Managed health care (21 - 30 of 203 items)
Medicare Private Health Plans: Selected Current Issues
GAO-12-1045T: Published: Sep 21, 2012. Publicly Released: Sep 21, 2012.
In March 2012, GAO issued a report on the Centers for Medicare & Medicaid Services (CMS) Medicare Advantage (MA) quality bonus payment demonstrationa demonstration CMS initiated rather than implementing the quality bonus program established under the Patient Protection and Affordable Care Act (PPACA). Compared to the PPACA quality bonus program, CMSs demonstration increases the n...
Department of Health and Human Services: Opportunities for Financial Savings and Program Improvements in Medicare and Medicaid Remain
GAO-12-719T: Published: May 9, 2012. Publicly Released: May 9, 2012.
Over the past several years, GAO has made a number of recommendations to the Centers for Medicare & Medicaid Services (CMS)an agency within the Department of Health and Human Services (HHS)to increase savings in Medicare fee-for-service and Medicare Advantage (MA), which is a private plan alternative to the traditional Medicare fee-for-service program. Open recommendations that could y...
Medicaid: Federal Oversight of Payments and Program Integrity Needs Improvement
GAO-12-674T: Published: Apr 25, 2012. Publicly Released: Apr 25, 2012.
Oversight of managed care rate-setting has been inconsistent. In August 2010, GAO reported that the Centers for Medicare & Medicaid Services (CMS) had not ensured that all states were complying with the managed care actuarial soundness requirements that rates be developed in accordance with actuarial principles, appropriate for the population and services, and certified by actuaries. For example,...
Drug Pricing: Research on Savings from Generic Drug Use
GAO-12-371R: Published: Jan 31, 2012. Publicly Released: Mar 1, 2012.
Our review identified articles that used varying approaches to estimate the savings associated with generic drug use in the United States. One group of studies estimated the savings in reduced drug costs that have accrued from the use of generics. For example, a series of studies estimated the total savings that have accrued to the U.S. health care system from substituting generic drugs for their...
Medicare Integrity Program: CMS Used Increased Funding for New Activities but Could Improve Measurement of Program Effectiveness
GAO-11-592: Published: Jul 29, 2011. Publicly Released: Aug 29, 2011.
The Medicare program makes about $500 billion in payments per year and continues to have a significant amount of improper payments--almost $48 billion in fiscal year 2010. The Centers for Medicare & Medicaid Services' (CMS) Medicare Integrity Program (MIP) is designed to identify and address fraud, waste, and abuse, which are all causes of improper payments. MIP's authorizing legislation provided...
Patient Protection and Affordable Care Act: Contracts Awarded and Consultants Retained by Federal Departments and Agencies to Assist in Implementing the Act
GAO-11-797R: Published: Jul 14, 2011. Publicly Released: Jul 14, 2011.
The Patient Protection and Affordable Care Act (PPACA), as amended by the Health Care and Education Reconciliation Act of 2010 (HCERA), contained provisions to increase access to health insurance coverage through: health insurance market reforms; an expansion of Medicaid eligibility; and the creation of health insurance exchanges to provide small employers and individuals access to coverage. In ad...
Medicare Secondary Payer: Process for Situations Involving Non-Group Health Plans
GAO-11-726T: Published: Jun 22, 2011. Publicly Released: Jun 22, 2011.
The Centers for Medicare & Medicaid Services (CMS) is responsible for protecting the Medicare program's fiscal integrity and ensuring that it pays only for those services that are its responsibility. Medicare Secondary Payer (MSP) provisions make Medicare a secondary payer to certain group health plans (GHP) and non-group health plans (NGHP), which include auto or other liability insurance, no-fau...
Defense Health Care: Access to Civilian Providers under TRICARE Standard and Extra
GAO-11-500: Published: Jun 2, 2011. Publicly Released: Jun 2, 2011.
The Department of Defense (DOD) provides health care through its TRICARE program, which is managed by the TRICARE Management Activity (TMA). TRICARE offers three basic options. Beneficiaries who choose TRICARE Prime, an option that uses civilian provider networks, must enroll. TRICARE beneficiaries who do not enroll in this option may obtain care from nonnetwork providers under TRICARE Standard or...
Medicare Fraud, Waste, and Abuse: Challenges and Strategies for Preventing Improper Payments
GAO-10-844T: Published: Jun 15, 2010. Publicly Released: Jun 15, 2010.
GAO has designated Medicare as a high-risk program since 1990, in part because the program's size and complexity make it vulnerable to fraud, waste, and abuse. Fraud represents intentional acts of deception with knowledge that the action or representation could result in an inappropriate gain, while abuse represents actions inconsistent with acceptable business or medical practices. Waste, which i...
Home Infusion Therapy: Differences between Medicare and Private Insurers' Coverage
GAO-10-426: Published: Jun 7, 2010. Publicly Released: Jun 14, 2010.
Infusion therapy--drug treatment generally administered intravenously--was once provided strictly in hospitals. However, clinical developments and emphasis on cost containment have prompted a shift to other settings, including the home. Home infusion requires coordination among providers of drugs, equipment, and skilled nursing care, as needed. GAO was asked to review home infusion coverage polici...