oversight

Health Care Fraud: Types of Providers Involved in Medicare Cases, and CMS Efforts to Reduce Fraud

Published by the Government Accountability Office on 2012-11-28.

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

                               United States Government Accountability Office

GAO                            Testimony
                               Before the Subcommittee on Health,
                               Committee on Energy and Commerce,
                               House of Representatives

                               HEALTH CARE FRAUD
For Release on Delivery
Expected at 10:00 a.m. EST
Wednesday, November 28, 2012



                               Types of Providers Involved
                               in Medicare Cases, and CMS
                               Efforts to Reduce Fraud
                               Statement of Kathleen M. King
                               Director, Health Care




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GAO-13-213T
Chairman Pitts, Ranking Member Pallone, and Members of the
Subcommittee:

I am pleased to be here today to discuss our work regarding health care
fraud in Medicare and to discuss strategies that could help reduce fraud.
Since 1990, GAO has designated Medicare as a high-risk program, as its
complexity and susceptibility to payment errors from various causes,
added to its size, have made it vulnerable to fraud. 1 Although there have
been convictions for multimillion dollar schemes that defrauded the
Medicare program, the extent of the problem is unknown as there are no
reliable estimates of the magnitude of fraud in the health care industry.
Fraud is difficult to detect because those involved are engaged in
intentional deception. According to the Department of Health and Human
Services’ Office of Inspector General (HHS-OIG), common health care
fraud schemes include providers or suppliers billing for services or
supplies not provided or not medically necessary, purposely billing for a
higher level of service than that provided, misreporting data to increase
payments, paying kickbacks to providers for referring beneficiaries for
specific services or to certain entities, or stealing providers’ or
beneficiaries’ identities.

Since 1997, Congress has provided funds specifically for activities to
address fraud, as well as waste and abuse, in Medicare and other federal
health care programs. In fiscal year 2011, the federal government
allocated at least $608 million in funding to investigate and prosecute




1
 In 1990, we began to report on government operations that we identified as “high risk” for
serious weaknesses in areas that involve substantial resources and provide critical
services to the public. Medicaid is among those programs we have identified as high-risk
and Medicare has been included since 1990. See GAO, High-Risk Series: An Update,
GAO-11-278 (Washington, D.C.: February 2011). See also
http://www.gao.gov/highrisk/risks/insurance/medicare_program.php. Medicare is the
federally financed health insurance program for persons age 65 or over, certain individuals
with disabilities, and individuals with end-stage renal disease. Medicare Parts A and B are
known as Medicare fee-for-service (FFS). Medicare Part A covers hospital and other
inpatient stays. Medicare Part B is optional, and covers hospital outpatient, physician, and
other services. Medicare beneficiaries have the option of obtaining coverage for Medicare
services from private health plans that participate in Medicare Advantage—Medicare’s
managed care program—also known as Part C. All Medicare beneficiaries may purchase
coverage for outpatient prescription drugs under Part D, either as a stand-alone benefit or
as part of a Medicare Advantage plan. Fraud involves an intentional act or representation
to deceive with the knowledge that the action or representation could result in gain.




Page 1                                                                         GAO-13-213T
cases of alleged fraud in health care programs. 2 The Centers for
Medicare and Medicaid Services (CMS)—an agency within HHS—
oversees Medicare, Medicaid, and the Children’s Health Insurance
Program (CHIP). Along with its contractors, CMS works to reduce fraud.
The HHS-OIG along with the Department of Justice (DOJ)—including its
Criminal and Civil Divisions, the U.S. Attorney’s Offices (USAOs)
throughout the country, and the Federal Bureau of Investigation (FBI)—
work together to investigate and prosecute cases of health care fraud.

My testimony today focuses on the types of providers that have been
investigated for fraud and the outcomes of those investigations, and
strategies that could be used to combat Medicare fraud. This statement is
informed primarily by our September 2012 report on health care fraud and
8 years of prior work on fraud, waste, and abuse in health care
programs. 3 A full list of the products that this testimony is based on is
provided at the end of this statement.

