Medicare Program Integrity: CMS Pursues Many Practices to Address Prescription Drug Fraud, Waste, and Abuse
Published: 2014-10-24T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Recent media reports and law enforcement actions have highlighted the problem of prescription drug fraud, waste, and abuse in the United States. Medicare, and the Part D prescription drug benefit, are susceptible to such fraud—a risk made greater by Medicare's size, scope, and complexity. GAO and others have raised questions about CMS's oversight of its activities to address fraud, waste, and abuse in Part D, as well as oversight of the contractors tasked with this work.
GAO examined (1) practices for promoting prescription drug program integrity, and (2) the extent that CMS's oversight of Medicare Part D program integrity, including the program integrity contractors, reflects these practices. To develop a list of practices, GAO interviewed 14 stakeholder groups involved in various aspects of prescription drug program integrity, including provider, beneficiary, and anti-fraud groups; identified and reviewed related documents; and conducted a search of eight bibliographic databases that included peer-reviewed articles and government documents. GAO organized the practices based on the three categories of GAO's Fraud Prevention Framework. To determine how CMS's oversight reflects these practices, GAO analyzed agency documents, such as contracts, manuals, work products, and CMS audits of contractors; and interviewed agency officials.
section_title: What GAO Found
paragraphs: GAO identified 23 practices for addressing prescription drug fraud, waste, and abuse that fall within three categories based on GAO's Fraud Prevention Framework—prevention, detection and monitoring, and investigation and prosecution.
The Department of Health and Human Services' (HHS) Centers for Medicare & Medicaid Services' (CMS) activities to address prescription drug fraud, waste, and abuse in the Medicare Part D prescription drug program reflect 14 of these 23 identified practices, some of which are in multiple categories, and the agency plans to implement 3 additional practices.
a practice if documentation or officials described activities as pilots or in the process of development, and that CMS was not pursuing a practice based on reviews of documentation and interviews with officials.
HHS generally agreed with our findings.

section_title: Letter
paragraphs: Recent media reports and law enforcement actions have highlighted the  problem of prescription drug fraud, waste, and abuse in the United  States. Examples of problematic activities include beneficiaries “doctor  shopping” to receive multiple prescriptions for opioids, such as OxyContin  or Vicodin, from different providers; providers found to have questionable  prescribing and billing practices; and diversion of prescription drugs by  beneficiaries, pharmacies, and others for uses other than intended.  Medicare and its prescription drug benefit, Part D, are susceptible to such  fraud—a risk made greater by Medicare’s size, scope, and complexity.
Since 2006, the Part D program has provided voluntary, outpatient  prescription drug coverage to the Medicare population. In 2013, Part D  had nearly 40 million beneficiaries and cost almost $70 billion, or about  12 percent of total Medicare expenditures. The program is administered  by the Centers for Medicare & Medicaid Services (CMS), within the  Department of Health and Human Services (HHS). CMS contracts with  private companies to provide benefits under Part D.
GAO, the HHS Office of Inspector General (OIG), and others have raised  questions about CMS’s oversight of its activities to address fraud, waste,  and abuse in Part D, as well as oversight of the contractors tasked with  assisting in these activities, the Medicare Drug Integrity Contractors   You asked us to examine practices for addressing fraud,  (MEDIC).waste, and abuse in prescription drug programs, and CMS’s use of these  practices. We examined (1) practices for promoting prescription drug  program integrity, and (2) the extent that CMS’s oversight of Medicare  Part D program integrity, including the MEDICs, reflects these practices.
To develop a list of practices for addressing prescription drug fraud,  waste, and abuse, we interviewed stakeholders involved in prescription  drug program integrity, such as groups representing prescribers,  pharmacies, beneficiaries, and others, to discuss program integrity  practices and identify documents that describe such practices.these interviews we identified an initial 213 documents that appeared to  address program integrity practices related to prescription drug fraud,  waste, and abuse. We reviewed each document to identify specific  practices and any relevant activities within those practices. We then   Through  conducted an additional search of eight bibliographic databases that  included peer-reviewed articles and government documents that yielded  an additional 642 documents that appeared to address program integrity  practices related to prescription drug fraud, waste, and abuse. We  reviewed the most recently published 10 percent, or 64 documents, to  determine whether they were relevant and if they described additional  specific practices not already determined through our review of the initial  213 documents. We did not identify any significantly different practices  and therefore discontinued our review of documents. We reviewed, in  total, 277 documents. We used GAO’s Fraud Prevention Framework to  organize the prescription drug program integrity practices we identified in  our review into one of three categories: prevention, detection and  monitoring, and investigation and prosecution. We did not evaluate the  practices we identified for their relative effectiveness.
