prompt_front: You are given two reports by the government agency.



Question: Write a one-page summary of the report 1.



Report 2: In accordance with the Improper Payments Information Act of 2002 (IPIA), as amended, and OMB guidance, CMS developed the PERM to estimate the national Medicaid improper payment rate  CMS has other mechanisms to review and assess program integrity risks in state Medicaid managed care programs, and it uses information from the PERM to target its program integrity activities and oversight of states’ Medicaid programs  IPIA requires federal executive branch agencies to, among other things, (1) identify programs and activities that may be susceptible to significant improper payments; and (2), on an annual basis, estimate the amount of improper payments for susceptible programs and activities  Agency heads must produce a statistically valid estimate or an estimate that is otherwise appropriate, using an OMB-approved alternate methodology  Those agencies with programs identified by OMB as being high priority for additional oversight and review are required to submit annual reports to their Inspectors General detailing the actions the agency plans to take to recover improper payments and prevent future improper payments  The Inspector General of each agency submitting such a report is required to review the quality of the improper payment estimates and methodology, among other things  OMB designated Medicaid as a high priority program  In addition, the Improper Payments Elimination and Recovery Act of 2010 requires the Inspector General of each agency to conduct a compliance review to report on the agency’s compliance with several criteria, one of which is that an agency has reported an improper payment rate of less than 10 percent for each program and activity  IPIA also directed OMB to issue guidance for agencies in implementing the IPIA improper payments requirements  Among other things, the OMB guidance requires that agencies review payments made at the point that federal funds are transferred to nonfederal entities and report on the root causes of identified improper payments  To calculate the Medicaid improper payment rate through the PERM, CMS computes an annual rolling average of improper payment rates across all states based on a 17-state, 3-year rotation cycle  In accordance with IPIA, as amended, OMB approved CMS’s PERM methodology, and the HHS-OIG conducts annual compliance reviews  Beginning with its annual improper payment compliance review for fiscal year 2014, the HHS-OIG established a rotating approach to reviewing the estimation methodology for high-priority programs, including Medicaid, that OMB deemed susceptible to improper payments  Due to the number and complexity of the programs, the HHS-OIG methodology reviews are scheduled to be performed over a 4-year period; the PERM estimation methodology will be reviewed as a part of its fiscal year 2017 compliance review  Each of the three components of the Medicaid PERM—FFS, managed care, and eligibility—is estimated differently: The FFS component of the PERM measures errors in a sample of FFS claims, which are records of services provided and the amount the Medicaid program paid for these services  For the majority of sampled FFS claims, the PERM review contractor performs a medical review, which includes a review of the medical documentation to determine errors that do not meet federal and state policies, such as medically unnecessary services, diagnosis coding errors, and policy violations  Any FFS claims that were paid for services that should have been covered under a managed care plan’s capitated payment are also considered errors  The managed care component of the PERM measures errors that occur in the capitated payments that state Medicaid agencies make to managed care organizations (MCO) on behalf of enrollees  Capitated payments are periodic payments approved by CMS that state Medicaid agencies make to contracted MCOs to cover the provision of medical services to enrollees, as well as the MCOs’ administrative expenses and their profits or earnings  The PERM assesses whether any payments made to the MCOs were in amounts different than those the state agency is contractually required to pay, which are approved by CMS  In contrast to the FFS component, the managed care component of the PERM neither includes a medical review of services delivered to enrollees, nor reviews of MCO records or data  The eligibility component of the PERM measures errors in state determinations of whether enrollees meet categorical and financial criteria for receipt of benefits under the Medicaid program  The eligibility component assesses determinations for both FFS and managed care enrollees  This component has not been calculated since 2014; instead, CMS piloted different approaches to update the methodologies used to assess enrollee eligibility, as the Patient Protection and Affordable Care Act changed income eligibility requirements for nonelderly, nonpregnant individuals who qualify for Medicaid  Beginning in the 2019 reporting year, eligibility reviews under the PERM will resume and will be conducted by a federal contractor  Medicaid program integrity consists of efforts to ensure that federal and state expenditures are used to deliver quality, necessary care to eligible enrollees, and efforts to prevent fraud, waste, and abuse  We have found in prior work that CMS’s and states’ program integrity efforts focused primarily on payments and services delivered under FFS and did not closely examine program integrity in Medicaid managed care  For Medicaid managed care, CMS has largely delegated program integrity oversight of MCOs to the states  States, in turn, generally oversee MCOs and the providers under contract to MCOs through their contracts with the MCOs and reporting requirements  Some program integrity risks for managed care are similar to those in FFS, including payments made for nonenrolled, ineligible, or deceased individuals; payments to ineligible, excluded, or deceased providers; and payments to providers for improper or false claims, such as payments for services that are not medically necessary  Other program integrity risks are more unique to managed care  For example, capitated payments generally reflect the average cost to provide covered services to enrollees, rather than a specific service  Federal law requires capitation rates to be actuarially sound, meaning that, among other things, they must be reasonably calculated for the populations expected to be covered and for the services expected to be furnished under contract  In order to receive federal funds for its managed care program, a state is required to submit the rates it pays MCOs and the methodology it uses to set those rates to CMS for review and approval  Additionally, federal and state oversight of Medicaid managed care can include ensuring that MCOs fulfill contractual provisions within their managed care contracts  In some cases, these provisions relate directly to program integrity activities, including plans and procedures for identifying, recovering, and reporting on overpayments made to providers  The managed care component of the PERM measures the accuracy of the capitated payments state Medicaid agencies make to MCOs  Specifically, a CMS contractor examines whether the state agency made capitated payments only for eligible enrollees, made capitated payments for the correct amount based on the contract and coverage requirements (time period and geographic location), made capitated payments based on the correct rate for enrollees, and did not make any duplicate payments for enrollees  CMS officials noted that the agency established capitated payments as the level of review, because the capitation rate is the transaction used to determine the federal match in managed care  In general, the federal government matches most state expenditures for Medicaid services on the basis of a statutory formula  In FFS, the federal match is provided for the amount the state pays a health care provider for delivering services to enrollees  With managed care, the federal match is provided for the amount of the capitation rate the state pays the MCO  Capitated payments do not directly relate to the provision of a specific service, but reflect the average cost to provide covered services to enrollees  As a result, CMS officials maintain that the capitated payment is the lowest transaction level at which the agency can clearly identify federal funds without making significant assumptions  Because the managed care component of the PERM review is limited to measuring capitated payments, it does not account for other program integrity risks—such as overpayments to providers and unallowable MCO costs  In addition to errors in capitated payments included in PERM reviews, CMS regulations state that overpayments in managed care include any payment made to an MCO or provider under contract to an MCO to which the MCO or provider is not entitled under Medicaid  Such overpayments included payments for services that were not provided or medically necessary; or to ineligible, excluded, or deceased providers, which are not measured by the PERM  Unallowable MCO costs refers to operating costs that MCOs cannot claim under their managed care contracts, such as certain marketing costs, or that the MCO reported incorrectly  Among the 27 audits and investigations of Medicaid managed care programs we reviewed, 10 identified about $68 million in MCO overpayments to providers and unallowable MCO costs that were not accounted for in PERM estimates  In addition, one investigation of an MCO operating in nine states resulted in a $137 5 million settlement to resolve allegations of false claims  (See app  I for a complete list of the audits and investigations we identified ) However, the full extent of these overpayments and unallowable costs is unknown, because these audits and investigations were conducted over more than 5 years and involved a small fraction of the more than 270 MCOs operating nationwide as of September 2017  Specifically, 24 of the audits and investigations represented reviews in 10 states and, in many cases, focused on individual providers or MCOs; there were about 90 MCOs operating in the 10 states as of September 2017, according to the Kaiser Family Foundation  Some examples of the audits and investigations that identified overpayments and unallowable costs include the following: The Washington State Auditor’s Office found that two MCOs made $17 5 million in overpayments to providers in 2010, which may have increased the state’s 2013 capitation rates  The New York State Comptroller found that two MCOs paid over $6 6 million to excluded and deceased providers from 2011 through 2014  The Massachusetts State Auditor found that one MCO paid $420,000 for health care services and unauthorized prescriptions from excluded providers in 2013 and 2014  The Department of Justice alleged that an MCO operating in several states submitted inflated expenditure information to the state Medicaid agencies, falsified encounter data, and manipulated claims costs and service provision costs in nine states  The MCO agreed to pay over $137 5 million to resolve these claims  The Texas State Auditor’s Office found that an MCO reported $3 8 million in unallowable costs for advertising, company events, gifts, and stock options, along with $34 million in other questionable costs in 2015  The New York State Comptroller also found that an MCO claimed over $260,000 in unallowable administrative expenses, which contributed to an increase in capitation rates across the state  To the extent that the state does not identify or know of MCO overpayments to providers or unallowable MCO costs, the overpayments and unallowable costs could inflate future capitation rates, as