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Medicare: Inadequate Review of Claims Payments Limits Ability to Control Spending

HEHS-94-42 Published: Apr 28, 1994. Publicly Released: Jun 08, 1994.
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Highlights

GAO reviewed the adequacy of Medicare contractors' postpayment review activities, focusing on: (1) whether the Health Care Financing Administration (HCFA) is identifying providers that are inappropriately billing the Medicare program; and (2) why Medicare spends so much for certain medical services.

Recommendations

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Health and Human Services To strengthen carriers' ability to identify and address Medicare losses to waste and abuse, the Secretary of Health and Human Services should direct the Administrator, HCFA, to provide carriers guidance and technical assistance to improve profiling and focused medical reviews.
Closed – Implemented
HCFA has increased its guidance to contractors, which is more explicit about the data and analysis methods contractors are required to use to identify potential claims payment problems.
Department of Health and Human Services To strengthen carriers' ability to identify and address Medicare losses to waste and abuse, the Secretary of Health and Human Services should direct the Administrator, HCFA, to identify legal issues that constrain carriers' audit and recovery efforts and make recommendations to Congress to eliminate such constraints.
Closed – Implemented
After identifying legal loopholes and other constraints hindering carriers' audit and recovery efforts, HCFA's recommendations were incorporated into the Administration's fraud and abuse legislative proposal. This legislation was presented in early 1997 and many of its provisions were enacted in the Balanced Budget Act of 1997.
Department of Health and Human Services To strengthen carriers' ability to identify and address Medicare losses to waste and abuse, the Secretary of Health and Human Services should direct the Administrator, HCFA, to amend Medicare procedures, such as those involving the projection of sample results, to enhance carriers' audit and recovery efforts.
Closed – Implemented
HCFA will be placing a new instruction pertaining to projection of audit sampling results for collection of overpayments into its Program Integrity Manual by the end of CY 2000. It will be similar to the new instruction covering part A overpayment audits.
Department of Health and Human Services To strengthen carriers' ability to identify and address Medicare losses to waste and abuse, the Secretary of Health and Human Services should direct the Administrator, HCFA, to revise Contractor Performance Evaluation Program evaluation criteria to include outcome measures that better assess carriers' postpayment review performance.
Closed – Implemented
HCFA has solicited suggestions from GAO and OIG for enhancing the Contractor Performance Evaluation Program, and has incorporated several of these suggestions into the fiscal year 1995 requirements.

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Topics

BeneficiariesBilling proceduresContract performanceHealth care costsHealth care servicesHealth insuranceHealth insurance cost controlMedicareOverpaymentsPhysiciansProgram abuses