To determine the extent to which CMS’s oversight of Medicare Part D,  including the MEDICs, reflects the practices we identified, we interviewed  agency officials involved in the oversight of the MEDICs and plan  sponsors. We also analyzed agency documents, such as the MEDIC  contracts and manuals; MEDIC work products, including the MEDICs’  most recent performance evaluations; plan sponsor contract materials  and memos; CMS findings from its 2013 audits of selected plan sponsors;  and CMS regulations. We used the reviewed materials and interviews  with CMS officials to determine which of the practices we identified that  CMS incorporates into its oversight of the Part D program, as well as the  practices CMS does not incorporate or plans to incorporate in the future.  We determined that CMS had implemented a practice if the agency  required or documented at least one activity within that practice, that CMS  planned a practice if documentation or officials described activities as  pilots or in the process of development, and that CMS was not pursuing  practices based on reviews of documentation and interviews with officials.
We conducted this performance audit from January 2014 to October 2014  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
subsections: section_title: Part D Plan Sponsors
paragraphs: The Medicare Part D program was designed to be administered by  private organizations—referred to as plan sponsors—that CMS contracts  with to provide outpatient prescription drug benefit plans to Medicare  beneficiaries. These sponsors may contract with other entities—called  First Tier, Downstream or Related Entities (FDR)—to help provide these  benefits. (See fig. 1.) FDRs include pharmacy benefit managers— companies that provide services such as contracting with a network of  pharmacies, managing formularies, and performing drug utilization  reviews on behalf of the sponsors—and pharmacies. CMS holds plan  sponsors responsible for oversight of their FDRs.
section_title: Part D Program Integrity
paragraphs: Program integrity responsibilities in Medicare Part D are shared by plan  sponsors, CMS’s Center for Program Integrity (CPI) and Center for  Medicare, and CMS’s program integrity contractors.
subsections: section_title: Plan Sponsors’ Responsibilities
paragraphs: Plan sponsors are required to have comprehensive compliance programs  that include elements intended to safeguard the Part D program from  fraud, waste, and abuse. CMS issued requirements for these programs  based on input from various sources, including plan sponsors and  industry representatives. CMS requires plan sponsors to monitor and audit their FDRs; analyze data to detect and prevent potential fraud, waste, and abuse; have a unit, such as a Special Investigation Unit (SIU), specifically  tasked with identifying and addressing fraud, waste, and abuse, or  ensure that the responsibilities generally conducted by an SIU are  conducted by a plan sponsor’s compliance department.
section_title: CMS’s Oversight
paragraphs: CMS’s CPI oversees Part D program integrity and coordinates with other  groups within CMS’s Center for Medicare that monitor plan sponsor  compliance with the Part D program. (See fig. 2.) Within the Center for  Medicare, one such group is the Medicare Parts C and D Oversight and  Enforcement Group, which ensures contractual compliance through  audits of plan sponsors. If those audits identify noncompliance with the  terms of the Part D contract, CMS may take a variety of actions that  include requiring corrective action plans, sending warning letters,  assessing civil money penalties, and terminating or not renewing a  contract. The other group, the Medicare Drug Benefit and C & D Data  Group, analyzes data to identify potential patient safety concerns, such as  overutilization of opioid drugs, that may also indicate potential fraud or  abuse.
CPI has primary responsibility for overseeing the two MEDICs tasked with  promoting program integrity in Medicare Part D:
The National Benefit Integrity (NBI) MEDIC is responsible for  preventing, detecting, and deterring Part D fraud, waste, and abuse.  This includes intake and handling of complaints from beneficiaries and  others as well as requests for information from law enforcement;  investigating providers and others and referring them to law  enforcement; and analyzing Part D program prescription drug event  records and other data to identify patterns indicative of potential fraud,  waste, or abuse.
