What GAO Found
In response to the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for overseeing Medicare and Medicaid, made widespread use of program waivers and other flexibilities to expand beneficiary access to care. Some preliminary information is available on the effects of these waivers. Specifically:
Medicare. CMS issued over 200 waivers and cited some of their benefits in a January 2021 report. For example, CMS reported that:
- Expansion of hospital capacity. More than 100 new facilities were added through the waivers that permitted hospitals to provide care in non-hospital settings, including beneficiaries’ homes.
- Workforce expansion. Waivers and other flexibilities that relaxed certain provider enrollment requirements and allowed certain nonphysicians, such as nurse practitioners, to provide additional services expanded the provider workforce.
- Telehealth waivers. Utilization of telehealth services—certain services that are normally provided in-person but can also be provided using audio and audio-video technology—increased sharply. For example, utilization increased from a weekly average of about 325,000 services in mid-March to peak at about 1.9 million in mid-April 2020.
Medicaid. CMS approved more than 600 waivers or other flexibilities aimed at addressing obstacles to beneficiary care, provider availability, and program enrollment. GAO has reported certain flexibilities such as telehealth as critical in reducing obstacles to care. Examples of other flexibilities included:
- Forty-three states suspended fee-for-service prior authorizations, which help ensure compliance with coverage and payment rules before beneficiaries can obtain certain services.
- Fifty states and the District of Columbia waived certain provider screening and enrollment requirements, such as criminal background checks.
While likely benefitting beneficiaries and providers, these program flexibilities also increase certain risks to the Medicare and Medicaid programs and raise considerations for their continuation beyond the pandemic. For example:
- Increased spending. Telehealth waivers can increase spending in both programs, if telehealth services are furnished in addition to in-person services.
- Program integrity. The suspension of some program safeguards has increased the risks of fraud, waste, and abuse that GAO previously noted in its High-Risk report series.
- Beneficiary health and safety. Although telehealth has enabled the safe provision of services, the quality of telehealth services has not been fully analyzed.
Why GAO Did This Study
Medicare and Medicaid—two federally financed health insurance programs—spent over $1.5 trillion on health care services provided to about 140 million beneficiaries in 2020. Recognizing the critical role of these programs in providing health care services to millions of Americans, the federal government has provided for increased funding and program flexibilities, including waivers of certain federal requirements, in response to the COVID-19 pandemic.
The CARES Act includes a provision for GAO to conduct monitoring and oversight of the federal government’s response to the COVID-19 pandemic. In response, GAO has issued a series of government-wide reports from June 2020 through March 2021. GAO is continuing to monitor and report on these services.
This testimony summarizes GAO’s findings from these reports related to Medicare and Medicaid flexibilities during the COVID-19 pandemic, as well as preliminary observations from ongoing work related to telehealth waivers in both programs. Specifically, the statement focuses on what is known about the effects of these waivers and flexibilities on Medicare and Medicaid, and considerations regarding their ongoing use.
To conduct this work, GAO reviewed federal laws, CMS documents and guidance, and interviewed federal and state officials. GAO also interviewed six provider and beneficiary groups, selected based on their experience with telehealth services.
GAO obtained technical comments from CMS and incorporated them as appropriate.
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- Information Technology: Federal Agencies Need to Take Urgent Action to Manage Supply Chain RisksBy Sam NewsDecember 15, 2020Few of the 23 civilian Chief Financial Officers Act agencies had implemented seven selected foundational practices for managing information and communications technology (ICT) supply chain risks. Supply chain risk management (SCRM) is the process of identifying, assessing, and mitigating the risks associated with the global and distributed nature of ICT product and service supply chains. Many of the manufacturing inputs for these ICT products and services originate from a variety of sources throughout the world. (See figure 1.) Figure 1: Examples of Locations of Manufacturers or Suppliers of Information and Communications Technology Products and Services None of the 23 agencies fully implemented all of the SCRM practices and 14 of the 23 agencies had not implemented any of the practices. The practice with the highest rate of implementation was implemented by only six agencies. Conversely, none of the other practices were implemented by more than three agencies. Moreover, one practice had not been implemented by any of the agencies. (See figure 2.) Figure 2: Extent to Which the 23 Civilian Chief Financial Officers Act Agencies Implemented Information and Communications Technology (ICT) Supply Chain Risk Management (SCRM) Practices As a result of these weaknesses, these agencies are at a greater risk that malicious actors could exploit vulnerabilities in the ICT supply chain causing disruption to mission operations, harm to individuals, or theft of intellectual property. For example, without establishing executive oversight