These products were developed using a variety of methodologies,
including analyses of fraud investigations and outcomes data obtained
from federal agencies, review of public court records, examination of
relevant policies and procedures, and interviews with agency officials. 4
The work on which these products were based was conducted 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. We believe that
the evidence obtained provided a reasonable basis for our findings and
conclusions based on our audit objectives.



2
 See Department of Health and Human Services and Department of Justice, Health Care
Fraud and Abuse Control Program Annual Report for Fiscal Year 2011: February 2012.
The program, which is under the joint direction of the Attorney General and the Secretary
of the Department of Health and Human Services (HHS) is designed to coordinate federal,
state, and local law enforcement activities with respect to health care fraud and abuse.
Additional funds to combat health care fraud spent by HHS and the Department of Justice
(DOJ) are not included in this figure.
3
 See GAO, Health Care Fraud: Types of Providers Involved in Medicare, Medicaid, and
the Children’s Health Insurance Program Cases; GAO-12-820 (Washington, D.C.: Sep. 7,
2012).
4
 The products listed at the end of this statement contain detailed information on the
methodologies used in our work.




Page 2                                                                         GAO-13-213T
                             In recently completed work, we found that medical facilities (such as
Medical Facilities           medical centers, clinics, and practices) and durable medical equipment
Were the Most                suppliers were the most frequent subjects of criminal fraud cases in
                             Medicare, Medicaid, and CHIP in 2010. 5 Hospitals and medical facilities
Frequent Subjects of         were the most frequent subjects of civil fraud cases, including cases that
Criminal                     resulted in judgments or settlements.
Investigations, and
Hospitals Were the
Most Frequent
Subjects of Civil
Investigations
Medical Facilities and       According to 2010 data, about one-quarter of the 7,848 subjects
Durable Medical              investigated in criminal health care fraud cases were medical facilities or
Equipment Suppliers Were     were affiliated with these facilities. Additionally, about 16 percent of
                             subjects were durable medical equipment suppliers. Among the subjects
the Most Frequent            investigated in criminal fraud cases, a small percentage (approximately
Subjects of Criminal Fraud   3 percent) were individuals who were beneficiaries of health care
Cases in 2010                programs.

                             Most of the subjects investigated for criminal fraud in 2010 were not
                             pursued—meaning that the HHS-OIG did not refer the subject’s case to
                             DOJ for prosecution. According to the 2010 data, 1,086 subjects were
                             charged in criminal fraud cases and approximately 85 percent of them
                             (925 subjects) were found guilty, pled guilty, or pled no contest to some or
                             all of the criminal charges against them. Among those subjects that were
                             found or pled guilty or no contest, the most frequent subjects were
                             medical facilities (18.7 percent) or durable medical equipment suppliers
                             (18.5 percent). See table 1 below for additional information on subjects
                             who were found or pled guilty or no contest in 2010 criminal cases by
                             provider type.




                             5
                              GAO-12-820. We use the term “subjects” to refer to individuals and entities involved in
                             fraud cases. These subjects can be individuals, such as a dentist or a nurse; an
                             organization, such as a pharmaceutical manufacturer; or a facility, such as a hospital.




                             Page 3                                                                        GAO-13-213T
Table 1: Number and Percentage of Criminal Health Care Fraud Subjects That Were
Found or Pled Guilty or No Contest by Provider Type, 2010

                                                                                                 Percentage of total
                                                            Number of subjects                   number of subjects
                                                               that were found                      that were found
                                                               or pled guilty or                    or pled guilty or
                                                                     no contest                           no contest
    Medical facilities
                                           a
         Medical centers or clinics                                                 130
                                                                                                                      18.7%
         Medical practices                                                            43
    Durable medical equipment suppliers                                             171                                    18.5
    Other centers, clinics, or facilities                                             58                                    6.3
    Other                                                                             49                                    5.3
    Home health agencies                                                              42                                    4.5
    Pharmacies                                                                        40                                    4.3
    Management service providers                                                      33                                    3.6
    Nursing homes                                                                     14                                    1.5
    Medical transportation companies                                                  14                                    1.5
    Pharmaceutical manufacturers or suppliers                                           9                                   1.0
    Mental health centers, clinics, or facilities                                       9                                   1.0
    Medical supply companies                                                            8                                   0.9
    Insurance companies                                                                 5                                   0.5
    Dental clinics or practices                                                         4                                   0.4
    Government employees, contractors, or grantees                                      3                                   0.3
    Hospitals                                                                           2                                   0.2
    Unknown affiliation
                       a
         Individuals                                                                220
         Health care providers                                                        52                                   31.6
         Data unavailable                                                             19
    Total                                                                           925
Source: GAO analysis of Department of Health and Human Services’ Office of Inspector General (HHS-OIG) and Department of
Justice’s (DOJ) U.S. Attorneys’ Offices (USAO) data.

