FRAUD DETECTION 

SYSTEMS

Centers for Medicare and 

Medicaid Services Needs to 

Expand Efforts to Support 

Program Integrity Initiatives

Statement of Valerie C. Melvin, Director

Information Management 

 and Technology Resources Issues

Testimony before the Subcommittees on 

Government Organization, Efficiency and Financial 

Management; and Health Care, District of Columbia, 

Census and the National Archives; Committee on 

Oversight and Government Reform, 

House of Representatives

For Release on Delivery 

Expected at 10:00 a.m. EST

Wednesday, December 7, 2011

GAO-12-292T

United States Government Accountability Office

GAO
 United States Government Accountability Office 

Accountability • Integrity • Reliability 

Highlights of GAO-12-292T, a testimony for 

Subcommittees of the Committee on 

Oversight and Government Reform, 

House of Representatives 

December 2011 

FRAUD DETECTION SYSTEMS 

Centers for Medicare and Medicaid Services Needs 

to Expand Efforts to Support Program Integrity 

Initiatives 

Why GAO Did This Study 

The Centers for Medicare and 

Medicaid Services (CMS) is 

responsible for administering and 

safeguarding its programs from loss of 

funds. As GAO reported in June 2011, 

CMS utilizes automated systems and 

tools to help improve the detection of 

improper payments for fraudulent, 

wasteful, and abusive claims. To 

integrate claims information and 

improve its ability to detect fraud, 

waste, and abuse in these programs, 

CMS initiated two information 

technology system programs: the 

Integrated Data Repository (IDR) and 

One Program Integrity (One PI). 

GAO was asked to testify on its June 

2011 report that examined CMS’s 

efforts to protect the integrity of the 

Medicare and Medicaid programs 

through the use of information 

technology (GAO-11-475). In that prior 

study, GAO assessed the extent to 

which IDR and One PI have been 

developed and implemented, and 

CMS’s progress toward achieving its 

goals and objectives for using these 

systems to detect fraud, waste, and 

abuse. 

What GAO Recommends 

GAO recommended in June 2011 that 

CMS take actions to finalize plans and 

schedules for achieving widespread 

use of IDR and One PI, and to define 

measurable benefits. CMS concurred 

with GAO’s recommendations. 

What GAO Found 

GAO previously reported that CMS had developed and begun using both IDR and 

One PI, but had not incorporated into IDR all data as planned. IDR is intended to 

be the central repository of Medicare and Medicaid data needed to help CMS and 

states’ program integrity staff and contractors prevent and detect improper 

payments. Program integrity analysts use these data to identify patterns of unusual 

activities or transactions that may indicate fraudulent charges or other types of 

improper payments. IDR has been operational and in use since September 2006 

but did not include all the data that were planned to be incorporated by fiscal year 

2010. For example, IDR included most types of Medicare claims data, but not the 

Medicaid data needed to help analysts detect improper payments of Medicaid 

claims. According to program officials, these data were not incorporated because 

of obstacles introduced by technical issues and delays in funding. Until the agency 

finalizes plans and develops reliable schedules for efforts to incorporate these 

data, CMS may face additional delays in making available all the data that are 

needed to support enhanced Medicare and Medicaid program integrity efforts. 

Additionally, CMS had not taken steps to ensure widespread use of One PI to 

enhance efforts to detect fraud, waste, and abuse. One PI is a web-based portal 

that is to provide CMS staff and contractors, and Medicaid analysts with a single 

source of access to data contained in IDR, as well as tools for analyzing those 

data. While One PI had been developed and deployed to users, no Medicaid 

analysts and only a few Medicare program integrity analysts were trained and 

using the system. Specifically, One PI program officials planned for 639 program 

integrity analysts, including 130 Medicaid analysts, to be using the system by the 

end of fiscal year 2010; however, as of October 2010, only 41—less than 7 

percent—were actively using the portal and tools. According to program officials, 

the agency’s initial training plans were insufficient and, as a result, they were not 

able to train the intended community of users. Until program officials finalize plans 

and develop reliable schedules for training users and expanding the use of One PI, 

the agency may continue to experience delays in reaching widespread use of the 

system. 

