Managed health care (11 - 20 of 203 items)
Advance Directives: Information on Federal Oversight, Provider Implementation, and Prevalence
GAO-15-416: Published: Apr 29, 2015. Publicly Released: Apr 29, 2015.
The Centers for Medicare & Medicaid Services (CMS) oversees providers' implementation of the advance directive requirement in the Patient Self Determination Act (PSDA) to maintain written policies and procedures to inform individuals about advance directives, and document information about individuals' advance directives in the medical record by providing guidance and monitoring covered providers...
Compounded Drugs: Payment Practices Vary across Public Programs and Private Insurers, and Medicare Part B Policy Should Be Clarified
GAO-15-85: Published: Oct 10, 2014. Publicly Released: Nov 10, 2014.
Medicare, Medicaid, and private health insurers have varying payment practices for compounded drugs, depending upon whether compounded drugs and their ingredients can be identified on health insurance claims, and Medicare's Part B payment policy for these drugs is unclear.For drugs dispensed in pharmacy settings, claims contain sufficient information for public programs and private insurers to ide...
Compounded Drugs: TRICARE's Payment Practices Should Be More Consistent with Regulations
GAO-15-64: Published: Oct 2, 2014. Publicly Released: Oct 2, 2014.
The Department of Defense's (DOD) TRICARE program paid for about 465,000 compounded drug prescriptions through its pharmacy benefit in fiscal year 2013; these prescriptions represented 0.3 percent of all prescription drugs paid for through TRICARE's pharmacy benefit in that year. Most of these compounded drug prescriptions were dispensed in retail pharmacies and to retirees and their family member...
Medicare Fraud: Progress Made, but More Action Needed to Address Medicare Fraud, Waste, and Abuse
GAO-14-560T: Published: Apr 30, 2014. Publicly Released: Apr 30, 2014.
The Centers for Medicare & Medicaid Services (CMS)—the agency within the Department of Health and Human Services (HHS) that oversees Medicare—has made progress in implementing several key strategies GAO identified in prior work as helpful in protecting Medicare from fraud; however, important actions that could help CMS and its program integrity contractors combat fraud remain incomplete.Provid...
Medicaid: Demographics and Service Usage of Certain High-Expenditure Beneficiaries
GAO-14-176: Published: Feb 19, 2014. Publicly Released: Feb 19, 2014.
In fiscal year 2009, states spent nearly a third (31.6 percent) of all Medicaid expenditures on the most expensive Medicaid-only beneficiaries, who were 4.3 percent of total Medicaid beneficiaries. States spent another third (33.1 percent) on all other Medicaid-only beneficiaries, who represented 81.2 percent of total Medicaid beneficiaries. Among dual eligible beneficiaries, a similar pattern exi...
Medicaid Managed Care: Use of Limited Benefit Plans to Provide Mental Health Services and Efforts to Coordinate Care
GAO-13-780: Published: Sep 30, 2013. Publicly Released: Sep 30, 2013.
Thirteen states reported that in fiscal year 2012 they paid a total of about $5.6 billion to limited benefit plans to provide mental health services to about 4.4 million adult Medicaid beneficiaries. States can enroll different populations--such as adults who are blind, disabled, or have developmental disabilities--in limited benefit plans, which could contribute to the variation in the number of...
Medicare Program Integrity: Increasing Consistency of Contractor Requirements May Improve Administrative Efficiency
GAO-13-522: Published: Jul 23, 2013. Publicly Released: Aug 22, 2013.
The Centers for Medicare & Medicaid Services' (CMS) contractors that conduct postpayment reviews on Medicare fee-for-service (FFS) claims were established by different legislative actions; are managed by different offices within CMS; and serve different functions in the program. These contractors include (1) Medicare Administrative Contractors that process and pay claims and are responsible for ta...
Medicaid: Enhancements Needed for Improper Payments Reporting and Related Corrective Action Monitoring
GAO-13-229: Published: Mar 29, 2013. Publicly Released: May 1, 2013.
The Centers for Medicare & Medicaid Services' (CMS) methodology for estimating a national improper payment rate for the Medicaid program is statistically sound. However, CMS's procedures did not provide for updating state data used in its methodology to recognize significant corrections or adjustments after the cutoff date. The Office of Management and Budget (OMB) requires that federal agencies e...
Indian Health Service: Capping Payment Rates for Nonhospital Services Could Save Millions of Dollars for Contract Health Services
GAO-13-272: Published: Apr 11, 2013. Publicly Released: Apr 11, 2013.
The Indian Health Service's (IHS) federal contract health services (CHS) programs primarily paid physicians at their billed charges, which were significantly higher than what Medicare and private insurers would have paid for the same services. IHS's policy states that federal CHS programs should purchase services from contracted providers at negotiated, reduced rates. However, of the almost $63 mi...
Medicare and Medicaid: Consumer Protection Requirements Affecting Dual-Eligible Beneficiaries Vary across Programs, Payment Systems, and States
GAO-13-100: Published: Dec 5, 2012. Publicly Released: Dec 5, 2012.
Medicare and Medicaid consumer protection requirements vary across programs, payment systems--either fee-for-service (FFS) or managed care--and states. Within Medicare, enrollment in managed care through the Medicare Advantage (MA) program must always be voluntary, whereas state Medicaid programs can require enrollment in managed care in certain situations. For example, Arizona requires nearly all...