Medicare: Further Action Could Improve Improper Payment Prevention and Recoupment Efforts
Published: 2014-05-20T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Due to its size, complexity, and susceptibility to mismanagement and improper payments, GAO has designated Medicare as a high-risk program. In 2013, Medicare financed health care services for approximately 51 million individuals at a cost of about $604 billion, and reported an estimated $50 billion in improper payments—payments that either were made in an incorrect amount or should not have been made at all. Most of these improper payments were made through the Medicare FFS program, which pays providers based on claims and uses contractors to pay the claims and ensure program integrity.
This statement focuses on the progress made and steps still to be taken by CMS to improve improper payment prevention and recoupment efforts in the Medicare FFS program. This statement is based on relevant GAO products and recommendations issued from 2007 through 2014 using a variety of methodologies. GAO also updated information by examining public documents and, in April 2014, GAO received updated information from CMS on its actions related to laws and regulations discussed in this statement.
section_title: What GAO Found
paragraphs: The Centers for Medicare & Medicaid Services (CMS), the agency within the Department of Health and Human Services (HHS) that oversees Medicare, has made progress improving improper payment prevention and recoupment efforts in the Medicare fee-for-service (FFS) program, but further actions are needed.
Provider enrollment . CMS has implemented certain provider enrollment screening procedures authorized by the Patient Protection and Affordable Care Act (PPACA) that address past weaknesses identified by GAO and others. The agency has also put in place other measures intended to strengthen existing procedures, but could do more to improve provider enrollment screening and ultimately reduce improper payments. For example, CMS has hired contractors to determine whether providers and suppliers have valid licenses, meet certain Medicare standards, and are at legitimate locations. CMS also recently contracted for fingerprint-based criminal history checks of providers and suppliers it has identified as high-risk. However, CMS has not implemented other screening actions authorized by PPACA that could further strengthen provider enrollment.
Prepayment controls . In response to GAO's prior recommendations, CMS has taken steps to improve the development of certain prepayment edits—prepayment controls used to deny Medicare claims that should not be paid; however, important actions that could further prevent improper payments have not yet been implemented. For example, CMS has implemented an automated edit to identify services billed in medically unlikely amounts, but has not implemented a GAO recommendation to examine certain edits to determine whether they should be revised to reflect more restrictive payment limits. GAO has found that wider use of prepayment edits could help prevent improper payments and generate savings for Medicare.
Postpayment claims reviews . Postpayment claims reviews help CMS identify and recoup improper payments. Medicare uses a variety of contractors to conduct such reviews, which generally involve reviewing a provider's documentation to ensure that the service was billed properly and was covered, reasonable, and necessary. GAO has found that differing requirements for the various contractors may reduce the efficiency and effectiveness of such reviews. To improve these reviews, GAO has previously recommended CMS examine ways to make the contractor requirements more consistent. CMS reported that it has begun to address these recommendations. Although the percentage of Medicare claims that undergo postpayment review remains very small, GAO has found that the overall number of postpayment claims reviews has been increasing in recent years. HHS has reported that the increase in claims reviews is one factor causing backlogs in the Medicare appeals process.
GAO has ongoing work focused on how CMS could continue its efforts to reduce improper Medicare payments. For instance, GAO is examining the extent to which CMS's provider enrollment system can help prevent and detect the continued enrollment of ineligible providers in Medicare. GAO also has work underway to examine whether CMS has strategies for coordinating postpayment review contractors' claims review activities.

section_title: Letter
paragraphs: I am pleased to be here today to discuss our work examining further  action Medicare could take to improve its improper payment prevention  and recoupment efforts. In 2013, Medicare financed health care services  for approximately 51 million individuals at a cost of about $604 billion, and  reported some of the largest estimates of improper payments among  federal programs—payments that either were made in an incorrect  amount or should not have been made at all. Due to its size, complexity,  and susceptibility to mismanagement and improper payments, we have  designated Medicare as a high-risk program since 1990.