the Washington State Auditor and New York State Comptroller noted in their findings  The PERM assesses the accuracy of capitated payments that states make to MCOs  States set capitation rates based on cost data— historical utilization and spending—that MCOs submit to the state Medicaid agencies, but the PERM does not consider these data  Unless removed from these cost data, unidentified overpayments and unallowable costs would likely inflate the MCO cost data that states use to set capitation rates  (See fig  1 ) As a result, future capitation rates would also be inflated, resulting in higher state and federal spending  In fiscal year 2017, the Medicaid managed care improper payment rate was 0 3 percent, while the FFS improper payment rate was 12 9 percent, leading to an assumption that the estimated risks in managed care are less significant than those estimated in FFS  However, the managed care component of the PERM does not determine whether MCO payments to providers were for services that were medically necessary, actually provided, accurately billed and delivered by eligible providers, or whether the MCO costs were allowable and appropriate  As a result, the PERM improper payment estimate potentially understates the extent of program integrity risks in Medicaid managed care  Moreover, this potential understatement in the PERM’s improper payment rate estimate may curtail investigations into the appropriateness of MCO spending  We previously reported that CMS and state program integrity efforts did not closely examine program integrity in Medicaid managed care, focusing primarily on payments and services delivered under FFS  Our current review of the 27 audits we identified encompassed a 5-year period, suggesting that reviews of managed care continue to be limited  An official from a state auditor’s office we spoke with suggested that some states may not audit services delivered under managed care, because of a low improper payment rate  In addition, he noted that his state Medicaid agency used the relatively low payment error rate in managed care as an indicator of few program integrity problems  As noted, CMS has increased its focus on and worked with states to improve oversight of Medicaid managed care; however, these efforts and the oversight efforts of states do not ensure the identification and reporting of overpayments and unallowable costs  In recent years, the agency has sought to strengthen oversight of managed care programs through updated regulations; reviews of states’ managed care programs (Focused Program Integrity Reviews) and collaborative audits, which are conducted jointly by federal program integrity contractors and states; and state monitoring of overpayments  Regulations  In May 2016, CMS updated its regulations for managed care programs in order to strengthen oversight  The updated regulations require a number of additional program integrity activities, such as those listed below  If fully implemented, these updated regulations may help with the identification and removal of overpayments and unallowable costs from data used to set future capitation rates  Under these regulations States must arrange for an independent audit of the accuracy, truthfulness, and completeness of the encounter and financial data submitted by MCOs, at least once every 3 years  Through contracts with MCOs, states must require MCOs to have a mechanism through which providers report and return overpayments to the MCOs  States must also require MCOs to promptly report any identified or recovered overpayments—specifying those that are potentially fraudulent—and submit an annual report on recovered overpayments to their state
Report 2:  CMS has taken steps to identify some fraud risks through several control activities that target areas the agency has designated as higher risk within Medicare and Medicaid, including specific provider types, such as home health agencies, and specific geographic locations  As discussed earlier, CMS officials told us that CPI initially focused on developing control activities for Medicare FFS and considers these activities to be the most mature of all CPI efforts to address fraud risks  CMS has identified fraud risks in the following selected examples, which are not an exhaustive list of its control activities  Data analytics to assist investigations in Medicare FFS  In 2011, CMS implemented FPS, a data-analytic system that screens all Medicare FFS claims to identify health-care providers with suspect billing patterns for further investigation  Medicare FFS contractors—ZPICs and UPICs— have used FPS to identify and prioritize leads for investigations of potential fraud by high-risk Medicare FFS providers  Contractors told us that FPS allows them to quickly identify and triage leads  CMS’s guidance requires contractors to prioritize investigations with the greatest program impact or urgency and identifies required criteria for prioritizing investigations, such as patient abuse or harm, multistate fraud, and high dollar amount of potential overpayments  One contractor we interviewed developed a risk-prioritization model that incorporated CMS’s required criteria, such as patient harm, as well as additional criteria, such as provider spikes in billing, into a tool that automatically creates a provider risk score to help the contractor focus and prioritize investigative resources  Prior authorization for Medicare FFS services or supplies  CMS published a final rule in December 2015 that identifies a master list of durable medical equipment, prosthetics, orthotics, and supplies for which CMS can require prior authorization before suppliers submit a Medicare FFS claim  In this rule, CMS identified 135 items that are frequently subject to unnecessary utilization and stated that the agency expects the final rule to result in savings in the form of reduced unnecessary utilization, fraud, waste, and abuse  Under this program, prior authorization is a condition of payment for claims  CMS can choose which items on the master list to subject to prior authorization  For example, in March 2017, it began requiring prior authorization for selected power wheelchairs in four states and expanded the prior authorization program for these items to all states in July 2017  CMS also began to test the use of prior authorization on a voluntary basis through a series of fixed-length demonstrations for items and services that have been associated with high levels of improper payments, including high incidences of fraud in some cases, and unnecessary utilization in certain geographic areas  For example, CMS began implementing a voluntary prior authorization demonstration in September 2012 for other power mobility devices, such as power scooters, in seven states where historically there has been extensive evidence of fraud and improper payments  CMS expanded the demonstration to an additional 12 states in October 2014, for a total of 19 states  According to the initial Federal Register notice, CMS planned to use the demonstration to develop improved methods for investigation and prosecution of fraud to protect federal funds from fraudulent actions and the resulting improper payments  Under the demonstration, providers and suppliers are encouraged—but not required—to submit a request for prior authorization for certain items before they provide the item to the beneficiary and submit a claim for payment  Revised provider screening and enrollment processes for Medicare FFS and Medicaid FFS  In response to PPACA, in 2011 CMS implemented a revised screening process for providers and suppliers who enroll in Medicare and Medicaid based on identified provider risk categories  CMS placed all Medicare provider and supplier types into one of three risk categories—limited, moderate, or high—based on its assessment of the potential risk of fraud, waste, and abuse each provider and supplier type poses  For example, CMS designated prospective (newly enrolling) home health agencies and prospective suppliers of durable medical equipment, prosthetics, orthotics, and supplies in the high-risk category  According to the final rule and our interviews with CMS officials, CMS developed these risk-based categories based on its review and synthesis of various information sources about the fraud risks posed by each provider and supplier type, including (1) the agency’s experience with claims data used to identify potentially fraudulent billing practices, (2) expertise of contractors responsible for investigating and identifying Medicare fraud, and (3) GAO and OIG reports  CMS designated specific screening activities for each risk category, with increased requirements for moderate- and high-risk provider and supplier types  For example, moderate- and high-risk providers and suppliers must receive preenrollment site visits, and high-risk providers and suppliers also are subject to fingerprint-based criminal-background checks  As part of the revised screening process, beginning in September 2011, CMS also undertook its first program-wide effort to rescreen, or revalidate, the enrollment records of about 1 5 million existing Medicare FFS providers and suppliers, to determine whether they remain eligible to bill Medicare  Temporary provider enrollment moratoriums for certain providers and geographic areas for Medicare FFS and Medicaid FFS  CMS identified certain provider types and geographic areas as high risk for fraud and used its authority under PPACA to implement temporary moratoriums to suspend enrollment of such Medicare and Medicaid providers in those areas  For example, in July 2016, CMS extended temporary moratoriums statewide on the enrollment of new Medicare Part B nonemergency ambulance suppliers and Medicare home health agencies statewide in six states, as applicable  The statewide moratoriums also apply to Medicaid  According to the Federal Register notice, CMS imposed the temporary moratoriums based on qualitative and quantitative factors suggesting a high risk of fraud, waste, or abuse, such as law-enforcement expertise with emerging fraud trends and investigations  CMS’s data analysis also confirmed the agency’s determination of a high risk of fraud, waste, and abuse for these provider and supplier types within certain geographic areas, according to the notice  Medicaid state program integrity reviews and desk reviews  CMS tailored state Medicaid program-integrity reviews to areas it identified as high risk for improper payments, such as personal care services, which may also be at high risk for fraud  In March 2017, we reported that, from fiscal years 2014 through 2016, CMS conducted focused reviews of state program-integrity efforts in 31 states, reviewing 10 or 11 states annually  For each state, CMS tailored its focused reviews to the state’s managed care plans and relevant other high-risk areas, including provider enrollment and screening, nonemergency medical transportation, and personal care services  CMS and state officials we spoke with as part of that work told us that the tailored oversight had been beneficial and helped identify areas for improvement  CMS has also initiated desk reviews of state program-integrity efforts  According to CMS, these desk reviews allow the agency to provide states with customized program- integrity oversight  Vulnerability tracking system for Medicare  CPI recently initiated an effort to centralize and formalize a vulnerability tracking process for Medicare, which could support identification of specific fraud risks, both in Medicare and possibly Medicaid  As described by CPI officials, the process aims to collect information on fraud-related vulnerabilities from CMS employees, contractors, and other sources, such as GAO and HHS OIG reports  The assess component of the Fraud Risk Framework calls for federal managers to plan regular fraud risk