Notes: Data in this table are for calendar year 2010. For the subjects in the DOJ’s USAO data, we
identified the provider type using the court documents obtained from the Public Access to Court
Electronic Records database. The data from HHS-OIG pertained only to health care fraud in
Medicare, Medicaid, and the Children’s Health Insurance Program; however, data from the USAOs
may have also included other health care fraud.
a
 Among the 130 subjects affiliated with medical centers or clinics, 8 subjects were beneficiaries.
Among the 220 individuals whose affiliation was unknown, 95 were beneficiaries. In total, there were
103 beneficiaries who were found or pled guilty or no contest to some or all of the criminal charges
against them. This represents approximately 11.1 percent of all criminal subjects who were found or
pled guilty or no contest.




Page 4                                                                                                       GAO-13-213T
                             Additionally, about 11 percent of the subjects found guilty or who pled
                             guilty or no contest were beneficiaries of health care programs. Among
                             the 925 subjects that were found or pled guilty or no contest, 103 subjects
                             were beneficiaries—95 of whom are listed as individuals in Table 1 and 8
                             of whom were affiliated with medical centers or clinics. For example, in
                             one of these criminal cases, a number of people associated with a
                             medical clinic, including owners, an administrator, employees, a
                             physician, and beneficiaries pled guilty or were convicted for their
                             participation in a scheme to defraud Medicare. The fraud scheme
                             involved recruiting beneficiaries through kickbacks for the purpose of
                             submitting bills for injection and infusion treatments, which were not
                             provided or not medically necessary.


Hospitals and Medical        Hospitals constituted nearly 20 percent of the 2,339 subjects of civil fraud
Facilities Were the Most     cases investigated in 2010, and other medical facilities accounted for
Frequent Subjects of Civil   about 18 percent of the subjects. Less than 1 percent of subjects involved
                             in civil health care fraud cases were beneficiaries of health care
Fraud Cases, Including       programs.
Cases That Resulted in
Judgments or Settlements     Not all of the subjects investigated in 2010 civil cases were pursued; by
                             pursued, we mean that the USAO or DOJ’s Civil Division received the
                             case and took some sort of action. Approximately 47 percent of subjects
                             were involved in civil cases that were pursued and the remaining
                             53 percent were involved in cases that were not pursued for a variety of
                             reasons, including lack of resources or insufficient evidence as reported
                             by the HHS-OIG. According to the 2010 data, 1,087 subjects were
                             involved in civil fraud cases that were pursued, and among those, 602
                             subjects were involved in cases that resulted in a judgment or settlement
                             for the government or the relator. 6 Twenty-seven percent of the subjects
                             in cases that were pursued were hospitals, and about 17 percent were
                             medical facilities. None of those 602 subjects were beneficiaries of health
                             care programs. See table 2 for additional information on provider types for




                             6
                              Individuals, known as relators, can bring civil health care fraud suits in the name of the
                             government under the False Claims Act (FCA). The FCA prohibits certain actions,
                             including the knowing presentation of a false claim for payment by the federal
                             government. 31 U.S.C. § 3729(a)(1)(A). In these cases, known as qui tam cases, the
                             relator can receive a portion of a monetary settlement, and reasonable expenses and
                             attorneys’ fees and costs. 31 U.S.C. § 3730(b),(d).




                             Page 5                                                                           GAO-13-213T
subjects where the case resulted in a settlement or judgment for the
government or relator.