The Centers for Medicare & Medicaid Services (CMS), the agency within  the Department of Health and Human Services (HHS) that oversees  Medicare, has estimated that improper payments in the Medicare  program were almost $50 billion in fiscal year 2013. CMS separately  calculates error rates and performance targets for the Medicare fee-for- service (FFS) program, Medicare Advantage, and the Medicare  Prescription Drug Benefit.70 percent of Medicare’s estimated improper payments in 2013. The  Medicare FFS estimated improper payments were about $36 billion or  about 10.1 percent of total FFS payments. This is about $6.5 billion   Medicare FFS accounted for more than   higher than in 2012 and did not meet the fiscal year 2013 target error rate  of 8.3 percent that the agency set for itself to reduce improper payments.  Improper payments may be a result of fraud, waste, or abuse, but it is  important to distinguish that the $50 billion in estimated improper  payments reported by CMS in fiscal year 2013 is not an estimate of fraud  in Medicare. Reported improper payment estimates include many types  of payments that should not have been made or were made in an  incorrect amount such as overpayments, underpayments, and payments  that were not adequately documented.
According to HHS, the primary cause of improper payments in Medicare  FFS was administrative and documentation errors in large part due to  insufficient documentation, meaning the medical records submitted by the  provider or supplier were inadequate to support payment for the services  billed. HHS has reported that physicians and suppliers substantially  contributed to insufficient documentation errors. HHS also cited the  provision of services that were found not to be medically necessary and  incorrect diagnosis coding as causes for FFS improper payments.  Medical necessity errors occur, for example, when a claim is paid for a  service that should have been provided in a less intensive setting. This  error type has accounted for the majority of Part A inpatient hospital  improper payments. For Medicare Advantage, HHS reported that the  majority of the improper payment estimate resulted from insufficient  documentation to support the diagnoses submitted by private health plans  for payment. HHS cited administrative and documentation errors as the  cause for all improper payments in the prescription drug benefit. Despite  CMS efforts to address these causes, reducing Medicare improper  payments continues to be a challenge.
Today, my testimony will focus on the progress made and steps still  needed by CMS to reduce improper payments in the Medicare FFS  program. I will focus on CMS’s progress with respect to three key  strategies we have identified in prior work that can help prevent improper  payments and recoup overpayments:
Strengthening provider enrollment standards and procedures to help  reduce the risk of enrolling entities intent on defrauding the program;  Improving prepayment controls, to ensure that claims are paid  correctly the first time; and  Improving postpayment claims review and recovery of improper  payments to reduce the likelihood of improper payments and recoup  overpayments.
My statement today is based primarily on previous GAO reports related to  Medicare program integrity efforts issued between January 2007 and  April 2014. A list of related GAO products is included at the end of this  statement.Medicare improper payments reported by HHS in its fiscal year 2013  agency financial report and with other publicly available information from  HHS’s website on Medicare appeals, and we received updated  information from CMS in April 2014 on its actions related to relevant laws,  regulations, and recommendations that had not yet been implemented  discussed in this statement. Our work for this statement and the products  on which it was based was conducted 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: CMS Has Improved Key Strategies for Preventing and Recouping Improper Payment, but More Can Be Done
paragraphs: CMS has made progress strengthening provider enrollment procedures  and prepayment controls in the Medicare program to help ensure that  payments are made correctly the first time, but the agency could further  improve upon its efforts by implementing additional enrollment  procedures and prepayment strategies. Likewise, additional  improvements to CMS’s postpayment claims review activities could  improve their efficiency and effectiveness.
subsections: section_title: CMS Has Implemented Certain Enrollment Procedures to Better Screen Providers, but Has Not Completed Others
paragraphs: CMS has implemented certain provider enrollment screening procedures  authorized by the Patient Protection and Affordable Care Act (PPACA)  and put in place other measures intended to strengthen existing  procedures. The changes to provider screening procedures are  intended to address past weaknesses identified by GAO and the HHS’s  Office of Inspector General (OIG) that allowed entities intent on  committing fraud to enroll in Medicare. Blocking the enrollment of such  providers helps to prevent Medicare from making improper payments.  Specifically, CMS added screenings of categories of provider enrollment  applications by risk level and contracted with new national enrollment  screening and site visit contractors.