assessments and assess risks to determine a fraud risk profile  Furthermore, federal internal control standards call for agency management to assess the internal and external risks their entities face as they seek to achieve their objectives  The standards state that, as part of this overall assessment, management should consider the potential for fraud when identifying, analyzing, and responding to risks  The Fraud Risk Framework states that, in planning the fraud risk assessment, effective managers tailor the fraud risk assessment to the program by, among other things, identifying appropriate tools, methods, and sources for gathering information about fraud risks and involving relevant stakeholders in the assessment process  Fraud risk assessments that align with the Fraud Risk Framework involve (1) identifying inherent fraud risks affecting the program, (2) assessing the likelihood and impact of those fraud risks, (3) determining fraud risk tolerance, (4) examining the suitability of existing fraud controls and prioritizing residual fraud risks, and (5) documenting the results  (See fig  6 ) Although, as discussed earlier, CMS has identified some fraud risks posed by providers in Medicare FFS and, to a lesser degree, Medicaid FFS, the agency has not conducted a fraud risk assessment for either the Medicare or Medicaid program  Such a risk assessment would provide the detailed information and insights needed to create a fraud risk profile, which, in turn, is the basis for creating an antifraud strategy  According to CMS officials, CMS has not conducted a fraud risk assessment for Medicare or Medicaid because, within CPI’s broader approach of preventing and eliminating improper payments, its focus has been on addressing specific vulnerabilities among provider groups that have shown themselves particularly prone to fraud, waste, and abuse  With this approach, however, it is unlikely that CMS will be able to design and implement the most-appropriate control activities to respond to the full portfolio of fraud risks  A fraud risk assessment consists of discrete activities that build upon each other  Specifically: Identifying inherent fraud risks affecting the program  As discussed earlier, CMS has taken steps to identify fraud risks  However, CMS has not used a process to identify inherent fraud risks from the universe of potential vulnerabilities facing Medicare and Medicaid programs, including threats from various sources  According to CPI officials, most of the agency’s fraud control activities are focused on fraud risks posed by providers  The Fraud Risk Framework discusses fully considering inherent fraud risks from internal and external sources in light of fraud risk factors such as incentives, opportunities, and rationalization to commit fraud  For example, according to CMS officials, the inherent design of the Medicare Part C program may pose fraud risks that are challenging to detect  A fraud risk assessment would help CMS identify all sources of fraudulent behaviors, beyond threats posed by providers, such as those posed by health-insurance plans, contractors, or employees  Assessing the likelihood and impact of fraud risks and determining fraud risk tolerance  CMS has taken steps to prioritize fraud risks in some areas, but it has not assessed the likelihood or impact of fraud risks or determined fraud risk tolerance across all parts of Medicare and Medicaid  Assessing the likelihood and impact of inherent fraud risks would involve consideration of the impact of fraud risks on program finances, reputation, and compliance  Without assessing the likelihood and impact of risks in Medicare or Medicaid or internally determining which fraud risks may fall under the tolerance threshold, CMS cannot be certain that it is aware of the most-significant fraud risks facing these programs and what risks it is willing to tolerate based on the programs’ size and complexity  Examining the suitability of existing fraud controls and prioritizing residual fraud risks  CMS has not assessed existing control activities or prioritized residual fraud risks  According to the Fraud Risk Framework, managers may consider the extent to which existing control activities—whether focused on prevention, detection, or response—mitigate the likelihood and impact of inherent risks and whether the remaining risks exceed managers’ tolerance  This analysis would help CMS to prioritize residual risks and to determine mitigation approaches  For example, CMS has not established preventive fraud control activities in Medicare Part C  Using a fraud risk assessment for Medicare Part C and closely examining existing fraud control activities and residual risks, CMS could be better positioned to address fraud risks facing this growing program and develop preventive control activities  Further, without assessing existing fraud control activities and prioritizing residual fraud risks, CMS cannot be assured that its current control activities are addressing the most-significant risks  Such analysis would also help CMS determine whether additional, preferably preventive, fraud controls are needed to mitigate residual risks, make adjustments to existing control activities, and potentially scale back or remove control activities that are addressing tolerable fraud risks  Documenting the risk-assessment results in a fraud risk profile  CMS has not developed a fraud risk profile that documents key findings and conclusions of the fraud risk assessment  According to the Fraud Risk Framework, the risk profile can also help agencies decide how to allocate resources to respond to residual fraud risks  Given the large size and complexity of Medicare and Medicaid, a documented fraud risk profile could support CMS’s resource-allocation decisions as well as facilitate the transfer of knowledge and continuity across CMS staff and changing administrations  Senior CPI officials told us that the agency plans to start a fraud risk assessment for Medicare and Medicaid after it completes a separate fraud risk assessment of the federally facilitated marketplace  This fraud risk assessment for the federally facilitated marketplace eligibility and enrollment process is being conducted in response to a recommendation we made in February 2016  In April 2017, CPI officials told us that this fraud risk assessment was largely completed, although in September 2017 CPI officials told us that the assessment was undergoing agency review  CPI officials told us that they have informed CM and CMCS officials that there will be future fraud risk assessments for Medicare and Medicaid; however, they could not provide estimated timelines or plans for conducting such assessments, such as the order or programmatic scope of the assessments  Once completed, CMS could use the federally facilitated marketplace fraud risk assessment and apply any lessons learned when planning for and designing fraud risk assessments for Medicare and Medicaid  According to the Fraud Risk Framework, factors such as size, resources, maturity of the agency or program, and experience in managing risks can influence how the entity plans the fraud risk assessment  Additionally, effective managers tailor the fraud risk assessment to the program when planning for it  The large scale and complexity of Medicare and Medicaid as well as time and resources involved in conducting a fraud risk assessment underscore the importance of a well-planned and tailored approach to identifying the assessment’s programmatic scope  Planning and tailoring may involve decisions to conduct a fraud risk assessment for Medicare and Medicaid programs as a whole or divided into several subassessments to reflect their various component parts (e g , Medicare FFS, Medicaid managed care) as well as determining the timing and order of assessments (e g , concurrently or consecutively for Medicare and Medicaid)  CMS’s existing fraud risk identification efforts as well as communication channels with stakeholders could serve as a foundation for developing a fraud risk assessment for Medicare and Medicaid  The leading practices identified in the Fraud Risk Framework discuss the importance of identifying appropriate tools, methods, and sources for gathering information about fraud risks and involving relevant stakeholders in the assessment process  CMS’s fraud risk identification efforts discussed earlier could provide key information about fraud risks and their likelihood and impact  Further, existing relationships and communication channels across CMS and its extensive network of stakeholders could support building a comprehensive understanding of known and potential fraud risks for the purposes of a fraud risk assessment  For example, the fraud vulnerabilities identified through data analysis and information sharing with states, health-insurance plans, law-enforcement organizations, and contractors through the HFPP could inform a fraud risk assessment  CPI’s Command Center missions—facilitated collaboration sessions that bring together experts from various disciplines to improve the processes for fraud prevention in Medicare and Medicaid—could bring together experts to identify potential or emerging fraud vulnerabilities or to brainstorm approaches to mitigate residual fraud risks  As CMS makes plans to move forward with a fraud risk assessment for Medicare and Medicaid, it will be important to consider the frequency with which the fraud risk assessment would need to be updated  While, according to the Fraud Risk Framework, the time intervals between updates can vary based on the programmatic and operating environment, assessing fraud risks on an ongoing basis is important to ensure that control activities are continuously addressing fraud risks  The constantly evolving fraud schemes, the size of the programs in terms of beneficiaries and expenditures, as well as continual changes in Medicare and Medicaid programs—such as development of innovative payment models and increasing managed-care enrollment—call for constant vigilance and regular updates to the fraud risk assessment  The design and implement component of the Fraud Risk Framework calls for federal managers to design and implement a strategy with specific control activities to mitigate assessed fraud risks and collaborate to help ensure effective implementation  According to the Fraud Risk Framework, effective managers develop and document an antifraud strategy that describes the program’s approach for addressing the prioritized fraud risks identified during the fraud risk assessment, also referred to as a risk-based antifraud strategy  A risk- based antifraud strategy describes existing fraud control activities as well as any new fraud control activities a program may adopt to address residual fraud risks  In developing a strategy and antifraud control activities, effective managers focus on fraud prevention over detection, develop a plan for responding to identified instances of fraud, establish collaborative relationships with stakeholders, and create incentives to help effectively implement the strategy  Additionally, as part of a documented strategy, management identifies roles and responsibilities of those involved in fraud risk management activities; describes control activities as well as plans for monitoring and evaluation, creates timelines, and communicates the antifraud strategy to employees and stakeholders, among other things  As discussed earlier, CMS has some control activities in place to identify fraud risk in Medicare and Medicaid, particularly in the FFS program  However, CMS has not developed and documented a risk-based antifraud strategy to guide its design and implementation of new antifraud activities and to better align and coordinate its existing activities to ensure it is targeting and mitigating the most-significant fraud risks  