Medicare: CMS Has Addressed Some Implementation Problems from Round 1 of the Durable Medical Equipment Competitive Bidding Program for the Round 1 Rebid
Published: 2010-09-15T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: To reduce spending on durable medical equipment (DME) and related items, under federal law the Centers for Medicare & Medicaid Services (CMS) is phasing in, with several rounds of bidding, a competitive bidding program (CBP) for certain DME and other items. Because of numerous concerns, the Medicare Improvements for Patient and Providers Act of 2008 (MIPPA) terminated the CBP round 1 supplier contracts and required CMS to repeat the CBP round 1, the rebid that began in 2009. In November 2009, GAO issued the report Medicare: CMS Working to Address Problems from Round 1 of the Durable Medical Equipment Competitive Bidding Program (GAO-10-27) that documented problems in CMS's implementation of CBP round 1. This statement discusses some of the problems GAO identified and how CMS has or plans to address them in the ongoing CBP rebid bidding process, particularly (1) the bid submission information provided to suppliers, (2) the electronic bid submission system, and (3) the bid disqualification notification process. For the 2009 report, GAO reviewed data provided by CMS and relevant laws and regulations, and interviewed CMS officials. For this statement, GAO also obtained select information on how CMS addressed the CBP round 1 problems identified in GAO's report by reviewing agency documents and interviewing CMS officials in August and September 2010.
section_title: What GAO Found
paragraphs: In the November 2009 report on CBP round 1, GAO noted that problems with the bidding process included poor timing and lack of clarity in bid submission information and the inability to inform suppliers of missing financial documentation. Several times after the CBP round 1 bid window opened, CMS provided new bidding information and clarified other bidding information. The bid window was also extended beyond the initial deadline. These changes made it more difficult for suppliers to submit correct bids. CMS improved implementation of these steps in the bidding process for the CBP round 1 rebid. For example, for the CBP round 1 rebid, CMS provided bidding information to suppliers prior to the bid window opening, including the rebid's request-for-bid instructions, which were available to potential bidding suppliers for over 2 months before the bid window opening. CMS also provided clearer financial documentation instructions and additional financial documentation tools to guide suppliers in the CBP round 1 rebid. For example, the request-for-bid instructions included a chart that more clearly explained which documents were to be submitted by the supplier's business type, for example, a sole proprietorship. CMS also conducted a financial document review during the round 1 rebid, which informed suppliers whether their bid submission was missing required financial documents. Of the 321 suppliers that were notified they had missing documentation, only 14 did not subsequently submit the missing documents. As CMS acknowledged, suppliers had difficulty entering bidding information in the bid submission system used in CBP round 1 and its user guide was not sufficiently detailed. CMS developed a new electronic bid submission system for the CBP round 1 rebid. CMS officials told us that the new system did not have significant operational issues and only a few suppliers experienced minor problems. GAO found that CMS had not effectively notified all suppliers about the opportunity for a postbidding review process in CBP round 1. To address GAO's 2009 recommendation that the agency effectively notify all suppliers of all aspects of the CBP round 1 rebid and future rounds, including any process to review disqualifications, CMS officials stated that the agency plans to notify the losing suppliers of the disqualification reasons by sending each of these suppliers a letter that will explain the process for asking questions or expressing concerns. Officials also stated that in the course of responding to suppliers' questions or concerns, if CMS determines an error was made, it is possible that the supplier may be offered a contract. In commenting on the information presented in this testimony, CMS officials stated they appreciated GAO noting the administrative improvements to the competitive bidding process the agency made for the round 1 rebid. The officials further stated that they believe that CMS made many improvements to the CBP.

section_title: Letter
paragraphs: I am pleased to be here today to discuss the Medicare competitive bidding  program for selected durable medical equipment (DME) and certain other  items. My testimony today is focused on how the Centers for Medicare &  Medicaid Services (CMS) is addressing bidding process problems we  identified during round 1 of the competitive bidding program—conducted  from 2007 to 2008—in our November 2009 report, and steps CMS has  taken to address those problems for the program’s round 1 rebid bidding  process, which is currently under way. Competitively determined  Medicare payments for items and services covered under the round 1 rebid  will be effective on or after January 1, 2011.
