For more than a decade,  the agency and its contractors have used automated software tools to  analyze data from various sources to detect patterns of unusual activities  or financial transactions that indicate payments could be made for  fraudulent charges or improper payments. The agency’s efforts led to the IDR  and One PI programs, which are intended to provide CMS and its  program integrity contractors with a centralized source of Medicare and  Medicaid data and a web-based portal and set of analytical tools by which  these data can be accessed and analyzed to help detect cases of fraud,  waste, and abuse. To achieve  its goal, CMS officials planned to implement a tool set that would provide  a single source of information to enable consistent, reliable, and timely  analyses and improve the agency’s ability to detect fraud, waste, and  abuse. IDR and One PI Were in Use, but Lacked Data and Functionality Essential to CMS’s Program Integrity Efforts

IDR had been in use by CMS and its contractors who conduct Medicare  program integrity analysis since September 2006 and incorporated data  related to claims for reimbursement of services under Medicare Parts A,  B, and D. According to program officials, the integration of these data into  IDR established a centralized source of data previously accessed from  multiple disparate system files. However, although the agency had been incorporating data from various  data sources since 2006, our prior report noted that IDR did not include  all the data that were planned to be incorporated by the end of 2010 and  that are needed to support enhanced program integrity initiatives. For  example, IDR did not include the Medicaid data that are critical to  analysts’ ability to detect fraud, waste, and abuse in this program. However, program officials had not defined plans and reliable schedules  for incorporating these data into IDR. Further, no Medicaid analysts had been trained to use the system. CMS Was Not Yet Positioned to Identify Financial Benefits or to Fully Meet Program Integrity Goals and Objectives through the Use of IDR and One PI

Because IDR and One PI were not being used as planned, CMS officials  were not in a position to determine the extent to which the systems were  providing financial benefits or supporting the agency’s initiatives to meet  program integrity goals and objectives. While CMS had shown some progress toward meeting the programs’  goals of providing a centralized data repository and enhanced analytical  capabilities for detecting improper payments due to fraud, waste, and  abuse, the implementation of IDR and One PI did not yet position the  agency to identify, measure, and track financial benefits realized from  reductions in improper payments as a result of the implementation of  either system. Further, program officials’ projection of financial benefits expected as a  result of implementing One PI was reported to be approximately $21  billion. They explained that, since the  program had not met its goal for widespread use of One PI, there were  not enough data available to quantify financial benefits attributable to the  use of the system. For  example, performance measures and targets for One PI included  increases in the detection of improper payments for Medicare Parts A and  B claims. CMS Needs to Take Actions to Achieve Widespread Use of IDR and One PI

Given the critical need for CMS to reduce improper payments within the  Medicare and Medicaid programs, we included in our June 2011 report a  number of recommended actions that we consider vital to helping the  agency achieve more widespread use of IDR and One PI for program  integrity purposes. Specifically, we recommended that the Administrator  of CMS  finalize plans and develop schedules for incorporating additional data  into IDR that identify all resources and activities needed to complete  tasks and that consider risks and obstacles to the IDR program;  implement and manage 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 and use One PI in their work;  conduct training in accordance with plans and established deadlines  to ensure schedules are met and program integrity contractors are  trained and able to meet requirements for using One PI; define any measurable financial benefits expected from the  implementation of IDR and One PI; and with stakeholder input, establish measurable, outcome-based  performance measures for IDR and One PI that gauge progress  toward meeting program goals. In conclusion, CMS’s success toward meeting goals to enhance program  integrity efforts through the use of IDR and One PI depends upon the  incorporation of all needed data into IDR, and effective use of the  systems by the agency’s broad community of Medicare and Medicaid  program integrity analysts.
Why GAO Did This Study

The Centers for Medicare and Medicaid Services (CMS) is responsible for administering and safeguarding its programs from loss of funds. As GAO reported in June 2011, CMS utilizes automated systems and tools to help improve the detection of improper payments for fraudulent, wasteful, and abusive claims. To integrate claims information and improve its ability to detect fraud, waste, and abuse in these programs, CMS initiated two information technology system programs: the Integrated Data Repository (IDR) and One Program Integrity (One PI). GAO was asked to testify on its earlier report that examined CMS's efforts to protect the integrity of the Medicare and Medicaid programs through the use of information technology. In that prior study, GAO assessed the extent to which IDR and One PI have been developed and implemented, and CMS's progress toward achieving its goals and objectives for using these systems to detect fraud, waste, and abuse.

What GAO Found

GAO previously reported that CMS had developed and begun using both IDR and One PI, but had not incorporated into IDR all data as planned. IDR is intended to be the central repository of Medicare and Medicaid data needed to help CMS and states' program integrity staff and contractors prevent and detect improper payments. Program integrity analysts use these data to identify patterns of unusual activities or transactions that may indicate fraudulent charges or other types of improper payments. IDR has been operational and in use since September 2006 but did not include all the data that were planned to be incorporated by fiscal year 2010. For example, IDR included most types of Medicare claims data, but not the Medicaid data needed to help analysts detect improper payments of Medicaid claims. According to program officials, these data were not incorporated because of obstacles introduced by technical issues and delays in funding. Until the agency finalizes plans and develops reliable schedules for efforts to incorporate these data, CMS may face additional delays in making available all the data that are needed to support enhanced Medicare and Medicaid program integrity efforts. Additionally, CMS had not taken steps to ensure widespread use of One PI to enhance efforts to detect fraud, waste, and abuse. One PI is a web-based portal that is to provide CMS staff and contractors, and Medicaid analysts with a single source of access to data contained in IDR, as well as tools for analyzing those data. While One PI had been developed and deployed to users, no Medicaid analysts and only a few Medicare program integrity analysts were trained and using the system. Specifically, One PI program officials planned for 639 program integrity analysts, including 130 Medicaid analysts, to be using the system by the end of fiscal year 2010; however, as of October 2010, only 41--less than 7 percent--were actively using the portal and tools. According to program officials, the agency's initial training plans were insufficient and, as a result, they were not able to train the intended community of users. Until program officials finalize plans and develop reliable schedules for training users and expanding the use of One PI, the agency may continue to experience delays in reaching widespread use of the system. While CMS had made progress toward its goals to provide a single repository of data and enhanced analytical capabilities for program integrity efforts, the agency was not yet positioned to identify, measure, and track benefits realized from its efforts. As a result, it was unknown whether IDR and One PI as implemented had provided financial benefits. According to IDR officials, they did not measure benefits realized from increases in the detection rate for improper payments because they relied on business owners to do so; One PI officials stated that, because of the limited use of that system, there were not enough data to measure and gauge the program's success toward achieving the $21 billion in financial benefits that the agency projected.

What GAO Recommends

GAO is not making new recommendations at this time. GAO recommended in June 2011 that CMS take actions to finalize plans and schedules for achieving widespread use of IDR and One PI, and to define measurable benefits. CMS concurred with GAO's recommendations.