Inadequate Controls Over Medicare Payments for Once-in-a-Lifetime Physician Procedures

HRD-84-23: Published: Feb 13, 1984. Publicly Released: Feb 13, 1984.

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GAO evaluated the controls that Medicare carriers have over payments for once-in-a-lifetime physician procedures. The Health Care Financing Administration (HCFA) promulgates program regulations and defines such procedures as certain types of surgical operations and initial service visits.

GAO found that there is a fairly widespread lack of compliance with the HCFA requirement to control payments for these physicians procedures. Overpayments at the two carriers reviewed by GAO indicated that overpayments are probably substantial nationwide.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: In October 1984, HCFA issued instructions to the carriers requiring them to screen claims for once-in-a-lifetime procedures.

    Recommendation: The Administrator, HCFA, should enforce the requirement that carriers implement controls for once-in-a-lifetime procedures.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

  2. Status: Closed - Implemented

    Comments: In June 1984, HCFA directed the carriers to pursue the overpayments. The carriers reported, in August 1984, that collections had been made.

    Recommendation: The Administrator, HCFA, should require the Equitable Life Assurance Society to collect all of the overpayments for dialysis treatments that were identified.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

  3. Status: Closed - Implemented

    Comments: HCFA is developing a core list of once-in-a-lifetime procedures.

    Recommendation: The Administrator, HCFA, should develop a core list of codes to be controlled as once-in-a-lifetime procedures while implementing the HCFA Common Procedure Coding System and require carriers to have edits for these procedures.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

  4. Status: Closed - Implemented

    Comments: HCFA is still studying the desirability of requiring carriers, as a permanent part of a beneficiary's record, to note the performance of once-in-a-lifetime procedures.

    Recommendation: The Administrator, HCFA, should examine the desirability of requiring carriers to make use of procedures that can only be performed once on a beneficiary a permanent part of beneficiaries' records.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

 

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