Table 2: Number and Percentage of Subjects in Civil Health Care Fraud Cases with
Judgment for Government or Relator, Settlement, or Both by Provider Type, 2010

                                                                                                  Percentage of total
                                                               Number of subjects                 number of subjects
                                                                    with judgment,                     with judgment,
                                                               settlement, or both                settlement, or both
 Hospitals                                                                             165                            27.4%
 Medical facilities
       Medical practices                                                                 65
       Medical centers or clinics                                                        35                                16.6
 Other centers, clinics, or facilities                                                   41                                 6.8
 Home health agencies                                                                    34                                 5.6
 Nursing homes                                                                           26                                 4.3
 Durable medical equipment suppliers                                                     25                                 4.2
 Management service providers                                                            21                                 3.5
 Dental clinics or practices                                                             21                                 3.5
 Pharmaceutical manufacturers or suppliers                                               19                                 3.2
 Insurance companies                                                                     15                                 2.5
 Pharmacies                                                                              13                                 2.2
 Medical transportation companies                                                        11                                 1.8
 Mental health centers, clinics, or facilities                                             5                                0.8
 Other                                                                                     5                                0.8
 Medical supply companies                                                                  3                                0.5
 Government employees, contractors, or grantees                                            2                                0.3
 Unknown affiliation
       Data unavailable                                                                  58
       Health care providers                                                             34
       Individuals                                                                         4                               15.9
 Total                                                                                 602
Source: GAO analysis of Department of Health and Human Services Office of the Inspector General (HHS-OIG), Department of
Justice’s U.S. Attorneys’ Offices (USAOs), and DOJ’s Civil Division data.

Notes: Data in this table are for calendar year 2010. For the subjects in the USAOs and DOJ’s Civil
Division data, we identified the provider type using the court documents obtained from the Public
Access to Court Electronic Records database. The data from HHS-OIG pertained only to health care
fraud in Medicare, Medicaid, and the Children’s Health Insurance Program; however, data from the
USAOs and DOJ’s Civil Division may also include other health care fraud.




Page 6                                                                                                       GAO-13-213T
                        CMS has made progress in implementing strategies to prevent fraud, and
CMS Has Made            recent legislation provided it with enhanced authority. However, CMS has
Progress in             not implemented some of the key strategies we identified in our prior work
                        to help CMS address challenges it faces in preventing fraud. Among
Implementing            others, these strategies include strengthening provider enrollment
Strategies to Prevent   processes and standards, improving pre- and post-payment claims
                        review, and developing a robust process for addressing identified
Fraud, but Further      vulnerabilities.
Actions are Needed
                        •   Strengthening provider enrollment processes and standards—As
                            we have reported in the past, strengthening the standards and
                            procedures for provider enrollment could help reduce the risk of
                            enrolling providers intent on defrauding Medicare. 7 Although CMS has
                            taken some important steps to identify and prevent fraud, including
                            implementing provisions in Patient Protection and Affordable Care Act
                            (PPACA), such as screening providers by risk level, more remains to
                            be done to prevent making erroneous Medicare payments because of
                            fraud. 8 In particular, we have found CMS could do more to strengthen
                            provider enrollment screening to avoid those intent on committing
                            fraud, such as requiring a surety bond for certain types of at-risk
                            providers and additional disclosure of information such as previous
                            payment suspensions from other federal programs.

                        •   Improving pre- and postpayment review of claims—As we have
                            reported in the past, having robust controls in claims payment
                            systems to prevent payment of problematic claims can help reduce
                            loss. 9 Effective prepayment edits that deny claims for ineligible
                            providers and suppliers depends on having timely and accurate
                            information about them, such as whether the providers are currently
                            enrolled and have the appropriate license or accreditation to provide
                            specific services. In prior work, we found weaknesses in the database
                            that maintains Medicare provider and supplier enrollment information
                            related to the frequency with which CMS’s contractors update


                        7
                         See GAO, Medicare Program Integrity: CMS Continues Efforts to Strengthen the
                        Screening of Providers and Suppliers, GAO-12-351, (Washington, D.C.: Apr. 10, 2012).
                        8
                         Pub. L. No. 111-148, 124 Stat.119 (2010), as amended by Health Care and Education
                        Reconciliation Act of 2010 (HCERA), Pub. L. No. 111-152, 124 Stat. 1029, which we refer
                        to collectively as PPACA.
                        9
                         See GAO, Medicare: Progress Made to Deter Fraud, but More Could Be Done,
                        GAO-12-801T, (Washington, D.C.: June 8, 2012).