While CMS had made progress toward its goals to provide a single repository of 

data and enhanced analytical capabilities for program integrity efforts, the agency 

was not yet positioned to identify, measure, and track benefits realized from its 

efforts. As a result, it was unknown whether IDR and One PI as implemented had 

provided financial benefits. According to IDR officials, they did not measure 

benefits realized from increases in the detection rate for improper payments 

because they relied on business owners to do so; One PI officials stated that, 

because of the limited use of that system, there were not enough data to 

measure and gauge the program’s success toward achieving the $21 billion in 

financial benefits that the agency projected. 

View GAO-12-292T or key components. 

For more information, contact Valerie Melvin 

at (202) 512-6304 or melvinv@gao.gov. 
Page 1 GAO-12-292T 

Chairmen Platts and Gowdy, Ranking Members Towns and Davis, and 

Members of the Subcommittees:

I am pleased to participate in today’s hearing on fraud and improper 

payments in the Medicaid program. At your request, my testimony will 

focus on our report earlier this year that examined the Centers for 

Medicare and Medicaid Services’ (CMS) efforts to protect the integrity of 

the Medicare and Medicaid programs through the use of information 

technology. Specifically, in June 2011 we reported on CMS’s utilization of 

automated systems and tools to help improve the detection of fraudulent, 

wasteful, and abusive claims that contribute to the billions of taxpayers’ 

dollars lost each year to improper payments within these programs.1

Operating within the Department of Health and Human Services, CMS 

conducts reviews to prevent improper payments before Medicare and 

Medicaid claims are paid and to detect claims that were paid in error. 

These activities are predominantly carried out by contractors who, along 

with CMS personnel, use various information technology solutions to 

consolidate and analyze data to help identify the improper payment of 

claims. For example, these program integrity analysts may use software 

tools to access data about claims and then use those data to identify 

patterns of unusual activities by attempting to match services with 

patients’ diagnoses.

In 2006, CMS initiated activities to centralize and make more accessible 

the data needed to conduct these analyses and to improve the analytical 

tools available to its own and contractor analysts. Our June 2011 report 

discussed two of these initiatives—the Integrated Data Repository (IDR), 

which is intended to provide a single source of data related to Medicare 

and Medicaid claims, and the One Program Integrity (One PI) system, a 

web-based portal2

 

1

GAO, Fraud Detection Systems: Centers for Medicare and Medicaid Services Needs to 

Ensure More Widespread Use, 

and suite of analytical software tools used to extract 

data from IDR and enable complex analyses of these data. According to 

CMS officials responsible for developing and implementing IDR and One 

PI, the agency had spent approximately $161 million on these initiatives 

by the end of fiscal year 2010. 

GAO-11-475 (Washington, D.C.: June 30, 2011).

2

The One PI portal is a web-based user interface that enables a single login through 

centralized, role-based access to the system.

 
Page 2 GAO-12-292T 

My testimony summarizes the results of our prior study, which specifically 

assessed the extent to which IDR and One PI had been developed and 

implemented, and CMS’s progress toward achieving its goals and 

objectives for using these systems to detect fraud, waste, and abuse. The 

information presented is based primarily on our previous work at CMS.

Additional information on our scope and methodology is available in the 

issued report.3 We also obtained and conducted a review of more recent 

documentation pertaining to the agency’s efforts to develop and 

implement the systems. We conducted this work in support of our 

testimony during November and December 2011 at CMS headquarters in 

Baltimore, Maryland. All work on which this testimony is based was 

conducted in accordance with generally accepted government auditing 

standards. 

Like financial institutions, credit card companies, telecommunications 

firms, and other private sector companies that take steps to protect 

customers’ accounts, CMS uses information technology to help predict or 

detect cases of improper claims and payments. For more than a decade, 

the agency and its contractors have used automated software tools to 

analyze data from various sources to detect patterns of unusual activities 

or financial transactions that indicate payments could be made for 

fraudulent charges or improper payments. For example, to identify 

unusual billing patterns and support investigations and referrals for 

prosecutions of cases, analysts and investigators access information 

about key actions taken to process claims as they are filed and the 

specific details about claims already paid. This would include accessing 

information on claims as they are billed, adjusted, and paid or denied; 

check numbers on payments of claims; and other specific information that 

could help establish provider intent.