Screening Provider Enrollment Applications by Risk Level: CMS and  the OIG issued a final rule in February 2011 to implement many of the  new screening procedures required by PPACA. CMS designated  three levels of risk—high, moderate, and limited—with different  screening procedures for categories of Medicare providers at each  level. Providers in the high-risk level are subject to the most rigorous  screening. Based in part on our work and that of the OIG, CMS  designated newly enrolling home health agencies and suppliers of  durable medical equipment, prosthetics, orthotics, and supplies  (DMEPOS) as high risk, and designated other providers as lower risk.
Providers at all risk levels are screened to verify that they meet  specific requirements established by Medicare, such as having  current licenses or accreditation and valid Social Security numbers.  High- and moderate-risk providers are also subject to unannounced  site visits.
Further, PPACA authorizes CMS to require fingerprint-based criminal  background checks of providers and suppliers depending on the risks  presented. In March 2014, CMS awarded a contract to a Federal  Bureau of Investigation-approved contractor that will enable the  agency to access criminal history information to help conduct those  checks of high-risk providers and suppliers. CMS has indicated that  the agency will continue to review the criteria for its screening levels  and will publish changes if the agency decides to update the  assignment of screening levels for categories of Medicare providers.  Doing so could become important because the Department of Justice  and HHS reported multiple convictions, judgments, settlements, or  exclusions against types of providers not currently at the high-risk  level, including community mental health centers and ambulance  providers.
National Enrollment Screening and Site Visit Contractors: CMS  contracted with two new contractors at the end of 2011 to assume  centralized responsibility for two functions that had been the  responsibility of multiple contractors. One of the new contractors is  conducting automated screenings to check that existing and newly  enrolling providers and suppliers have valid licensure, accreditation,  and a National Provider Identifier, and are not on the OIG list of  providers and suppliers excluded from participating in federal health  care programs. The second contractor conducts site visits of providers  to determine whether sites are legitimate and the providers meet  certain Medicare standards. A CMS official reported that, since the  implementation of the PPACA screening requirements, the agency  had revoked over 17,000 suspect providers’ privileges to bill the  Medicare program.
Although CMS has taken actions to strengthen the provider enrollment  process, we and the OIG have found that CMS has not taken other  actions authorized by PPACA and that could improve screening and  ultimately reduce improper payments. They include issuing a rule to require surety bonds for certain providers and suppliers as well as a rule  on provider and supplier disclosure requirements.
Surety Bonds: PPACA authorized CMS to require a surety bond for   Surety bonds may  certain types of at-risk providers and suppliers. serve as a source for recoupment of erroneous payments. DMEPOS  suppliers are currently required to post a surety bond at the time of  enrollment. CMS told us in April 2014 that the agency collected  about $1.6 million in DMEPOS supplier overpayments between  February 2012 and March 2013. However, also in April 2014, CMS  reported that it had not scheduled for publication a proposed rule to  impose a surety bond requirement as authorized by PPACA for other  types of at-risk providers and suppliers—such as home health  agencies and independent diagnostic testing facilities.
Providers and Suppliers Disclosure: CMS has not yet scheduled the  publication of a proposed rule for increased disclosures of prior  actions taken against providers and suppliers enrolling or revalidating  enrollment in Medicare, such as whether the provider or supplier has  been subject to a payment suspension from a federal health care  program. As we reported in April 2012, agency officials indicated  that developing the additional disclosure requirements has been  complicated by provider and supplier concerns about what types of  information will be collected, what CMS will do with it, and how the  privacy and security of this information will be maintained.
We are currently examining the ability of CMS’s provider enrollment  system to prevent and detect the continued enrollment of ineligible or  potentially fraudulent providers in Medicare. Specifically, we are  assessing the process used to enroll and verify the eligibility of Medicare  providers in Medicare’s Provider Enrollment, Chain, and Ownership  System (PECOS) and the extent to which CMS’s controls are designed to  prevent and detect the continued enrollment of ineligible or potentially  fraudulent providers in PECOS.
