More than 700 Members Of Transnational Organized Crime Groups Arrested in Central America in U.S. Assisted Operation

Today, senior law enforcement officials from the United States, El Salvador, Guatemala and Honduras announced criminal charges in Central America against more than 700 members of transnational criminal organizations, primarily MS-13 and 18th Street gangs, which resulted from a one-week coordinated law enforcement action under Operation Regional Shield (ORS).

ORS began in 2017 and is a Justice Department-led initiative to combat transnational organized crime that brings together gang prosecutors and investigators from El Salvador, Guatemala, Honduras, Mexico and the United States.  Through quarterly meetings, this group has coordinated multi-country investigations and simultaneous takedowns throughout the region. 

Authorities also announced the arrest of 36 individuals in El Salvador and Honduras involved in human smuggling networks that span Central America and the United States.  Among those arrested in Honduras, include one police commissioner, one police deputy inspector, and three law enforcement agents.  All arrestees were charged with human smuggling, money laundering and illegal association to commit a crime.  The charges were announced by U.S. Attorney General William P. Barr, Attorney General Raul Melara of El Salvador, Attorney General María Consuelo Porras Argueta of Guatemala, and the Attorney General of Honduras, Oscar Fernando Chinchilla, through the Public Ministry’s Press Office. 

“The U.S. Department of Justice and our law enforcement partners in Central America are committed to continued collaboration in locating and arresting gang members and associates engaged in transnational crimes,” said U.S. Attorney General Barr.  “Our countries are made safer by working together to protect national security and to ensure public safety in our neighborhoods.”

In 2017, the U.S. Attorney General, together with the Attorneys General of the three Central American countries, committed to combatting transnational organized crime and reducing illegal migration to the United States through increased cooperation and capacity building of law enforcement partners. These efforts have led to the following results this week:

Prosecutors in El Salvador filed criminal charges against 1,152 members of organized crime groups in the country, primarily MS-13 and 18th Street Gangs.  Within hours, the National  Civil Police had captured 572 of the defendants for charges involving terrorism, murder, extortion, kidnapping, vehicle theft, robbery, conspiracy, narcotics trafficking, money laundering, weapons violations, human trafficking and human smuggling.  Prosecutors and the Police also seized assets from these organized crime groups for forfeiture purposes. 

In Guatemala, the Anti-Extortions Prosecution Office, the Prosecutor’s Office against Transnational Crimes, the Special Unit against Transnational Gangs, and police officers executed 80 search warrants, arrested 40 individuals, and served 29 arrest warrants against individuals already in custody, all of who are members of the 18th Street gang and MS-13.  Authorities seized drugs and a firearm, and filed charges for extortion, illicit association, conspiracy to commit murder, and extortive obstruction.  This investigation involves four transportation companies as victims of extortion in the amount of $54,523.

In Honduras, ORS joint operation took place in different phases during a one-week period resulted in the arrest of over 75 MS-13 and 18th Street gang members and five police officers and the execution of over 10 search warrants. Illegal firearms, cellular phones, drugs and money were seized.  The arrestees were charged with illicit association, murder and conspiracy to commit murder, extortion and drug trafficking.  

On February 9, President Donald J. Trump issued an Executive Order on Enforcing Federal Law with Respect to Transnational Criminal Organizations and Preventing International Trafficking to dismantle and eradicate transnational criminal organizations threatening the safety of our communities. Pursuant to that order, the U.S. Department of Justice has made dismantling transnational human smuggling networks and gangs, including MS-13, a top priority.

Regional Shield anti-gang efforts have led to charges against more than 11,000 gang members since 2017, including gang leaders nationwide.  Many of these indictments included the seizure of gang assets including firearms and money.  Also, during that time, more than a dozen smuggling/trafficking structures were dismantled.  The capacity-building efforts in Central America of the Justice Department’s Office of Overseas Prosecutorial Development, Assistance and Training (OPDAT) have played a key role in bringing together the Attorneys General from El Salvador, Guatemala, and Honduras to form the regional operations targeting MS-13, 18th Street, and other gangs, as well as human smuggling transnational organizations. Additionally, as a result of OPDAT’s capacity building efforts, the Justice Department’s partners in Central America have strengthened cooperation and developed the skills, tools, and techniques to maximize results against all forms of transnational organized crime impacting the region and the United States. 