Antifraud strategy  CMS officials told us that CPI does not have a documented risk-based antifraud strategy  Although CMS has developed several documents that describe efforts to address fraud, the agency has not developed a risk-based antifraud strategy for Medicare and Medicaid because, as discussed earlier, it has not conducted a fraud risk assessment that would serve as a foundation for such strategy  In 2016, CPI identified five strategic objectives for program integrity, which include antifraud elements and an emphasis on prevention  However, according to CMS officials, these objectives were identified from discussions with CMS leadership and various stakeholders and not through a fraud risk assessment process to identify inherent fraud risks from the universe of potential vulnerabilities, as described earlier and called for in the leading practices  These strategic objectives were presented at an antifraud conference in 2016, but were not announced publicly until the release of the Annual Report to Congress on the Medicare and Medicaid Integrity Programs for Fiscal Year 2015 in June 2017  Stakeholder relationships and communication  CMS has established relationships and communicated with stakeholders, but, without an antifraud strategy, stakeholders we spoke with lacked a common understanding of CMS’s strategic approach  Prior work on practices that can help federal agencies collaborate effectively calls for a strategy that is shared with stakeholders to promote trust and understanding  Once an antifraud strategy is developed, the Fraud Risk Framework calls for managers to collaborate to ensure effective implementation  Although some CMS stakeholders were able to describe various CMS program- integrity priorities and activities, such as home health being a fraud risk priority, the stakeholders could not communicate, articulate, or cite a common CMS strategic approach to address fraud risks in its programs  Incentives  The Fraud Risk Framework discusses creating incentives to help ensure effective implementation of the antifraud strategy once it is developed  Currently, some incentives within stakeholder relationships may complicate CMS’s antifraud efforts  As discussed earlier, CMS is a partner and provides oversight to states’ program-integrity functions  Officials from one state told us that they were reluctant to share their program vulnerabilities because CMS would use this information to later audit the state  Among contractors, CMS encourages information sharing through conferences and workshops; however, competition for CMS business among contractors can be a disincentive to information sharing  CMS officials acknowledged this concern and said that they expect contractors to share information related to fraud schemes, outcomes of investigations, and tips for addressing fraud, but not proprietary information such as algorithms to risk-score providers  Without developing and documenting an antifraud strategy based on a fraud risk assessment, as called for in the design and implement component of the Fraud Risk Framework, CMS cannot ensure that it has a coordinated approach to address the range of fraud risks and to appropriately target and allocate resources for the most-significant risks  Considering fraud risks to which the Medicare and Medicaid programs are most vulnerable, in light of the malicious intent of those who aim to exploit the programs, would help CMS to examine its current control activities and potentially design new ones with recognition of fraudulent behavior it aims to prevent  This focus on fraud is distinct from a broader view of program integrity and improper payments by considering the intentions and incentives of those who aim to deceive rather than well-intentioned providers who make mistakes  Also, continued growth of the programs, such as growth of Medicare Part C and Medicaid managed care, call for consideration of preventive fraud control activities across the entire network of entities involved  Further, considering the large size and complexity of Medicare and Medicaid and the extensive stakeholder network involved in managing fraud in the programs, a strategic approach to managing fraud risks within the programs is essential to ensure that a number of existing control activities and numerous stakeholder relationships and incentives are being aligned to produce desired results  Once developed, an antifraud strategy that is clearly articulated to various CMS stakeholders would help CMS to address fraud risks in a more coordinated and deliberate fashion  Thinking strategically about existing control activities, resources, tools, and information systems could help CMS to leverage resources while continuing to integrate Medicare and Medicaid program-integrity efforts along functional lines  A strategic approach grounded in a comprehensive assessment of fraud risks could also help CMS to identify future enhancements for existing control activities, such as new preventive capabilities for FPS or additional fraud factors in provider enrollment and revalidation, such as provider risk scoring, to stay in step with evolving fraud risks  The evaluate and adapt component of the Fraud Risk Framework calls for federal managers to evaluate outcomes using a risk-based approach and adapt activities to improve fraud risk management  Furthermore, according to federal internal control standards, managers should establish and operate monitoring activities to monitor the internal control system and evaluate the results, which may be compared against an established baseline  Ongoing monitoring and periodic evaluations provide assurances to managers that they are effectively preventing, detecting, and responding to potential fraud  CMS has established monitoring and evaluation mechanisms for its program-integrity activities that it could incorporate into an antifraud strategy  In Medicare, CMS has taken steps to measure the rate of fraud in a particular service area  We have previously reported that agencies may face challenges measuring outcomes of fraud risk management activities in a reliable way  These challenges include the difficulty of measuring the extent of deterred fraud, isolating potential fraud from legitimate activity or other forms of improper payments, and determining the amount of undetected fraud  Despite these challenges, CMS has taken steps to estimate a fraud baseline—meaning the rate of probable fraud—in the home health benefit  In fiscal year 2016, CMS conducted a pretest in the Miami-Dade area of Florida to evaluate its potential measurement approach that could later be used in a nationwide study of probable fraud among home health agencies  The pretest was not a random sample and was not intended to produce a rate of fraud, but instead was intended to test the interview instruments and data-collection methodology CMS might use in a study nationwide  CMS and its contractor collected information from home health agencies, the attending providers, and Medicare beneficiaries in the Miami-Dade area in order to test these interview instruments  CMS completed this pretest, but, according to CMS officials, the agency does not yet have plans to roll out a nationwide study that would estimate a probable fraud rate for the Medicare FFS home health benefit  In its 2015 annual report to Congress, CMS stated that “documenting the baseline amount of fraud in Medicare is of critical importance, as it allows officials to evaluate the success of ongoing fraud prevention activities ” CMS officials working on the pilot told us that having an estimate of the rate of fraud in home health benefits would allow CMS to reliably assess its efforts at eliminating or reducing fraud  Without a baseline, officials said, the agency cannot know whether its antifraud efforts are as effective as they could be  We previously reported that the lack of a baseline for the amount of health-care fraud that exists limits CMS’s ability to determine whether its activities are effectively reducing health care fraud and abuse  A baseline estimate could provide an understanding of the extent of fraud and, with additional information on program activities, could help to inform decision making related to allocation of resources to combat health-care fraud  As described in the Fraud Risk Framework, in the absence of a fraud baseline, agencies can gather additional information on the short-term or intermediate outcomes of some antifraud initiatives, which may be more readily measured  For example, CMS has developed some performance measures to provide a basis for monitoring its progress towards meeting the program-integrity goals set in the HHS Strategic Plan and Annual Performance Plan  Specifically, CMS measures whether it is meeting its goal of “increasing the percentage of Medicare FFS providers and suppliers identified as high risk that receive an administrative action ” CMS does not set specific antifraud goals for other parts of Medicare or Medicaid; other CMS performance measures relate to measuring or reducing improper payments in CHIP, Medicaid, and the various parts of Medicare  CMS uses return-on-investment and savings estimates to measure the effectiveness of its Medicare program-integrity activities and FPS  For example, CMS uses return-on-investment to measure the effectiveness of FPS and, in response to a recommendation we made in 2012, CMS developed outcome-based performance targets and milestones for FPS  CMS has also conducted individual evaluations of its program-integrity activities, such as an interim evaluation of the prior-authorization demonstration for power mobility devices that began in 2012 and is currently implemented in 19 states  Commensurate with greater maturity of control activities in Medicare FFS compared to other parts of Medicare and Medicaid, monitoring and evaluation activities for Medicare Parts C and D and Medicaid are more limited  For example, CMS calculates savings for its program-integrity activities in Medicare Parts C and D, but not a full return-on-investment  CMS officials told us that calculating costs for specific activities is challenging because of overlapping activities among contractors  CMS officials said they continue to refine methods and develop new savings estimates for additional program-integrity activities  According to the Fraud Risk Framework, effective managers develop a strategy and evaluate outcomes using a risk-based approach  In developing an effective strategy and antifraud activities, managers consider the benefits and costs of control activities  Ongoing monitoring and periodic evaluations provide reasonable assurance to managers that they are effectively preventing, detecting, and responding to potential fraud  Monitoring and evaluation activities can also support managers’ decisions about allocating resources, and help them to demonstrate their continued commitment to effectively managing fraud risks  As CMS takes steps to develop an antifraud strategy, it could include plans for refining and building on existing methods such as return-on- investment or savings measures, and setting appropriate targets to evaluate the effectiveness of all of CMS’s antifraud efforts  Such a strategy would help CMS to efficiently allocate program-integrity resources and to ensure that the agency is effectively preventing, detecting, and responding to potential fraud  For example, while doing so would involve challenges, CMS’s strategy could detail plans to advance efforts to measure a potential fraud rate through baseline and periodic measures  Fraud rate measurement efforts could also inform risk assessment activities, identify currently unknown fraud risks, align resources to priority risks, and develop effective outcome metrics for antifraud controls  Such a strategy would also help CMS ensure that it has effective