The Outreach & Education (O&E) MEDIC provides Part D fraud,  waste, and abuse education to plan sponsors and other stakeholders  by working in concert with CMS to develop educational and training  tools, and by facilitating information-sharing opportunities, such as  fraud alerts, conferences, and other meetings.
CPI also oversees the Part D Recovery Audit Contractor (RAC) program,  which is tasked with reviewing paid Medicare claims—or, for Part D,  prescription drug event data—from plan sponsors and their pharmacies to  determine overpayments and underpayments; providing information to  CPI to help prevent future improper payments; and referring any potential  fraud identified during the auditing process to the NBI MEDIC to  investigate. While the Part D RAC may conduct work similar to the NBI  MEDIC, the focus of the RAC is improper payments—such as  overpayments—while the MEDIC’s focus is potential fraud, waste, and  abuse.
section_title: We Identified Multiple Prevention, Detection, and Investigation Practices to Address Prescription Drug Fraud, Waste, and Abuse
paragraphs: We identified a total of 23 practices for addressing prescription drug  fraud, waste, and abuse that fall within one or more of the three  categories based on the Fraud Prevention Framework: (1) prevention,   (2) detection and monitoring, and (3) investigation and prosecution.  Counting only once the practices that fall within more than one category,  we identified 16 unique practices.
subsections: section_title: Prevention
paragraphs: We identified eight practices related to the prevention of prescription drug  fraud, waste, and abuse that can include multiple activities, as shown in  table 1. For example, one prevention practice, limiting the supply of  abused drugs, can help prevent abuse by restricting the amount of  potentially abused drugs that are available. This is done by conducting  the following activities: offering “take-back” programs where patients can safely dispose of  any unused medications, preventing use or abuse by others;  securing information and materials, such as Drug Enforcement  Administration (DEA) registration numbers and prescription pads,that could prevent bad actors from illegally obtaining prescription  drugs; and developing abuse-resistant drugs that could hamper efforts to abuse  them.
section_title: Detection and Monitoring
paragraphs: We identified nine practices related to the detection and monitoring of  prescription drug fraud, waste, and abuse, as shown in table 2. For  example, the collaboration practice includes sharing information about  specific fraud schemes and potentially fraudulent providers that can help  other interested parties—such as other insurers—find those schemes and  providers within their own systems. These practices also help monitor  individuals who have been identified as potentially abusing drugs or  health care benefits. For example, one practice we identified is recipient  restriction programs—called “lock-ins”—that typically require certain  patients to use one prescribing physician and one dispensing pharmacy— to better track their prescription drug use.
section_title: Investigation and Prosecution
paragraphs: We identified six practices related to the investigation and prosecution of  prescription drug fraud, waste, and abuse, as shown in table 3. Practices  include having investigative staff knowledgeable of prescription drug  schemes and experienced in investigating them, as well as having the  ability to take actions to enforce prescription drug rules.
section_title: CMS’s Part D Program Integrity Efforts Reflect Many of the Practices We Identified
paragraphs: CMS pursues many of the practices we identified that can be used to  prevent, detect, and investigate prescription drug fraud, waste, and  abuse. In addition, CMS plans to add new and strengthen certain existing  practices, but will not adopt certain other practices for a variety of  reasons.
subsections: section_title: CMS, with Its Contractors, Has Implemented Many Program Integrity Practices, Particularly within the Categories of Detection and Monitoring and Investigation and Prosecution
paragraphs: CMS activities to address prescription drug fraud, waste, and abuse  reflect 14 of the 23 total practices we identified, based on interviews with  officials and review of agency documents. Most of the practices CMS  pursues—10 of its 14 practices—relate to the detection and monitoring,  and investigation and prosecution categories.
CMS implements its prescription drug program integrity practices by  assigning activities to and working with plan sponsors, the MEDICs, and  others. For example,  for prevention, CMS works with the O&E MEDIC to develop  educational materials that plan sponsors can download from the O&E  MEDIC’s website and customize for their beneficiaries;  for detection and monitoring, CMS requires plan sponsors to have  compliance programs, which incorporate multiple practices we  identified, such as data analysis, collaboration, and education; the NBI  MEDIC also analyzes data and shares the results with plan sponsors;  and  for investigations and prosecutions, plan sponsors and the NBI  MEDIC are expected to have staff who can identify and investigate  potential fraud, waste, and abuse.