section_title: CMS Has Improved Prepayment Controls, but More Could Be Done to Prevent Improper Payments
paragraphs: CMS has enhanced its efforts to reduce improper payments by improving  prepayment controls, particularly prepayment edits to deny claims that  should not be paid. CMS has stated that one of its key goals is to pay  claims properly the first time—that is, to ensure that payments go to  legitimate providers in the right amount for reasonable and necessary  services covered by the program for eligible beneficiaries. To do so,  among other things, CMS uses prepayment controls such as prepayment  edits—instructions that CMS’s contractors, including Medicare  Administrative Contractors (MAC), program into claims processing  systems that compare claim information to Medicare requirements in  order to approve or deny claims or to flag them for additional review. For  example, some prepayment edits are related to service coverage and  payment, while others are implemented to verify that the claim is properly  filled out, that providers are enrolled in Medicare, or that patients are  eligible Medicare beneficiaries.and its contractors are automated and applied to all claims; if a claim  does not meet the criteria of the edits, it is automatically denied. Other  prepayment edits are manual; they flag a claim for individual review by  trained staff to determine whether it should be paid.
Most of the edits implemented by CMS  We previously evaluated CMS’s implementation of prepayment edits   and found that while use of prepayment edits saved Medicare at least  $1.76 billion in fiscal year 2010, the savings could have been greater had  prepayment edits been used more widely. For example, based on our  analysis of a limited number of national policies and local coverage  determinations in 2012, we identified $14.7 million and $100 million in  payments, respectively, that were inconsistent with policies and  determinations and were therefore improper. Such inconsistencies could  have been identified using automated edits.
As we recommended, CMS has taken steps to improve the development  of certain prepayment edits that are implemented nationwide. For  example, the agency has centralized the development and  implementation of automated edits based on a type of national policy  called national coverage determinations. In addition, CMS has modified  its processes for identifying provider billing of services that are medically  unlikely, in order to prevent circumvention of automated edits designed to  identify an unusually large quantity of services provided to the same  patient. However, as of April 2014, CMS had not fully implemented  several of the recommendations we made in 2013 that we believe would  promote greater use of prepayment edits and better ensure proper  payment. For example, the agency did not include, in its written  guidance to agency staff on procedures for ensuring consideration of  automated edits, time frames for making decisions on whether an edit  would be developed nor did it include requirements for assessing the  effects of corrective actions taken. In addition, although CMS has taken  initial steps to improve the data it collects about local prepayment edits  implemented by its contractors, it had not yet determined a final process  for how it would obtain and disseminate information about these edits  across contractors. Nor does CMS require contractors to share  information with each other about the underlying policies and savings  related to their most effective edits, as the agency currently lacks a  database to collect such information. Having information about the most  effective local edits would enable contractors to determine the most  appropriate approach for implementing Medicare payment policy  effectively, which could help reduce improper payments.
To help prevent improper payments, CMS also implemented a specific  type of national edit, called a Medical Unlikely Edit (MUE), which limits the  amount of a service that is paid when billed by a provider for a beneficiary  on the same day. The limits for certain services that have been  fraudulently or abusively billed are unpublished to deter providers from  billing up to the maximum allowable limit. In 2013, we reported that CMS  may be missing opportunities to prevent improper payments because it  has not systematically evaluated MUE limits to determine whether   In  national edits should be revised to reflect more restrictive local limits.addition, we found that CMS and its contractors did not have a system in  place for examining claims to determine the extent to which providers  may be exceeding unpublished MUE limits and whether payments for  such services were proper. As a result, we recommended that CMS  examine contractor edits to determine whether any national unpublished  MUE limits should be revised, consider reviewing claims to identify  providers that exceed the unpublished MUE limits, and determine  whether the provider’s billing was proper. HHS agreed with these  recommendations, but as of April 2014, CMS had not implemented them.
section_title: Postpayment Claims Reviews Have Increased in Recent Years, but More Could Be Done to Increase Consistency across Contractors
paragraphs: Medicare uses four types of contractors to conduct postpayment claims  reviews to identify and recoup overpayments.the same Medicare coverage and payment guidelines.
MACs, in addition to conducting prepayment claims reviews, conduct  postpayment claims reviews to help ensure accurate payment and  specifically to identify payment errors. This includes identifying ways  to address future payment errors—for example, through automated  controls that can be added on a prepayment basis and by educating  providers with a history of a sustained or high level of billing errors to  ensure that they comply with Medicare billing requirements.