In 2009, Medicare spent $8.1 billion on DME, other items, and related  supplies. Since 1989, Medicare has paid for most DME through fee  schedules. Medicare payment for DME is generally equal to 80 percent of  the lesser of either the supplier’s actual charge or the Medicare fee  schedule for a particular item or service. Both we and the Department of  Health and Human Services’ (HHS) Office of Inspector General have  reported that Medicare and its beneficiaries have sometimes paid higher- than-market rates for various medical equipment and supply items. These  overpayments increase costs to both Medicare and its beneficiaries. As  we have previously stated, competitive bidding can reduce Medicare  program payments by providing an incentive for suppliers to accept lower  payment amounts for items and services to retain their ability to serve  Medicare beneficiaries and potentially increase their market share.
The Medicare Prescription Drug, Improvement, and Modernization Act of  2003, required CMS to phase in a competitive bidding program (CBP) for  DME suppliers. CMS contracted with Palmetto GBA to implement the CBP  bidding and contract award process and with Maricom to develop a Web- based electronic bid submission system. CBP round 1 was conducted in  2007 and 2008 for 10 competitive bidding areas. For the bidding, CMS  chose certain DME items in 10 product categories—generally high cost  and high volume items and services—that were most likely to result in  Medicare savings if competitively acquired. The round 1 suppliers  submitted bids for supplying one or more of these 10 DME product  categories in 1 or more of the 10 competitive bidding areas. There were  6,374 bids submitted by 1,010 suppliers. In March 2008, CMS began  offering contracts to winning suppliers to provide DME to Medicare  beneficiaries. The contracts between CMS and suppliers became effective  on July 1, 2008.
Round 1’s bid submission and contract award processes raised concerns  about the CBP implementation. Therefore, on July 15, 2008,  implementation of the CBP round 1 was stopped—after 2 weeks—by the  enactment of the Medicare Improvements for Patients and Providers Act  of 2008 (MIPPA), which terminated the contracts already awarded to  suppliers, delayed the program’s restart, and required CMS to repeat the  competition for CBP round 1 in 2009—referred to in this statement as the  CBP round 1 rebid. MIPPA also imposed additional criteria for how CMS  should conduct later CBP rounds, including the round 1 rebid and  subsequent rounds that will expand the CBP to additional areas.
Our November 2009 report documented round 1 implementation  problems. We found, for example, that CMS did not provide suppliers with  timely and clear bid submission information, used an inadequate  electronic bid submission system, and did not have a process to inform  bidders of missing financial documentation—42 percent of all submitted  bids were disqualified due to incomplete financial documentation. In our  report, we recommended that if CMS decides to review suppliers’  disqualified bids during the round 1 rebid and future rounds, it should  notify all suppliers of any such process, give suppliers equal opportunity  for such reviews, and clearly indicate how suppliers can request a review.
In October 2009, CMS began the CBP round 1 rebid process. The bid  window closed in December 2009. There were 6,215 complete bids  submitted by 1,011 bidding suppliers. On July 1, 2010, CMS announced the  competitively determined DME single payment amounts, which are the  new payment amounts that Medicare will pay for each item covered under  the CBP. These payments will replace the applicable fee schedule amounts  for the selected DME items in the competitive bidding areas. Under the  round 1 rebid, CMS estimated that compared to the 2009 Medicare fee  schedule, the volume-weighted reduction in CBP’s single payment  amounts for items averaged 32 percent. Under round 1, the estimated  payment reductions compared to the 2008 Medicare fee schedule averaged  26 percent. CMS also announced on July 1, 2010, that it would begin  mailing contract offers to winning suppliers. CMS officials informed us  that 1,287 bids are included in the initial wave of contract offers. CMS  officials also stated that they plan to announce the winning suppliers that  accepted contracts in September 2010.
In my testimony today, I will discuss problems we identified in the round 1  competitive bidding process and how CMS has or plans to address the  problems in the ongoing rebid bidding process regarding (1) providing  suppliers with bid submission information, (2) use of an electronic bid  submission system, and (3) the bid disqualification notification process.
