Claims processing (1 - 10 of 188 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 (...
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'...
Veterans' Health Care: Preliminary Observations on VHA's Claims Processing Delays and Efforts to Improve the Timeliness of Payments to Community Providers
GAO-16-380T: Published: Feb 11, 2016. Publicly Released: Feb 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. GAO's preliminary work from the sites it visited shows that in fiscal year 2015, VHA's claims processing was sig...
International Classification of Diseases: CMS Has Updated Systems and Supported Stakeholders' Efforts to Use New Codes
GAO-15-789: Published: Sep 17, 2015. Publicly Released: Sep 17, 2015.
The Centers for Medicare & Medicaid Services (CMS) has finished updating its systems with the changes it determined were needed to process the new International Classification of Diseases codes (ICD-10) on Medicare fee-for-service claims. In 2007, CMS began taking steps to identify components of its systems that needed to be changed to update the ICD codes from version 9 to 10. CMS began making th...
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...
Improper Payments: TRICARE Measurement and Reduction Efforts Could Benefit from Adopting Medical Record Reviews
GAO-15-269: Published: Feb 18, 2015. Publicly Released: Feb 18, 2015.
The Defense Health Agency (DHA), the agency within the Department of Defense (DOD) responsible for administering the military health program known as TRICARE, uses a methodology for measuring TRICARE improper payments that is less comprehensive than the methodology used to measure improper payments in Medicare, the federal health care program for the elderly and certain disabled individuals. Both...
International Classification of Diseases: CMS's Efforts to Prepare for the New Version of the Disease and Procedure Codes
GAO-15-255: Published: Jan 28, 2015. Publicly Released: Feb 6, 2015.
The Centers for Medicare & Medicaid Services (CMS), within the Department of Health and Human Services (HHS), has undertaken a number of efforts to prepare for the October 1, 2015, transition to the 10th revision of the International Classification of Diseases (ICD-10) codes, which are used for documenting patient medical diagnoses and inpatient medical procedures. CMS has developed educational ma...
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...
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...