Zone Program Integrity Contractors (ZPIC), the CMS contractors  responsible for detecting and investigating fraud, perform  postpayment claims reviews as a part of their investigations.
Therefore, ZPIC reviews generally focus on providers whose billing  patterns are unusual or aberrant in relation to those of similar  providers in order to identify potential fraud.
The Comprehensive Error Rate Testing (CERT) contractor estimates  the Medicare FFS improper payment rate by using the results of  postpayment claims reviews conducted on a sample of claims  processed by the MACs. CERT reviews may also help identify  program vulnerabilities by measuring the payment accuracy of each  MAC, and the Medicare FFS improper payment rate by type of claim  and service.
Recovery audit contractors (RAC) conduct postpayment claims  reviews to identify improper payments. Use of RACs was designed to  be in addition to MACs’ existing claims review processes, since the  number of postpayment reviews conducted by MACs and other  contractors was small relative to the number of claims paid and the  amount of improper payments. Whereas RACs are paid on a  contingency fee basis based on the amount of improper payments  they recoup, the other three contractors are paid under the terms of  their contract using appropriated funds. In February 2014, CMS  announced a “pause” in the RAC program as the agency makes  changes to the program and starts a new procurement process for the  next round of recovery audit contracts. CMS said it anticipates  awarding all five of these new Medicare FFS recovery audit contracts  by the end of summer 2014.
All four types of contractors conduct complex reviews of claims. Complex  reviews involve manual examinations of each claim and any related  documentation requested and received from the provider, including paper  files, to determine whether the service was billed properly, and was  covered, reasonable, and necessary. Licensed clinical professionals,  such as licensed practical nurses, and certified coders typically perform  the reviews. Contractors have physician medical directors on staff who  provide guidance about making payment determinations on the basis of  medical records and other documentation and who may discuss such  determinations with providers.
In addition to conducting complex reviews, RACs also conduct automated  and semiautomated postpayment claims reviews. Automated reviews use  computer programming logic to check claims for evidence of improper  coding or other mistakes. Automated postpayment reviews analyze paid  claims and identify those that can be determined to be improper without  examining any additional documentation, such as when a durable medical  equipment supplier bills for items that should have been included as part   Semiautomated  of a bundled payment for a skilled nursing facility stay.reviews use computer programming logic to check for possible improper  payments, but allow providers to send in information to rebut the claim  denial before it is implemented. If providers send in information, RAC staff  review it before making a final determination.
Our prior work has found that the overall number of postpayment claims  reviews has been increasing in recent years, but remains a very small  percentage of total Medicare claims submitted. year for which we have data, the four types of Medicare postpayment  review contractors conducted about 2.3 million claims reviews, which is a  55 percent increase from 2011. RACs conducted about 2.1 million, or   90 percent, of these reviews in 2012. All four types of contractors listed  except the CERT contractor increased the number of claims they  reviewed in 2012, as shown in table 1.
GAO, Medicare Program Integrity: Increasing Consistency of Contractor Requirements  May Improve Administrative Efficiency. GAO-13-522 (Washington, D.C.: July 23, 2013).
Reviews completed by MACs do not include the reviews performed by the three legacy contractors  that were continuing to provide claims administration services as of June 2013.  RAC data are reported for fiscal years 2011 and 2012, rather than calendar year.  Automated reviews use computer programming logic to check claims for evidence of improper  coding or other mistakes. Only the RACs conducted automated postpayment reviews.
RAC complex reviews are based on the number of additional documentation requests received and  also include semiautomated reviews.
While the number of postpayment reviews has increased significantly, the  percentage of Medicare claims reviewed after payment remains small.  The 2.3 million reviews performed by these four types of contractors  accounted for less than 1 percent of the more than 1 billion FFS claims  paid annually. About 1.4 million of the reviews were complex reviews  which required the submission of documentation for review.
As a systematic matter, the increase in postpayment claims reviews is  one factor causing backlogs and delays at the third level of the Medicare  appeals process. Medicare providers and suppliers can appeal  prepayment and postpayment claims determinations through the  Medicare appeals process, which offers four levels of administrative  review followed by judicial review. The first two levels of appeals for FFS  claims are managed by two CMS contractors—the MAC that processed  the original claim and a Qualified Independent Contractor, in that order.
