Medicare (1 - 9 of 9 items) in Past Year
Medicare: Initial Results of Revised Process to Screen Providers and Suppliers, and Need for Objectives and Performance Measures
GAO-17-42: Published: Nov 15, 2016. Publicly Released: Dec 15, 2016.
GAO's analysis of the Centers for Medicare & Medicaid Services' (CMS) Medicare enrollment data found that CMS used its revised enrollment screening process to screen and revalidate over 2.4 million unique new applications and existing enrollment records. GAO's analysis showed that the screening resulted in over 23,000 new applications being denied or rejected and over 703,000 existing enrollment r...
Health Care Quality: HHS Should Set Priorities and Comprehensively Plan Its Efforts to Better Align Health Quality Measures
GAO-17-5: Published: Oct 13, 2016. Publicly Released: Oct 13, 2016.
While the full extent of misalignment among health care quality measures is unknown, it can have adverse effects on providers and efforts to improve quality of care. Misalignment occurs when health care payers require providers to report on measures that focus on different quality issues or define the measures using different specifications. GAO identified three studies that provided some informat...
Skilled Nursing Facilities: CMS Should Improve Accessibility and Reliability of Expenditure Data
GAO-16-700: Published: Sep 7, 2016. Publicly Released: Oct 6, 2016.
The Centers for Medicare & Medicaid Services (CMS)—the agency within the Department of Health and Human Services (HHS) that administers Medicare—collects and reports expenditure data from skilled nursing facilities (SNF), but it has not taken key steps to make the data readily accessible to public stakeholders or to ensure their reliability. SNFs are required to self-report their expenditures...
Medicare Part B: CMS Should Take Additional Steps to Verify Accuracy of Data Used to Set Payment Rates for Drugs
GAO-16-594: Published: Jul 1, 2016. Publicly Released: Aug 1, 2016.
In 2014, the most recent year for which data were available, the Medicare program and its beneficiaries spent about $21 billion on approximately 46 million administrations of 551 Part B drugs paid based on average sales price (ASP). Six drugs—each exceeding $1 billion in expenditures—accounted for 36 percent of all expenditures on Part B ASP drugs, while a different 10 drugs—each administere...
Medicare Program: Continued Action Required to Address Weaknesses in Provider and Supplier Enrollment Controls
GAO-16-703T: Published: May 24, 2016. Publicly Released: May 24, 2016.
In June 2015 and April 2016, GAO reported on CMS's implementation of enrollment-screening procedures that the Centers for Medicare & Medicaid Services (CMS) uses to prevent and detect ineligible or potentially fraudulent providers and suppliers from enrolling into its Provider Enrollment, Chain and Ownership System (PECOS). GAO identified weaknesses in CMS's verification of provider practice locat...
Medicare: Claim Review Programs Could Be Improved with Additional Prepayment Reviews and Better Data
GAO-16-394: Published: Apr 13, 2016. Publicly Released: May 13, 2016.
The Centers for Medicare & Medicaid Services (CMS) uses different types of contractors to conduct prepayment and postpayment reviews of Medicare fee-for-service claims at high risk for improper payments. Medicare Administrative Contractors (MAC) conduct prepayment and postpayment reviews; Recovery Auditors (RA) generally conduct postpayment reviews; and the Supplemental Medical Review Contractor (...
Medicare Advantage: Action Needed to Ensure Appropriate Payments for Veterans and Nonveterans
GAO-16-137: Published: Apr 11, 2016. Publicly Released: May 11, 2016.
In fiscal year 2010, the Department of Veterans Affairs (VA) health care system provided $2.4 billion in inpatient and outpatient services to the 833,684 veterans enrolled in Medicare Advantage (MA), a private plan alternative to Medicare fee-for-service (FFS). While the Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), generally pa...
Medicaid Program Integrity: Improved Guidance Needed to Better Support Efforts to Screen Managed Care Providers
GAO-16-402: Published: Apr 22, 2016. Publicly Released: May 6, 2016.
GAO found that the selected states and Medicaid managed care plans face significant challenges in screening providers for eligibility to participate in the Medicaid program. Based on information we received from two selected states and 16 selected plans, GAO found that the states and plans used information that was fragmented across 22 databases managed by 15 different federal agencies to screen p...
Medicare: Opportunities Exist to Recover Potential Overpayments to Providers with Criminal Backgrounds
GAO-16-365R: Published: Apr 13, 2016. Publicly Released: Apr 13, 2016.
Opportunities exist for the Centers for Medicare & Medicaid Services (CMS) to recover about $1.3 million in potential overpayments to 16 out of 66 potentially ineligible providers with criminal backgrounds who were enrolled in Medicare before CMS implemented more extensive background-check processes in April 2014. These 16 providers had Medicare claims paid to them while they were potentially inel...