“Since 2017, we have taken a joint and coordinated approach as northern triangle countries with our strategic partner, the United States of America,” said Attorney General Raul Melara of El Salvador.  “To give our Salvadoran people a response and ensure that criminals face justice, we have strengthened the work of our Specialized Prosecution Units to be more effective in combating organized crime and terrorist organizations.  I am committed as Attorney General to continuing this coordinated effort.  We will only eradicate transnational organized crime by combining efforts as a region and by continuing to work together.”    

“As Attorney General of the Republic and Chief of the Public Ministry, I reaffirm my commitment to the fight against transnational organized crime, one of the main goals of my administration,” said Attorney General María Consuelo Porras Argueta of Guatemala.  “To this end, we have increased efforts to provide an effective response to the population through the creation of the Prosecutor’s Office against Transnational Crimes, the Special Unit against Transnational Gangs, the Special Unit against Crimes in Airports and Airfields, the signing of the statement of the Advisory Group of General Prosecutors of the Northern Triangle, which I have the honor to preside; among other strategic actions to combat transnational organized crime with frontal actions against drug trafficking, gangs, organized crime and smuggling of migrants.”

“I consider that, due to the regional threat posed by these transnational crimes, equal interagency and regional efforts should come into effect,” said Attorney General Oscar Fernando Chinchilla of Honduras.  “Only by joining forces, the damaging consequences produced by these criminal organizations could be neutralized.”

In El Salvador, Guatemala, and Honduras, the investigations into transnational criminal organizations is being handled by regional gang prosecutors who receive State Department-funded training and mentoring from the Federal Bureau of Investigation (FBI), U.S. Immigration and Customs Enforcement’s Homeland Security Investigations (HSI) and OPDAT. With support from State Department’s Bureau of International Narcotics and Law Enforcement, prosecutors from OPDAT helped establish task forces in the region and work with FBI’s local Transnational Anti-Gang (TAG) units, as well as HSI’s Transnational Criminal Investigative Units (TCIUs). These efforts have helped Central American partners convict thousands of criminals, seize over $1 billion in illicit assets, and coordinate dozens of transnational investigations with their U.S. counterparts.

Law enforcement agencies involved in this latest sixth ORS operation included El Salvador’s Fiscalia General de la Republica (FGR) and the Policia Nacional Civil (PNC); Honduras Policía Nacional, la Dirección Nacional de Servicios Especiales de Investigación (DNSEI), Agencia Técnica de Investigaciones Criminales (ATIC), and Fuerza Nacional Anti Maras y Pandillas (FNAMP) and Guatemala’s Prosecutor’s Office against Transnational Crimes, National Civil Police, Special National Division of Criminal Investigation, National Civil Police’s Anti-Gang Unit, Public Ministry, Anti-Extortions Prosecution Office, and the Special Unit against Transnational Gangs.

The year 2020 marks the 150th anniversary of the Department of Justice.  Learn more about the history of our agency at www.Justice.gov/Celebrating150Years.

Salvadoran Police arrest multiple gang members in Operation Regional Shield.

Photo courtesy of El Salvador Attorney General’s Office.

Salvadoran Police arrest multiple gang members in Operation Regional Shield.  

 Salvadoran authorities seize cash from gang members which they will forfeit as proceeds of criminal activities.

Photo courtesy of El Salvador Attorney General’s Office.

Salvadoran authorities seize cash from gang members which they will forfeit as proceeds of criminal activities.  

Members of the 18th Street gang are arrested in Operation Regional Shield.

Photo courtesy of El Salvador Attorney General’s Office.

