descriptions of the data used to set rates, CMS officials focused
primarily on the appropriateness of the data rather than their reliability.
Additionally, we found that actuarial certification does not ensure that the
data used to set rates are reliable. In particular, our review of rate-setting
documentation found that some actuaries’ certifications included a
disclaimer that if the data used were incomplete or inaccurate then the
rates would need to be revised. Furthermore, some actuaries noted that
they did not audit or independently verify the data and relied on the state
or health plans to ensure that the data were accurate and complete. With
limited information on data quality, CMS cannot ensure that states’
managed care rates are appropriate, which places billions of federal and
state dollars at risk for misspending. States and other sources have
information on the quality of data used for rate setting—information that
CMS could obtain. In addition, CMS could conduct or require periodic
audits of data used to set rates; CMS is required to conduct such audits
for the Medicare managed care program.

CMS took a number of steps that may address some of the variation that
contributed to inconsistent oversight, such as requiring regional office
officials to use a detailed checklist when reviewing states’ rate setting;
use of the checklist had previously been optional. However, we found
variations in CMS oversight even when the checklist was used. Thus, to
improve oversight of states’ Medicaid managed care rate setting, we
recommended that CMS (1) implement a mechanism for tracking state
compliance, including tracking the effective dates of approved rates;
(2) clarify guidance for CMS officials on conducting rate-setting reviews,
such as identifying what evidence is sufficient to demonstrate state
compliance with the actuarial soundness requirements, and how officials


Page 6                                                             GAO-12-674T
                   should document their reviews; and (3) make use of information on data
                   quality in overseeing states’ rate setting. HHS agreed with these
                   recommendations, and as of June 2011, CMS officials indicated they
                   were investigating ways to create an easily accessible database to help
                   them more closely monitor the status of rate-setting approvals, reviewing
                   and updating its guidance, and looking into incorporating information
                   about data quality into its review and approval of Medicaid managed care
                   rates.


                   In our prior work, we have reported on varied financing arrangements
CMS Oversight of   involving supplemental payments that shifted costs from the states to the
Medicaid           federal government. In some cases, the providers did not retain the full
                   amount of the payments as some states required providers to return
Supplemental       most, or all, of the supplemental payment to the state. Our work found
Payments Needs     that while a variety of federal legislative and CMS actions have helped
Improvement        curb inappropriate financing arrangements, gaps in oversight remain.
                   Because such financing arrangements effectively increased the federal
                   Medicaid share, they could compromise the fiscal integrity of Medicaid’s
                   federal and state partnership.

                   Our most recent reports on supplemental payments underscore these
                   gaps in federal oversight. In May 2008, we reported that CMS had not
                   reviewed all supplemental payment arrangements to ensure that these
                   payments were appropriate and used for Medicaid purposes. 12 In
                   November 2009, we found that ongoing federal oversight of supplemental
                   payments was warranted, in part, because two of the four states reviewed
                   did not comply with federal requirements to account for all Medicaid




                   12
                    See GAO, Medicaid: CMS Needs More Information on the Billions of Dollars Spent on
                   Supplemental Payments, GAO-08-614 (Washington D.C.: May 30, 2008).




                   Page 7                                                                  GAO-12-674T
payments when calculating DSH payment limits for uncompensated
hospital care. 13

Recently implemented requirements have the potential to improve
oversight of some supplemental payments, but concerns about other
payments remain. 14 For example, there are now improved transparency
and accountability requirements in place for DSH payments. However,
these requirements are not in place for non-DSH supplemental payments,
which may be increasing. Specifically, in 2006, states reported making
$6.3 billion in non-DSH supplemental Medicaid payments, of which the
federal share was $3.7 billion, but not all states were reporting their
payments. By 2010, this amount had grown to $14 billion, with a federal
share of $9.6 billion. However, according to CMS officials, states’
reporting of non-DSH supplemental payments was likely incomplete.

As a result of our prior work, we have made numerous recommendations
aimed at improving federal oversight of supplemental payments. Some
key recommendations we made have not been implemented by CMS. We
have recommended that CMS adopt transparency requirements for non-
DSH supplemental payments and develop a strategy to ensure all state
supplemental payment arrangements have been reviewed by CMS. CMS
has taken some action to address some of these recommendations but
we continue to believe additional action is warranted. CMS has raised
concern that congressional action may be necessary to fully address our
concerns. Additionally, given continued concerns associated with
Medicaid supplemental payments, we have work under way related to
states’ reporting and CMS’s oversight of DSH and non-DSH supplemental
payments.



