Medicare: Improvements Needed in the Identification of Inappropriate Hospital Care
PEMD-90-7
Published: Dec 20, 1989. Publicly Released: Dec 20, 1989.
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Highlights
Pursuant to a congressional request, GAO examined both Medicare and private programs' approaches to assessing the appropriateness of hospital care and reducing the level of inappropriate hospital care.
Recommendations
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Health and Human Services | The Secretary of Health and Human Services should require the Administrator, HCFA, to expand prospective utilization review in the Medicare program. This step should be preceded by a systematic examination of the cost-effectiveness of various options, including those described in this report. If HCFA lacks legislative authority to implement particular options, such as advisory prospective determinations and the use of incentives or penalties for complying with prospective review decisions, it should seek that authority from Congress. It is also important to evaluate the current retrospective review requirements in light of the expanded prospective reviews, in order to avoid unnecessary duplication and improve the efficiency and effectiveness of both types of review. |
Closed – Not Implemented
The agency prefers to wait and see what results the current prospective review procedures produce. It considers advisory opinions inappropriate for Medicare.
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Topics
Claims processingContract oversightHealth care cost controlHealth insurance cost controlHospital care servicesMedical expense claimsMedical recordsMedicareQuality assuranceSurgery