Members of the 18th Street gang are arrested in Operation Regional Shield.  

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    In the government’s ongoing response to the COVID-19 pandemic, the Congress and the administration have taken action on multiple fronts to address challenges that have contributed to catastrophic loss of life and profound economic disruption. These actions have helped direct much-needed federal assistance to support many aspects of public life, including local public health systems and private-sector businesses. However, the nation faces continued public health risks and economic difficulties for the foreseeable future. Among other challenges, the public health system, already strained from months of responding to COVID-19 cases, will face the additional task of managing the upcoming flu season. At the same time, many of the federal, state, and local agencies responsible for responding to the ongoing public health emergency are called on to prepare for and respond to the current hurricane season. Timely and concerted federal leadership will be required in responding to these and other challenges. GAO has identified lessons learned and issues in need of continued attention by the Congress and the administration, including the need to collect reliable data that can drive decision-making; to establish mechanisms for accountability and transparency; and to protect against ongoing cyber threats to patient information, intellectual property, public health data, and intelligence. Attention to these issues can help to make federal efforts as effective as possible. GAO has also identified a number of opportunities to help the federal government prepare for the months ahead while improving the ongoing federal response: Medical Supply Chain The Department of Health and Human Services (HHS) and the Federal Emergency Management Agency (FEMA), with support from the Department of Defense (DOD), have taken numerous, significant efforts to mitigate supply shortages and expand the medical supply chain. For example, the agencies have coordinated to deliver supplies directly to nursing homes and used Defense Production Act authorities to increase the domestic production of supplies. However, shortages of certain types of personal protective equipment and testing supplies remain due to a supply chain with limited domestic production and high global demand. The Food and Drug Administration (FDA) and FEMA have both identified shortages, and officials from seven of the eight states GAO interviewed in July and August 2020 identified previous or ongoing shortages of testing supplies, including swabs, reagents, tubes, pipettes, and transport media. Testing supply shortages have contributed to delays in turnaround times for testing results. Delays in processing test results have multiple serious consequences, including delays in isolating those who test positive and tracing their contacts in a timely manner, which can in turn exacerbate outbreaks by allowing the virus to spread undetected. In addition, states and other nonfederal entities have experienced challenges tracking supply requests made through the federal government and planning for future needs. GAO is making the following recommendations: HHS, in coordination with FEMA, should immediately document roles and responsibilities for supply chain management functions transitioning to HHS, including continued support from other federal partners, to ensure sufficient resources exist to sustain and make the necessary progress in stabilizing the supply chain. HHS, in coordination with FEMA, should further develop and communicate to stakeholders plans outlining specific actions the federal government will take to help mitigate supply chain shortages for the remainder of the pandemic. HHS and FEMA—working with relevant stakeholders—should devise interim solutions, such as systems and guidance and dissemination of best practices, to help states enhance their ability to track the status of supply requests and plan for supply needs for the remainder of the COVID-19 pandemic response. HHS and the Department of Homeland Security (DHS) objected to GAO’s initial draft recommendations. GAO made revisions based on their comments. GAO maintains that implementation of its modified recommendations is both warranted and prudent. These actions could contribute to ensuring a more effective response by helping to mitigate challenges with the stability of the medical supply chain and the ability of nonfederal partners to track, plan, and budget for ongoing medical supply needs. Vaccines and Therapeutics Multiple federal agencies continue to support the development and manufacturing of vaccines and therapeutics to prevent and treat COVID-19. These efforts are aimed at accelerating the traditional timeline to create a vaccine (see figure). Traditional Timeline for Development and Creation of a Vaccine Note: See figure 5 in the report. As these efforts proceed, clarity on the