MEDICAID

Federal Oversight of 

Payments and Program 

Integrity Needs 

Improvement 

Statement of Carolyn L. Yocom 

Director, Health Care

Testimony 

Before the Subcommittees on Health Care, District of Columbia, 

Census and the National Archives and Regulatory Affairs, 

Stimulus Oversight and Government Spending, Committee on 

Oversight and Government Reform, House of Representatives 

For Release on Delivery 

Expected at 9:30 a.m. EDT

Wednesday, April 25, 2012

GAO-12-674T

United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-12-674T, a testimony before 

the Subcommittees on Health Care, District of 

Columbia, Census and the National Archives and 

Regulatory Affairs, Stimulus Oversight and 

Government Spending, Committee on Oversight and 

Government Reform, House of Representatives

April 25, 2012

MEDICAID

Federal Oversight of Payments and Program 

Integrity Needs Improvement

Why GAO Did This Study

Medicaid, a joint federal-state health 

care program, financed care for 

about 67 million people at a cost of 

$401 billion in fiscal year 2010. At the 

federal level, CMS, an agency within 

the Department of Health and Human 

Services, is responsible for overseeing 

the design and operations of states’ 

Medicaid programs, while the states 

administer their respective programs’ 

day-to-day operations. The shared 

financing arrangement between the 

federal government and the states 

presents challenges for program 

oversight and Medicaid has been on 

GAO’s list of high-risk programs since 

2003, in part, because of concerns 

about the fiscal management of the 

program. Our prior work has shown 

that CMS continues to face challenges 

overseeing the Medicaid program.

GAO was asked to testify on CMS’s 

oversight of Medicaid. GAO’s 

testimony is based on prior work 

conducted from June 1993 through 

December 2011 related to CMS’s 

oversight of (1) states’ rate setting 

methodologies for certain managed 

care arrangements, particularly the 

requirements that rates be actuarially 

sound; (2) supplemental payments, 

which are payments made to certain 

providers that are separate from and in 

addition to standard Medicaid 

payments for services; and 

(3) program integrity, which focuses on 

ensuring that payments made are in 

the correct amount, to the correct 

provider, for an eligible beneficiary.

What GAO Found

Oversight of managed care rate-setting has been inconsistent. In August 

2010, GAO reported that the Centers for Medicare & Medicaid Services (CMS) 

had not ensured that all states were complying with the managed care actuarial 

soundness requirements that rates be developed in accordance with actuarial 

principles, appropriate for the population and services, and certified by actuaries. 

For example, GAO found significant gaps in CMS’s oversight of 2 of the 26 states

reviewed—CMS had not reviewed one state’s rates in multiple years and had not 

completed a full review of another state’s rates since the actuarial soundness 

requirements became effective. Variation in practices across CMS regional 

offices contributed to these gaps and other inconsistencies in the agency’s 

oversight of states’ rate setting. GAO’s previous work also found that CMS’s 

efforts to ensure the quality of the data used to set rates were generally limited to 

requiring assurances from states and health plans—efforts that did not provide 

the agency with enough information to ensure the quality of the data used. With 

limited information on data quality, CMS cannot ensure that states’ managed 

care rates are appropriate, which places billions of federal and state dollars at 

risk for misspending. GAO made recommendations to improve CMS’s oversight.

Oversight of supplemental payments needs improvement. GAO has reported 

on varied financing arrangements involving supplemental payments—

disproportionate share hospital (DSH) payments states are required to make to 

certain hospitals, and other non-DSH supplemental payments—that increase 

federal funding without a commensurate increase in state funding. GAO’s work 

has found that while a variety of federal legislative and CMS actions have helped 

curb inappropriate financing arrangements, gaps in oversight remain. For 

example, while there are federal requirements designed to improve transparency 

and accountability for state DSH payments, similar requirements are not in 

place for non-DSH supplemental payments, which may be increasing. From 

2006 to 2010, state-reported non-DSH supplemental payments increased from 

$6.3 billion to $14 billion; however, according to CMS officials, reporting was 

likely incomplete. GAO made numerous recommendations aimed at improving 

oversight of supplemental payments.