For our 2009 report, we reviewed data provided by CMS and Palmetto  GBA; reviewed federal laws, regulations, and policies concerning the  bidding and contract award processes; reviewed documents from the CBP  round 1 bidding process, and interviewed CMS and Palmetto GBA officials  about the CBP round 1 bid process and efforts to resolve problems that  arose. For this testimony, we also obtained information on CMS responses  to problems we identified in our 2009 report by reviewing agency  documents and interviewing CMS officials. We also reviewed the available  materials provided on the CMS and Palmetto GBA CBP Web sites and  analyzed the results from the inquiries from suppliers received by the  Palmetto GBA customer service center. We shared the information in this  statement with CMS officials. Our work was performed in accordance with  generally accepted government auditing standards for the 2009 report  from June 2008 through September 2009 and for this testimony from  August through September 2010. Those standards require that we plan and  perform the audit to obtain sufficient, appropriate evidence to provide a  reasonable basis for our findings and conclusions based on our audit  objectives. We believe that the evidence obtained provides a reasonable  basis for our findings and conclusions based on our audit objectives.
subsections: section_title: Problems Were Identified in the CBP Round 1 Bidding Process in Providing Suppliers with Bid Submission Information, but Some Improvements Were Made in the CBP Round 1 Rebid Process
paragraphs: For CBP round 1, we found problems with the bidding process, including  poor timing and lack of clarity in bid submission information and CMS’s  inability to inform suppliers of missing financial documentation. In  comparison with CBP round 1, CMS provided CBP round 1 rebid bidding  information to suppliers earlier, and its financial documentation  instructions were clearer and suppliers were notified of missing  documentation. CMS also added program information about determining  suppliers’ capacity, and provided directories to inform suppliers about  state licensure requirements.
subsections: section_title: CMS Had Difficulty Providing Clear Bidding Information to Suppliers in CBP Round 1, but Improved Its Communication about Bidding Information for the CBP Round 1 Rebid
paragraphs: CMS had difficulty providing clear bidding information in CBP round 1.  For example, CMS provided new bidding information several times after  the bid window opened, such as announcing the 10 financial measures  used to evaluate the financial viability of bidding suppliers; clarified CBP  round 1’s bidding information in response to supplier confusion, such as  providing additional explanatory information concerning the request-for- bid instructions; and extended the bid window deadline. These changes in  bidding information made it more difficult for suppliers to submit correct  bids. CMS and Palmetto GBA acknowledged that during CBP round 1  suppliers did not always understand the request-for-bid instructions. The  instructions were not available to suppliers until the day the bid window  opened. During the first 2 months of the bid window, while suppliers were  preparing their bid submissions, Palmetto GBA held informational bidder  conference calls on how to submit bids and maintained audio recordings  on the CBP Web site for a limited time. Questions also were not organized  by subject matter, and while the Web site had a frequently asked questions  section, it was difficult for suppliers to determine when questions had  been added.
CMS improved its communication with suppliers about bidding  information for the CBP round 1 rebid. For example, CMS provided  suppliers with bidding information before the bidding window opened on  October 21, 2009, so that bid window extensions were not needed. Prior  to the bid window opening, the rebid’s request-for-bid instructions had  been available to potential bidding suppliers for over 2 months, since  August 3, 2009, and CMS had already held seven informational bidder  conference calls. Transcripts, audio recordings, and PowerPoint  presentations from the calls were available on the Palmetto GBA CBP Web  site throughout the round 1 rebid. CMS made two minor clarifications to  the CBP round 1 rebid instructions. First, on the day the bid window  opened, CMS provided the actual bid submission deadlines, including the  covered document review date, and provided further instructions on how  a supplier needed to approve a bid in the online bidding system and   would submit the required hard copy financial documents. Second, on  November 17, 2009, CMS clarified that the financial statements for the last  operating year that suppliers were required to submit as part of their bids  could be for either calendar or fiscal years.