federal government’s plans for distributing and administering vaccine, as well as timely, clear, and consistent communication to stakeholders and the public about those plans, is essential. DOD is supporting HHS in developing plans for nationwide distribution and administration of a vaccine. In September 2020, HHS indicated that it will soon send a report to Congress outlining a distribution plan, but did not provide a specific date for doing so. GAO recommends that HHS, with support from DOD, establish a time frame for documenting and sharing a national plan for distributing and administering COVID-19 vaccine, and in developing such a plan ensure that it is consistent with best practices for project planning and scheduling and outlines an approach for how efforts will be coordinated across federal agencies and nonfederal entities. DOD partially concurred with the recommendation, clarifying that it is supporting HHS in developing plans for nationwide distribution and administration of vaccine. HHS neither agreed nor disagreed with the recommendation, but noted factors that complicate the publication of a plan. GAO maintains that a time frame is necessary so all relevant stakeholders will be best positioned to begin their planning.On September 16, 2020, HHS and DOD released two documents outlining a strategy for any COVID-19 vaccine. GAO will evaluate these documents and report on them in future work.GAO will also continue to conduct related work, including examining federal efforts to accelerate the development and manufacturing of COVID-19 vaccines and therapeutics. COVID-19 Data Data collected by the Centers for Disease Control and Prevention (CDC) suggest a disproportionate burden of COVID-19 cases, hospitalizations, and deaths exists among racial and ethnic minority groups, but GAO identified gaps in these data. To help address these gaps, on July 22, 2020, CDC released a COVID-19 Response Health Equity Strategy. However, the strategy does not assess whether having the authority to require states and jurisdictions to report race and ethnicity information is necessary to ensure CDC can collect such data. CDC’s strategy also does not specify how it will involve key stakeholders, such as health care providers, laboratories, and state and jurisdictional health departments. GAO recommends that CDC (1) determine whether having the authority to require the reporting of race and ethnicity information for cases, hospitalizations, and deaths is necessary for ensuring more complete data, and if so, seek such authority from Congress; (2) involve key stakeholders to help ensure the complete and consistent collection of demographic data; and (3) take steps to help ensure its ability to comprehensively assess the long-term health outcomes of persons with COVID-19, including by race and ethnicity. HHS agreed with the recommendations. In addition, HHS’s data on COVID-19 in nursing homes do not capture the early months of the pandemic. HHS’s Centers for Medicare & Medicaid Services (CMS) began requiring nursing homes to report COVID-19 data to CDC by May 17, 2020, starting with information as of May 8, 2020, but made reporting prior to May 8, 2020 optional. By not requiring nursing homes to submit data from the first 4 months of 2020, HHS is limiting the usefulness of the data in helping to understand the effects of COVID-19 in nursing homes. GAO recommends that HHS, in consultation with CMS and CDC, develop a strategy to capture more complete data on COVID-19 cases and deaths in nursing homes retroactively back to January 1, 2020. HHS partially agreed with this recommendation by noting the value of having complete data, but expressed concern about the burden of collecting it. GAO maintains the importance of collecting these data to inform the government’s continued response and recovery, and HHS could ease the burden by incorporating data previously reported to CDC or to state or local public health offices. Economic Impact Payments The Department of the Treasury’s (Treasury) Internal Revenue Service (IRS) has issued economic impact payments (EIP) to all eligible individuals for whom IRS has the necessary information to do so; however, not everyone eligible was able to be initially identified. To help ensure all eligible recipients received their payments in a more timely manner, IRS took several actions to address challenges GAO reported on in June, including a policy change—reopening the Non-Filers tool registration period for federal benefit recipients and extending it through September 30—that should allow some eligible recipients to receive supplemental payments for qualifying children sooner than expected. However, Treasury and IRS lack updated information on how many eligible recipients have yet to receive these funds. The lack of such information could hinder outreach efforts and place potentially millions of individuals at risk of missing their payment. GAO recommends that Treasury, in coordination with IRS, (1) update