13
  See GAO, Medicaid: Ongoing Federal Oversight of Payments to Offset Uncompensated
Hospital Care Costs Is Warranted, GAO-10-69 (Washington D.C.: Nov. 20, 2009). Federal
Medicaid law caps the amount of DSH supplemental payments a state may pay to an
individual hospital each fiscal year. DSH supplemental payments cannot exceed the
unreimbursed cost of furnishing hospital services to Medicaid beneficiaries and the
uninsured. In determining a hospital’s unreimbursed costs, states must offset costs with all
Medicaid payments received by the hospital. See 42 U.S.C. § 1396r-4(g). Thus, other
Medicaid payments—including all supplemental payments—count against a hospital’s
DSH cap.
14
  See the Medicare Prescription Drug, Improvement, and Modernization Act of 2003,
Pub. L. No. 108-173, § 1001(d), 117 Stat. 2066, 2430-2431 (2003) (codified, as amended,
at 42 U.S.C. § 1395r-4(j)) and Medicaid Program, Disproportionate Share Hospital
Payments, Final Rule, 73 Fed. Reg. 77,904 (Dec. 19, 2008).




Page 8                                                                         GAO-12-674T
                       In December 2011, we testified that the key challenge CMS faced in
CMS’s Expanded Role    implementing the statutorily established federal Medicaid Integrity
in Ensuring Medicaid   Program was ensuring effective coordination to avoid duplicating state
                       program integrity efforts, particularly in the area of auditing provider
Program Integrity      claims. 15 At the outset of the Medicaid Integrity Program, CMS stressed
Presents Challenges    the need for effective coordination and acknowledged the potential for
to and Opportunities   duplication with states’ ongoing efforts to identify Medicaid overpayments.

for Assisting States   However, the National Provider Audit Program results—the largest
                       component of the Medicaid Integrity Program—call into question the
                       effectiveness of CMS’s communication, and its ability to avoid duplication
                       with state audit programs. After examining CMS’s program expenditures,
                       we found that overpayments identified by its audit contractors since fiscal
                       year 2009 were not commensurate with its contractors’ costs. From fiscal
                       years 2009 through 2011, CMS authorized 1,663 provider audits in
                       44 states. However, CMS’s reported return on investment from these
                       audits was negative. While its contractors identified $15.2 million in
                       overpayments in fiscal year 2010, the combined cost of the National
                       Provider Audit Program was about $36 million. In addition, CMS reported
                       in 2011 that it was redesigning the National Provider Audit Program to
                       achieve better results. Data limitations—in particular, the use of summary
                       data that states submit to CMS on a quarterly basis—may have
                       hampered the contractors’ ability to identify improper claims beyond what
                       states already identified. It remains to be seen, however, whether CMS’s
                       redesign of the National Provider Audit Program will result in an increase
                       in identified overpayments.

                       CMS’s other core oversight activities—triennial comprehensive state
                       program integrity reviews and annual assessments—are broad in scope
                       and were conceived to provide a basis for the development of appropriate
                       technical assistance. However, we found that much of the information
                       collected from the annual assessments duplicated information collected
                       during triennial reviews. Further, our review of a sample of assessments
                       revealed missing data and a few implausible measures, such as one state
                       reporting over 38 million managed care enrollees. Improved data
                       collection activities and dialogue with states will help CMS ensure that it




                       15
                         See GAO, Medicaid Program Integrity: Expanded Federal Role Presents Challenges to
                       and Opportunities for Assisting States, GAO-12-288T (Washington, D.C.: Dec. 7, 2011).




                       Page 9                                                                    GAO-12-674T
                  has complete and reliable state information on which to direct its training
                  and technical assistance resources appropriately.

                  Finally, we found that the Medicaid Integrity Institute appears to promote
                  effective state coordination and collaboration. We reported that states
                  have uniformly praised the institute and a special June 2011 session
                  brought together Medicaid program integrity officials and representatives
                  of Medicaid Fraud Control Units—independent state units responsible for
                  investigating and prosecuting Medicaid fraud—in 39 states to improve
                  working relations between these important partners.

                  As we testified in December 2011, CMS’s expanded role in ensuring
                  Medicaid program integrity has presented both challenges to and
                  opportunities for assisting states with their activities to ensure proper
                  payments. We have ongoing work reviewing CMS’s Medicaid program
                  integrity activities that will provide additional information about CMS’s
                  oversight efforts in this area.


                  Chairmen Gowdy and Jordan, this concludes by prepared statement. I
                  would be happy to answer any questions that you or other Members may
                  have.