Challenges exist related to CMS’s role ensuring program integrity. In 

December 2011, GAO testified that the key challenge CMS faced in 

implementing the statutorily established federal Medicaid Integrity Program was 

ensuring effective coordination to avoid duplicating state program integrity efforts, 

particularly in the area of auditing provider claims. GAO found that overpayments 

identified by its audit contractors since fiscal year 2009 were not commensurate 

with its contractors’ costs, and CMS reported in 2011 that it was redesigning its 

audit program to achieve better results. Data limitations may have hampered the 

contractors’ ability to identify improper claims beyond what states had already 

identified. With regard to CMS’s other core oversight activities—annual 

assessments and triennial comprehensive state program integrity reviews—GAO 

found that much of the information collected from the annual assessments 

duplicated information collected during triennial reviews. Finally, CMS’s Medicaid 

Integrity Institute, a national training program, appears to promote effective state 

coordination and collaboration. 

View GAO-12-674T. For more information, 

contact Carolyn L. Yocom at (202) 512-7114 

or yocomc@gao.gov.
 

Page 1 GAO-12-674T 

Chairmen Gowdy and Jordan, Ranking Members Davis and Kucinich, and 

Members of the Subcommittees:

I am pleased to be here today as you explore oversight of Medicaid—a 

joint federal-state program that in 2010 financed health care for about 

67 million people. Given the size and complexity of this $401 billion 

program, the federal government and its state partners continue to face 

challenges finding the proper balance between states’ flexibility to 

administer their Medicaid programs and the shared federal-state 

responsibility to manage program finances efficiently and economically. 

Ensuring the program’s long-term sustainability is critical as Medicaid 

plays a crucial and growing role in providing health care coverage for a 

variety of vulnerable populations, including certain low-income children, 

families, and individuals who are aged or disabled.

Medicaid is jointly funded by the federal and state governments. At the 

federal level, the Centers for Medicare & Medicaid Services (CMS), an 

agency within the Department of Health and Human Services (HHS), is 

responsible for overseeing the design and operations of states’ Medicaid 

programs, while the states administer their respective programs’ day-today operations. Within broad federal requirements, states have some 

flexibility in deciding the range of medical services to provide, which 

individuals to cover, and the amount to pay providers. The federal 

government matches state expenditures for most Medicaid services using 

the Federal Medical Assistance Percentage, a statutory formula that is 

based, in part, on each state’s per capita income.1

The shared financing arrangement between the federal government and 

the states, however, presents challenges for program oversight and 

requires sustained vigilance on the part of CMS and the Congress. Our 

prior work has shown that CMS continues to face challenges overseeing 

the fiscal management of the Medicaid program. Because of concerns 

about the program’s fiscal management, size, growth, and diversity, 

Medicaid has been on GAO’s list of high-risk programs since 2003.2

 

1

Under this statutory formula, the federal government’s share of Medicaid expenditures 

can range from 50 to 83 percent.

2

See GAO, High-Risk Series: An Update, GAO-11-278 (Washington, D. C.: Feb. 2011).

 
 

Page 2 GAO-12-674T 

You asked GAO to testify today on our previous work related to CMS’s 

oversight of the Medicaid program. My remarks will focus on our findings 

related to CMS’s oversight of the following three areas of the Medicaid 

program:

1. states’ rate-setting methodologies for capitated managed care 

arrangements, particularly the statutory and regulatory requirements 

that rates be actuarially sound;3

2. supplemental payments, which are payments made to certain 

providers that are separate from and in addition to standard Medicaid 

payments for services; and

3. program integrity, which focuses on ensuring that payments made are 

in the correct amount, to the correct provider, for an eligible 

beneficiary.

My testimony is based on our previous work assessing federal oversight 

of Medicaid managed care rate-setting, and supplemental payment 

arrangements, as well as our work assessing CMS’s program integrity 

activities. We conducted this body of work from June 1993 through 

December 2011 in accordance with generally accepted government 

auditing standards. Those standards require that we plan and perform the 

audit to obtain sufficient, appropriate evidence to provide a reasonable 

basis for our findings and conclusions based on our audit objectives.

The federal government and the states share responsibilities for financing 

and administering Medicaid. As a result of flexibility in the program’s 

design, Medicaid consists of 56 distinct state-based programs.4

 

3

See 42 U.S.C. § 1396b(m)(2)(A)(iii), 42 C.F.R. 438.6(c).