and refine the estimate of eligible recipients who have yet to file for an EIP to help target outreach and communications efforts and (2) make estimates of eligible recipients who have yet to file for an EIP, and other relevant information, available to outreach partners to raise awareness about how and when to file for EIP. Treasury and IRS neither agreed nor disagreed with the recommendations and described actions they are taking in concert with the recommendations to notify around 9 million individuals who may be eligible for an EIP. Coronavirus Relief Fund The Coronavirus Relief Fund (CRF) is the largest program established in the four COVID-19 relief laws that provides aid to states, the District of Columbia, localities, tribal governments, and U.S. territories. Audits of entities that receive federal funds, including CRF payments, are critical to the federal government’s ability to help safeguard those funds. Auditors that conduct single audits follow guidance in the Single Audit Act’s Compliance Supplement, which the Office of Management and Budget (OMB) updates and issues annually in coordination with federal agencies. OMB issued the 2020 Compliance Supplement in August 2020, but the Compliance Supplement specified that OMB is still working with federal agencies to identify the needs for additional guidance for auditing new COVID-19-related programs, including the CRF payments, as well as existing programs with compliance requirement changes. According to OMB, an addendum on COVID-19-related programs, including the CRF payments, will be issued in the fall of 2020. Further delays in issuing this guidance could adversely affect auditors’ ability to issue consistent and timely reports. GAO recommends that OMB, in consultation with Treasury, issue the addendum to the 2020 Compliance Supplement as soon as possible to provide the necessary audit guidance, as many single audit efforts are underway. OMB neither agreed nor disagreed with the recommendation. Guidance for K-12 Schools State and local school district officials tasked with reassessing their operating status and ensuring their school buildings are safe are generally relying on guidance and recommendations from federal, state, and local public health and education officials. However, portions of CDC’s guidance on reopening K-12 schools are inconsistent, and some federal guidance appears misaligned with CDC’s risk-based approach on school operating status. Based on GAO’s review, Education has updated the information and CDC has begun to do so. GAO recommends that CDC ensure that, as it makes updates to its guidance related to schools’ operating status, the guidance is cogent, clear, and internally consistent. HHS agreed with the recommendation. Tracking Contract Obligations Federal agencies are tracking contract actions and associated obligations in response to COVID-19 using a National Interest Action (NIA) code in the Federal Procurement Data System-Next Generation. The COVID-19 NIA code was established in March 2020 and was recently extended until March 31, 2021, while a draft of this report recommending that DHS and DOD extend the code beyond September 30, 2020, was with the agencies for comment. GAO has identified inconsistencies in establishing and closing these codes following previous emergencies, and has continued concerns with the criteria that DHS and DOD rely on to determine whether to extend or close a code and whether the code meets long-term needs. GAO recommends that DHS and DOD make updates to the 2019 NIA Code Memorandum of Agreement so as to enhance visibility for federal agencies, the public, and Congress on contract actions and associated obligations related to disaster events, and to ensure the criteria for extending or closing the NIA code reflect government-wide needs for tracking contract actions in longer-term emergencies, such as a pandemic. DHS and DOD did not agree, but GAO maintains implementation of its recommendation is essential. Address Cybersecurity Weaknesses Since March 2020, malicious cyber actors have exploited COVID-19 to target organizations that make up the health care and public health critical infrastructure sector, including government entities, such as HHS. GAO has identified numerous cybersecurity weaknesses at multiple HHS component agencies, including CMS, CDC, and FDA, over the last 6 years, such as weaknesses in key safeguards to limit, prevent, and detect inappropriate access to computer resources. Additionally, GAO’s March 2019 high-risk update identified cybersecurity and safeguarding the systems supporting the nation’s critical infrastructure, such as health care, as high-risk areas. As of July 2020, CMS, FDA, and CDC had made significant progress by implementing 350 (about 81 percent) of the 434 recommendations GAO issued in previous reports to address these weaknesses. Based on the imminent cybersecurity threats, GAO recommends that HHS expedite implementation of GAO’s prior recommendations