Beneficiaries (11 - 20 of 186 items)
Medicare and Medicaid: Additional Oversight Needed of CMS's Demonstration to Coordinate the Care of Dual-Eligible Beneficiaries
GAO-16-31: Published: Dec 18, 2015. Publicly Released: Jan 19, 2016.
Due to the flexibility that states have in designing their Financial Alignment Demonstrations, the integrated care organizations that GAO interviewed in California, Illinois, Massachusetts, Virginia, and Washington implemented care coordination for dual-eligible Medicare and Medicaid beneficiaries in a variety of ways. For example, these organizations assigned care coordinators to beneficiaries us...
Workers' Compensation: Health Benefit Programs for Returned Peace Corps Volunteers and for Employees of U.S. Agency for International Development Contractors
GAO-16-28R: Published: Oct 30, 2015. Publicly Released: Oct 30, 2015.
Peace Corps and the U.S. Agency for International Development (USAID) both provide health benefits through workers' compensation programs. Peace Corps provides benefits to returned Peace Corps volunteers who sustain illnesses or injuries connected to their Peace Corps service under the Federal Employees' Compensation Act (FECA) program administered by the Department of Labor (DOL). USAID provides...
Medicare: Considerations for Expansion of the Appropriate Use Criteria Program
GAO-15-816: Published: Sep 30, 2015. Publicly Released: Sep 30, 2015.
The Centers for Medicare & Medicaid Services (CMS)—an agency within the Department of Health and Human Services (HHS)—has proposed initial plans and timeframes for implementing the Medicare appropriate use criteria (AUC) program for advanced diagnostic imaging services, such as computed tomography, magnetic resonance imaging, and positron emission tomography. AUC are a type of clinical practic...
Medicare Advantage: Actions Needed to Enhance CMS Oversight of Provider Network Adequacy
GAO-15-710: Published: Aug 31, 2015. Publicly Released: Sep 28, 2015.
The Centers for Medicare & Medicaid Services (CMS) is the agency within the Department of Health and Human Services (HHS) responsible for overseeing the Medicare Advantage (MA) program—Medicare's private plan alternative. Since 2011, CMS has defined an adequate MA provider network as meeting two criteria: a minimum number of providers and maximum travel time and distance to those providers. To r...
Medicaid: Additional Reporting May Help CMS Oversee Prescription-Drug Fraud Controls
GAO-15-390: Published: Jul 8, 2015. Publicly Released: Aug 10, 2015.
GAO found indicators of potential prescription-medication fraud and abuse among thousands of Medicaid beneficiaries and hundreds of prescribers during fiscal year 2011—the most-recent year for which reliable data were available in four selected states: Arizona, Florida, Michigan, and New Jersey. These states accounted for about 13 percent of all fiscal year 2011 Medicaid payments. Specifically,...
Medicare Part B Drugs: Action Needed to Reduce Financial Incentives to Prescribe 340B Drugs at Participating Hospitals
GAO-15-442: Published: Jun 5, 2015. Publicly Released: Jul 6, 2015.
Certain providers, including hospitals that serve a disproportionate number of low-income patients, have access to discounted prices on outpatient drugs through the 340B Drug Pricing Program, which is administered by the Health Resources and Services Administration (HRSA) within the Department of Health & Human Services (HHS). In 2012, these hospitals—referred to as 340B disproportionate share h...
Medicaid: Service Utilization Patterns for Beneficiaries in Managed Care
GAO-15-481: Published: May 29, 2015. Publicly Released: Jun 29, 2015.
Based on GAO's analysis of 2010 encounter data reported by 19 states, the number of professional services utilized by adult beneficiaries ranged from about 13 to 55. For children, the number of professional services utilized per beneficiary was lower, ranging from about 6 to 16 among the 19 states. Professional services included four categories of services: (1) evaluation and management (E/M) serv...
Medicaid: CMS Could Take Additional Actions to Help Improve Provider and Beneficiary Fraud Controls
GAO-15-665T: Published: Jun 2, 2015. Publicly Released: Jun 2, 2015.
GAO found thousands of Medicaid beneficiaries and hundreds of providers involved in potential improper or fraudulent payments during fiscal year 2011—the most-recent year for which reliable data were available in four selected states: Arizona, Florida, Michigan, and New Jersey. These states had about 9.2 million beneficiaries and accounted for 13 percent of all fiscal year 2011 Medicaid payments...
Medicare: Potential Uses of Electronically Readable Cards for Beneficiaries and Providers
GAO-15-319: Published: Mar 25, 2015. Publicly Released: Apr 24, 2015.
The Centers for Medicare & Medicaid Services (CMS)—the agency that administers Medicare—could use electronically readable cards in Medicare for a number of different purposes. Three key uses include authenticating beneficiary and provider presence at the point of care, electronically exchanging beneficiary medical information, and electronically conveying beneficiary identity and insurance inf...
Sole Community Hospitals: Early Indications Show That TRICARE's Revised Reimbursement Rules Have Not Affected Access to Care
GAO-15-402: Published: Apr 15, 2015. Publicly Released: Apr 15, 2015.
TRICARE's revised reimbursement rules for Sole Community Hospitals (SCHs), which provide health care in rural areas or where similar hospitals do not exist under certain criteria, approximate those for Medicare's. Specifically, both programs reimburse SCHs using the greater of either a cost-based amount or the allowed amount under a diagnostic-related-group-based payment system, although each prog...