Medicaid:

Improvements Needed in Programs To Prevent Abuse

HRD-87-75: Published: Sep 1, 1987. Publicly Released: Sep 1, 1987.

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GAO reviewed Medicaid abuse in six states and provider abuse in four states to: (1) determine whether the states were effective in identifying Medicaid abuse; and (2) assess the extent of states' actions to apply sanctions against Medicaid abusers.

GAO found that: (1) the Department of Health and Human Services (HHS) has not taken effective action to strengthen management controls over states' postpayment utilization review programs; (2) some states do not effectively use their computerized management information systems to identify potential Medicaid abuse; (3) some states review only a small portion of the potentially abusive recipients they identify; (4) most states have applied few sanctions against abusive Medicaid recipients; and (5) the Health Care Financing Administration (HCFA) has adequate resources to provide technical assistance to states with problems in using their information systems.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: HHS did not concur with this recommendation, but stated that its fiscal year 1988 monitoring efforts would help clarify what program results data, if any, should be collected.

    Recommendation: The Secretary of Health and Human Services should instruct the Administrator, HCFA, to collect annual data on program results to monitor states' utilization control programs and use those data in determining which states will be subject to Systems Performance Reviews, and as additional indicators of: (1) states needing technical assistance; and (2) states using successful SURS techniques.

    Agency Affected: Department of Health and Human Services

  2. Status: Closed - Implemented

    Comments: HHS agreed that it is desirable to disseminate data on successful techniques, but did not agree that it should provide advice on evaluating states' efforts.

    Recommendation: The Secretary of Health and Human Services should instruct the Administrator, HCFA, to establish procedures to provide technical assistance to states experiencing problems using SURS and periodically identify, evaluate, and disseminate information on innovative SURS techniques to states for their consideration.

    Agency Affected: Department of Health and Human Services

  3. Status: Closed - Implemented

    Comments: GAO was unable to identify anyone at HHS tracking this recommendation.

    Recommendation: The Secretary of Health and Human Services should instruct the Administrator, HCFA, to include in the Systems Performance Review guidelines a requirement to document: (1) technical problems the states are having using SURS to identify Medicaid abusers; and (2) successful SURS techniques developed by states to identify, review, or sanction Medicaid abusers.

    Agency Affected: Department of Health and Human Services

  4. Status: Closed - Not Implemented

    Comments: HHS did not agree with this recommendation, stating that the systems performance review is ill-suited for measuring this type of performance.

    Recommendation: The Secretary of Health and Human Services should revise the Systems Performance Review to include specific evaluations of how effectively states use the Surveillance and Utilization Review Subsystem (SURS) to identify potential abusers. Specifically, the review should determine if a state's screens and class groups are reasonable in view of the potential abuse identified in the annual assessment, and if parameters are reasonable in light of the review requirement.

    Agency Affected: Department of Health and Human Services

  5. Status: Closed - Not Implemented

    Comments: HHS stated that it is premature to establish such requirements given the present understanding of federal and state practices.

    Recommendation: The Secretary of Health and Human Services should instruct the Administrator, HCFA, to revise the Systems Performance Review to link a state's assessment of its potential abuse problems to the number of potential abusers that the state must review to meet review requirements.

    Agency Affected: Department of Health and Human Services

  6. Status: Closed - Implemented

    Comments: HHS plans to research the criteria used by selected states to determine whether there is a need for HCFA-developed identification criteria.

    Recommendation: The Secretary of Health and Human Services should instruct the Administrator, HCFA, to require states to annually assess the extent of the recipient and provider abuse in the state using a set of HCFA-developed identification criteria.

    Agency Affected: Department of Health and Human Services

  7. Status: Closed - Not Implemented

    Comments: HHS did not agree that the deficiencies cited are a material internal control weakness.

    Recommendation: The Secretary of Health and Human Services should instruct the Administrator, HCFA, to include Medicaid postpayment utilization review program deficiencies as material internal control weaknesses in the Federal Managers' Financial Integrity Act's reporting and tracking system.

    Agency Affected: Department of Health and Human Services

 

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