of SCRM activities, agencies are limited in their ability to make risk decisions across the organization about how to most effectively secure their ICT product and service supply chains. Moreover, agencies lack the ability to understand and manage risk and reduce the likelihood that adverse events will occur without reasonable visibility and traceability into supply chains. Officials from the 23 agencies cited various factors that limited their implementation of the foundational practices for managing supply chain risks. The most commonly cited factor was the lack of federal SCRM guidance. For example, several agencies reported that they were waiting for federal guidance to be issued from the Federal Acquisition Security Council—a cross-agency group responsible for providing direction and guidance to executive agencies to reduce their supply chain risks—before implementing one or more of the foundational practices. According to Office of Management and Budget (OMB) officials, the council expects to complete this effort by December 2020. While the additional direction and guidance from the council could further assist agencies with the implementation of these practices, federal agencies currently have guidance to assist with managing their ICT supply chain risks. Specifically, the National Institute of Standards and Technology (NIST) issued ICT SCRM-specific guidance in 2015 and OMB has required agencies to implement ICT SCRM since 2016. Until agencies implement all of the foundational ICT SCRM practices, they will be limited in their ability to address supply chain risks across their organizations effectively. Federal agencies rely extensively on ICT products and services (e.g., computing systems, software, and networks) to carry out their operations. However, agencies face numerous ICT supply chain risks, including threats posed by counterfeiters who may exploit vulnerabilities in the supply chain and, thus, compromise the confidentiality, integrity, or availability of an organization's systems and the information they contain. For example, in September 2019, the Department of Homeland Security's Cybersecurity and Infrastructure Security Agency reported that federal agencies faced approximately 180 different ICT supply chain-related threats. To address threats such as these, agencies must make risk-based ICT supply chain decisions about how to secure their systems. GAO was asked to conduct a review of federal agencies' ICT SCRM practices. The specific objective was to determine the extent to which federal agencies have implemented foundational ICT SCRM practices. To do so, GAO identified seven practices from NIST guidance that are foundational for an organization-wide approach to ICT SCRM and compared them to policies, procedures, and other documentation from the 23 civilian Chief Financial Officers Act agencies. This is a public version of a sensitive report that GAO issued in October 2020. Information that agencies deemed sensitive was omitted and GAO substituted numeric identifiers that were randomly assigned for the names of the agencies due to sensitivity concerns. The foundational practices comprising ICT SCRM are: establishing executive oversight of ICT activities, including designating responsibility for leading agency-wide SCRM activities; developing an agency-wide ICT SCRM strategy for providing the organizational context in which risk-based decisions will be made; establishing an approach to identify and document agency ICT supply chain(s); establishing a process to conduct agency-wide assessments of ICT supply chain risks that identify, aggregate, and prioritize ICT supply chain risks that are present across the organization; establishing a process to conduct a SCRM review of a potential supplier that may include reviews of the processes used by suppliers to design, develop, test, implement, verify, deliver, and support ICT products and services; developing organizational ICT SCRM requirements for suppliers to ensure that suppliers are adequately addressing risks associated with ICT products and services; and developing organizational procedures to detect counterfeit and compromised ICT products prior to their deployment. GAO also interviewed relevant agency officials. In the sensitive report, GAO made a total of 145 recommendations to the 23 agencies to fully implement foundational practices in their organization-wide approaches to ICT SCRM. Of the 23 agencies, 17 agreed with all of the recommendations made to them; two agencies agreed with most, but not all of the recommendations; one agency disagreed with all of the recommendations; two agencies neither agreed nor disagreed with the recommendations, but stated they would address them; and one agency had no comments. GAO continues to believe that all of the recommendations are warranted, as discussed in the sensitive report. For more information, contact Carol C. Harris at (202) 512-4456 or harrisCC@gao.gov.[Read More…]
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- How We ReImagined HHSBy Sam NewsNovember 16, 2020On October 1, 2020, I [Read More…]
- Former Media Producer Indicted on Charges of Extortion and Obstruction of JusticeBy Sam NewsJanuary 27, 2021A federal grand jury in the District of Puerto Rico returned an indictment Tuesday charging a former media producer with extortion and obstruction of justice during a federal investigation in San Juan, Puerto Rico.[Read More…]
- United States Reaches Settlement with Federal Way Public Schools to Resolve Student Complaints of Harassment on the Basis of Religion and National OriginBy Sam NewsNovember 12, 2020Today the Justice Department’s Civil Rights Division and the U.S. Attorney’s Office for the Western District of Washington announced a settlement agreement with Federal Way Public Schools in Washington to resolve an investigation into allegations of peer-on-peer harassment on the basis of religion and national origin.[Read More…]