performance measures in place to assess its antifraud efforts beyond those related to providers in Medicare FFS, and establish appropriate targets to measure the agency’s progress in addressing fraud risks  As CMS makes plans to move forward with a strategy and to further develop evaluation and monitoring mechanisms, it will be important to share its efforts with stakeholders  The Fraud Risk Framework states that effective managers communicate lessons learned from fraud risk management activities to stakeholders  For example, CMS could be a leader to states in measuring the effectiveness of program-integrity efforts  Officials in three of the four states we spoke with expressed interest in receiving CMS guidance on how to measure the effectiveness of their Medicaid program-integrity efforts, such as by providing models for how to calculate return-on-investment  Medicare and Medicaid provide health insurance to over 129 million Americans, but the size—in terms of number of beneficiaries and amount of expenditures—as well as complexity of these programs make them inherently susceptible to fraud and improper payments  CMS currently manages these risks across its programs as part of a broader approach to identifying and controlling for multiple sources of improper payments and by developing relationships with an extensive network of stakeholders  In Medicare and Medicaid specifically, we note that CMS has taken many important steps toward implementing a strategic approach for managing fraud  However, the agency could benefit by more fully aligning its efforts with the four components of the Fraud Risk Framework  CMS is well positioned to leverage its fraud risk management efforts— such as demonstrated leadership for combating fraud, existing control activities, and stakeholder relationships—to provide additional antifraud training, as well as to develop an antifraud strategy based on fraud risk assessments for Medicare and Medicaid  We recognize that the effort may be challenging, given the size and complexity of Medicare and Medicaid, and the need to balance antifraud activities with CMS’s other mission priorities  However, by not employing the actions identified in the Fraud Risk Framework and incorporating them in its approach to managing fraud risks, CMS is missing a significant opportunity to better ensure employee vigilance against fraud, and to organize and focus its many antifraud and program-integrity activities and related resources into a comprehensive strategy  Such a strategy would (1) provide reasonable assurance that CMS is targeting the most-significant fraud risks in its programs and (2) help protect the government’s substantial and growing investments in these programs  We are making the following three recommendations to CMS: The Administrator of CMS should provide fraud-awareness training relevant to risks facing CMS programs and require new hires to undergo such training and all employees to undergo training on a recurring basis  (Recommendation 1) The Administrator of CMS should conduct fraud risk assessments for Medicare and Medicaid to include respective fraud risk profiles and plans for regularly updating the assessments and profiles  (Recommendation 2) The Administrator of CMS should, using the results of the fraud risk assessments for Medicare and Medicaid, create, document, implement, and communicate an antifraud strategy that is aligned with and responsive to regularly assessed fraud risks  This strategy should include an approach for monitoring and evaluation  (Recommendation 3) We provided a draft of this report to HHS and DOJ for comment  HHS provided written comments, which are reprinted in appendix I  DOJ did not have comments  HHS and DOJ also provided technical comments, which we incorporated as appropriate  In commenting on this report, HHS agreed with our three recommendations  Specifically, in response to our first recommendation to provide required fraud-awareness training to all employees, HHS stated that it will develop and implement a fraud-awareness training plan to ensure all CMS employees receive training  Regarding our second recommendation to conduct fraud risk assessments for Medicare and Medicaid, HHS stated that it is currently conducting a fraud risk assessment on the federally facilitated marketplace and, when this assessment is complete, will apply the lessons learned in assessing this program to fraud risk assessments of Medicare and Medicaid  In response to our third recommendation to create, document, implement, and communicate an antifraud strategy that is aligned with and responsive to regularly assessed fraud risks, HHS stated that it will develop respective risk-based antifraud strategies after completing fraud risk assessments for Medicare and Medicaid  We are sending copies of this report to the Acting Secretary of Health and Human Services, the Administrator of CMS, the Assistant Attorney General for Administration at DOJ, as well as appropriate congressional committees and other interested parties  In addition, this report is available at no charge on the GAO website at http://www gao gov  If you or your staff members have any questions about this report, please contact me at (202) 512-6722 or bagdoyans@gao gov  Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report  GAO staff who made contributions to this report are listed in appendix II  In addition to the contact named above, Tonita Gillich (Assistant Director), Irina Carnevale (Analyst-in-Charge), Michael Duane, Laura Sutton Elsberg, and Catrin Jones made key contributions to this report  Also contributing to the report were Lori Achman, James Ashley, Colin Fallon, Leslie V  Gordon, Maria McMullen, Sabrina Streagle, and Shana Wallace 

ground_truth: Senators and Representatives are frequently asked to support or sponsor proposals recognizing historic events and outstanding achievements by individuals or institutions. Among the various forms of recognition that Congress bestows, the Congressional Gold Medal is often considered the most distinguished. Through this venerable tradition—the occasional commissioning of individually struck gold medals in its name—Congress has expressed public gratitude on behalf of the nation for distinguished contributions for more than two centuries. Since 1776, this award, which initially was bestowed on military leaders, has also been given to such diverse individuals as Sir Winston Churchill and Bob Hope, George Washington and Robert Frost, Joe Louis and Mother Teresa of Calcutta. Congressional gold medal legislation generally has a specific format. Once a gold medal is authorized, it follows a specific process for design, minting, and awarding. This process includes consultation and recommendations by the Citizens Coinage Advisory Commission (CCAC) and the U.S. Commission of Fine Arts (CFA), pursuant to any statutory instructions, before the Secretary of the Treasury makes the final decision on a gold medal's design. Once the medal has been struck, a ceremony will often be scheduled to formally award the medal to the recipient. In recent years, the number of gold medals awarded has increased, and some have expressed interest in examining the gold medal awarding process. Should Congress want to make such changes, several individual and institutional options might be available. The individual options include decisions made by Members of Congress as to what individual or groups might be honored; potential specification of gold medal design elements; and where gold medals for groups might be housed once the award is made. The institutional options could include House, Senate, or committee rules for the consideration of gold medal legislation and whether statutory standards on the number of gold medals issued per year or per Congress might be established for gold medals.

prompt_front: You are given two reports by the government agency.



Question: Write a one-page summary of the report 2.

Report 1: Since the late 1700s, Congress has expressed public gratitude to individuals and groups by awarding medals and other similar decorations  The first Congressional Gold Medals were issued by the Continental Congress  Since that time, Congress has awarded gold medals to express public gratitude for distinguished contributions, dramatize the virtues of patriotism, and perpetuate the remembrance of great events  This tradition of authorizing individually struck gold medals bearing the portraits or actions of honorees is rich with history  Although Congress has approved legislation stipulating specific requirements for numerous other awards and decorations, there are no permanent statutory provisions specifically relating to the creation of Congressional Gold Medals  When such an award has been deemed appropriate, Congress has, by special action, provided for the creation of a personalized medal to be given in its name  The first Congressional Gold Medals were issued by the Continental Congress  As initially conceived, Congressional Gold Medals were awards "imbued with the conviction that only the very highest achievements [were] entitled to such a distinction, and that the value of a reward is enhanced by its rarity!" At that time, the Continental Congress concluded there was no better way to honor "and preserve the memory of illustrious characters and splendid events than medals—whether we take into consideration the imperishable nature of the substance whence they are formed, the facility of multiplying copies, or the practice of depositing them in the cabinets of the curious " The first gold medals were struck in Paris under the direction of Colonel David Humphrey  Following a long-standing historical practice, Congress commissioned gold medals as tributes for what were considered to be the most distinguished achievements  Silver and bronze medals, and ceremonial swords, were awarded for less eminent, but still notable, accomplishments  However, only the gold medal has been continuously awarded to the present day  The first Congressional Gold Medal was authorized on March 25, 1776, for George Washington, then commander of the Continental Army, for his "wise and spirited conduct" in bringing about British evacuation of Boston  During the next 12 years, the Continental Congress authorized an additional six gold medals for Revolutionary military leaders  Table 1 lists the Congressional Gold Medals issued by the Continental Congress, the year, the awardee, and the reason the medal was authorized  The gold medal conferred upon Major Henry "Light Horse Harry" Lee for his "remarkable prudence" and "bravery" during the surprise raid of Paulus Hook, NJ, was the first to be struck in the United States  Following the ratification of the Constitution, the first two Congressional Gold Medals were given in 1800 to Captain Thomas Truxtun for his gallant effort during the action between the U S  frigate Constellation and the French ship La Vengeance and in 1805 to Commodore Edward Preble for gallantry and good conduct during the War with Tripoli  After those medals were awarded, Congress issued gold medals primarily for military achievements in the War of 1812 and the Mexican War  All told, 27 gold medals were awarded for the War of 1812, and a series of medals were awarded for expeditions led by Major General Zachary Taylor and Major General Winfield Scott in the Mexican War  General Taylor received three Congressional Gold Medals, while General Scott received one  In 1854, Congress began to broaden the scope of activities that merited a Congressional Gold Medal  This change was prompted by Commander Duncan N  Ingraham of the USS St  Louis 's rescue of Martin Koszta from illegal seizure and imprisonment about the Austrian war-brig Hussar   Subsequently, gold medals were issued to several individuals recognized for nonmilitary heroic