Health care programs (11 - 20 of 195 items)
Medicare Advantage: CMS Should Fully Develop Plans for Encounter Data and Assess Data Quality before Use
GAO-14-571: Published: Jul 31, 2014. Publicly Released: Sep 2, 2014.
The Centers for Medicare & Medicaid Services (CMS) is collecting Medicare Advantage (MA) encounter data—information on the services and items furnished to enrollees—that are more comprehensive than the beneficiary diagnosis data the agency currently uses to risk adjust capitated payments to MA organizations (MAO). CMS, an agency within the Department of Health and Human Services (HHS), makes t...
Defense Health Care Reform: Actions Needed to Help Realize Potential Cost Savings from Medical Education and Training
GAO-14-630: Published: Jul 31, 2014. Publicly Released: Jul 31, 2014.
In its 2013 plans for the implementation of the Defense Health Agency (DHA), the Department of Defense (DOD) outlined the responsibilities of a new Education and Training Directorate, but has not demonstrated how its proposed reforms will result in cost savings. The National Defense Authorization Act for Fiscal Year 2013 required DOD to develop business case analyses for its shared service proposa...
Private Health Insurance: Early Effects of Medical Loss Ratio Requirements and Rebates on Insurers and Enrollees
GAO-14-580: Published: Jul 10, 2014. Publicly Released: Jul 10, 2014.
The Patient Protection and Affordable Care Act (PPACA) established federal minimum medical loss ratio (MLR) standards for the percentage of premiums private insurers must spend on their enrollees' medical care claims and activities to improve health care quality, as opposed to what they spend on administrative (“non-claims”) costs. Insurers report to the Centers for Medicare & Medicaid Service...
Federal Employees Health Benefits Program: Oversight of Carriers' Fraud and Abuse Programs
GAO-14-39: Published: Nov 14, 2013. Publicly Released: Dec 16, 2013.
The Office of Personnel Management (OPM) Healthcare & Insurance--Federal Employee Insurance Operations office, which we refer to as OPM's contracting office, monitors Federal Employees Health Benefits Program (FEHBP) carriers' compliance with requirements and other guidance for preventing, detecting, and eliminating fraud and abuse. These requirements include establishing a program to assess vulne...
Medicaid Demonstration Waivers: Approval Process Raises Cost Concerns and Lacks Transparency
GAO-13-384: Published: Jun 25, 2013. Publicly Released: Jul 18, 2013.
The 10 new demonstrations GAO examined expanded states' use of federal funds and implemented new coverage strategies. Arizona and Texas established funding pools to make new supplemental payments beyond what they could have made under traditional Medicaid requirements and receive federal matching funds for the payments. All 10 demonstrations were approved to use different coverage strategies or im...
CMS: Activities, Staffing, and Funding for the Center for Strategic Planning
GAO-13-377R: Published: Apr 1, 2013. Publicly Released: May 1, 2013.
CSP's activities, staff, and funding support strategic planning by individual CMS offices and centers as well as the agency itself. CMS officials told us that CSP assists individual offices and centers in developing strategic plans for their units, leads the agency's senior-level strategic planning meetings, and is helping to develop a centralized approach to monitor the implementation of CMS's ag...
GAO's 2013 High-Risk Update: Medicare and Medicaid
GAO-13-433T: Published: Feb 27, 2013. Publicly Released: Feb 27, 2013.
Medicare Program: CMS has not met GAO's criteria to have the Medicare program removed from the High-Risk List. For example, although CMS has made progress in measuring and reducing improper payment rates in different parts of the program, it has yet to demonstrate sustained progress in lowering the rates. Because the size of Medicare relative to other programs leads to aggregate improper payments...
Patient Protection and Affordable Care Act: Effect on Long-Term Federal Budget Outlook Largely Depends on Whether Cost Containment Sustained
GAO-13-281: Published: Jan 31, 2013. Publicly Released: Feb 26, 2013.
The effect of the Patient Protection and Affordable Care Act (PPACA), enacted in March 2010, on the long-term fiscal outlook depends largely on whether elements in PPACA designed to control cost growth are sustained. There was notable improvement in the longer-term outlook after the enactment of PPACA under GAO's Fall 2010 Baseline Extended simulation, which assumes both the expansion of health ca...
Preventive Health Activities: Available Information on Federal Spending, Cost Savings, and International Comparisons Has Limitations
GAO-13-49: Published: Dec 6, 2012. Publicly Released: Jan 7, 2013.
The Departments of Health and Human Services (HHS), Veterans Affairs (VA), and Defense (DOD) administer programs that include preventive health activities such as health screenings and education campaigns, but the departments reported that they do not track department-wide spending on these activities. Departments reported that determining such spending is challenging because these activities can...
Medicare Program Integrity: Greater Prepayment Control Efforts Could Increase Savings and Better Ensure Proper Payment
GAO-13-102: Published: Nov 13, 2012. Publicly Released: Dec 10, 2012.
Use of prepayment edits saved Medicare at least $1.76 billion in fiscal year 2010, but GAO found that savings could have been greater had prepayment edits been more widely used. GAO illustrated this point using analysis of a limited number of national policies and local coverage determinations (LCD), which are established by each Medicare administrative contractor (MAC) to specify coverage rules i...