The NBI and O&E MEDICs reported completing work for a variety of  practices, and CMS rated elements of the MEDICs’ work from satisfactory  to exceptional on their most recent performance assessments.
CMS paid approximately $17 million in 2013 to the NBI MEDIC to analyze  data, process and review complaints, and develop investigations to  promote Part D program integrity. In the most recently completed contract  year, the NBI MEDIC reported the following: processing almost 7,000 complaints to determine whether they  identified potential fraud, for which CMS most recently rated the  contractor “exceptional”;  completing 7 data analysis projects and initiating 41 new projects, for  which CMS most recently rated the contractor “exceptional”; and  referring almost 400 cases that represented approximately   $5.1 billion in potential fraud to law enforcement, for which CMS most  recently rated the contractor “satisfactory” for its investigations and  “exceptional” for its law enforcement referrals.
subsections: section_title: O&E MEDIC
paragraphs: CMS paid approximately $1.7 million in 2013 to the O&E MEDIC to  provide outreach and education that assists CMS in communicating  program integrity efforts as well as supporting fraud, waste, and abuse  oversight audits. In the most recently completed contract year, the O&E  MEDIC reported the following: developing 59 outreach and education materials, such as fraud  awareness flyers and frequently asked questions; developing 33 training products, such as webinars and job aids; and executing 8 conferences, including with stakeholders we interviewed,  and providing 22 presentations at other conferences and meetings.
CMS rated each element of the O&E MEDIC’s work as “satisfactory.”
Table 4 identifies the practices implemented by CMS and its contractors.
section_title: CMS May Adopt Some Practices, but Not Others, for a Number of Reasons
paragraphs: CMS is planning to implement another 3 of the 23 total practices and to  strengthen 4 that it has already implemented, but officials stated that the  agency is not pursuing 6 practices for a number of reasons.
The three additional practices CMS plans to implement are the following:
Detection and Monitoring: Prescription Drug Monitoring Program  (PDMP). CMS officials said the agency is seeking access to PDMP  data through several avenues. For example, CMS and the NBI  MEDIC are working with the PDMP Center of Excellence to obtain de- identified PDMP data to assist the MEDIC in detecting potential  patterns of prescription drug fraud, waste, and abuse.
Investigation and Prosecution: PDMPs. CMS officials said CMS and  the NBI MEDIC are also working with four states—Idaho, Indiana,  Massachusetts, and New York—to obtain PDMP data as another data  source to help investigate potential prescription drug diversion. Idaho  currently is the only state that allows Medicare access to its PDMP,  while the other states have expressed interest in providing information  to CMS.
Investigation and Prosecution: Enforcement. Under the recently  issued rule, which established a Medicare enrollment requirement for  prescribers of drugs covered by Part D, CMS can revoke a  physician’s or eligible professional’s Medicare enrollment if the DEA  or a state agency has suspended or revoked the individual’s  prescriber privileges. CMS may also revoke enrollment where it  determines the individual has prescribing patterns or conducts  practices that are abusive or represent a threat to the health and  safety of Medicare beneficiaries, or both. Prior to this new  requirement, CMS could not directly take administrative actions  against a Part D provider. CMS officials also reported that they are  working with OIG on how best to pursue other enforcement options,  such as “permissive exclusions,” which allow OIG to exclude  providers from federal health programs for certain other actions, such  as misdemeanor convictions for certain offenses.
CMS is planning to strengthen four practices that it has already  implemented, which correspond to all three categories.
Prevention: Screening. CMS issued a final rule in May 2014 that is  intended to strengthen Part D prescriber and beneficiary screening.  The rule establishes a Medicare enrollment requirement for  prescribers of drugs covered by Part D, effective June 2015. As a  result, CMS is to screen these prescribers during the Medicare  enrollment process to verify that they meet specific requirements,  such as having current licenses or accreditation and valid Social  Security numbers. Additionally, this final rule authorizes CMS to  revoke a physician’s or eligible professional’s Medicare enrollment for  certain abuses of the program, or based upon a suspension or  revocation of the prescriber’s DEA certificate or state authority to  prescribe drugs. As with fee-for-service providers, CMS will revalidate  enrollment information when changes or updates are submitted and  during a 5-year revalidation process. CMS is still considering whether  to require pharmacies that dispense covered Part D drugs to enroll  into the Medicare program.
