Claims processing (11 - 20 of 188 items)
Medicare Fraud: Progress Made, but More Action Needed to Address Medicare Fraud, Waste, and Abuse
GAO-14-560T: Published: Apr 30, 2014. Publicly Released: Apr 30, 2014.
The Centers for Medicare & Medicaid Services (CMS)—the agency within the Department of Health and Human Services (HHS) that oversees Medicare—has made progress in implementing several key strategies GAO identified in prior work as helpful in protecting Medicare from fraud; however, important actions that could help CMS and its program integrity contractors combat fraud remain incomplete.Provid...
Medicare Program Integrity: Contractors Reported Generating Savings, but CMS Could Improve Its Oversight
GAO-14-111: Published: Oct 25, 2013. Publicly Released: Nov 25, 2013.
The Centers for Medicare and Medicaid Services (CMS) paid its Zone Program Integrity Contractors (ZPIC) about $108 million in 2012. ZPICs reported spending most of this funding on fraud case development, primarily for investigative staff, who in 2012 reported conducting about 3,600 beneficiary interviews, almost 780 onsite inspections, and reviews of more than 200,000 Medicare claims.ZPICs reporte...
Medicare Information Technology: Centers for Medicare and Medicaid Services Needs to Pursue a Solution for Removing Social Security Numbers from Cards
GAO-13-761: Published: Sep 10, 2013. Publicly Released: Oct 17, 2013.
The Centers for Medicare and Medicaid Services (CMS)--which is the agency within the Department of Health and Human Services (HHS) responsible for administering Medicare--has not taken needed steps, such as designating a business owner and establishing a business case for an information technology (IT) project, that would result in selecting and implementing a technical solution for removing Socia...
Medicare Program Integrity: Increasing Consistency of Contractor Requirements May Improve Administrative Efficiency
GAO-13-522: Published: Jul 23, 2013. Publicly Released: Aug 22, 2013.
The Centers for Medicare & Medicaid Services' (CMS) contractors that conduct postpayment reviews on Medicare fee-for-service (FFS) claims were established by different legislative actions; are managed by different offices within CMS; and serve different functions in the program. These contractors include (1) Medicare Administrative Contractors that process and pay claims and are responsible for ta...
Medicare: Action Needed to Address Higher Use of Anatomic Pathology Services by Providers Who Self-Refer
GAO-13-445: Published: Jun 24, 2013. Publicly Released: Jul 15, 2013.
Self-referred anatomic pathology services increased at a faster rate than non-self-referred services from 2004 to 2010. During this period, the number of self-referred anatomic pathology services more than doubled, growing from 1.06 million services to about 2.26 million services, while non-self-referred services grew about 38 percent, from about 5.64 million services to about 7.77 million service...
GAO's 2013 High-Risk Update: Medicare and Medicaid
GAO-13-433T: Published: Feb 27, 2013. Publicly Released: Feb 27, 2013.
Medicare Program: CMS has not met GAO's criteria to have the Medicare program removed from the High-Risk List. For example, although CMS has made progress in measuring and reducing improper payment rates in different parts of the program, it has yet to demonstrate sustained progress in lowering the rates. Because the size of Medicare relative to other programs leads to aggregate improper payments...
Medicare Program Integrity: Greater Prepayment Control Efforts Could Increase Savings and Better Ensure Proper Payment
GAO-13-102: Published: Nov 13, 2012. Publicly Released: Dec 10, 2012.
Use of prepayment edits saved Medicare at least $1.76 billion in fiscal year 2010, but GAO found that savings could have been greater had prepayment edits been more widely used. GAO illustrated this point using analysis of a limited number of national policies and local coverage determinations (LCD), which are established by each Medicare administrative contractor (MAC) to specify coverage rules i...
Health Care Fraud: Types of Providers Involved in Medicare Cases, and CMS Efforts to Reduce Fraud
GAO-13-213T: Published: Nov 28, 2012. Publicly Released: Nov 28, 2012.
In recently completed work, we found that medical facilities (such as medical centers, clinics, and practices) and durable medical equipment suppliers were the most frequent subjects of criminal fraud cases in Medicare, Medicaid, and CHIP in 2010. Hospitals and medical facilities were the most frequent subjects of civil fraud cases, including cases that resulted in judgments or settlements. Accord...
Medicare: Important Steps Have Been Taken, but More Could Be Done to Deter Fraud
GAO-12-671T: Published: Apr 24, 2012. Publicly Released: Apr 24, 2012.
The Centers for Medicare & Medicaid Services (CMS)the agency that administers Medicarehas made progress in implementing several key strategies GAO identified in prior work as helpful in protecting Medicare from fraud; however, some actions that could help combat fraud remain incomplete.Provider Enrollment: GAOs previous work found persistent weaknesses in Medicares enrollme...
Medicare Program Integrity: CMS Continues Efforts to Strengthen the Screening of Providers and Suppliers
GAO-12-351: Published: Apr 10, 2012. Publicly Released: Apr 23, 2012.
Medicare claims are screened against enrollment information, using automated enrollment-related prepayment edits, in an effort to prevent improper payments to ineligible providers and supplierssuch as those that are no longer active in the Medicare program or are not properly licensed to provide the services for which they have submitted claims. Officials with the contractors we interviewed...