                  For further information about this statement, please contact Carolyn L.
GAO Contact and   Yocom at (202) 512-7114 or yocomc@gao.gov. Contact points for our
Staff             Offices of Congressional Relations and Public Affairs may be found on
                  the last page of this statement. Michelle B. Rosenberg, Assistant Director;
Acknowledgments   Eagan Kemp; Drew Long; Peter Mangano; Christina Ritchie; and Hemi
                  Tewarson were key contributors to this statement.




                  Page 10                                                           GAO-12-674T
Appendix I: Abbreviations
              Appendix I: Abbreviations




              CMS               Centers for Medicare & Medicaid Services
              DSH               Disproportionate Share Hospital
              FFS               fee-for-service
              HHS               Department of Health and Human Services
              PCCM              primary care case management




              Page 11                                                      GAO-12-674T
Related GAO Products
             Related GAO Products




             Medicaid Program Integrity: Expanded Federal Role Presents
             Challenges to and Opportunities for Assisting States. GAO-12-288T.
             Washington, D.C.: December 7, 2011.

             Fraud Detection Systems: Additional Actions Needed to Support
             Program Integrity Efforts at Centers for Medicare and Medicaid Services.
             GAO-11-822T. Washington, D.C.: July 12, 2011.

             Fraud Detection Systems: Centers for Medicare and Medicaid Services
             Needs to Ensure More Widespread Use. GAO-11-475. Washington, D.C.:
             June 30, 2011.

             Improper Payments: Recent Efforts to Address Improper Payments and
             Remaining Challenges. GAO-11-575T. Washington, D.C.: April 15, 2011.

             Medicare and Medicaid Fraud, Waste, and Abuse: Effective
             Implementation of Recent Laws and Agency Actions Could Help Reduce
             Improper Payments. GAO-11-409T. Washington, D.C.: March 9, 2011.

             Opportunities to Reduce Potential Duplication in Government
             Programs, Save Tax Dollars, and Enhance Revenue. GAO-11-318SP.
             Washington, D.C.: March 1, 2011.

             High-Risk Series: An Update. GAO-11-278. Washington, D.C.:
             February 2011.

             Medicaid Managed Care: CMS’s Oversight of States’ Rate Setting Needs
             Improvement. GAO-10-810. Washington D.C.: August 4, 2010.

             Medicaid: Ongoing Federal Oversight of Payments to Offset
             Uncompensated Hospital Care Costs Is Warranted. GAO-10-69.
             Washington D.C.: November 20, 2009.

             Medicaid: Fraud and Abuse Related to Controlled Substances Identified
             in Selected States. GAO-09-1004T. Washington, D.C.: September 30,
             2009.

             Medicaid: Fraud and Abuse Related to Controlled Substances Identified
             in Selected States. GAO-09-957. Washington, D.C.: September 9, 2009.

             Improper Payments: Progress Made but Challenges Remain in
             Estimating and Reducing Improper Payments. GAO-09-628T.
             Washington, D.C.: April 22, 2009.


             Page 12                                                       GAO-12-674T
           Related GAO Products




           Medicaid: CMS Needs More Information on the Billions of Dollars
           Spent on Supplemental Payments. GAO-08-614. Washington D.C.:
           May 30, 2008.

           Medicaid Financing: Long-standing Concerns about Inappropriate
           State Arrangements Support Need for Improved Federal Oversight.
           GAO-08-650T. Washington D.C.: April 3, 2008.

           Medicaid Demonstration Waivers: Recent HHS Approvals Continue to
           Raise Cost and Oversight Concerns. GAO-08-87. Washington, D.C.:
           January 31, 2008.

           Medicaid Financing: Long-standing Concerns about Inappropriate
           State Arrangements Support Need for Improved Federal Oversight.
           GAO-08-255T. Washington D.C.: November 1, 2007.

           Medicaid Financing: Federal Oversight Initiative Is Consistent with
           Medicaid Payment Principles but Needs Greater Transparency.
           GAO-07-214. Washington D.C.: March 30, 2007.

           Medicaid Financial Management: Steps Taken to Improve Federal
           Oversight but Other Actions Needed to Sustain Efforts. GAO-06-705.
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           Medicaid Integrity: Implementation of New Program Provides
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           Medicaid Financing: States’ Use of Contingency-Fee Consultants to
           Maximize Federal Reimbursements Highlights Need for Improved Federal
           Oversight. GAO-05-748. Washington, D.C.: June 28, 2005.

           Medicaid Fraud and Abuse: CMS’s Commitment to Helping States
           Safeguard Program Dollars Is Limited. GAO-05-855T. Washington, D.C.:
           June 28, 2005.

           Medicaid Program Integrity: State and Federal Efforts to Prevent
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           Medicaid: State Efforts to Control Improper Payments. GAO-01-662.
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