The rule is also intended to strengthen screening of Part D  beneficiaries. Currently, plan sponsors are to verify beneficiaries’ Part D eligibility. While incarcerated or confined beneficiaries are  generally ineligible for Part D coverage, recent OIG reports found that  CMS paid for prescription drugs for such beneficiaries.implements the exclusion of beneficiaries incarcerated for 30 days or  more from receiving Part D benefits starting January 1, 2015, by  removing the facilities where individuals are incarcerated from the  definition of a plan’s service area.
Detection and Monitoring: Collaboration. CMS is seeking to  strengthen collaboration through a new voluntary web-based system  created by the NBI MEDIC—PLATO—that is intended to allow CMS  and plan sponsors to more easily share information on fraud schemes  and potential bad actors. For example, plan sponsors may use the  system to share information on specific suspect providers so that  other plan sponsors can determine whether they should also  investigate or take actions against those providers. CMS officials said  that they anticipate that PLATO will be accessible to plan sponsors by  the end of 2014. In addition, according to agency officials, CMS is  working with the NBI MEDIC to develop and implement predictive  models in PLATO to help identify potential fraud schemes that can be  shared with plan sponsors, such as a model for identifying prescribers  who provide certain controlled substances to patients without a valid  medical need.
Detection and Monitoring: Compliance Program. CMS is pursuing  options for improving its oversight of plan sponsors’ compliance  programs. In 2013, among the plan sponsors that it audited, CMS  found weaknesses in the majority of plan sponsors’ compliance  programs for addressing fraud, waste, and abuse. During that year,  CMS audited 29 plan sponsors, representing 14 percent of all plan  sponsors and, of those, nearly all (94 percent) had findings related to  fraud, waste, and abuse activities, according to officials. These  officials also reported that almost all weaknesses were addressed  through a corrective action plan. In January 2014, CMS proposed a  rule that would require, among other things, that plan sponsors hire an  independent auditor to verify that any required corrective action plans  addressed deficiencies found during a program audit. CMS did not  finalize this requirement in the final rule issued in May 2014, and as of  October 2014, CMS officials did not provide a proposed completion  date.
In addition, CMS officials reported that the agency has an initiative  under way to gather information that could help improve oversight of  plan sponsors’ practices to address fraud, waste, and abuse. As part  of this initiative, CMS interviewed five plan sponsors about how they  use the information CMS provided to them on new fraud schemes and  potentially fraudulent providers. Based on this information, CMS  officials reported that they could change how the agency audits plan  sponsors’ fraud, waste, and abuse activities, or increase the  requirements for sponsors’ activities, in order to improve oversight.However, CMS officials noted that any changes will be based on the  agency’s final assessment of lessons learned from the initiative, which  was still in progress as of August 2014.
Investigation and Prosecution: Collaboration. CMS is working to  develop a more formal way to share information about fraudulent  providers with relevant state medical boards, CMS officials said, so  that the medical boards can conduct additional investigations to  determine whether the board should impose sanctions on those  providers, such as revoking a provider’s medical license.
CMS is not pursuing six practices that appear in two categories,  prevention and detection and monitoring, because the agency considers  the practices to be outside the scope of its program integrity activities, is  concerned about limiting beneficiaries’ access to services, or for other  reasons.
Prevention, and Detection and Monitoring: Clinical Guidelines. While  CMS uses clinical guidelines to review plan sponsors’ formularies to  ensure access to certain drugs, CMS does not require plan sponsors  to carry out activities within these program integrity practices, such as  filling only the prescriptions for the lowest effective dose, promoting  alternatives to opioids, or screening their patients for potential drug  abuse. However, CMS provides training materials to providers on  such topics to promote patient safety, and other parts of Medicare  cover screening for drug abuse under certain conditions.
Prevention: Health Information Technology. CMS does not use health  information technology for program integrity purposes, but  encourages its use by, for example, providing information to Medicare  beneficiaries on the benefits of electronic health records.
Prevention: PDMPs. CMS guidance to physicians has encouraged  prescribers to check their states’ PDMP prior to prescribing certain  drugs; however, variations in state practices regarding access to  PDMPs means that not all prescribers may be able to conduct checks,  according to CMS officials.