activities or their work in specific fields  For example, in 1864 Cornelius Vanderbilt was honored for donating a steamship to the United States; in 1867 Cyrus W  Field was praised for his work in the laying of the transatlantic cable; and Private George F  Robinson was awarded for saving Secretary of State William H  Seward from an assassination attempt  At this time, Congress also established the Medal of Honor as a military award and increasingly focused the Congressional Gold Medal as an award for individuals and events  In the 20 th and 21 st centuries, Congress continued to broaden the scope of Congressional Gold Medals to include recognition of excellence in such varied fields as the arts, athletics, aviation, diplomacy, entertainment, exploration, medicine, politics, religion, and science  Several of the following individuals were the first in their specialties to be awarded gold medals: Composer George M  Cohan (1936) was the first entertainer to receive a gold medal, for his patriotic songs "Over There" and "A Grand Old Flag " Wilbur and Orville Wright (1909) were the first aeronautical or space pioneers to receive a gold medal, for their achievements in demonstrating to the world the potential of aerial navigation  Lincoln Ellsworth (1926) was the first explorer honored, for his polar flight in 1925 and transpolar flight in 1926  Major Walter Reed and his associates (1928) were the first scientists honored, for discovering the cause and means of transmission of yellow fever in 1921  Vice President Alben W  Barkley (1949) was the first political honoree  In the late 20 th and early 21 st centuries, numerous other individuals have been honored for a variety of contributions including civil rights activism and humanitarian contributions  For a complete list of Congressional Gold Medal recipients since 1776, see the Appendix   Once a Congressional Gold Medal bill is introduced, it is typically referred to the House Committee on Financial Services or the Senate Committee on Banking, Housing, and Urban Affairs  The process for considering legislation varies between the House and Senate  In the House, there are currently no chamber or committee rules regarding the procedures for gold medal bills  In some past Congresses, the House Financial Services Committee had adopted a committee rule that prohibited its Domestic Monetary Policy and Technology Subcommittee from holding a hearing on commemorative medal legislation—including Congressional Gold Medals—"unless the legislation is cosponsored by at least two-thirds of the members of the House " Informal practices regarding cosponosrship requirements, however, may still exist  In the Senate, the Banking, Housing, and Urban Affairs Committee in the 116 th Congress requires that at least 67 Senators cosponsor any Congressional Gold Medal bill before being considered by the committee  This committee rule presumably does not formally preclude committee consideration of a House bill referred to it  The committee rule also does not prevent the Senate from considering or passing gold medal legislation  Referred bills may be brought to the floor without committee consideration; in other cases, a bill may avoid being referred to committee at all  In current practice, many enacted gold medal bills receive no formal committee consideration  Rather, the Senate often discharges the committee of the bill by unanimous consent; however, it appears that this discharge practice only occurs after the requisite number of cosponsors sign on to a Senate bill  Although Congress has approved legislation stipulating requirements for numerous other awards and decorations, there are no permanent statutory provisions specifically relating to the creation of Congressional Gold Medals  When a Congressional Gold Medal has been deemed appropriate, Congress has, by legislative action, provided for the creation of a medal on an ad hoc basis  Additionally, there is no statutory limit on the number of Congressional Gold Medals that may be struck in a given year  Congressional Gold Medal legislation generally has certain features, including findings that summarize the subject's history and importance; specifications for awarding the medal; instructions, if any, for the medal's design and striking; permission to mint and sell duplicates; and certification that medals are minted pursuant to existing requirements for national medals (5 U S C  §5111)  Congressional Gold Medal legislation typically includes a section of findings  These often include historical facts about the people or groups being awarded the medal  For example, the legislation to authorize the Congressional Gold Medal to the World War II members of the "Doolittle Tokyo Raiders" stated the following: Congressional Gold Medal legislation typically includes a section that provides details on the presentation, design, and striking of the medal  For example, the legislation to authorize the Congressional Gold Medal to the Foot Soldiers who participated in Bloody Sunday, Turnaround Tuesday, or the final Selma to Montgomery Voting Rights March in March of 1965 stated the following: Additionally, this section can contain specific instructions to the Smithsonian, when it is the recipient of the physical gold medal, on its display and availability to be loaned to other institutions  For example, the legislation authorizing the American Fighter Aces Congressional Gold Medal stated the following: Gold medal legislation also generally authorizes the Secretary of the Treasury to strike and sell duplicate medals in bronze  The duplicates are generally sold in two sizes: 1 5 inches and 3 inches  Duplicates are sold at a price which allows the U S  Mint to cover the cost of striking the gold medal  For example, legislation authorizing the 65 th Infantry Regiment, known as the Borinqueneers, Congressional Gold Medal stated the following: Gold medal legislation generally contains a statement that these awards are considered as national medals for the purpose of the U S  Mint's statutory requirements for producing medals  For example, legislation authorizing the Montford Point Marines Congressional Gold Medal stated the following: In some cases, authorizing legislation includes language authorizing appropriations for a Congressional Gold Medal  In these examples, Congress has authorized a specific sum from the United States Mint Public Enterprise Fund to pay for the cost of the medal  In cases where the authorization of appropriations is provided, a provision requiring that proceeds from the sale of duplicates be deposited in the same Fund is generally included  For example, legislation authorizing the Women Airforce Service Pilots Congressional Gold Medal stated the following: Congressional Gold Medal designs vary for each issuance  In general, the authorizing legislation provides that the Secretary of the Treasury "shall strike a gold medal with suitable emblems, devices, and inscriptions, to be determined by the Secretary " When designing a Congressional Gold Medal, the Secretary consults with the Citizens Coinage Advisory Commission (CCAC) and the U S  Commission of Fine Arts (CFA) before determining the final design  Established by P L  108-15 , the CCAC advises the Secretary of the Treasury on theme and design of all U S  coins and medals  For Congressional Gold Medals, the CCAC advises the Secretary "on any theme or design proposals relating to     Congressional Gold Medals " The CCAC consists of 11 members appointed by the Secretary of the Treasury, with four persons appointed upon the recommendation of the congressional leadership (one each by the Speaker of the House, the House minority leader, the Senate majority leader, and the Senate minority leader)  The CCAC meets several times each year to consider design suggestions for coins and medals  For each coin considered, the CCAC provides advice to the Secretary "on thematic, technical, and design issues related to the production of coins " Recommendations are then published to the committee's website, at http://www ccac gov   In tandem with recommendations received from the CCAC, the U S  Mint also seeks a recommendation from the U S  Commission of Fine Arts  Established in 1910, the CFA advises "upon the location of statues, fountains, and monuments in the public squares, streets, and parks in the District of Columbia; the selection of models for statues, fountains, and monuments erected under the authority of the Federal Government; the selection of artists; and questions of art generally when required to do so by the President or a committee of Congress " This includes review of commemorative coins when they are presented by the U S  Mint and the issuance of recommendations for a coin's design  For example, in March 2014, the U S  Mint presented several alternative designs for the First Special Service Force Congressional Gold Medal  In a letter to the U S  Mint, the CFA provided recommendations on the design for the gold medal  CFA's letter stated the following: After receiving advice from the CCAC and the CFA, the Secretary of the Treasury, through the U S  Mint, finalizes the coin's design and schedules it for production  Figure 1 shows the final design of two Congressional Gold Medals: the New Frontier Gold Medal for Neil Armstrong, Michael Collins, Buzz Aldrin, and John Glenn; and the Jack Nicklaus Gold Medal  As Members of Congress contemplate introducing legislation, and the House or the Senate potentially consider Congressional Gold Medal measures, there are several issues that could be considered  These can be divided into issues for individual Members of Congress with respect to individual Congressional Gold Medals, and issues for Congress as an institution  Individual issues include choices Members may make about which people or groups might be honored and whether specific design elements might be specified statutorily  Institutional issues might include committee or chamber rules on the consideration of Congressional Gold Medals and creating standards for the issuance of gold medals  Some Congressional Gold Medals have honored individuals (e g , Arnold Palmer, Muhammad Yunus), some discrete groups of individuals (e g , General of the Army George Catlett Marshall and Fleet Admiral Ernest Joseph King, Ruth and Billy Graham), and some larger groups (e g , military units such as Women Airforce Service Pilots ["WASP"], Monuments Men)  In choosing whom or what to recognize, Members of Congress generally evaluate whether they believe that the individual's or group's activities merit recognition by Congress  Congressional Gold Medals are "the highest civilian honor award program     [to] honor national achievement in patriotic, humanitarian, and artistic endeavors " There are no specific criteria to determine whether or not an individual or group meets those lofty goals  Instead, each individual or group is judged on their merits by Congress should the legislation be considered  Congressional Gold Medal authorizations generally do not specify design elements  Instead, they direct the Secretary of the Treasury to "strike a gold medal with suitable emblems, devices, and inscriptions to be determined by the Secretary " Should Congress want to specify particular design elements, they might be included in the authorizing legislation  This would provide the Secretary of the Treasury with congressional intent on what should be incorporated into the gold medal design  Similar statutory specificity is sometimes included in commemorative coin legislation  Such specification, however, could serve to limit design choices for the gold medal and might alter the cost structure of striking the award, if the required element diverges from standard practices  Congressional Gold Medal legislation for groups generally provides that only a single gold medal is struck