Problems in Administering Medicare's Health Maintenance Organization Demonstration Projects in Florida
HRD-85-48
Published: Mar 08, 1985. Publicly Released: Mar 08, 1985.
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Highlights
In response to a congressional request, GAO reviewed the operations of Florida health maintenance organizations (HMO) to determine: (1) if Medicare beneficiaries were enrolled and disenrolled in HMO in a timely fashion; and (2) how a requirement that, except for emergency services, all health care services for enrolled beneficiaries must be provided or authorized by the HMO was administered.
Recommendations
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator of the Health Care Financing Administration (HCFA) to take action to identify and correct the systemic problems leading to the erroneous physician and hospital payments that GAO found. Corrective action should center on overcoming the problems of intermediaries' and carriers' not knowing when beneficiaries are enrolled in an HMO because of the delays in recording enrollments and problems with the computerized exchange of data among the carriers, intermediaries, HMO, and HCFA. |
Verification of time lags between the effective date of enrollment for all Medicare HMO enrollees in South Florida and the dates the information was posted to the HCFA Health Insurance Beneficiary Master File showed no delays in recording enrollments as of November 1, 1985.
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Topics
Erroneous paymentsHealth care servicesHealth maintenance organizationsHospitalsMedicareInternal controlsOverpaymentsRecords managementBeneficiariesPhysicians