Prevention: Limit the Supply of Abused Drugs. CMS officials told us  that the agency does not conduct activities to limit the supply of  abused drugs because this practice is beyond the scope of Part D  program integrity efforts. For example, CMS does not operate “take  back” days where beneficiaries can dispose of any unneeded  prescription drugs, since, until recently, DEA required a law  enforcement presence at such events, which CMS cannot provide.CMS also does not address the supply of abuse-resistant drugs,  officials said, since that is the responsibility of the Food and Drug  Administration and pharmaceutical manufacturers.
Detection and Monitoring: Lock-ins. CMS does not monitor Medicare  beneficiaries through a “lock-in” or restricted recipient program. We  previously recommended that CMS consider a restricted recipient  program for Medicare Part D that would limit certain beneficiaries to  one prescriber, one pharmacy, or both for receiving prescriptions, and  that the agency should seek congressional authority, as appropriate,  to do so.  CMS, in responding to our recommendation, stated that it  did not agree that a restricted recipient program was necessarily the  appropriate control for the Part D program, and raised concerns about  restricting beneficiaries’ access to services.2014, OIG recommended that CMS restrict certain beneficiaries to a  limited number of pharmacies and prescribers, and CMS concurred   However, in August  with the recommendation, but stated the agency needs—and is  receptive to—legislative authority to “lock in” beneficiaries in Part D.
Currently, the agency requires plan sponsors to review data to identify  beneficiaries potentially at risk for overutilization of certain drugs,  including opioids, and to monitor those beneficiaries. Monitoring  may include notifying their prescribers of the overutilization, case  management, and point-of-sale edits, which are beneficiary-specific  edits that can vary based on the situation. For example, the edits may  prevent a beneficiary from receiving certain types of prescription  drugs or an excessive amount of a particular drug.
See appendix I for the status of all 23 program integrity practices we  identified and whether CMS and its contractors have implemented,  planned to implement, or are not pursuing them.
section_title: Agency Comments
paragraphs: We provided a draft of this report to the Department of Health and Human  Services (HHS) for comment and HHS provided written comments, which  are reprinted in appendix II. In its comments, HHS generally agreed with  our findings, and provided more information regarding our finding that  CMS is not pursuing 6 of the 23 practices we identified for prescription  drug fraud, waste, and abuse. Generally, the agency provided additional  information for why CMS is not pursuing certain practices as part of its  program integrity efforts, such as the use of clinical guidelines, PDMPs,  and lock-in programs. Regarding the practice of health information  technology, while HHS noted that CMS requires the development by   Part D sponsors of electronic prescription drug programs and the use of  e-prescribing is encouraged, these activities were not identified by CMS  officials as specific program integrity efforts. Regarding the practice of  limiting the supply of abused drugs, HHS described CMS activities that  we considered under a different practice—the use of prepayment edits.  Our descriptions and examples of these practices, as well as the other 17  practices, are included in tables 1, 2, and 3 in this report. HHS also  provided a recent example of its program integrity efforts to address  fraud, waste, and abuse in the Part D program, in which HHS sent letters  to providers identified as very high prescribers of certain controlled  substances to give information to these providers to help them evaluate  whether their high prescribing level of these drugs is appropriate for their  patient population, and to identify areas where their prescribing could be  modified. HHS also provided technical comments, which we incorporated  as appropriate.
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If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or at kingk@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff who made key contributions to this report  are listed in appendix III.
section_title: Appendix I: Status of Practices by CMS and Its Contractors to Address Prescription Drug Fraud, Waste, and Abuse
paragraphs: Table 5 shows the 23 prevention, detection and monitoring, and  investigation and prosecution practices we identified, their CMS status  (implemented, planned, or not pursuing), and examples of the activities.  We determined that CMS had implemented a practice if the agency  required or documented at least one activity within that practice, that CMS  planned a practice if documentation or officials described activities as  pilots or in the process of development, and that CMS was not pursuing  practices based on reviews of documentation and interviews with officials.
section_title: Appendix II: Comments from the Department of Health and Human Services
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
paragraphs: Kathleen M. King, (202) 512-7114 or kingk@gao.gov.
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Karen Doran, Assistant Director;  Elizabeth Morrison; Lisa Rogers; Eden Savino; and Jennifer Whitworth  made key contributions to this report.