regarding cybersecurity weaknesses at its component agencies. HHS agreed with the recommendation. As of September 10, 2020, the U.S. had over 6.3 million cumulative reported cases of COVID-19 and over 177,000 reported deaths, according to federal agencies. The country also continues to experience serious economic repercussions and turmoil. Four relief laws, including the CARES Act, were enacted as of September 2020 to provide appropriations to address the public health and economic threats posed by COVID-19. As of July 31, 2020, the federal government had obligated a total of $1.6 trillion and expended $1.5 trillion of the COVID-19 relief funds as reported by federal agencies on USAspending.gov. The CARES Act includes a provision for GAO to report bimonthly on its ongoing monitoring and oversight efforts related to the COVID-19 pandemic. This third report examines key actions the federal government has taken to address the COVID-19 pandemic and evolving lessons learned relevant to the nation’s response to pandemics. GAO reviewed data, documents, and guidance from federal agencies about their activities and interviewed federal and state officials, as well as industry representatives. GAO is making 16 new recommendations for agencies that are detailed in this Highlights and in the report. For more information, contact A. Nicole Clowers at (202) 512-7114 or clowersa@gao.gov.
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  • Medicaid Information Technology: Effective CMS Oversight and States’ Sharing of Claims Processing and Information Retrieval Systems Can Reduce Costs
    In U.S GAO News
    The Centers for Medicare and Medicaid Services (CMS) has reimbursed billions of dollars to states for the development, operation, and maintenance of claims processing and information retrieval systems—the Medicaid Management Information Systems (MMIS) and Eligibility and Enrollment (E&E) systems. Specifically, from fiscal year 2008 through fiscal year 2018, states spent a total of $44.1 billion on their MMIS and E&E systems. CMS reimbursed the states $34.3 billion of that total amount (see figure). Money Spent by States and Reimbursed by CMS from 2008–2018 for Medicaid Management Information Systems (MMIS) and Eligibility and Enrollment (E&E) Systems For fiscal years 2016 through 2018, CMS approved 93 percent and disapproved 0.4 percent of MMIS funding requests, while for E&E it approved 81 percent and disapproved 1 percent of the requests. The remaining 6.6 percent of MMIS requests and 18 percent of E&E requests were either withdrawn by states or were pending. GAO estimates that CMS had some level of supporting evidence of its review for about 74 percent of MMIS requests and about 99 percent of E&E requests. However, GAO estimates that about 100 percent of E&E requests and 68 percent of MMIS requests lacked pertinent information that would be essential for indicating that a complete review had been performed. Among CMS requirements for system implementation funding is that states submit an alternatives analysis, feasibility study, and cost benefit analysis. However, GAO found that about 45 percent of such requests it sampled for fiscal years 2016 through 2018 did not include these required documents. The above weaknesses were due, in part, to a lack of formal, documented procedures for reviewing state funding requests. CMS also lacked a risk-based process for overseeing systems after federal funds were provided. CMS provided helpful comments and recommendations to states in selected cases, but in other instances it did not. In two states that had contractors struggling to deliver successful projects, state officials said they had not received recommendations or technical assistance from CMS. The states eventually terminated the projects after spending a combined $38.5 million in federal funds. According to CMS officials, they rely largely on states to oversee systems projects. This perspective is consistent with a 2018 Office of Management and Budget (OMB) decision that federal information technology (IT) grants totaling about $9 billion annually would no longer be tracked on OMB's public web site on IT investment performance. Accordingly, the CMS and Health and Human Services chief information officers (CIO) are not involved in overseeing MMIS or E&E projects. Similarly, 21 of 47 states responding to GAO's survey reported that their state CIO had little or no involvement in overseeing their MMISs. Such non-involvement of officials with duties that should be heavily focused on successful acquisition and operation of IT projects could be hindering states' ability to effectively implement systems. To improve oversight, CMS has begun a new outcome-based initiative that focuses the agency's review of state funding requests on the successful achievement of business outcomes. However, as of February 2020, CMS had not yet established a timeline for including MMIS and E&E systems in the new outcome-based process. CMS had various initiatives aimed at reducing duplication of Medicaid systems (see table). Description and Status of Centers for Medicare and Medicaid Services Initiatives Aimed at Reducing Duplication by Sharing, Leveraging, and Reusing Medicaid Information Technology Initiative Description Implementation status Number of surveyed states reporting use of the initiative Reuse Repository Used by states to collect and share reusable artifacts. Made available in August 2017. As of January 2020, CMS was no longer supporting this initiative. 