Medicare: Rehabilitation Service Claims Paid Without Adequate Information
HRD-87-91
Published: Jul 09, 1987. Publicly Released: Jul 09, 1987.
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Highlights
GAO reviewed the need to improve the processes Medicare intermediaries use to review claims for outpatient rehabilitation services.
Recommendations
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Health Care Financing Administration | The Administrator, HCFA, after complying with the appropriate regulatory clearance process, should implement the physical therapy guidelines and utilization screens already developed and require intermediaries to apply them to rehabilitation physical therapy services provided in all outpatient settings, including comprehensive outpatient rehabilitation facilities (CORF). |
Closed – Implemented
HCFA guidelines and screens for outpatient physical therapy were issued in August 1988. These guidelines and screens were not applied to CORF, however.
|
| Health Care Financing Administration | The Administrator, HCFA, should: (1) develop and implement guidelines that clearly identify the document types and contents needed by intermediaries to make appropriate Medicare coverage decisions for the other types of outpatient rehabilitation therapy services; and (2) require intermediaries to use the guidelines for reviewing providers' claims for rehabilitation services. |
Closed – Implemented
HCFA issued guidelines in May 1989, but the requirements relate only to claims subject to medical review, not all claims.
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Topics
Claims settlementEligibility determinationsHealth insuranceHealth insurance cost controlInsurance claimsInternal controlsMedicarePatient care servicesRehabilitation programsTherapyMedical history