Medicare (21 - 30 of 1,464 items)
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...
Veterans' Health Care: Proper Plan Needed to Modernize System for Paying Community Providers
GAO-16-353: Published: May 11, 2016. Publicly Released: May 11, 2016.
To help ensure that veterans are provided timely and accessible health care services, the Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) has purchased care from non-VA community providers through its care in the community programs since as early as 1945. VHA's agency-wide data show that in fiscal year 2015, it processed about 66 percent of claims within the agency'...
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...
Patient Protection and Affordable Care Act: CMS Should Act to Strengthen Enrollment Controls and Manage Fraud Risk
GAO-16-506T: Published: Mar 17, 2016. Publicly Released: Mar 17, 2016.
The Patient Protection and Affordable Care Act (PPACA) requires applicant information be verified to determine eligibility for enrollment or income-based subsidies. To implement this verification process, the Centers for Medicare & Medicaid Services (CMS) created an electronic system called the “data services hub” (data hub), which, among other things, provides a single link to federal sources...
Provider Networks: Comparison of Child-Focused Network Adequacy Standards between CHIP and Private Health Plans
GAO-16-219: Published: Feb 5, 2016. Publicly Released: Mar 7, 2016.
Broad federal provider network adequacy standards apply to health plans in the joint federal-state State Children's Health Insurance Program (CHIP) and to qualified health plans (QHP)—private health plans offered on health insurance exchanges. These standards measure the adequacy of the networks of physicians, hospitals, and other providers participating in each plan. The five selected states GA...
Nonemergency Medical Transportation: Updated Medicaid Guidance Could Help States
GAO-16-238: Published: Feb 2, 2016. Publicly Released: Mar 3, 2016.
The nonemergency medical transportation (NEMT) benefits offered by Medicare and Medicaid differ. Medicare provides NEMT via ambulance only when other means of transportation, such as a taxi or wheelchair van, would jeopardize the health of the beneficiary. Medicaid NEMT is generally available for beneficiaries who have no other means of transportation to medical services. States are responsible fo...
Health Care Fraud: Information on Most Common Schemes and the Likely Effect of Smart Cards
GAO-16-216: Published: Jan 22, 2016. Publicly Released: Feb 22, 2016.
GAO's review of 739 health care fraud cases that were resolved in 2010 showed the following:About 68 percent of the cases included more than one scheme with 61 percent including two to four schemes and 7 percent including five or more schemes.The most common health care fraud schemes were related to fraudulent billing, such as billing for services that were not provided (about 43 percent of cases)...
Medicaid: Efforts to Exclude Nonemergency Transportation Not Widespread, but Raise Issues for Expanded Coverage
GAO-16-221: Published: Jan 15, 2016. Publicly Released: Feb 16, 2016.
States' efforts to exclude nonemergency medical transportation (NEMT) benefits from enrollees who are newly eligible for Medicaid under the Patient Protection and Affordable Care Act (PPACA) are not widespread. Of the 30 states that expanded Medicaid as of September 30, 2015, 25 reported that they did not undertake efforts to exclude the NEMT benefit for newly eligible enrollees, 3 states reported...