CMS uses many different means to store and manipulate data and, since 

the establishment of the agency’s program integrity initiatives in the 

1990s, has built multiple disparate databases and analytical software 

tools to meet individual and unique needs of various programs within the 

agency. In addition, data on Medicaid claims are scattered among the 

states in multiple systems and data stores, and are not readily available 

to CMS. According to agency program documentation, these 

 

3

GAO-11-475. 

Background
Page 3 GAO-12-292T 

geographically distributed, regional approaches to storing and analyzing 

data result in duplicate data and limit the agency’s ability to conduct 

analyses of data on a nationwide basis.

CMS has been working for most of the past decade to consolidate its 

disparate data and analytical tools. The agency’s efforts led to the IDR 

and One PI programs, which are intended to provide CMS and its 

program integrity contractors with a centralized source of Medicare and 

Medicaid data and a web-based portal and set of analytical tools by which 

these data can be accessed and analyzed to help detect cases of fraud, 

waste, and abuse.

In 2006, CMS officials expanded the scope of a 3-year-old data 

modernization strategy to not only modernize data storage technology, 

but also to integrate Medicare and Medicaid data into a centralized

repository so that CMS and its partners could access the data from a 

single source. They called the expanded program IDR.

According to program officials, the agency’s vision was for IDR to become 

the single repository for CMS’s data and enable data analysis within and 

across programs. Specifically, this repository was to establish the 

infrastructure for storing data related to Medicaid and Medicare Parts A, 

B, and D claims processing,4

Initial program plans and schedules also included the incorporation of 

additional data from legacy CMS claims-processing systems that store 

as well as a variety of other agency 

functions, such as program management, research, analytics, and 

business intelligence. CMS envisioned an incremental approach to 

incorporating data into IDR. Specifically, it intended to incorporate data 

related to paid claims for Medicare Part D by the end of fiscal year 2006, 

and for Medicare Parts A and B by the end of fiscal year 2007. The 

agency also planned to begin to incrementally add all Medicaid data for 

the 50 states in fiscal year 2009 and to complete this effort by the end of 

fiscal year 2012.

 

4

Medicare Part A provides payment for inpatient hospital, skilled nursing facility, some 

home health, and hospice services, while Part B pays for hospital outpatient, physician, 

some home health, durable medical equipment, and preventive services. Further, all 

Medicare beneficiaries may purchase coverage for outpatient prescription drugs under 

Medicare Part D. 

CMS’s Initiative to Develop 

a Centralized Source of 

Medicare and Medicaid 

Data
Page 4 GAO-12-292T 

and process data related to the entry, correction, and adjustment of 

claims as they are being processed, along with detailed financial data 

related to paid claims. According to program officials, these data, called 

“shared systems” data, are needed to support the agency’s plans to 

incorporate tools to conduct predictive analysis of claims as they are 

being processed, helping to prevent improper payments. Shared systems 

data, such as check numbers and amounts related to claims that have 

been paid, are also needed by law enforcement agencies to help with 

fraud investigations. CMS initially planned to have all the shared systems 

data included in IDR by July 2008.

Table 1, presented in our prior report, summarized CMS’s original 

planned dates and actual dates for incorporating the various types of data 

into IDR as of the end of fiscal year 2010.

Table 1: Data Incorporated into IDR as of the End of Fiscal Year 2010

Type of data Original planned date Actual date

Medicare Part D January 2006 January 2006

Medicare Part B September 2007 May 2008

Medicare Part A September 2008 May 2008

Shared systems July 2008 Not incorporated (planned for 

November 2011)

Medicaid for 5 states September 2009 Not incorporated (planned for 

September 2014)

Medicaid for 20 states September 2010 Not incorporated (planned for 

September 2014)

Medicaid for 35 states September 2011 Not incorporated (planned for 

September 2014)

Medicaid for 50 states September 2012 Not incorporated (planned for 

September 2014)

Source: GAO analysis of CMS data.