The third level of appeal is to an Administrative Law Judge (ALJ) at the  Office of Medicare Hearings and Appeals (OMHA), a separate staff  division within HHS. A Part A or Part B appeal filed with OMHA should  generally be decided within 90 days of the appeal being filed. However,  due to a backlog of cases, OMHA currently reports that the average time  for appeals to be decided in fiscal year 2014 is 346 days. The number of  appeals filed at the ALJ level increased from 59,601 in fiscal year 2011 to  384,651 in fiscal year 2013, according to OMHA. OMHA’s website  currently says that new appeals will take about 28 months before they are  put on an ALJ’s hearing docket. OMHA has reported that part of the  reason for the backlog in Medicare appeals is the increase in  postpayment contractor activities. We have been asked to examine the  Medicare appeals process, including the reasons for the appeals backlog  and what HHS is doing to address it.
We have made recommendations to CMS in the past to improve the  postpayment claims review process, and we continue to do work in this  area. In October 2012, we reported on CMS’s Fraud Prevention System  (FPS), which uses predictive analytics to analyze Medicare FFS claims.   FPS is intended to detect aberrant billing practices as quickly as possible  so they can be investigated to determine whether the payments are  proper. At the time, we recommended that CMS integrate FPS with  Medicare’s payment-processing system to allow for the prevention of  payments until suspect claims could be investigated by ZPICs. Although  CMS reported in April 2014 that it had integrated the systems, the system  still does not have the ability to suspend payment until suspect claims can  be investigated. CMS has begun to implement prepayment edits in FPS  that automatically deny claims based on attributes of the FPS edit which  reviews the claim against historical claims across all lines of business.
In July 2013, we reported that the differences in CMS’s postpayment  claims review requirements for the four types of contractors may reduce  the efficiency and effectiveness of claims reviews by complicating  providers’ compliance with the requirements. For instance, while RACs  have to obtain approval from CMS for the billing issues they choose to  review on a widespread basis and notify providers and suppliers of those  issues on their websites, the other contractors do not. In addition, the  minimum number of days that CMS requires a contractor to give a  provider to submit additional documentation for a complex review before  the claim can be found improper for lack of documentation varies among  the contractors from 30 days for ZPICs to 75 days for the CERT  contractor. Staffing requirements and quality assurance requirements  also vary among the four types of contractors. We recommended that  CMS examine all postpayment review requirements for contractors to  determine whether they could be made more consistent without negative  effects on program integrity. We also recommended that CMS reduce  differences in those requirements where it can be done without impeding  the efficiency of its efforts to reduce improper payments. In commenting  on that report, CMS agreed with our recommendations and stated that the  agency was beginning to review its requirements for postpayment claims  reviews. We are following up on this work with a study reviewing, among  other things, whether CMS has strategies for coordinating postpayment  review contractors’ claims review activities.
In conclusion, given the amount of estimated improper payments in the  Medicare program, the imperative for CMS to use all available authorities  to prevent and recoup improper payments is clear. Although CMS has  taken important steps to strengthen key strategies for identifying and  preventing improper payments, the agency must continue to improve  upon these efforts. Identifying the nature, extent, and underlying causes  of improper payments and developing adequate corrective action  processes to address vulnerabilities are essential prerequisites to  reducing them. As CMS continues its implementation of PPACA,  additional evaluation and oversight will help determine whether  implementation of relevant provisions has been effective in reducing  improper payments. We are continuing to conduct a body of work that  assesses CMS’s efforts to refine and improve its ability to prevent,  identify, and recoup improper payments. Notably, we are currently  assessing the extent to which CMS’s information system can help prevent  and detect the continued enrollment of ineligible or potentially fraudulent  providers in Medicare. Additionally, we are examining CMS’s oversight of  some of the contractors that conduct postpayment reviews of claims  including whether CMS has a strategy for coordinating these contractors’  claims review activities. Separately, we have also been asked to examine  the Medicare appeals process, including the reasons for the appeals  backlog and how it is being addressed. Through this work, we hope to  develop further recommendations for CMS to help the agency continue to  refine its efforts to reduce improper Medicare payments.