- Israel-Lebanon Maritime NegotiationsBy Sam NewsDecember 22, 2020
- Preclearance Request for ApplicationBy Sam NewsSeptember 30, 2020Airport operators and [Read More…]
- Comparative Effectiveness Research: Patient-Centered Outcomes Research Institute and HHS Continue Activities and Plan New EffortsBy Sam NewsNovember 18, 2020GAO found that the Patient-Centered Outcomes Research Institute (PCORI)—a federally funded, nonprofit corporation—and the Department of Health and Human Services (HHS) have continued to perform comparative clinical effectiveness research (CER) activities required by law since our prior report issued in 2015. CER evaluates and compares health outcomes, risks, and benefits of medical treatments, services, or items. The requirements direct PCORI and HHS to, among other things, fund CER and disseminate and facilitate the implementation of CER findings. GAO's analysis of PCORI and HHS documents show that they allocated a total of about $3.6 billion for CER activities and program support during fiscal years 2010 through 2019 from the Patient Centered Outcomes Research Trust Fund (Trust Fund). Specifically, PCORI allocated about $2 billion for research awards and another $542 million for other awards, to be paid over multiple years. HHS allocated about $598 million for activities such as the dissemination and implementation of CER findings. PCORI and HHS also allocated about $470 million for program support. PCORI and HHS Allocations for Comparative Clinical Effectiveness Research (CER) Activities, Fiscal Years 2010 through 2019 aTotals may not add up due to rounding. bPCORI and HHS allocated $457 million and $13 million for program support, respectively. PCORI assessed the effectiveness of its activities using performance measures and targets. Since fiscal year 2017, when early CER projects were completed, PCORI officials reported that the institute met its performance targets, such as an increased number of research citations of its CER findings in news and online sources. HHS described accomplishments or assessed the effectiveness of its dissemination and implementation activities. PCORI and HHS officials told GAO they are planning comprehensive evaluations of their CER dissemination and implementation activities as part of their strategic plans for the next 10 years. The 2010 Patient Protection and Affordable Care Act (PPACA) authorized establishment of PCORI to conduct CER and improve its quality and relevance. PPACA also established new requirements for HHS to, among other things, disseminate findings from federally funded CER and coordinate federal programs to build data capacity for this research. To fund CER activities, PPACA established the Trust Fund, which provided a total of about $3.6 billion to PCORI and HHS for CER activities during fiscal years 2010 through 2019. The Further Consolidated Appropriations Act, 2020, added new CER requirements and extended funding at similar levels through fiscal year 2029. PPACA and the Appropriations Act 2020 included provisions that GAO review PCORI and HHS's CER activities. This report describes (1) the CER activities PCORI and HHS carried out to meet legislative requirements, (2) how PCORI and HHS allocated funding to those CER activities, and (3) PCORI and HHS efforts to evaluate the effectiveness of their CER dissemination and implementation activities, such as changes in medical practice. GAO reviewed legislative requirements and PCORI and HHS documentation and data for fiscal years 2010-2019. GAO also interviewed PCORI and HHS officials and obtained information from nine selected stakeholder groups that were familiar with PCORI's or HHS's CER activities. These groups included payer, provider, and patient organizations. GAO incorporated technical comments from PCORI and HHS as appropriate. For more information, contact John Dicken at (202) 512-7114 or firstname.lastname@example.org.[Read More…]
- Remarks by Attorney General William P. Barr on his Acceptance of the Christifideles Laici Award at the 2020 National Catholic Prayer BreakfastBy Sam NewsSeptember 23, 2020Remarks as Prepared as [Read More…]
- Secretary Pompeo’s Video Remarks at the Prague 5G Security Conference 2020By Sam NewsSeptember 26, 2020
- Justice Department Sues to Shut Down Florida Tax Return PreparersBy Sam NewsFebruary 23, 2021The United States has filed a complaint in the U.S. District Court for the Southern District of Florida seeking to bar three Miami Gardens-area tax return preparers and their businesses and franchises, from owning or operating a tax return preparation business and preparing tax returns for others, the Justice Department announced today. The United States has simultaneously filed a request for a preliminary injunction that would immediately prohibit defendants from further preparing taxes during the pendency of the suit.[Read More…]
- Assistant Secretary Schenker’s Travel to Oman and Saudi ArabiaBy Sam NewsDecember 2, 2020
- United States Joins Christchurch Call to Action to Eliminate Terrorist and Violent Extremist Content OnlineBy Sam NewsMay 9, 2021Ned Price, Department [Read More…]
- Special Envoy Pham Participates in Ministerial Roundtable for the Central SahelBy Sam NewsOctober 20, 2020
- San Antonio Return Preparer Pleads Guilty in Tax Fraud SchemeBy Sam NewsOctober 20, 2020A San Antonio, Texas, tax return preparer pleaded guilty today to aiding and assisting in the preparation of false tax returns, announced Principal Deputy Assistant Attorney General Richard E. Zuckerman of the Department of Justice’s Tax Division and U.S. Attorney Gregg N. Sofer of the Western District of Texas.[Read More…]
