Medicare Providers' Legal Expenses

HEHS-95-214R: Published: Jul 18, 1995. Publicly Released: Jul 18, 1995.

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Pursuant to a congressional request, GAO provided information on Medicare reimbursement of providers' legal expenses, focusing on: (1) the conditions that Medicare imposes on provider legal expense reimbursements and whether these conditions differ from those applied in other government contexts; (2) the amount Medicare spends on providers' legal expenses; and (3) whether Medicare providers have abused current provisions covering legal expense reimbursement. GAO noted that: (1) the Health Care Financing Administration has not specified the conditions under which legal fees are reimbursable; (2) Medicare decides whether providers' legal fees are reimbursable on a case-by-case basis; (3) the provisions for reimbursing Medicare providers' legal fees are more generous than those in other government contexts in that providers can be reimbursed by Medicare regardless of outcome and providers' legal expenses are not capped; (4) in 1994, 46 home health agencies had a combined total of $6.5 million in legal expenses; and (5) home health care agencies are more likely to submit claims for Medicare reimbursement and to appeal denied cost adjustments, despite limited chances of success.

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