The 

challenges inherent in overseeing a program of Medicaid’s size and 

diversity make the program vulnerable to inappropriate program 

spending. CMS is responsible for overseeing state Medicaid programs. 

For example, CMS is responsible for ensuring that states’ capitated 

managed care payments meet actuarial soundness requirements, that 

supplemental payments are appropriate, and for supporting and

4

The 56 Medicaid programs include 1 for each of the 50 states, the District of Columbia, 

Puerto Rico, Samoa, Guam, the Commonwealth of the Northern Mariana Islands, and the 

United States Virgin Islands.

Background 
 

Page 3 GAO-12-674T 

overseeing state program integrity activities—activities intended to 

address Medicaid fraud, waste, and abuse.5

Managed care is a significant component of the Medicaid program, with 

nearly half of all Medicaid enrollees—approximately 20.7 million 

individuals—enrolled in capitated managed care in 2008.6 In 2007, there 

was a total of over $62 billion in federal and state spending for managed 

care. Under managed care, states use capitation payments to 

prospectively pay health plans to provide or arrange for services for 

Medicaid enrollees. Such capitation payments are required by federal law 

to be actuarially sound.7 CMS regulations, first issued in 2002, define 

actuarially sound rates as those that are (1) developed in accordance with 

generally accepted actuarial principles and practices, (2) appropriate for 

the populations to be covered and the services to be furnished, and 

(3) certified as meeting applicable regulatory requirements by qualified 

actuaries.8 In order to receive federal funds for their managed care 

programs, states must submit documentation to CMS regional offices for 

review, including a description of their rate-setting methodology and data 

used to set rates. This review, completed by CMS regional office staff, is 

designed to ensure that a state complies with the regulatory requirements 

for setting actuarially sound rates.

 

5

Fraud involves an intentional act or representation to deceive with the knowledge that the 

action or representation could result in gain. Waste results from clerical errors or the 

provision of medically unnecessary services. Abuse typically involves actions that are 

inconsistent with acceptable business and medical practices that result in unnecessary 

program costs. 

6

Throughout this report, the term managed care refers only to capitated managed care 

arrangements, which are arrangements through which a health plan is prospectively paid 

a fixed monthly rate per enrollee to provide or arrange for most health services. States 

may also have primary care case management (PCCM) programs under which a primary 

care provider is paid a nominal monthly, per person, case management fee to coordinate 

care for beneficiaries, in addition to fee-for-service (FFS) reimbursement for any health 

care services they provide. While some consider PCCM programs to be managed care, 

we consider those programs to be FFS-based arrangements because participating 

providers are predominately paid on a FFS basis. 

7

See 42 U.S.C. § 1396b(m)(2)(A)(iii).

8

See 42 CFR §438.6(c)(1)(i).

Managed Care Rate Setting 

and Actuarial Soundness
 

Page 4 GAO-12-674T 

Most state Medicaid programs make supplemental payments to certain 

providers in addition to the standard payments states make to these 

providers for Medicaid services. For purposes of this testimony, we 

have grouped supplemental payments into two broad categories: 

(1) Disproportionate Share Hospital (DSH) payments, which states are 

required to make to hospitals that treat large numbers of low-income 

uninsured people and Medicaid patients;9 and (2) non-DSH supplemental 

payments, which are not required by statute or regulation. In fiscal year 

2010, states made more than $31 billion in supplemental payments; the 

federal share was more than $19 billion. CMS is responsible for 

overseeing these payment arrangements to ensure the propriety of 

expenditures for which states seek federal reimbursement, including 

whether states were appropriately financing their share.

Program integrity activities are designed to prevent, or detect and 

recover, improper payments throughout the Medicaid program. The 

Deficit Reduction Act of 2005 expanded CMS’s role regarding Medicaid 

program integrity, establishing the Medicaid Integrity Program to provide 

effective federal support and assistance to states to combat fraud, waste, 

and abuse.10

• National Provider Audit Program—a program through which separate 

CMS contractors analyze claims data to identify aberrant claims and 

potential billing vulnerabilities, and conduct postpayment audits based 

on data analysis leads in order to identify overpayments to Medicaid 

providers.

CMS’s core program integrity activities include:

• Comprehensive program integrity reviews—comprehensive 

management reviews that are conducted every 3 years to assess the 

effectiveness of each state’s program integrity efforts and determine 

whether the state’s policies and procedures comply with federal law 

and regulations.

