Beneficiaries (1 - 10 of 11 items) in Past Year
Medicaid: CMS Needs Better Data to Monitor the Provision of and Spending on Personal Care Services
GAO-17-169: Published: Jan 12, 2017. Publicly Released: Feb 13, 2017.
Two data systems managed by the Centers for Medicare & Medicaid Services (CMS)—the federal agency that oversees Medicaid—collect information from states on the provision of and spending on personal care services:The Medicaid Statistical Information System (MSIS) collects detailed information from provider claims on services rendered to individual Medicaid beneficiaries and state payments for t...
Medicaid Managed Care: Improved Oversight Needed of Payment Rates for Long-Term Services and Supports
GAO-17-145: Published: Jan 9, 2017. Publicly Released: Feb 8, 2017.
Out of six states with Medicaid managed long-term services and supports (MLTSS) programs that GAO selected for review, five set clear financial incentives in their payment rates for managed care organizations (MCO) to provide care in the community versus in an institution. However, most of the selected states did not opt to link payments or penalties to MCO performance on MLTSS goals. These goals,...
Medicaid: Program Oversight Hampered by Data Challenges, Underscoring Need for Continued Improvements
GAO-17-173: Published: Jan 6, 2017. Publicly Released: Feb 6, 2017.
GAO found that available Medicaid expenditure and utilization data do not provide CMS with sufficient information to consistently ensure that payments are proper or that beneficiaries have access to covered services. The Centers for Medicare & Medicaid Services (CMS), the agency within the Department of Health and Human Services (HHS) that administers the Medicaid program, relies on two key data s...
Medicaid: CMS Has Taken Steps, but Further Efforts Are Needed to Control Improper Payments
GAO-17-386T: Published: Jan 31, 2017. Publicly Released: Jan 31, 2017.
GAO's prior work has identified four Medicaid program integrity issues—where the program is vulnerable to improper payments such as those made for services that were not covered, were not medically necessary, or were not provided—as well as actions taken by the Centers for Medicare & Medicaid Services (CMS) to address the issues and additional actions that should be taken.Enrollment Verificati...
Medicare Advantage: Limited Progress Made to Validate Encounter Data Used to Ensure Proper Payments
GAO-17-223: Published: Jan 17, 2017. Publicly Released: Jan 19, 2017.
Since GAO issued its July 2014 report, the Centers for Medicare & Medicaid Services (CMS) within the Department of Health and Human Services (HHS) has made limited progress to validate the completeness and accuracy of Medicare Advantage (MA) encounter data. CMS collects encounter data—detailed information about the care and health status of MA enrollees—to determine payments to MA organization...
Medicaid Personal Care Services: CMS Could Do More to Harmonize Requirements across Programs
GAO-17-28: Published: Nov 23, 2016. Publicly Released: Dec 22, 2016.
Four states that GAO reviewed varied in how they implemented safeguards to protect beneficiaries receiving in-home personal care services from harm and in their methods to help ensure billed services were actually provided. For example, to help keep beneficiaries safe, the four selected states—California, Maryland, Oregon, and Texas—reported that they monitored beneficiaries by having case man...
Medicare: CMS's Round 2 Durable Medical Equipment and National Mail-order Diabetes Testing Supplies Competitive Bidding Programs
GAO-16-570: Published: Sep 15, 2016. Publicly Released: Oct 17, 2016.
The number of beneficiaries receiving durable medical equipment (DME) items covered under the competitive bidding program (CBP) generally decreased after implementation of two CBP phases that began July 1, 2013—round 2 and the national mail-order program for diabetes testing supplies. Under the CBP, (administered by the Centers for Medicare & Medicaid Services (CMS)), only competitively selected...
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...
Medicaid Fee-For-Service: State Resources Vary for Helping Beneficiaries Find Providers
GAO-16-809: Published: Aug 29, 2016. Publicly Released: Sep 29, 2016.
According to the Centers for Medicare & Medicaid Services (CMS), as of July 2014, over 40 percent of nearly 71 million Medicaid beneficiaries were in fee-for-service (FFS) arrangements—traditional FFS and primary care case management—in which participating providers are paid for each delivered service (e.g., an office visit, test, or procedure). The percentage of beneficiaries in FFS arrangeme...
Physician-administered Drugs: Comparison of Payer Payment Methodologies
GAO-16-780R: Published: Aug 1, 2016. Publicly Released: Aug 31, 2016.
Payment methodologies for physician-administered drugs varied across Medicare fee-for-service, Medicaid fee-for-service, the Department of Veterans Affairs (VA) health care system, the VA Choice program, and two large private payers GAO reviewed. Compared to Medicare, other federal payers generally paid rates that were the same or lower. For example, for 10 high-expenditure drugs, VA paid rates th...