Medicare plans (1 - 10 of 18 items)
Medicare Advantage: Limited Progress Made to Validate Encounter Data Used to Ensure Proper Payments
GAO-17-223: Published: Jan 17, 2017. Publicly Released: Jan 19, 2017.
Since GAO issued its July 2014 report, the Centers for Medicare & Medicaid Services (CMS) within the Department of Health and Human Services (HHS) has made limited progress to validate the completeness and accuracy of Medicare Advantage (MA) encounter data. CMS collects encounter data—detailed information about the care and health status of MA enrollees—to determine payments to MA organization...
Physician-administered Drugs: Comparison of Payer Payment Methodologies
GAO-16-780R: Published: Aug 1, 2016. Publicly Released: Aug 31, 2016.
Payment methodologies for physician-administered drugs varied across Medicare fee-for-service, Medicaid fee-for-service, the Department of Veterans Affairs (VA) health care system, the VA Choice program, and two large private payers GAO reviewed. Compared to Medicare, other federal payers generally paid rates that were the same or lower. For example, for 10 high-expenditure drugs, VA paid rates th...
Medicare Part B: Data on Coupon Discounts Needed to Evaluate Methodology for Setting Drug Payment Rates
GAO-16-643: Published: Jul 27, 2016. Publicly Released: Aug 26, 2016.
In 2015, manufacturers of 29 of the 50 high-expenditure Medicare Part B drugs GAO analyzed offered coupon programs, which reduce the costs patients incur for specific drugs. Part B drugs are typically administered by a physician. Coupon programs are prohibited in the Medicare program but are generally available to privately insured patients. GAO obtained data on coupon discounts for 18 drugs. GAO...
Medicare Part B: CMS Should Take Additional Steps to Verify Accuracy of Data Used to Set Payment Rates for Drugs
GAO-16-594: Published: Jul 1, 2016. Publicly Released: Aug 1, 2016.
In 2014, the most recent year for which data were available, the Medicare program and its beneficiaries spent about $21 billion on approximately 46 million administrations of 551 Part B drugs paid based on average sales price (ASP). Six drugs—each exceeding $1 billion in expenditures—accounted for 36 percent of all expenditures on Part B ASP drugs, while a different 10 drugs—each administere...
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...
Medicare Part B: Expenditures for New Drugs Concentrated among a Few Drugs, and Most Were Costly for Beneficiaries
GAO-16-12: Published: Oct 23, 2015. Publicly Released: Nov 20, 2015.
New Medicare Part B drugs were more likely than new drugs not paid under Part B to be biologics, that is, products derived from living sources; be approved to treat a narrower range of conditions; and to have used a Food and Drug Administration (FDA) program to expedite their development and review. Sixty-one percent of the 83 new Part B drugs approved by FDA from 2006 through 2013 were biologics,...
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...
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 Physical Therapy: Self-Referring Providers Generally Referred More Beneficiaries but Fewer Services per Beneficiary
GAO-14-270: Published: Apr 30, 2014. Publicly Released: Jun 2, 2014.
From 2004 to 2010, non-self-referred physical therapy (PT) services increased at a faster rate than self-referred PT services. During this period, the number of self-referred PT services per 1,000 Medicare fee-for-service beneficiaries was generally flat, while non-self-referred PT services grew by about 41 percent. Similarly, the growth rate in expenditures associated with non-self-referred PT se...
Medicare: Contractors and Private Plans Play a Major Role in Administering Benefits
GAO-14-417T: Published: Mar 4, 2014. Publicly Released: Mar 4, 2014.
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) reformed the way the Centers for Medicare & Medicaid Services (CMS), the agency that administers Medicare, contracts with claims administration contractors. From its inception, the process for selecting Medicare fee-for-service (FFS) claims administration contractors was stipulated by Congress and differed from most o...