                        Page 7                                                                     GAO-13-213T
      enrollment information and the timeliness and accuracy of
      information. 10 Although CMS is working to improve the timeliness and
      accuracy of the provider and supplier information, it is too soon to tell
      if these efforts will better prevent payments to ineligible providers and
      suppliers. Additionally, further actions are needed to improve use of
      CMS technology systems that could help CMS and program integrity
      contractors identify fraud both before and after claims have been
      paid. 11 For example, we recently examined CMS’s new predictive
      analytics system—the Fraud Prevention System—and found that
      although it has been implemented and is in use, it is not yet fully
      integrated with existing information technology systems. This level of
      integration would allow for the prevention of payments until suspect
      claims can be investigated and determined to be valid. 12 To ensure
      that the implementation of the Fraud Prevention System is successful,
      we recommended to CMS that it define quantifiable benefits expected
      and mechanisms for measuring the results of using the system. In
      response to our report, HHS officials agreed with our recommendation
      and noted that CMS intends to establish outcome-based performance
      targets based on the first year of the system’s implementation.

•     Developing a robust process for addressing identified
      vulnerabilities—As we have reported in the past, having
      mechanisms in place to resolve vulnerabilities that lead to improper
      payments is critical to effective program management and could help
      address fraud. 13 For example, fraud in the Medicare program can be
      reduced by making it more difficult for thieves to steal beneficiaries’
      Social Security numbers (SSN), which are printed on beneficiaries’
      Medicare cards. In recent work, we found that CMS had not
      committed to a plan for removing SSNs from Medicare cards, and that
      CMS’s cost estimates for options it explored to remove SSNs were
      not well documented or reliable. We recommended that CMS select
      an approach for removing the SSN from the Medicare card that best



10
    GAO-12-351.
11
 See GAO, Fraud Detection Systems: Centers for Medicare and Medicaid Services
Needs to Ensure More Widespread Use, GAO-11-475 (Washington, D.C.: June 30, 2011).
12
  See GAO, Medicare Fraud Prevention: CMS Has Implemented a Predictive Analytics
System, but Needs to Define Measures to Determine Its Effectiveness, GAO-13-104
(Washington, D.C.: Oct. 15, 2012).
13
    GAO-12-801T.




Page 8                                                                 GAO-13-213T
     protects beneficiaries from identity theft and minimizes burdens for
     providers, beneficiaries, and CMS; we also recommended that CMS
     develop an accurate, well-documented cost estimate for such an
     option using standard cost-estimating procedures. 14 CMS agreed with
     our recommendation and indicated that it would take steps to revise
     its cost estimates on the basis of concerns we highlighted.

Although CMS has taken some important steps to identify and prevent
fraud, including implementing provisions in PPACA, more remains to be
done to prevent making erroneous Medicare payments because of fraud.
It is critical that CMS implement and make full use of new authorities
granted by recent legislation, as well as incorporate recommendations
made by us, and the HHS-OIG in these areas. Moving from “pay and
chase” to effective deterrence that prevents fraud from occurring in the
first place is key to ensuring that federal funds are used efficiently and for
their intended purposes.

As the authorities and requirements in recent legislation become part of
Medicare’s operations, additional evaluation and oversight will be
necessary to determine whether they are implemented as required and
have the desired effect. We are investing significant resources in a body
of work that assesses CMS efforts to refine and improve its fraud
detection and prevention efforts. Notably, we are assessing the
effectiveness of different types of prepayment edits in Medicare and of
CMS’s oversight of its contractors in implementing those edits to help
ensure that Medicare pays claims correctly the first time. Additionally, we
have a study underway that is examining how federal agencies—such as
CMS, HHS-OIG, and DOJ—are allocating funds received from the Health
Care Fraud and Abuse Control Program to reduce fraud, as well as the
effectiveness of such efforts. We are also examining a number of issues
concerning CMS’s oversight and management of its Zone Program
Integrity Contractors—the contractors responsible for detecting and
investigating potential fraud—including how they prioritize their work and
are evaluated by CMS. In addition, we are examining CMS’s oversight of
some of the contractors that conduct reviews of claims after payment.
These studies are focused on additional actions for CMS that could help
the agency more systematically reduce fraud in the Medicare program.