- Financial Audit: IRS’s FY 2020 and FY 2019 Financial StatementsBy Sam NewsNovember 10, 2020In GAO's opinion, the Internal Revenue Service's (IRS) fiscal years 2020 and 2019 financial statements are fairly presented in all material respects, and although certain controls could be improved, IRS maintained, in all material respects, effective internal control over financial reporting as of September 30, 2020. GAO's tests of IRS's compliance with selected provisions of applicable laws, regulations, contracts, and grant agreements detected no reportable instances of noncompliance in fiscal year 2020. Limitations in the financial systems IRS uses to account for federal taxes receivable and other unpaid assessment balances, as well as other control deficiencies that led to errors in taxpayer accounts, continued to exist during fiscal year 2020.These control deficiencies affect IRS's ability to produce reliable financial statements without using significant compensating procedures. In addition, unresolved information system control deficiencies from prior audits, along with application and general control deficiencies that GAO identified in IRS's information systems in fiscal year 2020, placed IRS systems and financial and taxpayer data at risk of inappropriate and undetected use, modification, or disclosure. IRS continues to take steps to improve internal controls in these areas. However, the remaining deficiencies are significant enough to merit the attention of those charged with governance of IRS and therefore represent continuing significant deficiencies in internal control over financial reporting related to (1) unpaid assessments and (2) financial reporting systems. Continued management attention is essential to fully addressing these significant deficiencies. The CARES Act, enacted in March 2020, and other COVID-19 pandemic relief laws contained a number of tax relief provisions to address financial stress caused by the COVID-19 pandemic. For example, the Economic Impact Payments provisions in the CARES Act provided for direct payments for eligible individuals to be implemented through the tax code. Implementing the provisions related to these Economic Impact Payment required extensive IRS work, and resulted in it issuing approximately $275 billion in payments as of September 30, 2020. IRS faced difficulties in issuing these payments as rapidly as possible, such as in identifying eligible recipients, preventing improper payments, and combating fraud based on identity theft. IRS discusses the challenges in carrying out its responsibilities under the CARES Act in its unaudited Management's Discussion and Analysis, which is included with the financial statements. As part of monitoring and oversight of the federal government's efforts to prepare for, respond to, and recover from the COVID-19 pandemic, GAO has issued a number of reports on federal agencies' implementation of the CARES Act and other COVID-19 pandemic relief laws, including reports providing information on, and recommendations to strengthen, IRS's implementation of the tax-related provisions. In accordance with the authority conferred by the Chief Financial Officers Act of 1990, as amended, GAO annually audits IRS's financial statements to determine whether (1) the financial statements are fairly presented and (2) IRS management maintained effective internal control over financial reporting. GAO also tests IRS's compliance with selected provisions of applicable laws, regulations, contracts, and grant agreements. IRS's tax collection activities are significant to overall federal receipts, and the effectiveness of its financial management is of substantial interest to Congress and the nation's taxpayers. Based on prior financial statement audits, GAO made numerous recommendations to IRS to address internal control deficiencies. GAO will continue to monitor, and will report separately, on IRS's progress in implementing prior recommendations that remain open. Consistent with past practice, GAO will also be separately reporting on the new internal control deficiencies identified in this year's audit and providing IRS recommendations for corrective actions to address them. In commenting on a draft of this report, IRS stated that it continues its efforts to improve its financial systems controls. For more information, contact Cheryl E. Clark at (202) 512-3406 or email@example.com.[Read More…]
- Private Equity CEO Enters into Non-prosecution Agreement on International Tax Fraud Scheme and Agrees to Pay $139 Million, to Abandon $182 Million in Charitable Contribution Deductions, and to Cooperate with Government InvestigationsBy Sam NewsOctober 15, 2020Robert F. Smith, the Chairman and Chief Executive Officer of a San Francisco based private equity company, entered into a Non-Prosecution Agreement (the agreement) with the Department of Justice, for his involvement from 2000 through 2015 in an illegal scheme to conceal income and evade millions in taxes by using an offshore trust structure and offshore bank accounts, announced Principal Deputy Assistant Attorney General Richard E. Zuckerman of the Tax Division, U.S. Attorney David L. Anderson for the Northern District of California, and Chief of Internal Revenue Service (IRS) Criminal Investigation Jim Lee. In that agreement, Smith admits his involvement in the illegal scheme and agrees to cooperate with ongoing investigations and to pay back taxes and penalties in full.[Read More…]
- Counselor Brechbühl’s Travel to NigeriaBy Sam NewsOctober 27, 2020
- U.S. Attorney Transition BeginsBy Sam NewsFebruary 9, 2021Continuing the practice of new administrations, President Biden and the Department of Justice have begun the transition process for the U.S. Attorneys.[Read More…]