Medicare (71 - 80 of 1,464 items)
Private Health Insurance: Concentration of Enrollees among Individual, Small Group, and Large Group Insurers from 2010 through 2013
GAO-15-101R: Published: Dec 1, 2014. Publicly Released: Dec 1, 2014.
The Patient Protection and Affordable Care Act (PPACA) requires GAO to study competition and market concentration in the health insurance market. For this study, we examined individual, small group, and large group health insurance markets prior to the implementation of key PPACA provisions that went into effect in 2014 and that could affect competition and market concentration among health insure...
Group Purchasing Organizations: Funding Structure Has Potential Implications for Medicare Costs
GAO-15-13: Published: Oct 24, 2014. Publicly Released: Nov 24, 2014.
According to representatives from the 5 large group purchasing organizations (GPO) in GAO's review, GPO contracting generally involves three phases: (1) issue requests for proposals or invitations for vendors to competitively bid for a contract, (2) review proposals, and (3) negotiate and award contracts. GPOs reported negotiating and awarding different types of contracts to vendors in different s...
Medicare Program Integrity: CMS Pursues Many Practices to Address Prescription Drug Fraud, Waste, and Abuse
GAO-15-66: Published: Oct 24, 2014. Publicly Released: Nov 24, 2014.
GAO identified 23 practices for addressing prescription drug fraud, waste, and abuse that fall within three categories based on GAO's Fraud Prevention Framework—prevention, detection and monitoring, and investigation and prosecution.The Department of Health and Human Services' (HHS) Centers for Medicare & Medicaid Services' (CMS) activities to address prescription drug fraud, waste, and abuse in...
Health Care Transparency: Actions Needed to Improve Cost and Quality Information for Consumers
GAO-15-11: Published: Oct 20, 2014. Publicly Released: Nov 18, 2014.
Results obtained from two selected private consumer transparency tools GAO reviewed—websites with health cost or quality information comparing different health care providers—show that some providers are paid thousands of dollars more than others for the same service in the same geographic area, regardless of the quality of such services. For example, the cost for maternity care at selected ac...
Small Business Health Insurance Exchanges: Low Initial Enrollment Likely due to Multiple, Evolving Factors
GAO-15-58: Published: Nov 13, 2014. Publicly Released: Nov 13, 2014.
Though all of the Small Business Health Options Programs (SHOPs) required by the Patient Protection and Affordable Care Act were operational, many features were not yet available and enrollment was low as of June 2014. According to the Centers for Medicare & Medicaid Services (CMS), the agency that oversees the SHOPs, all 33 of the SHOPs run by CMS (federally facilitated, or FF-SHOPs) and 14 of th...
Compounded Drugs: Payment Practices Vary across Public Programs and Private Insurers, and Medicare Part B Policy Should Be Clarified
GAO-15-85: Published: Oct 10, 2014. Publicly Released: Nov 10, 2014.
Medicare, Medicaid, and private health insurers have varying payment practices for compounded drugs, depending upon whether compounded drugs and their ingredients can be identified on health insurance claims, and Medicare's Part B payment policy for these drugs is unclear.For drugs dispensed in pharmacy settings, claims contain sufficient information for public programs and private insurers to ide...
Compounded Drugs: TRICARE's Payment Practices Should Be More Consistent with Regulations
GAO-15-64: Published: Oct 2, 2014. Publicly Released: Oct 2, 2014.
The Department of Defense's (DOD) TRICARE program paid for about 465,000 compounded drug prescriptions through its pharmacy benefit in fiscal year 2013; these prescriptions represented 0.3 percent of all prescription drugs paid for through TRICARE's pharmacy benefit in that year. Most of these compounded drug prescriptions were dispensed in retail pharmacies and to retirees and their family member...
Disabled Dual-Eligible Beneficiaries: Integration of Medicare and Medicaid Benefits May Not Lead to Expected Medicare Savings
GAO-14-523: Published: Aug 29, 2014. Publicly Released: Sep 29, 2014.
Overall spending for high-expenditure disabled dual-eligible beneficiaries—those in the top 20 percent of spending in their respective states—was driven largely by Medicaid spending, and the service use and health status often differed widely between those with high Medicare expenditures and high Medicaid expenditures. For these beneficiaries, Medicaid expenditures accounted for nearly two-thi...
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...
Medicare Program Integrity: Increased Oversight and Guidance Could Improve Effectiveness and Efficiency of Postpayment Claims Reviews
GAO-14-474: Published: Jul 18, 2014. Publicly Released: Aug 13, 2014.
The Centers for Medicare & Medicaid Services (CMS) within the Department of Health and Human Services (HHS) has taken steps to prevent its contractors from conducting certain duplicative postpayment claims reviews—reviews of the same claims that are not permitted by the agency—but CMS neither has reliable data nor provides sufficient oversight and guidance to measure and fully prevent duplicat...