 

9

See 42 U.S.C. §§ 1396a(13)(A)(iv), 1396r-4. States’ DSH programs are subject to limits 

on overall annual federal expenditures, on the amount of DSH payments a state may 

make, and on the DSH payments individual hospitals may receive. 

10See Pub. L. No. 109-171, § 6034, 120 Stat. 4, 74-78 (2006). 

Supplemental Payments

Program Integrity
 

Page 5 GAO-12-674T 

• State program integrity assessments—annual assessments in which 

CMS collects data on state Medicaid integrity activities—including 

program integrity staffing and expenditures, audits, fraud referrals, 

and recoveries—for the purposes of program evaluation and technical 

assistance support.

CMS also provides training and technical assistance to states. For 

example, CMS’s Medicaid Integrity Institute is the first national Medicaid 

integrity training program and offers state officials training and 

opportunities to develop relationships with program integrity staff from 

other states.

We found that CMS had not ensured that all states were complying with 

the actuarial soundness requirements and did not have sufficient efforts in 

place to ensure that states were using reliable data to set managed care 

rates.11

• First, CMS had not reviewed one state’s rate setting for multiple years 

and only determined that the state was not in compliance with the 

requirements through the course of our work.

Specifically, in August 2010, we reported that there were 

significant gaps in CMS’s oversight of 2 of the 26 states included in our 

review.

• Second, at the time of our work, CMS had not completed a full review 

of a second state’s rate setting since the actuarial soundness 

requirements became effective in August 2002, and therefore may 

have provided federal funds for managed care rates that were not in 

compliance with all of the requirements.

In addition to these gaps in oversight, we found inconsistencies in the 

reviews CMS completed. For example, the extent to which CMS ensured 

state compliance with some of the actuarial soundness requirements was 

unclear because CMS officials did not always document their review or 

cite evidence of the state’s compliance. When officials did cite evidence, 

the evidence did not always appear to meet the actuarial soundness 

requirements. Variation in practices across CMS regional offices 

contributed to these gaps and other inconsistencies in the agency’s 

 

11See GAO, Medicaid Managed Care: CMS’s Oversight of States’ Rate Setting Needs 

Improvement, GAO-10-810 (Washington D.C.: Aug. 4, 2010).

CMS’s Oversight of 

Managed Care Rate 

Setting Was 

Inconsistent and Did 

Not Ensure the 

Quality of the Data 

Used to Set Rates
 

Page 6 GAO-12-674T 

oversight of states’ rate setting. For example, regional offices varied in the 

extent to which they tracked state compliance with the actuarial 

soundness requirements, their interpretations of how extensive a review 

of a state’s rate setting was needed, and their determinations regarding 

sufficient evidence for meeting the actuarial soundness requirements.

We also reported in 2010 that CMS’s efforts to ensure the quality of the 

data used to set rates were generally limited to requiring assurances from 

states and health plans—efforts that did not provide the agency with 

enough information to ensure the quality of the data used. CMS 

regulations require states to describe the data used as the basis for rates 

and provide assurances from their actuaries that the data were 

appropriate for rate setting. The regulations do not include requirements 

for the type, amount, or age of the data used to set rates, and states are 

not required to report to CMS on the quality of the data. When reviewing 

states’ descriptions of the data used to set rates, CMS officials focused 

primarily on the appropriateness of the data rather than their reliability. 

Additionally, we found that actuarial certification does not ensure that the 

data used to set rates are reliable. In particular, our review of rate-setting 

documentation found that some actuaries’ certifications included a 

disclaimer that if the data used were incomplete or inaccurate then the 

rates would need to be revised. Furthermore, some actuaries noted that 

they did not audit or independently verify the data and relied on the state 

or health plans to ensure that the data were accurate and complete. With 

limited information on data quality, CMS cannot ensure that states’ 

managed care rates are appropriate, which places billions of federal and 

state dollars at risk for misspending. States and other sources have 

information on the quality of data used for rate setting—information that 

CMS could obtain. In addition, CMS could conduct or require periodic 

audits of data used to set rates; CMS is required to conduct such audits 

for the Medicare managed care program.