Also in 2006, CMS initiated the One PI program with the intention of 

developing and implementing a portal and software tools that would 

enable access to and analysis of claims, provider, and beneficiary data 

from a centralized source. The agency’s goal for One PI was to support 

the needs of a broad program integrity user community, including agency 

program integrity personnel and contractors who analyze Medicare claims 

data, along with state agencies that monitor Medicaid claims. To achieve 

its goal, CMS officials planned to implement a tool set that would provide 

a single source of information to enable consistent, reliable, and timely 

CMS’s Initiative to Develop 

and Implement Analytical 

Tools for Detecting Fraud, 

Waste, and Abuse
Page 5 GAO-12-292T 

analyses and improve the agency’s ability to detect fraud, waste, and 

abuse. These tools were to be used to gather data from IDR about 

beneficiaries, providers, and procedures and, combined with other data, 

find billing aberrancies or outliers. For example, an analyst could use 

software tools to identify potentially fraudulent trends in ambulance 

services by gathering the data about claims for ambulance services and 

medical treatments, and then use other software to determine 

associations between the two types of services. If the analyst found 

claims for ambulance travel costs but no corresponding claims for 

medical treatment, it might indicate that further investigation could prove 

that the billings for those services were fraudulent. 

According to agency program planning documentation, the One PI 

system was also to be developed incrementally to provide access to IDR 

data, analytical tools, and portal functionality. CMS planned to implement 

the One PI portal and two analytical tools for use by program integrity 

analysts on a widespread basis by the end of fiscal year 2009. The 

agency engaged contractors to develop the system.

IDR had been in use by CMS and its contractors who conduct Medicare 

program integrity analysis since September 2006 and incorporated data 

related to claims for reimbursement of services under Medicare Parts A, 

B, and D. According to program officials, the integration of these data into 

IDR established a centralized source of data previously accessed from 

multiple disparate system files.

However, although the agency had been incorporating data from various 

data sources since 2006, our prior report noted that IDR did not include 

all the data that were planned to be incorporated by the end of 2010 and 

that are needed to support enhanced program integrity initiatives. For 

example, IDR did not include the Medicaid data that are critical to 

analysts’ ability to detect fraud, waste, and abuse in this program. While 

program officials initially planned to incorporate 20 states’ Medicaid data 

into IDR by the end of fiscal year 2010, the agency had not incorporated 

any of these data into the repository. Program officials told us that the 

original plans and schedules for obtaining Medicaid data did not account 

for the lack of funding for states to provide Medicaid data to CMS, or the 

variations in the types and formats of data stored in disparate state 

Medicaid systems. Consequently, the officials were not able to collect the 

data from the states as easily as they expected and did not complete this 

activity as originally planned.

IDR and One PI Were 

in Use, but Lacked

Data and 

Functionality 

Essential to CMS’s 

Program Integrity 

Efforts
Page 6 GAO-12-292T 

In December 2009, CMS initiated another agencywide program intended 

to, among other things, identify ways to collect Medicaid data from the 

many disparate state systems and incorporate the data into a single data 

store. As envisioned by CMS, this program, the Medicaid and Children’s 

Health Insurance Program Business Information and Solutions (MACBIS) 

program, was to include activities in addition to providing expedited 

access to current data from state Medicaid programs. According to 

agency planning documentation, as a result of efforts to be initiated under 

the MACBIS program, CMS would incorporate Medicaid data for all 50 

states into IDR by the end of fiscal year 2014.

However, program officials had not defined plans and reliable schedules 

for incorporating these data into IDR. Until the agency does so, it cannot 

ensure that current development, implementation, and deployment efforts 

will provide the data and technical capabilities needed to enhance efforts 

to detect potential cases of fraud, waste, and abuse.

