GAO Finds CMS Well Behind Projections For Instituting Fraud Detection Systems

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The Centers for Medicare & Medicaid Services is well behind its timetable for fully implementing and using two fraud detection information technology systems, according to a Government Accountability Office report (GAO-11-475) released July 12. CMS has made progress in implementation, but the two anti-fraud systems—the Integrated Data Repository (IDR) and One Program Integrity (One PI)—do not yet “provide all the data and functionality initially planned,” GAO said.

For instance, although CMS planned for 639 program integrity analysts to be using One PI by the end of fiscal 2010, as of October 2010, less than 7 percent were actively using the portal and the tools, GAO said in its report, Fraud Detection Systems: Centers for Medicare and Medicaid Services Needs to Ensure Widespread Use.

CMS intended the IDR program to provide a single source of data related to the Medicare and Medicaid programs, the report said. One PI is a web-based portal and suite of analytical software tools designed to extract data from IDR and enable complex analyses of the information.

CMS initiated the two information technology system programs to integrate claims data and improve its ability to detect fraud, waste, and abuse in the Medicare and Medicaid programs, which the agency administers, GAO said.

Improper payments to the two programs were estimated to amount to about $70 billion in fiscal year 2010, GAO said. Although One PI officials have said the program could result in $21 million in savings over the nine-year lifecycle of the project, GAO said not enough data are available to measure this estimate.

IDR has been operational since 2006, but it does not include all the data that were planned to be incorporated by fiscal year 2010.

“For example, IDR includes most types of Medicare claims data, but not the Medicaid data needed to help analysts detect improper payments of Medicaid claims,” GAO said. “IDR also does not include data from other CMS systems that are needed to help analysts prevent improper payments, such as information about claims at the time they are filed and being processed.”

CMS program officials told GAO that these data are not incorporated because of technical obstacles and delays in funding, the report said.

“Further, the agency has not finalized plans or developed reliable schedules for efforts to incorporate these data,” GAO said. “Until it does so, CMS may face additional delays in making available all the data that are needed to support enhanced program integrity efforts.”

GAO Recommendations

To help ensure that the development and implementation of IDR and One PI are successful, GAO recommended that CMS take the following steps:

• finalize plans and develop schedules for incorporating data into the IDR that identify all resources and activities needed to complete tasks;

• implement plans for incorporating data in IDR to meet schedule milestones;

• establish plans and reliable schedules for training all program integrity analysts intended to use One PI;

• establish and communicate deadlines for program integrity contractors to complete training on One PI;

• conduct training in accordance with established deadlines;

• define reasonable financial benefits expected of implementation of the two programs; and

• with stakeholder help, establish measurable, outcome-based performance measures for IDR and One PI that gauge progress toward meeting program goals.

In written comments on a draft of the report, CMS said it concurred with GAO's recommendations and the agency identified steps it was taking to implement them.

Among these steps were refinement of training plans to ensure that all program integrity contractors are trained and able to use One PI, as well as efforts to define measurable financial benefits expected from augmenting the data in IDR.

“If these and other identified actions are implemented in accordance with our recommendations, CMS will be better positioned to meet the goals and objectives of its program integrity initiatives,” GAO said.

GAO received a request to investigate implementation of the IDR and One PI projects by Sen. Thomas R. Carper (D-Del.), chairman of the Senate Homeland Security and Governmental Affairs Federal Financial Management, Government Information, Federal Services, and International Security Subcommittee; Sen. Scott Brown (R-Mass.), the subcommittee's ranking member; and Sen. John McCain (R-Ariz.). The GAO report was discussed July 12 at a Senate hearing.

The GAO report is available at http://www.gao.gov/new.items/d11475.pdf .