25 of the 50 reporting states Poplin Project Was to provide free, open-source application program interfaces for states to use in developing their modular Medicaid systems. Initiative never fully implemented. As of January 2020, CMS was no longer supporting this initiative. Three of the 50 reporting states Open Source Provider Screening Module Open-source module for states to use at no charge. Made available in August 2018. As of January 2020, CMS was no longer supporting this initiative. One of the 50 states reported attempting to use the module. Medicaid Enterprise Cohort Meetings A forum where states can discuss sharing, leveraging, and/or reuse of Medicaid technologies. As of January 2020, Cohort meetings were being held on a monthly basis. 47 of the 50 states reported participating in the meetings. Source: GAO analysis of agency data. | GAO-20-179 However, as of January 2020, the agency was no longer supporting most of these initiatives because they failed to produce the desired results. CMS regulations and GAO's prior work have highlighted the importance of reducing duplication by sharing and reusing Medicaid IT. To illustrate the potential for reducing duplication, 53 percent of state Medicaid officials responding to our survey reported using the same contractor to develop their MMIS. Nevertheless, selected states are taking the initiative to share systems or modules. Further support by CMS could result in additional sharing initiatives and potential cost savings. The Medicaid program is the largest source of health care funding for America's most at-risk populations and is funded jointly by states and the federal government. GAO was asked to assess CMS's oversight of federal expenditures for MMIS and E&E systems used for Medicaid. This report examines (1) the amount of federal funds that CMS has provided to state Medicaid programs to support MMIS and E&E systems, (2) the extent to which CMS reviews and approves states' funding requests for the systems and oversees the use of these funds, and (3) CMS's and states' efforts to reduce potential duplication of Medicaid IT systems. GAO assessed information related to MMIS and E&E systems, such as state expenditure data, federal regulations, and CMS guidance to the states for submitting funding requests, states' system funding requests, and IT project management documents. GAO also evaluated a generalizable sample of approved state funding requests from fiscal years 2016 through 2018 to analyze, among other things, CMS's review and approval process and conducted interviews with agency and state Medicaid officials. GAO also reviewed relevant regulations and guidance on promoting, sharing, and reusing MMIS and E&E technologies; and surveyed 50 states and six territories (hereafter referred to as states) regarding the MMIS and E&E systems, and assessed the complete or partial responses received from 50 states. GAO is making nine recommendations to improve CMS's processes for approving and overseeing the federal funds for MMIS and E&E systems and for bolstering efforts to reduce potential duplication. Among these recommendations are that CMS should develop formal, documented procedures that include specific steps to be taken in the advanced planning document review process and instructions on how CMS will document the reviews; develop, in consultation with the HHS and CMS CIOs, a documented, comprehensive, and risk-based process for how CMS will select IT projects for technical assistance and provide recommendations to assist states that is aimed at improving the performance of the systems; encourage state Medicaid program officials to consider involving state CIOs in overseeing Medicaid IT projects; establish a timeline for implementing the outcome-based certification process for MMIS and E&E systems; and identify, prior to approving funding for systems, similar projects that other states are pursuing so that opportunities to share, leverage, or reuse systems or system modules are considered. In written comments on a draft of this report, the department concurred with eight of the nine recommendations, and described steps it had taken and/or planned to take to address them. The department did not state whether it concurred with GAO's recommendation to encourage state officials to consider involving state CIOs in Medicaid IT projects. HHS stated that it was unable to discern evidence as to whether a certain structure contributed to a specific outcome. GAO believes, consistent with federal law, that CIOs are critically important to the success of IT projects. For more information, contact Vijay D’Souza at (202) 512-6240 or dsouzav@gao.gov.