In addition to the Medicaid data, initial program integrity requirements 

included the incorporation of the shared systems data by July 2008; 

however, all of these data had not been added to IDR. According to IDR 

program officials, the shared systems data were not incorporated as 

planned because funding for the development of the software and 

acquisition of the hardware needed to meet this requirement was not 

approved until the summer of 2010. Subsequently, IDR program officials 

developed project plans and identified user requirements. In updating us 

on the status of this activity, the officials told us in November 2011 that 

they began incorporating shared systems data in September 2011 and 

plan to make them available to program integrity analysts in spring 2012.

Beyond the IDR initiative, CMS program integrity officials had not taken 

appropriate actions to ensure the use of One PI on a widespread basis for 

program integrity purposes. According to program officials, the system was 

deployed to support Medicare program integrity goals in September 2009 

as originally planned and consisted of a portal that provided web-based 

access to software tools used by CMS and contractor analysts to retrieve 

and analyze data stored in IDR. As implemented, the system provided 

access to two analytical tools—a commercial off-the-shelf decision support 

tool that is used to perform data analysis to, for example, detect patterns of 

activities that may identify or confirm suspected cases of fraud, waste, or 

abuse, and another tool that provides users extended capabilities to 

perform more complex analyses of data. For example, it allows the user to 
Page 7 GAO-12-292T 

customize and create ad hoc queries of claims data across the three 

Medicare plans.

However, while program officials deployed the One PI portal and two

analytical tools, the system was not being used as widely as planned 

because CMS and contractor analysts had not received the necessary 

training. In this regard, program planning documentation from August 

2009 indicated that One PI program officials had planned for 639 analysts 

to be trained and using the system by the end of fiscal year 2010, 

including 130 analysts who conduct reviews of Medicaid claims.5

Further, no Medicaid analysts had been trained to use the system. While 

the use of One PI cannot be fully optimized for Medicaid integrity 

purposes until the states’ Medicaid claims data are incorporated into IDR, 

the tools provided by the system could be used to supplement data 

currently available to Medicaid program integrity analysts and to enhance 

their ability to detect payments of fraudulent claims. For example, with 

training, Medicaid analysts may be able to compare data from their state 

systems to Medicare claims data in IDR to identify duplicate claims for the 

same service.

However, CMS confirmed that by the end of October 2010, only 42 

Medicare analysts who were intended to use One PI had been trained, 

with 41 actively using the portal and tools. These users represented fewer 

than 7 percent of the users originally intended for the program.

Program officials responsible for implementing the system acknowledged 

that their initial training plans and efforts had been insufficient and that 

they had consequently initiated activities and redirected resources to 

redesign the One PI training plan in April 2010; they began to implement 

the new training program in July of that year.

As we reported in June, One PI officials stated that 62 additional analysts 

had signed up to be trained in 2011, and that the number of training 

classes for One PI had been increased from two to four per month. 

Agency officials, in commenting on our report, stated that since January 

 

5

This group of analysts included state Medicaid program integrity personnel along with 

CMS analysts who implement the Medi-Medi data match program. This program was 

established in 2001 and was designed to identify improper billing and utilization patterns 

by matching Medicare and Medicaid claims information on providers and beneficiaries to 

reduce fraudulent schemes that cross program boundaries.
Page 8 GAO-12-292T 

2011, 58 new users had been trained; however, they did not identify an 

increase in the number of actual users of the system.6

Nonetheless, while these activities indicated some progress toward 

increasing the number of One PI users, the number of users reported to 

be trained and using the system represented a fraction of the population 

of 639 intended users. Moreover, One PI program officials had not yet 

made detailed plans and developed schedules for completing training of 

all the intended users. Agency officials concurred with our conclusion that 

CMS needed to take more aggressive steps to ensure that its broad 

community of analysts is trained, including those who conduct analyses of 

Medicaid claims data. Until it does so, the use of One PI may remain 

limited to a much smaller group of users than the agency intended and 

CMS will continue to face obstacles in its efforts to deploy One PI for 

widespread use throughout its community of program integrity analysts.