CMS took a number of steps that may address some of the variation that 

contributed to inconsistent oversight, such as requiring regional office 

officials to use a detailed checklist when reviewing states’ rate setting; 

use of the checklist had previously been optional. However, we found 

variations in CMS oversight even when the checklist was used. Thus, to 

improve oversight of states’ Medicaid managed care rate setting, we 

recommended that CMS (1) implement a mechanism for tracking state 

compliance, including tracking the effective dates of approved rates; 

(2) clarify guidance for CMS officials on conducting rate-setting reviews, 

such as identifying what evidence is sufficient to demonstrate state 

compliance with the actuarial soundness requirements, and how officials 
 

Page 7 GAO-12-674T 

should document their reviews; and (3) make use of information on data 

quality in overseeing states’ rate setting. HHS agreed with these 

recommendations, and as of June 2011, CMS officials indicated they 

were investigating ways to create an easily accessible database to help 

them more closely monitor the status of rate-setting approvals, reviewing 

and updating its guidance, and looking into incorporating information 

about data quality into its review and approval of Medicaid managed care 

rates.

In our prior work, we have reported on varied financing arrangements 

involving supplemental payments that shifted costs from the states to the 

federal government. In some cases, the providers did not retain the full 

amount of the payments as some states required providers to return 

most, or all, of the supplemental payment to the state. Our work found 

that while a variety of federal legislative and CMS actions have helped 

curb inappropriate financing arrangements, gaps in oversight remain. 

Because such financing arrangements effectively increased the federal 

Medicaid share, they could compromise the fiscal integrity of Medicaid’s 

federal and state partnership.

Our most recent reports on supplemental payments underscore these 

gaps in federal oversight. In May 2008, we reported that CMS had not 

reviewed all supplemental payment arrangements to ensure that these 

payments were appropriate and used for Medicaid purposes.12

 

12See GAO, Medicaid: CMS Needs More Information on the Billions of Dollars Spent on 

Supplemental Payments,

In 

November 2009, we found that ongoing federal oversight of supplemental 

payments was warranted, in part, because two of the four states reviewed

did not comply with federal requirements to account for all Medicaid 

GAO-08-614 (Washington D.C.: May 30, 2008).

CMS Oversight of 

Medicaid 

Supplemental 

Payments Needs 

Improvement 
 

Page 8 GAO-12-674T 

payments when calculating DSH payment limits for uncompensated 

hospital care.13

Recently implemented requirements have the potential to improve 

oversight of some supplemental payments, but concerns about other 

payments remain.14

As a result of our prior work, we have made numerous recommendations 

aimed at improving federal oversight of supplemental payments. Some 

key recommendations we made have not been implemented by CMS. We 

have recommended that CMS adopt transparency requirements for nonDSH supplemental payments and develop a strategy to ensure all state 

supplemental payment arrangements have been reviewed by CMS. CMS 

has taken some action to address some of these recommendations but 

we continue to believe additional action is warranted. CMS has raised 

concern that congressional action may be necessary to fully address our 

concerns. Additionally, given continued concerns associated with 

Medicaid supplemental payments, we have work under way related to 

states’ reporting and CMS’s oversight of DSH and non-DSH supplemental 

payments.

For example, there are now improved transparency 

and accountability requirements in place for DSH payments. However, 

these requirements are not in place for non-DSH supplemental payments, 

which may be increasing. Specifically, in 2006, states reported making 

$6.3 billion in non-DSH supplemental Medicaid payments, of which the 

federal share was $3.7 billion, but not all states were reporting their 

payments. By 2010, this amount had grown to $14 billion, with a federal

share of $9.6 billion. However, according to CMS officials, states’ 

reporting of non-DSH supplemental payments was likely incomplete.

 

13See GAO, Medicaid: Ongoing Federal Oversight of Payments to Offset Uncompensated 

Hospital Care Costs Is Warranted, GAO-10-69 (Washington D.C.: Nov. 20, 2009). Federal 

Medicaid law caps the amount of DSH supplemental payments a state may pay to an 

individual hospital each fiscal year. DSH supplemental payments cannot exceed the 

unreimbursed cost of furnishing hospital services to Medicaid beneficiaries and the 

uninsured. In determining a hospital’s unreimbursed costs, states must offset costs with all 

Medicaid payments received by the hospital. See 42 U.S.C. § 1396r-4(g). Thus, other 

Medicaid payments—including all supplemental payments—count against a hospital’s 

DSH cap.