For the CBP round 1 rebid, Palmetto GBA maintained suppliers’ frequently  asked questions on the CBP’s Web site by topic. The questions were  provided for three topics—Bidding Guidelines, Bidding Process, and  Payment Policies—and dated in chronological order, unlike in CBP   round 1, so suppliers could more easily determine when new ones were  posted on the Web site. The Web site also has a “What’s New” section to  allow suppliers to find any new CBP information, for example, information  for the suppliers that were offered contracts, such as the form to request  that business locations be added or removed from their contracts.
section_title: Unclear CBP Round 1 Financial Documentation Instructions Led to Many Bid Disqualifications, but CBP Round 1 Rebid Instructions Were Clearer
paragraphs: In our 2009 report, we found that financial documentation instructions  were sometimes unclear in CBP round 1. CMS acknowledged that during  CBP round 1 many suppliers had particular difficulty complying with the  financial documentation requirements and that the statement of cash  flow—described as a statement of changes in financial position—was the  document most often missing. We found that CMS’s CBP round 1 financial  documentation instructions did not clearly address differences among  supplier business types—for example, a sole proprietorship business  versus a publicly traded national corporation—and among the financial  documents needed to submit a bid for each type. Because business types  could not easily be cross-referenced to the request-for-bid instructions,  suppliers were at risk of submitting incomplete or inaccurate financial  documentation. We also found that CMS’s CBP round 1 request-for-bid  instructions had inconsistent information about the requirements for the  credit report and credit score submission. For example, the bid  submission form stated that a credit rating and score—rather than using  the term credit report—had to be submitted. Near the end of the bid  window, Palmetto GBA then issued a “required document reminder” that  all bidders had to submit both a credit report and a credit score.
For the CBP round 1 rebid, CMS clarified financial documentation  instructions by providing additional tools to guide suppliers through the  bid submission process. The request-for-bid instructions included a  chart—Required Financial Documents by Business Type—that more  clearly explained which documents were to be submitted by business type.  For example, the chart specified which portions of a supplier’s tax return  were required based on its business type such as a sole proprietorship.
The chart also included a credit report column that stated bidders must  submit a “Credit Report with numerical score completed within 90 days of  bid submission,” and the bid instructions included the same description.  To further assist suppliers to provide the correct financial documents, the  instructions included a Required Financial Documents appendix with  sample documents and more specific explanations of the income  statement, balance sheet, statement of cash flow, revenue and expense  portion of the tax return, and the credit report, along with a Checklist of  Required Hardcopy Documents for Bid Submission.
For the CBP round 1 rebid, CMS officials told us they notified bidding  suppliers that submitted their hard copy financial documents by the  round’s covered review date of any missing documents, as required by  MIPPA. Once notified, suppliers had 10 business days to submit their  missing documentation. CMS officials told us that 791 suppliers  submitted their financial documentation by the CBP round 1 rebid covered  document review date and 321 were notified that they had missing  documentation. Fourteen suppliers did not subsequently submit the  missing documents and their bids were disqualified. For this review, tax  record documents were the most often missing financial documentation.
section_title: In CBP Round 1, Questions Were Raised about CMS’s Ability to Estimate the Capacity of Suppliers to Furnish DME Items, but CMS Added a Systematic Method to Estimate Supplier Capacity for the CBP Round 1 Rebid
paragraphs: In CBP round 1, questions were raised about the capacity of some  suppliers to fulfill their awarded contracts on day one of the CBP’s  contract period, including whether they had experience providing the  DME product category, had business locations in the competitive bidding  areas, and could expand their businesses, if needed, to supply all Medicare  beneficiaries in their competitive bidding areas. CMS officials told us that  the CBP’s Program Advisory and Oversight Committee (PAOC) raised  concerns that suppliers new to a competitive bidding area, new to a DME  product category, or that reported high capacity figures would not be able  to increase reported capacity in time to meet the projected demand for the  DME items in the competitive bidding areas.
To address the concerns, CMS officials told us that the agency added a  systematic method of reviewing suppliers’ capacity and expansion plans  for the CBP round 1 rebid. CMS developed a three-step method to  determine whether a supplier new to a product category or a competitive  bidding area or an experienced supplier that reported high capacity figures  would be able to increase capacity to meet the projected demand for the  DME items. The three steps were as follows:    First, CMS determined whether the total capacity of all experienced  suppliers in the competitive bidding area reporting modest growth  projections and eligible for a competitive bidding program contract offer  could meet the projected demand for items in the contract’s first year. If  the capacity from these experienced suppliers was sufficient to cover the  item demand on day one of the program, then the capacity offered by any  additional suppliers with expansion plans and eligible for a contract offer  was considered surplus capacity and no further review was conducted.