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  • VA Disability Benefits: Process for Identifying Conditions Presumed to be Service Connected and Challenges in Processing Complex Gulf War Illness Claims
    In U.S GAO News
    GAO has reported on the Department of Veterans Affairs' (VA) use of research to identify and add new illnesses to its list of presumptive conditions for both Gulf War Illness and Agent Orange—a tactical herbicide used extensively during the Vietnam Era. VA entered into agreements with the National Academy of Sciences to assess the link between certain exposures and illnesses experienced by veterans, and uses the Academy's findings to inform its lists of presumptive conditions. GAO also reported in 2017 that VA did not have a single set of uniform criteria to define Gulf War Illness (a case definition) that could improve research, clinical diagnosis, and treatment of Gulf War veterans. GAO recommended that VA prepare and document a plan to develop a single case definition. In response, VA convened a group of subject matter experts from VA and the Department of Defense to create a multi-step plan to develop a case definition. According to VA, it is in the final stages of the plan and will bring together experts in 2021 to review new research and work toward delineating a definition. Further, according to VA, the department continues to support research on conditions related to Gulf War service as well as Agent Orange exposure and will use the findings to consider future presumptive conditions. In 2017, GAO reported on challenges that VA faced in processing complex, presumptive disability claims for veterans who served in the Gulf War—claims that were being denied at higher rates than other disability claims. At the time of GAO's review, VA officials stated that Gulf War Illness claims may be denied at a higher rate, in part, because they are not always well understood by VA staff, and veterans sometimes do not have medical records to adequately support their claims. The challenges we identified included: Inconsistent requests for disability medical exams. VA claims processors can request that a veteran undergo a disability medical exam to help determine whether the conditions in the claim exist and are linked to service. GAO found that claims processors were inconsistent in asking for an exam, in part, due to confusion about the guidance. VA issued training on the topic and in April 2017 completed a review of Gulf War claims to assess the effectiveness of the training and help ensure future consistency. Inconsistent disability medical exam reports. Veterans Health Administration disability medical examiners did not always complete medical exam reports properly and sometimes offered a medical opinion when one was not necessary. GAO recommended that VA require all examiners to complete Gulf War medical exam training before conducting these exams, and VA implemented this recommendation. Since our 2017 report, VA has allowed contracted medical examiners to complete these exams, and in 2018 GAO found VA was not monitoring whether all contractors completed required training. GAO recommended VA improve its oversight of training, but the department has not fully implemented this recommendation from GAO's 2018 report. VA provides disability compensation to millions of veterans with service-connected disabilities. Veterans are generally entitled to these benefits if they can prove their injuries or illnesses were incurred or aggravated by active military service. For certain claims, VA presumes a condition is due to a veteran's service. For example, VA can provide benefits to any veteran with certain symptoms, from respiratory disorders to gastrointestinal issues, who served in Southwest Asia from 1990 to the present, without the veteran needing to prove cause. GAO refers to these as Gulf War Illness claims. In 2017, GAO issued Gulf War Illness: Improvements Needed for VA to Better Understand, Process, and Communicate Decisions on Claims ( GAO-17-511 ), which identified needed improvements in VA's processing of Gulf War Illness claims. In 2018, GAO issued Agent Orange: Actions Needed to Improve Accuracy and Communication of Information on Testing and Storage Locations ( GAO-19-24 ). This statement summarizes information from these reports on how VA determined certain presumptive conditions and challenges VA faced with processing Gulf War Illness claims. In GAO's 2017 report, it recommended that VA develop a plan to establish a single case definition of Gulf War Illness and make Gulf War Illness training mandatory for medical examiners. VA implemented the recommendations. For more information, contact Elizabeth Curda at (202) 512-7215 or curdae@gao.gov.
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