and specifies where it will be located after it is formally awarded  In many cases, the gold medal is given to the Smithsonian for appropriate display and where it can be made available for research  In other cases, the gold medal is provided to an organization that represents the honored group  Since most gold medal legislation contains a provision on the medal's location, a Member of Congress can help determine where the medal will be located  As discussed above under " Authorizing Congressional Gold Medals ," neither the House nor Senate rules provide any restrictions specifically concerning consideration of Congressional Gold Medal legislation on the House or Senate floor  In the 116 th Congress, the Senate Committee on Banking, Housing, and Urban Affairs requires that at least 67 Senators must cosponsor any Senate Congressional Gold Medal bill before being considered by the committee  Currently, the House Financial Services Committee has not adopted any specific rules concerning committee consideration of Congressional Gold Medal legislation, although it has required a minimum number of cosponsors in past Congresses for committee consideration  As demonstrated by the discontinuation of the House Financial Services Committee rule requiring a minimum number of cosponsors for committee gold medal legislation, committee rules can be changed from Congress to Congress  Should the committee want to place requirements on its consideration of gold medal legislation, the Financial Services Committee could readopt its former rule, or something similar  Adopting committee rules to require a minimum number of cosponsors might encourage bill sponsors to build support among Representatives for gold medal bills  Such a minimum requirement, however, could potentially limit the number or type of gold medal bills the committee considers  Since only the Senate Committee on Banking, Housing, and Urban Affairs has a rule that imposes a formal qualification on the potential committee consideration of gold medal legislation, the possible path forward for a bill can be different within each chamber  Should the House, the Senate, or both want to adopt similar language for committee or chamber consideration of gold medal legislation, such language could be incorporated into future committee rules, into House and Senate Rules, or into law  Taking steps to formally codify the gold medal consideration process might provide sponsors with a single process for award consideration, which could make it easier for gold medal bills to meet minimum requirements for consideration across both the House and Senate  Such codification could also limit congressional flexibility and might result in fewer proposals or authorizations to comply with new standards  Currently, there is no statutory limit to the number of Congressional Gold Medals that can be authorized  Should Congress want to place a limit on the number of gold medals awarded, standards could be adopted to provide a maximum number of gold medals authorized in any year or Congress  Congress has previously adopted similar standards for commemorative coins—only two coins may be minted in any given calendar year  Legislation to place a limit on the number of gold medals authorized has previously been introduced and considered in the House  During the 109 th Congress (2005-2006), H R  54 passed the House and would have restricted the Secretary of the Treasury from striking "more than 2 congressional gold medals for presentation     in any calendar year " Introduced by Representative Michael Castle, the stated purpose of the legislation was to "maintain the prestige of the medal by limiting the number that may be awarded each year," and to "clarify that recipients are individuals and not groups " Passage of the measure, he argued, would "ensure the future integrity and true honor of the award " H R  54 did not receive further consideration in the Senate  While proponents of a limit on the number of gold medals issued might make arguments similar to those made by Representative Castle, opponents believe that Congress should reserve the right to authorize as many gold medals as it deems necessary, without consideration of the number struck in any calendar year  Representative Joseph Crowley in opposing the legislation told his House colleagues, "We are rushing to act on an issue that does not represent a problem " "Who that received this medal in the past," he asked, "was not worthy of it?" Further, Crowley argued that "there are occasions when more than one person is justified to receive the medal for their honorable actions in tandem with others " He continued by emphasizing that had this bill already been law, "Congress would not have been able to issue" a Congressional Gold Medal "to the Little Rock Nine," to "President and Mrs  Reagan," or to "Martin Luther King and Coretta Scott King " Congressional Gold Medals have long been an important way for Congress to express public gratitude for important historical events and achievements  Congressional Gold Medals, which have been issued since the American Revolution, are "the highest civilian honor award program     [to] honor national achievement in patriotic, humanitarian, and artistic endeavors " In recent years, the number of gold medals awarded has "soared from four or five per decade for most of its history to an average of almost twenty in the 1980s, 1990s, and 2000s " Each Congress, legislation to award Congressional Gold Medals is introduced  In the 113 th Congress (2013-2014), 52 bills were introduced, 34 in the House and 18 in the Senate, to award a gold medal  In the 114 th Congress (2015-2016), 52 bills were introduced, 38 in the House and 14 in the Senate  In the 115 th Congress (2017-2018), 55 bills were introduced, 33 in the House and 22 in the Senate  Based on the number of measures offered in both chambers, some Members of Congress clearly feel it is important to recognize individuals and groups for their patriotic, humanitarian, and artistic achievements  Several considerations appear important when Members decide to introduce gold medal legislation  These include who should be honored, how many medals should be awarded in a given Congress, and whether specific design elements should be prescribed for the medal design  As Congress continues to consider legislation to award future gold medals, these considerations and others will likely be important factors for issuing the award 


Report 2:  States must use this information when setting actuarially sound capitation rates  Through contracts with MCOs, states must also require MCOs to report specific data, information, and documentation  In addition, the MCO’s chief executive officer or authorized representative must certify the accuracy and completeness of the reported data, information, and documentation  States must enroll MCO providers that are not otherwise enrolled with the state to provide services to enrollees in Medicaid FFS, and revalidate the enrollment at least once every 5 years  Initially this requirement was to start for MCO contracts beginning on July 1, 2018  Subsequently enacted legislation codified this requirement in statute and moved the implementation to January 1, 2018  It is too early to know if these regulations will assure better oversight of MCO payments to providers and the data used to set future capitation rates  The above program integrity requirements only went into effect recently—for contracts starting on or after July 1, 2017, and January 1, 2018  In addition, CMS issued a notice in June 2017 stating that the agency will use its enforcement discretion to assist states that are unable to implement new requirements by the required compliance date  Also, CMS has delayed issuance of implementing guidance for certain provisions until the agency completes its review, a step that may further delay states’ implementation  The agency has designated Medicaid managed care for “deregulatory action” and plans to propose a new rule, but has not indicated which of these provisions, if any, would be revised  Focused Program Integrity Reviews  In fiscal year 2014, CMS implemented its Focused Program Integrity Reviews in order to target high-risk program integrity areas in each state, including managed care  As we previously reported, these focused reviews are narrower in scope than the prior reviews conducted by CMS, but they still involve on-site visits to states  In its focused reviews of managed care, CMS found that several states had incomplete oversight of MCO payments to providers, even though the agency relies on states to verify reported MCO overpayments and to ensure the overpayments are excluded from the data used to set capitation rates  In the 27 focused reviews of managed care from 2014 to 2017, CMS found that MCOs in 17 states reported fewer overpayments to their state Medicaid agencies than CMS would expect  For example, MCOs in at least 5 states reported that overpayments were less than 0 1 percent of their total managed care expenditures; while CMS noted in 1 focused review that overpayments typically equal 1 to 10 percent of total expenditures in managed care  CMS also found that 5 of the 27 states did not verify that MCOs excluded overpayments from these data, and 1 state did not exclude overpayments from the capitation rate setting  This is consistent with our March 2017 report in which we noted that CMS commonly found that MCOs reported low amounts of recovered overpayments and conducted few reviews to identify overpayments  Also, officials from three of the five states we interviewed for that report said the focused reviews gave them leverage in dealing with MCOs or led MCOs to focus more on program integrity  We also reported that CMS officials recommended states take steps to improve their oversight of MCOs, based on the focused review findings  The findings from CMS’s focused reviews of managed care also highlight the need for greater federal oversight of states  Without these reviews, it is unclear if states would independently identify MCOs’ reporting of overpayments or work to strengthen MCO reporting  Yet, CMS has not yet published the focused reviews of managed care in 13 states, and it may only conduct a focused review in a state once every three or more years  Given CMS’s timeline for the focused reviews, it may take years to determine if corrective actions result in improved program integrity in services delivered through managed care  Collaborative audits  CMS has expanded the federal-state collaborative audits beyond FFS, and has begun to engage states to participate in collaborative audits of MCOs and providers under contract to MCOs  As a part of the collaborative audit process, the state volunteers to jointly develop the audit processes the federal contractors follow  CMS officials told us that federal contractors have completed 14 collaborative audits of providers under contract to MCOs in three states—Arizona, the District of Columbia, and Tennessee  Only the audit of Trusted Healthcare, an MCO in the District of Columbia, has been published  That audit identified $129,000 in overpayments in a sample of MCO payments to providers, which, if generalized to all of the MCO’s payments over 6 months, would equate to over $4 million in overpayments  According to CMS, three additional states—Louisiana, Nebraska, and New Hampshire—have shown interest in collaborative audits of their MCOs, although such audits require states to prepare data files for the federal contractor and commit staff time  In our March 2017 report, we found that states’ participation in FFS collaborative audits varied and some states reported barriers to their participation  Expanding collaborative audits in managed care will require commitment from and coordination with states  State monitoring of overpayments