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Medicare Part B: Regional Variation in Denial Rates for Medical Necessity

PEMD-95-10 Published: Dec 19, 1994. Publicly Released: Dec 19, 1994.
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Highlights

Pursuant to a congressional request, GAO reviewed Medicare Part B claims processing, focusing on the: (1) differences in carriers' denial rates for lack of medical necessity; and (2) factors that contribute to intercarrier variations in denial rates.

Recommendations

Recommendations for Executive Action

Agency Affected Recommendation Status
Health Care Financing Administration To improve its oversight of the Medicare Part B program, HCFA should issue instructions to carriers on how to classify the reason for denial when reporting this information.
Closed – Not Implemented
No action has been taken.
Health Care Financing Administration To improve its oversight of the Medicare Part B program, HCFA should analyze intercarrier screen usage (including the stringency of screen criteria), identify effective screens, and disseminate this information to all carriers.
Closed – Not Implemented
No action has been taken.
Health Care Financing Administration To improve its oversight of the Medicare Part B program, HCFA should direct carriers to profile the subpopulation of providers responsible for a disproportionate share of medical necessity denials in order to devise a strategy for addressing this problem.
Closed – Not Implemented
No action has been taken.

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