Chairman Lankford, Ranking Member Speier, and Members of the  Subcommittee, this concludes my prepared remarks. I would be pleased  to respond to any questions you may have at this time.
section_title: GAO Contact and Staff Acknowledgments
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. Lori Achman, Assistant  Director; Rebecca Abela; Jennel Lockley; and Jennifer Whitworth were  key contributors to this statement.
section_title: Appendix I: Abbreviations
section_title: Related GAO Products
paragraphs: Medicare Fraud: Progress Made, but More Action Needed to Address  Medicare Fraud, Waste, and Abuse. GAO-14-560T. Washington, D.C.:  April 30, 2014.
Medicare Program Integrity: Contractors Reported Generating Savings,  but CMS Could Improve Its Oversight. GAO-14-111. Washington, D.C.:  October 25, 2013.
Health Care Fraud and Abuse Control Program: Indicators Provide  Information on Program Accomplishments, but Assessing Program  Effectiveness Is Difficult. GAO-13-746. Washington, D.C.: September 30,  2013.
Medicare Program Integrity: Increasing Consistency of Contractor  Requirements May Improve Administrative Efficiency. GAO-13-522.  Washington, D.C.: July 23, 2013.
Medicare Program Integrity: Few Payments in 2011 Exceeded Limits  under One Kind of Prepayment Control, but Reassessing Limits Could Be  Helpful. GAO-13-430. Washington, D.C.: May 9, 2013.
Medicare Fraud Prevention: CMS Has Implemented a Predictive  Analytics System, but Needs to Define Measures to Determine Its  Effectiveness. GAO-13-104. Washington, D.C.: October 15, 2012.
Medicare Program Integrity: Greater Prepayment Control Efforts Could  Increase Savings and Better Ensure Proper Payment. GAO-13-102.  Washington, D.C.: November 13, 2012.
Health Care Fraud: Types of Providers Involved in Medicare, Medicaid,  and the Children’s Health Insurance Program Cases. GAO-12-820.  Washington, D.C.: September 7, 2012.
Program Integrity: Further Action Needed to Address Vulnerabilities in  Medicaid and Medicare Programs. GAO-12-803T. Washington, D.C.:  June 7, 2012.
Medicare: Important Steps Have Been Taken, but More Could Be Done to  Deter Fraud. GAO-12-671T. Washington, D.C.: April 24, 2012.
Medicare Program Integrity: CMS Continues Efforts to Strengthen the  Screening of Providers and Suppliers. GAO-12-351. Washington, D.C.:  April 10, 2012.
Improper Payments: Remaining Challenges and Strategies for  Governmentwide Reduction Efforts. GAO-12-573T. Washington, D.C.:  March 28, 2012.
Fraud Detection Systems: Centers for Medicare and Medicaid Services  Needs to Expand Efforts to Support Program Integrity Initiatives.   GAO-12-292T. Washington, D.C.: December 7, 2011.
Medicare Integrity Program: CMS Used Increased Funding for New  Activities but Could Improve Measurement of Program Effectiveness.  GAO-11-592. Washington, D.C.: July 29, 2011.
Improper Payments: Reported Medicare Estimates and Key Remediation  Strategies. GAO-11-842T. Washington, D.C.: July 28, 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.
Improper Payments: Progress Made but Challenges Remain in  Estimating and Reducing Improper Payments. GAO-09-628T.  Washington, D.C.: April 22, 2009.
Medicare: Thousands of Medicare Providers Abuse the Federal Tax  System. GAO-08-618. Washington, D.C.: June 13, 2008.
Improper Payments: Status of Agencies’ Efforts to Address Improper  Payment and Recovery Auditing Requirements. GAO-08-438T.  Washington, D.C.: January 31, 2008.
Improper Payments: Federal Executive Branch Agencies’ Fiscal Year  2007 Improper Payment Estimate Reporting. GAO-08-377R. Washington,  D.C.: January 23, 2008.
Medicare: Improvements Needed to Address Improper Payments for  Medical Equipment and Supplies. GAO-07-59. Washington, D.C.:  January 31, 2007.
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