in managed care  States are required to report overpayments they have identified and recouped along with state expenditures on a quarterly basis  However, based on the responses of the program integrity officials in 13 of the 16 states we contacted, most officials were unable to define the magnitude of overpayments in their managed care programs, which may signify a need for greater federal oversight or coordination  Specifically, officials in 7 of the 13 states could not or did not identify the share of total reported Medicaid overpayments that occurred in managed care  In 11 of the 13 states, officials responded that they did not directly monitor MCO payments to providers  Of those 11 states, officials in 4 said they depend on MCOs to report overpayments and exclude the overpayments from the data used to set capitation rates  As long as states are not taking action to identify overpayments in managed care, they cannot be assured that they are accurately paying MCOs for medically necessary services provided to enrollees  Federal internal control standards call for agency management to identify, analyze, and respond to risks  CMS has taken some steps to identify, analyze, and respond to risks through its regulations, Focused Program Integrity Reviews, and collaborative audits  However, key CMS and state oversight efforts fall short of mitigating the limitations of the PERM estimates of improper payments for managed care, because they do not ensure the identification and reporting of overpayments to providers and unallowable MCO costs  Without addressing these key risks, CMS and states cannot ensure the integrity of Medicaid managed care programs  The 0 3 percent improper payment rate for Medicaid managed care, as measured by the PERM, is significantly lower than the improper payment rate of 12 9 percent for Medicaid FFS  However, this difference does not signal better oversight; rather, it represents differences in the review criteria between FFS and managed care, which result in a less complete accounting for the program integrity risks in managed care  The PERM does not account for key program integrity risks in Medicaid managed care: specifically, unidentified overpayments and unallowable costs  One federal investigation of an MCO operating in nine states resulted in a settlement of $137 5 million to resolve allegations of false claims that were not captured in the national Medicaid improper payment rate estimate  Further, CMS found that MCOs and states do not provide sufficient oversight in Medicaid managed care to address the risks that are not accounted for in the PERM, findings that are reinforced by our reports on Medicaid managed care program integrity  CMS has taken steps to improve its oversight of Medicaid managed care, yet these efforts fall short of ensuring that the agency and states will be able to identify and address overpayments to providers and unallowable MCO costs  Without better measurement of program risks—particularly as expenditures for Medicaid managed care continue to grow—CMS cannot be certain that the low improper payment rate for managed care, as measured by the PERM, accurately reflects lower risks in managed care  The Administrator of CMS should consider and take steps to mitigate the program risks that are not measured in the PERM, such as overpayments and unallowable costs; such an effort could include actions such as revising the PERM methodology or focusing additional audit resources on managed care  (Recommendation 1) We provided a draft of this report to the Department of Health and Human Services (HHS) for comment  In its written comments, HHS concurred with our recommendation, and indicated that it will review regulatory authority and audit resources to determine the best way to account for Medicaid program risks that are not accounted for in the PERM  However, HHS stated that the PERM is not intended to measure all Medicaid program integrity risks, and utilizing the PERM measurement in that way would be a misunderstanding and misuse of the reported rate  HHS also commented that a review of payments from MCOs to providers is outside the scope of IPIA  In addition, HHS asserted that including such a review would diminish the value of PERM reporting—because it would require significant assumptions about the amount of federal share in MCO payments to providers  Further, HHS maintained that such a review also would result in a measurement that was not comparable to other programs or agencies, which would diminish the value of government- wide improper payment rate reporting  We acknowledge that the current PERM methodology has been approved by OMB  However, we maintain that the PERM likely underestimates program integrity risks in Medicaid managed care  To ensure the appropriate targeting of program integrity activities, CMS needs better information about these risks  Given the size of the Medicaid program, its vulnerability to improper payments, and the growth in managed care, it is critical to have a full accounting of program integrity risks in managed care in order to best ensure the integrity of the whole Medicaid program  In its written comments, HHS also summarized several activities it uses to oversee and support states’ Medicaid program integrity efforts, including state program integrity reviews; collaborative audits conducted by federal contractors; Medicaid Integrity Institute training for state employees; and the Medicaid Provider Enrollment Compendium  HHS also provided technical comments, which we incorporated as appropriate  HHS’s comments are reprinted in appendix II  As agreed with your offices, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date  At that time, we will send copies to the Secretary of Health and Human Services, the Administrator of CMS, appropriate congressional committees, and other interested parties  In addition, the report will be available at no charge on the GAO website at http://www gao gov  If you or your staff members have any questions about this report, please contact me at (202) 512-7114 or at yocomc@gao gov  Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report  GAO staff that made key contributions to this report are listed in appendix III  We reviewed 16 federal and state audits and 11 notices of investigations of Medicaid managed care organizations (MCO) and providers issued from January 2012 to September 2017  As the findings below show, the audits and investigations represent a limited number of reviews that, in many cases, focused on individual states and individual providers or MCOs within that state  Given the limited scope and number of states reviewed, the amount of the overpayments and unallowable costs occurring nationwide is unknown  These audits and investigations show cases of MCO overpayments to providers or unallowable costs, which are not accounted for by the Centers for Medicare & Medicaid Services’ Payment Error Rate Measurement (PERM) ; errors in capitated payments (e g , capitated payments made for deceased individuals), which are accounted for in the PERM; and gaps in managed care oversight  When reporting overpayments and unallowable costs identified in the audits and investigations, we only include amounts specifically attributed to MCOs in our total  This total does not include the following: overpayments and unallowable costs identified in those audits and investigations that did not distinguish between the amounts attributable to MCOs, Medicaid fee-for-service, or Medicare; overpayments and unallowable costs identified in criminal proceedings that are not yet resolved; and errors in capitated payments, as those payments would be reviewed by the PERM  As a result, the total amount of overpayments and unallowable costs and capitated payment errors in this appendix exceed what we report  In addition to the contact named above, Leslie V  Gordon (Assistant Director), Pauline Adams (Analyst-in-Charge), Erika Huber, and Drew Long made key contributions to this report  Also contributing were Muriel Brown and Jennifer Whitworth 

ground_truth: The improper payment rate is a sentinel measure of program integrity risks for the Medicaid program. CMS and the states oversee Medicaid, whose size, structure, and diversity make it vulnerable to improper payments. CMS estimates the Medicaid improper payment rate annually through its PERM, which includes an estimate for Medicaid managed care, in which states contract with MCOs to provide services to Medicaid enrollees. GAO was asked to study the PERM methodology for managed care. In this report, GAO examined the extent to which the PERM accounts for program integrity risks in Medicaid managed care, including CMS's and states' oversight. GAO identified program integrity risks reported in 27 federal and state audits and investigations issued between January 2012 and September 2017; reviewed federal regulations and guidance on the PERM and CMS's Focused Program Integrity Reviews; and contacted program integrity officials in the 16 states with a majority of 2016 Medicaid spending for managed care, as well as CMS officials and program integrity experts. The Centers for Medicare & Medicaid Services' (CMS) estimate of improper payments for Medicaid managed care has limitations that are not mitigated by the agency's and states' current oversight efforts. One component of the Payment Error Rate Measurement (PERM) measures the accuracy of capitated payments, which are periodic payments that state Medicaid agencies make to managed care organizations (MCO) to provide services to enrollees and to cover other allowable costs, such as administrative expenses. However, the managed care component of the PERM neither includes a medical review of services delivered to enrollees, nor reviews of MCO records or data. Further, GAO's review of the 27 federal and state audits and investigations identified key program risks. Ten of the 27 federal and state audits and investigations identified about $68 million in overpayments and unallowable MCO costs that were not accounted for by PERM estimates; another of these investigations resulted in a $137.5 million settlement. These audits and investigations were conducted over more than 5 years and involved a small fraction of the more than 270 MCOs operating nationwide as of September 2017. To the extent that overpayments and unallowable costs are unidentified and not removed from the cost data used to set capitation rates, they may allow inflated MCO payments and minimize the appearance of program risks in Medicaid managed care. CMS and states have taken steps to improve oversight of Medicaid managed care through updated regulations, focused reviews of states' managed care programs, and federal program integrity contractors' audits of managed care services. However, some of these efforts went into effect only recently, and others are unlikely to address the risks in managed care across all states. Furthermore, these efforts do not ensure the identification and reporting of overpayments to providers and unallowable costs by MCOs. Federal internal control standards call for agency management to identify and respond to risks. Without addressing key risks, such as the extent of overpayments and unallowable costs, CMS cannot be certain that its estimated improper payment rate for managed care (0.3 percent compared with 12.9 percent in Medicaid fee-for-service) accurately reflects program risks. The Administrator of CMS should consider and take steps to mitigate the program risks that are not measured in the PERM, such as overpayments and unallowable costs; such an effort could include actions such as revising the PERM methodology or focusing additional audit resources on managed care. HHS concurred with this recommendation. HHS also provided technical comments, which were incorporated as appropriate.