Because IDR and One PI were not being used as planned, CMS officials

were not in a position to determine the extent to which the systems were 

providing financial benefits or supporting the agency’s initiatives to meet 

program integrity goals and objectives. As we have reported, agencies 

should forecast expected benefits and then measure actual financial 

benefits accrued through the implementation of IT programs.7 Further, the 

Office of Management and Budget (OMB) requires agencies to report 

progress against performance measures and targets for meeting them 

that reflect the goals and objectives of the programs.8

 

6

In further updating these data, on November 30, 2011, CMS officials reported to us that a 

total of 215 program integrity analysts had been trained and were using One PI, including 

51 Medi-Medi and state Medicaid analysts. However, we did not validate the data 

provided to us by program officials on November 30, 2011.

To do this, 

performance measures should be outcome-based and developed with 

stakeholder input, and program performance must be monitored, 

measured, and compared to expected results so that agency officials are 

7

GAO, Secure Border Initiative: DHS Needs to Reconsider Its Proposed Investment in 

Key Technology Program, GAO-10-340 (Washington, D.C.: May 5, 2010) and DOD

Business Systems Modernization: Planned Investment in Navy Program to Create 

Cashless Shipboard Environment Needs to be Justified and Better Managed, 

GAO-08-922 (Washington, D.C.: Sept. 8, 2008). 

8

Office of the President, Office of Management and Budget, Guide to the Program 

Assessment Rating Tool (Washington, D.C.: January 2008).

CMS Was Not Yet 

Positioned to Identify 

Financial Benefits or 

to Fully Meet Program 

Integrity Goals and 

Objectives through 

the Use of IDR and 

One PI
Page 9 GAO-12-292T 

able to determine the extent to which goals and objectives are being met. 

In addition, industry experts describe the need for performance measures 

to be developed with stakeholders’ input early in a project’s planning 

process to provide a central management and planning tool and to 

monitor the performance of the project against plans and stakeholders’ 

needs.

While CMS had shown some progress toward meeting the programs’ 

goals of providing a centralized data repository and enhanced analytical 

capabilities for detecting improper payments due to fraud, waste, and 

abuse, the implementation of IDR and One PI did not yet position the 

agency to identify, measure, and track financial benefits realized from 

reductions in improper payments as a result of the implementation of 

either system. For example, program officials stated that they had 

developed estimates of financial benefits expected to be realized through 

the use of IDR. Their projection of total financial benefits was reported to 

be $187 million, based on estimates of the amount of improper payments 

the agency expected to recover as a result of analyzing data provided by 

IDR. With estimated life cycle program costs of $90 million through fiscal 

year 2018, the resulting net benefit expected from implementing IDR was 

projected to be $97 million. However, as of March 2011, program officials 

had not identified actual financial benefits of implementing IDR.

Further, program officials’ projection of financial benefits expected as a 

result of implementing One PI was reported to be approximately $21 

billion. This estimate was increased from initial expectations based on 

assumptions that accelerated plans to integrate Medicare and Medicaid 

data into IDR would enable One PI users to identify increasing numbers 

of improper payments sooner than previously estimated, thus allowing the 

agency to recover more funds that have been lost due to payment errors.

However, the implementation of One PI had not yet produced outcomes 

that positioned the agency to identify or measure financial benefits. CMS 

officials stated at the end of fiscal year 2010—more than a year after 

deploying One PI—that it was too early to determine whether the program 

had provided any financial benefits. They explained that, since the 

program had not met its goal for widespread use of One PI, there were 

not enough data available to quantify financial benefits attributable to the 

use of the system. These officials said that as the user community 

expanded, they expected to be able to begin to identify and measure 

financial and other benefits of using the system.
Page 10 GAO-12-292T 

In addition, program officials had not developed and tracked outcomebased performance measures to help ensure that efforts to implement 

One PI and IDR would meet the agency’s goals and objectives for 

improving the results of its program integrity initiatives. For example, 

outcome-based measures for the programs would indicate improvements 

to the agency’s ability to recover funds lost because of improper 

payments of fraudulent claims. However, while program officials defined 

and reported to OMB performance targets for IDR related to some of the 

program’s goals, they did not reflect the goal of the program to provide a 

single source of Medicare and Medicaid data that supports enhanced 

program integrity efforts. Additionally, CMS officials had not developed 

quantifiable measures for meeting the One PI program’s goals. For 

example, performance measures and targets for One PI included 

increases in the detection of improper payments for Medicare Parts A and 

B claims. However, the limited use of the system had not generated 

enough data to quantify the amount of funds recovered from improper 

payments.