Second, if the total capacity of the experienced suppliers identified in step  one did not meet the projected demand for the first year of the contract,  then CMS reviewed the expansion plans provided by the new and high- growth or high-volume suppliers to verify their capacity to furnish the  items. The expansion plan review involved an in-depth examination of the  supplier’s financial information, specifically to verify whether the supplier  had the liquid assets and available credit needed to expand capacity. If the  verified capacity from these suppliers with expansion plans was sufficient  to meet demand, CMS determined that the suppliers eligible for a CBP  contract offer had the ability to meet demand on day one of the program.
Third, if the results of the first two steps indicated that more suppliers  were needed to meet demand on day one of the program, CMS made more  suppliers eligible for a CBP contract offer.
As of September 10, 2010, CMS had not disclosed how many capacity  evaluations were conducted during the CBP round 1 rebid.
section_title: In CBP Round 1, CMS Awarded Some Contracts to Suppliers That Were Not Yet Licensed, but CMS Provided Directories to Inform Suppliers of State Licensure Requirements in the CBP Round 1 Rebid
paragraphs: In 2009, we found that some suppliers that won CBP round 1 contracts  were not yet licensed in states where they would be operating. For the  CBP round 1 rebid, CMS further clarified the state licensure requirement,  stating that suppliers must be licensed for the product category in the  competitive bidding area in which they are bidding, and if a competitive  bidding area covers more than one state, the supplier needs to obtain  applicable licensure in all states. In order to better inform suppliers about  these licensure requirements, CMS and Palmetto GBA provided licensure  state directories for the 11 states included in the CBP round 1 rebid  competitive bidding areas. The directories, which served only as guides for  suppliers, provided a list of licenses required by each state for each  product category for suppliers with a physical location in that state.  Suppliers without a physical location in the state but that would be  providing DME items and services to Medicare beneficiaries in the state  were directed to consult the appropriate state licensing agency; contact  information for those agencies was also provided. The suppliers were  required to file copies of applicable state licenses with the National  Supplier Clearinghouse—which processes Medicare enrollment  applications by DME suppliers—prior to submitting a bid.
section_title: Electronic Bid Submission System Used in CBP Round 1 Had Operational Problems, and CMS Developed a New Bid System for the CBP Round 1 Rebid
paragraphs: CMS acknowledged that CBP round 1’s competitive bid submission  system—CBSS—had operational problems that affected suppliers’ ability  to submit their bids. These problems included, for example, loss of bid  submission data caused by CBSS security features that automatically  logged suppliers out after 2 hours and that timed out suppliers if there was  no activity for 30 minutes, and cases when CBSS was unavailable because  of unscheduled downtimes. Additionally, CBSS did not have a “cut and  paste” function and manual data reentry was time-consuming and  increased the risk of suppliers inputting incorrect data that could  disqualify a bid. CMS officials also acknowledged that the CBSS user guide  was not very detailed or user friendly.
CMS developed a new electronic bid submission—DBidS—for the CBP  round 1 rebid. DBidS was designed to address CBSS’s specific deficiencies  by being more user friendly and easier for suppliers to navigate and  providing a logical flow of the requested data, as well as detailed bidding  instructions in user-friendly language. Suppliers were provided a DBidS  reference guide on the DMEPOS Competitive Bidding Program Web site  that included screen shot explanations for the bid submission Forms A  and B. It also has a “copy and paste” function for the transfer of certain  data and many data-saving points to minimize loss of data. Suppliers could  have more than one employee access DBidS at the same time, but to  control data input DBidS will not allow more than one employee to input  the same data at the same time. DBidS has status indicators to indicate  whether the bidding forms are “complete,” “incomplete,” or “pending  approval,” and has links in the system to direct suppliers to the incomplete  data. CMS officials told us that DBids did not have significant operational  issues and only a few suppliers experienced minor problems.
section_title: CMS Did Not Effectively Notify All Suppliers about the Postbidding Review Opportunity in CBP Round 1, and Plans to Communicate with All Losing Suppliers in the CBP Round 1 Rebid after Contract Suppliers are Announced
paragraphs: In CBP round 1, CMS sent notification letters to both the winning and  losing suppliers before announcing the final winning suppliers that  accepted contracts for the CBP. The letters sent to suppliers that had bids  disqualified included an attachment using seven general reason codes to  explain the grounds for the disqualifications. Disqualified bids were  ineligible to compete on price and were not considered for a contract  award. During CBP round 1, CMS also conducted a postbidding review  process through which the agency considered concerns raised by losing  suppliers and in some cases, reversed decisions to disqualify the bids of  certain suppliers. We found that CMS had not effectively notified suppliers  about the opportunity for this postbidding review process. To improve  future rounds of the CBP, we recommended in our 2009 report that if CMS  decides to conduct a review of disqualification decisions made during the  CBP round 1 rebid and future rounds, CMS should notify all suppliers of  any such process, give suppliers equal opportunity for such reviews, and  clearly indicate how they can request a review. CMS agreed with our  recommendation.