14See the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, 

Pub. L. No. 108-173, § 1001(d), 117 Stat. 2066, 2430-2431 (2003) (codified, as amended, 

at 42 U.S.C. § 1395r-4(j)) and Medicaid Program, Disproportionate Share Hospital 

Payments, Final Rule, 73 Fed. Reg. 77,904 (Dec. 19, 2008).
 

Page 9 GAO-12-674T 

In December 2011, we testified that the key challenge CMS faced in 

implementing the statutorily established federal Medicaid Integrity 

Program was ensuring effective coordination to avoid duplicating state 

program integrity efforts, particularly in the area of auditing provider 

claims.15

However, the National Provider Audit Program results—the largest 

component of the Medicaid Integrity Program—call into question the 

effectiveness of CMS’s communication, and its ability to avoid duplication 

with state audit programs. After examining CMS’s program expenditures, 

we found that overpayments identified by its audit contractors since fiscal 

year 2009 were not commensurate with its contractors’ costs. From fiscal 

years 2009 through 2011, CMS authorized 1,663 provider audits in 

44 states. However, CMS’s reported return on investment from these 

audits was negative. While its contractors identified $15.2 million in 

overpayments in fiscal year 2010, the combined cost of the National 

Provider Audit Program was about $36 million. In addition, CMS reported 

in 2011 that it was redesigning the National Provider Audit Program to 

achieve better results. Data limitations—in particular, the use of summary 

data that states submit to CMS on a quarterly basis—may have 

hampered the contractors’ ability to identify improper claims beyond what 

states already identified. It remains to be seen, however, whether CMS’s 

redesign of the National Provider Audit Program will result in an increase 

in identified overpayments.

At the outset of the Medicaid Integrity Program, CMS stressed 

the need for effective coordination and acknowledged the potential for 

duplication with states’ ongoing efforts to identify Medicaid overpayments.

CMS’s other core oversight activities—triennial comprehensive state 

program integrity reviews and annual assessments—are broad in scope 

and were conceived to provide a basis for the development of appropriate 

technical assistance. However, we found that much of the information 

collected from the annual assessments duplicated information collected 

during triennial reviews. Further, our review of a sample of assessments 

revealed missing data and a few implausible measures, such as one state 

reporting over 38 million managed care enrollees. Improved data 

collection activities and dialogue with states will help CMS ensure that it 

 

15See GAO, Medicaid Program Integrity: Expanded Federal Role Presents Challenges to 

and Opportunities for Assisting States, GAO-12-288T (Washington, D.C.: Dec. 7, 2011).

CMS’s Expanded Role 

in Ensuring Medicaid 

Program Integrity 

Presents Challenges 

to and Opportunities 

for Assisting States
 

Page 10 GAO-12-674T 

has complete and reliable state information on which to direct its training 

and technical assistance resources appropriately.

Finally, we found that the Medicaid Integrity Institute appears to promote 

effective state coordination and collaboration. We reported that states 

have uniformly praised the institute and a special June 2011 session 

brought together Medicaid program integrity officials and representatives 

of Medicaid Fraud Control Units—independent state units responsible for 

investigating and prosecuting Medicaid fraud—in 39 states to improve 

working relations between these important partners.

As we testified in December 2011, CMS’s expanded role in ensuring 

Medicaid program integrity has presented both challenges to and 

opportunities for assisting states with their activities to ensure proper 

payments. We have ongoing work reviewing CMS’s Medicaid program 

integrity activities that will provide additional information about CMS’s 

oversight efforts in this area.

Chairmen Gowdy and Jordan, this concludes by prepared statement. I 

would be happy to answer any questions that you or other Members may 

have.

For further information about this statement, please contact Carolyn L. 

Yocom at (202) 512-7114 or yocomc@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this statement. Michelle B. Rosenberg, Assistant Director; 

Eagan Kemp; Drew Long; Peter Mangano; Christina Ritchie; and Hemi 

Tewarson were key contributors to this statement.

GAO Contact and 

Staff 

Acknowledgments 
Appendix I: Abbreviations

Page 11 GAO-12-674T 

CMS Centers for Medicare & Medicaid Services

DSH Disproportionate Share Hospital

FFS fee-for-service 

HHS Department of Health and Human Services

PCCM primary care case management

Appendix I: Abbreviations
Related GAO Products

Page 12 GAO-12-674T 

Medicaid Program Integrity: Expanded Federal Role Presents 

Challenges to and Opportunities for Assisting States. GAO-12-288T. 