Moreover, measures of One PI’s program performance did not accurately 

reflect the existing state of the program. Specifically, indicators to be 

measured for the program included the number of states using One PI for 

Medicaid integrity purposes and decreases in the Medicaid payment error 

rate; however, One PI did not have access to those data because they 

were not yet incorporated into IDR.

Because it lacked meaningful outcome-based performance measures and 

sufficient data for tracking progress toward meeting performance targets, 

CMS did not have the information needed to ensure that the systems 

were useful to the extent that benefits realized from their implementation

could help the agency meet program integrity goals. Until the agency is 

better positioned to identify and measure financial benefits and 

establishes outcome-based performance measures to help gauge 

progress toward meeting program integrity goals, it cannot be assured 

that the systems will contribute to improvements in CMS’s ability to detect 

and prevent fraud, waste, and abuse, and improper payments of 

Medicare and Medicaid claims.
Page 11 GAO-12-292T 

Given the critical need for CMS to reduce improper payments within the 

Medicare and Medicaid programs, we included in our June 2011 report a 

number of recommended actions that we consider vital to helping the 

agency achieve more widespread use of IDR and One PI for program 

integrity purposes. Specifically, we recommended that the Administrator 

of CMS

• finalize plans and develop schedules for incorporating additional data 

into IDR that identify all resources and activities needed to complete 

tasks and that consider risks and obstacles to the IDR program;

• implement and manage plans for incorporating data in IDR to meet 

schedule milestones;

• establish plans and reliable schedules for training all program integrity 

analysts intended to use One PI; 

• establish and communicate deadlines for program integrity 

contractors to complete training and use One PI in their work;

• conduct training in accordance with plans and established deadlines 

to ensure schedules are met and program integrity contractors are 

trained and able to meet requirements for using One PI;

• define any measurable financial benefits expected from the 

implementation of IDR and One PI; and

• with stakeholder input, establish measurable, outcome-based 

performance measures for IDR and One PI that gauge progress 

toward meeting program goals.

In commenting on a draft of our report, CMS agreed with the 

recommendations and indicated that it planned to take steps to address 

the challenges and problems that we identified during our study.

In conclusion, CMS’s success toward meeting goals to enhance program 

integrity efforts through the use of IDR and One PI depends upon the 

incorporation of all needed data into IDR, and effective use of the 

systems by the agency’s broad community of Medicare and Medicaid 

program integrity analysts. It is also essential that the agency identify 

measurable financial benefits and performance goals expected to be 

attained through improvements in its ability to prevent and detect 

CMS Needs to Take 

Actions to Achieve 

Widespread Use of 

IDR and One PI 
Page 12 GAO-12-292T 

fraudulent, wasteful, and abusive claims and resulting improper 

payments. In taking these steps, the agency will better position itself to 

determine whether these systems are useful for enhancing CMS’s ability 

to identify fraud, waste, and abuse and, consequently, reduce the loss of 

billions of dollars to improper payments of Medicare and Medicaid claims.

Chairmen Platts and Gowdy, Ranking Members Towns and Davis, and 

Members of the Subcommittees, this concludes my prepared statement. I 

would be pleased to answer any questions that you may have.

If you have questions concerning this statement, please contact Valerie 

C. Melvin, Director, Information Management and Technology Resources 

Issues, at (202) 512-6304 or melvinv@gao.gov. Other individuals who 

made key contributions include Teresa F. Tucker (Assistant Director), 

Amanda C. Gill, and Lee A. McCracken.

GAO Contact and 

Staff 

Acknowledgments

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