For the CBP round 1 rebid, CMS sent notification letters to winning  suppliers beginning in July 2010. CMS officials informed us that after the  CBP round 1 rebid contracting process is completed, CMS plans to send  letters to all disqualified suppliers with the reasons why their bids were  disqualified. CMS officials said the letters will explain the process by  which suppliers may ask questions and express concerns. CMS officials  also stated that in the course of responding to such questions or concerns,  if CMS determines an error was made, it is possible that a CBP contract  may be offered to the supplier.
As required by MIPPA, we will study the CBP round 1 rebid, including, for  example, the program’s impact on Medicare beneficiary access to items  and services and on DME small business suppliers. Our study is to be  completed no later than one year after the CBP round 1 rebid’s Medicare  competitively determined payments are first made, which become  effective for covered items and services on January 1, 2011.
section_title: Agency Comments
paragraphs: In commenting on the information presented in this testimony, CMS  officials stated they appreciated GAO noting the administrative  improvements to the competitive bidding process the agency made for the  round 1 rebid. The officials further stated that they believe that CMS made  many improvements to the CBP. CMS also provided technical comments  that we incorporated as appropriate.
Mr. Chairman, this concludes my prepared statement. I would be happy to  answer any questions you or other members of the subcommittee may  have.
section_title: Appendix I: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
paragraphs: For further information about this statement, please contact Kathleen M.  King at (202) 512-7114 or kingk@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this statement.
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, key contributors to this testimony  were Martin T. Gahart, and Christie Motley, Assistant Directors; Lori  Achman; Kye Briesath; Krister Friday; Thomas Han; Erica Pereira; Hemi  Tewarson; Opal Winebrenner; and Charles Youman.
section_title: Related GAO Products
paragraphs: Medicare Fraud, Waste, and Abuse: Challenges and Strategies for  Preventing Improper Payments. GAO-10-844T. Washington, D.C.: June 15,  2010.
Medicare: CMS Working to Address Problems from Round 1 of the  Durable Medical Equipment Competitive Bidding Program. GAO-10-27.  Washington, D.C.: November 6, 2009.
Medicare: Covert Testing Exposes Weaknesses in the Durable Medical  Equipment Supplier Screening Process. GAO-08-955. Washington, D.C.:  July 3, 2008.
Medicare: Competitive Bidding for Medical Equipment and Supplies  Could Reduce Program Payments, but Adequate Oversight Is Critical.  GAO-08-767T. Washington, D.C.: May 6, 2008.
Medicare: Improvements Needed to Address Improper Payments   for Medical Equipment and Supplies. GAO-07-59. Washington, D.C.:  January 31, 2007.
Medicare Payment: CMS Methodology Adequate to Estimate National  Error Rate. GAO-06-300. Washington, D.C.: March 24, 2006.
Medicare Durable Medical Equipment: Class III Devices Do Not   Warrant a Distinct Annual Payment Update. GAO-06-62. Washington,  D.C.: March 1, 2006.
Medicare: More Effective Screening and Stronger Enrollment Standards  Needed for Medical Equipment Suppliers. GAO-05-656. Washington, D.C.:  September 22, 2005.
Medicare: CMS’s Program Safeguards Did Not Deter Growth in Spending  for Power Wheelchairs. GAO-05-43. Washington, D.C.: November 17, 2004.
Medicare: Past Experience Can Guide Future Competitive Bidding for  Medical Equipment and Supplies. GAO-04-765. Washington, D.C.:  September 7, 2004.
Medicare: CMS Did Not Control Rising Power Wheelchair Spending.  GAO-04-716T. Washington, D.C.: April 28, 2004.
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