Washington, D.C.: December 7, 2011.

Fraud Detection Systems: Additional Actions Needed to Support 

Program Integrity Efforts at Centers for Medicare and Medicaid Services. 

GAO-11-822T. Washington, D.C.: July 12, 2011.

Fraud Detection Systems: Centers for Medicare and Medicaid Services 

Needs to Ensure More Widespread Use. GAO-11-475. Washington, D.C.: 

June 30, 2011.

Improper Payments: Recent Efforts to Address Improper Payments and 

Remaining Challenges. GAO-11-575T. Washington, D.C.: April 15, 2011.

Medicare and Medicaid Fraud, Waste, and Abuse: Effective 

Implementation of Recent Laws and Agency Actions Could Help Reduce 

Improper Payments. GAO-11-409T. Washington, D.C.: March 9, 2011.

Opportunities to Reduce Potential Duplication in Government 

Programs, Save Tax Dollars, and Enhance Revenue. GAO-11-318SP. 

Washington, D.C.: March 1, 2011.

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

February 2011.

Medicaid Managed Care: CMS’s Oversight of States’ Rate Setting Needs 

Improvement. GAO-10-810. Washington D.C.: August 4, 2010.

Medicaid: Ongoing Federal Oversight of Payments to Offset 

Uncompensated Hospital Care Costs Is Warranted. GAO-10-69. 

Washington D.C.: November 20, 2009.

Medicaid: Fraud and Abuse Related to Controlled Substances Identified 

in Selected States. GAO-09-1004T. Washington, D.C.: September 30, 

2009.

Medicaid: Fraud and Abuse Related to Controlled Substances Identified 

in Selected States. GAO-09-957. Washington, D.C.: September 9, 2009.

Improper Payments: Progress Made but Challenges Remain in 

Estimating and Reducing Improper Payments. GAO-09-628T. 

Washington, D.C.: April 22, 2009.

Related GAO Products
Related GAO Products

Page 13 GAO-12-674T 

Medicaid: CMS Needs More Information on the Billions of Dollars 

Spent on Supplemental Payments. GAO-08-614. Washington D.C.: 

May 30, 2008.

Medicaid Financing: Long-standing Concerns about Inappropriate 

State Arrangements Support Need for Improved Federal Oversight. 

GAO-08-650T. Washington D.C.: April 3, 2008.

Medicaid Demonstration Waivers: Recent HHS Approvals Continue to 

Raise Cost and Oversight Concerns. GAO-08-87. Washington, D.C.: 

January 31, 2008.

Medicaid Financing: Long-standing Concerns about Inappropriate 

State Arrangements Support Need for Improved Federal Oversight. 

GAO-08-255T. Washington D.C.: November 1, 2007.

Medicaid Financing: Federal Oversight Initiative Is Consistent with 

Medicaid Payment Principles but Needs Greater Transparency. 

GAO-07-214. Washington D.C.: March 30, 2007.

Medicaid Financial Management: Steps Taken to Improve Federal 

Oversight but Other Actions Needed to Sustain Efforts. GAO-06-705. 

Washington D.C.: June 22, 2006.

Medicaid Integrity: Implementation of New Program Provides 

Opportunities for Federal Leadership to Combat Fraud, Waste, and 

Abuse. GAO-06-578T. Washington, D.C.: March 28, 2006.

Medicaid Financing: States’ Use of Contingency-Fee Consultants to 

Maximize Federal Reimbursements Highlights Need for Improved Federal 

Oversight. GAO-05-748. Washington, D.C.: June 28, 2005.

Medicaid Fraud and Abuse: CMS’s Commitment to Helping States 

Safeguard Program Dollars Is Limited. GAO-05-855T. Washington, D.C.: 

June 28, 2005.

Medicaid Program Integrity: State and Federal Efforts to Prevent 

and Detect Improper Payments. GAO-04-707. Washington, D.C.: 

July 16, 2004.

Medicaid: State Efforts to Control Improper Payments. GAO-01-662. 

Washington, D.C.: June 7, 2001.

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