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Medicare: Lessons Learned From HCFA's Implementation of Changes to Benefits

HEHS-00-31 Published: Jan 25, 2000. Publicly Released: Feb 08, 2000.
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Highlights

Pursuant to a congressional request, GAO provided information on the Health Care Financing Administration's (HCFA) efforts to implement changes to the Medicare program, focusing on HCFA's implementation of the: (1) expansion of the partial hospitalization benefit; and (2) more recent changes under the Balanced Budget Act of 1997 (BBA) to determine whether HCFA is acting upon lessons learned from the partial hospitalization program.

Recommendations

Recommendations for Executive Action

Agency Affected Recommendation Status
Health Care Financing Administration The Administrator, HCFA, should establish a process for implementing legislated Medicare benefit changes that will ensure: (1) careful assessment of the potential effects of benefit changes on the program; (2) sufficient explanation of the benefit changes to enable contractors to review and correctly pay claims; (3) adequate claims monitoring to detect irregularities, patterns of abuse, or other potential problems; and (4) timely corrective action should problems with the benefit arise.
Closed – Implemented
HCFA continues to refine its processes to ensure the programmatic integrity of legislated benefit changes. When the Balanced Budget Refinement Act suspended the BBA's annual reimbursement limits for therapy services for 2 years, HCFA expeditiously awarded to a Program Safeguard Contractor (PSC) a task order to assist in preparing mandated reports to Congress. The contractor will develop a coordinated strategy for the review of therapy services provided in all settings, excluding inpatient hospital, that decreases error rates and encourages the delivery of covered therapy services to Medicare beneficiaries. Consistent with GAO recommendations, this effort includes data collection and statistical analysis, development of evidence-based medical review protocols, educational materials, and a public relations effort to ensure appropriate claims payment. This recommendation should be considered completed.

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Topics

Claims processingFraudHealth insuranceHealth insurance cost controlHospital care servicesInternal controlsMedical expense claimsMedical information systemsMedicareMental care facilitiesProgram abuses