14
 See GAO, Medicare: CMS Needs an Approach and a Reliable Cost Estimate for
Removing Social Security Numbers from Medicare Cards, GAO-12-831 (Washington,
D.C.: Aug. 1, 2012).




Page 9                                                                GAO-13-213T
Because of the amount of program funding at risk, fraud will remain an
inherent threat to Medicare, so continuing vigilance to reduce
vulnerabilities will be necessary. Individuals intent on defrauding
Medicare will continue to develop new approaches to try to circumvent
program safeguards and investigative and enforcement efforts. Although
targeting certain types of providers that CMS has identified as high risk
may be useful, it may allow other types of providers committing fraud to
go unnoticed. We will continue to assess efforts to fight fraud and provide
recommendations to CMS, as appropriate, that we believe will assist the
agency and its contractors in this important task. We urge CMS to
continue its efforts as well.

Chairman Pitts, Ranking Member Pallone, and Members of the
Subcommittee, this concludes my prepared statement. I would be happy
to answer any questions you or other members of the subcommittee may
have.


If you or your staff have any questions about this testimony, please
contact me at (202) 512-7114 or kingk@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this statement. Martin T. Gahart, Assistant Director;
Christie Enders; and Drew Long were key contributors to this statement.




Page 10                                                          GAO-13-213T
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             Medicare Fraud Prevention: CMS Has Implemented a Predictive
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             Effectiveness. GAO-13-104. Washington, D.C.: October 15, 2012.

             Health Care Fraud: Types of Providers Involved in Medicare, Medicaid,
             and the Children’s Health Insurance Program Cases. GAO-12-820.
             Washington, D.C.: September 7, 2012.

             Medicare: CMS Needs an Approach and a Reliable Cost Estimate for
             Removing Social Security Numbers from Medicare Cards. GAO-12-831.
             Washington, D.C.: August 1, 2012.

             Medicare: Progress Made to Deter Fraud, but More Could Be Done.
             GAO-12-801T. Washington, D.C.: June 8, 2012.

             Medicare Program Integrity: CMS Continues Efforts to Strengthen the
             Screening of Providers and Suppliers. GAO-12-351. Washington, D.C.:
             April 10, 2012.

             Improper Payments: Remaining Challenges and Strategies for
             Governmentwide Reduction Efforts. GAO-12-573T. Washington, D.C.:
             March 28, 2012.

             2012 Annual Report: Opportunities to Reduce Duplication, Overlap and
             Fragmentation, Achieve Savings, and Enhance Revenue.
             GAO-12-342SP. Washington, D.C.: February 28, 2012.

             Fraud Detection Systems: Centers for Medicare and Medicaid Services
             Needs to Expand Efforts to Support Program Integrity Initiatives.
             GAO-12-292T. Washington, D.C.: December 7, 2011.

             Medicare Part D: Instances of Questionable Access to Prescription
             Drugs. GAO-12-104T. Washington, D.C.: October 4, 2011.

             Medicare Part D: Instances of Questionable Access to Prescription
             Drugs. GAO-11-699. Washington, D.C.: September 6, 2011.

             Medicare Integrity Program: CMS Used Increased Funding for New
             Activities but Could Improve Measurement of Program Effectiveness.
             GAO-11-592. Washington, D.C.: July 29, 2011.

             Improper Payments: Reported Medicare Estimates and Key Remediation
             Strategies. GAO-11-842T. Washington, D.C.: July 28, 2011.


             Page 11                                                      GAO-13-213T
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           Fraud Detection Systems: Additional Actions Needed to Support Program
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           Fraud Detection Systems: Centers for Medicare and Medicaid Services
           Needs to Ensure More Widespread Use. GAO-11-475. Washington, D.C.:
           June 30, 2011.

           High-Risk Series: An Update. GAO-11-278. Washington, D.C.:
           February 16, 2011.




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           Page 12                                                      GAO-13-213T
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