Medicare (11 - 20 of 353 items)
Medicare: Increasing Hospital-Physician Consolidation Highlights Need for Payment Reform
GAO-16-189: Published: Dec 18, 2015. Publicly Released: Dec 18, 2015.
Vertical consolidation is a financial arrangement that occurs when a hospital acquires a physician practice and/or hires physicians to work as salaried employees. The number of vertically consolidated hospitals and physicians increased from 2007 through 2013. Specifically, the number of vertically consolidated hospitals increased from about 1,400 to 1,700, while the number of vertically consolidat...
Medicare: Considerations for Expansion of the Appropriate Use Criteria Program
GAO-15-816: Published: Sep 30, 2015. Publicly Released: Sep 30, 2015.
The Centers for Medicare & Medicaid Services (CMS)—an agency within the Department of Health and Human Services (HHS)—has proposed initial plans and timeframes for implementing the Medicare appropriate use criteria (AUC) program for advanced diagnostic imaging services, such as computed tomography, magnetic resonance imaging, and positron emission tomography. AUC are a type of clinical practic...
Medicare Advantage: Actions Needed to Enhance CMS Oversight of Provider Network Adequacy
GAO-15-710: Published: Aug 31, 2015. Publicly Released: Sep 28, 2015.
The Centers for Medicare & Medicaid Services (CMS) is the agency within the Department of Health and Human Services (HHS) responsible for overseeing the Medicare Advantage (MA) program—Medicare's private plan alternative. Since 2011, CMS has defined an adequate MA provider network as meeting two criteria: a minimum number of providers and maximum travel time and distance to those providers. To r...
International Classification of Diseases: CMS Has Updated Systems and Supported Stakeholders' Efforts to Use New Codes
GAO-15-789: Published: Sep 17, 2015. Publicly Released: Sep 17, 2015.
The Centers for Medicare & Medicaid Services (CMS) has finished updating its systems with the changes it determined were needed to process the new International Classification of Diseases codes (ICD-10) on Medicare fee-for-service claims. In 2007, CMS began taking steps to identify components of its systems that needed to be changed to update the ICD codes from version 9 to 10. CMS began making th...
Private Health Insurance: The Range of Premiums and Plan Availability for Individuals in 2014 and 2015
GAO-15-687: Published: Aug 10, 2015. Publicly Released: Sep 9, 2015.
As of 2014, key provisions of the Patient Protection and Affordable Care Act (PPACA) resulted in the establishment of health insurance exchanges in each state and changed how insurers determined health insurance premiums. Individual market consumers generally had access to more health plans in 2015 compared to 2014, and in both years the lowest-cost plans were available through exchanges in most o...
Medicare Administrative Contractors: CMS Should Consider Whether Alternative Approaches Could Enhance Contractor Performance
GAO-15-372: Published: Apr 30, 2015. Publicly Released: Jun 1, 2015.
As of February 2015, 16 Medicare Administrative Contractors (MAC) administered claims submitted by Medicare providers and suppliers. Twelve were A/B MACs that administered Medicare Part A and Part B claims for inpatient hospital care, outpatient physician and hospital services, and home health and hospice care, among other services, in specific jurisdictions. Four other MACs administered claims fo...
Medicare: Results from the First Two Years of the Pioneer Accountable Care Organization Model
GAO-15-401: Published: Apr 22, 2015. Publicly Released: May 22, 2015.
Health care providers and suppliers voluntarily form accountable care organizations (ACO) to provide coordinated care to patients with the goal of reducing spending while improving quality. Within the Centers for Medicare & Medicaid Services (CMS), the Center for Medicare & Medicaid Innovation (CMMI) began testing the Pioneer ACO Model in 2012. Under this model, ACOs can earn additional Medicare p...
Sole Community Hospitals: Early Indications Show That TRICARE's Revised Reimbursement Rules Have Not Affected Access to Care
GAO-15-402: Published: Apr 15, 2015. Publicly Released: Apr 15, 2015.
TRICARE's revised reimbursement rules for Sole Community Hospitals (SCHs), which provide health care in rural areas or where similar hospitals do not exist under certain criteria, approximate those for Medicare's. Specifically, both programs reimburse SCHs using the greater of either a cost-based amount or the allowed amount under a diagnostic-related-group-based payment system, although each prog...
Drug Discount Program: Status of GAO Recommendations to Improve 340B Drug Pricing Program Oversight
GAO-15-455T: Published: Mar 24, 2015. Publicly Released: Mar 24, 2015.
In its September 2011 report, GAO found that the Health Resources and Services Administration's (HRSA) oversight of the 340B Program was inadequate to provide reasonable assurance that program participants—covered entities and drug manufacturers—were in compliance with program requirements. Specifically, GAO found the programprimarily relied on covered entities and manufacturers to police them...
International Classification of Diseases: CMS's Efforts to Prepare for the New Version of the Disease and Procedure Codes
GAO-15-255: Published: Jan 28, 2015. Publicly Released: Feb 6, 2015.
The Centers for Medicare & Medicaid Services (CMS), within the Department of Health and Human Services (HHS), has undertaken a number of efforts to prepare for the October 1, 2015, transition to the 10th revision of the International Classification of Diseases (ICD-10) codes, which are used for documenting patient medical diagnoses and inpatient medical procedures. CMS has developed educational ma...