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Medicare: Better Controls Needed for Peer Review Organizations' Evaluations

HRD-88-13 Published: Oct 08, 1987. Publicly Released: Oct 08, 1987.
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Highlights

In response to a congressional request, GAO reviewed the Health Care Financing Administration's (HCFA) evaluation of peer review organizations' (PRO) contract performance for contract renewal, to assess: (1) whether HCFA properly evaluated PRO performance; and (2) how HCFA determined the level of funding for new PRO contracts.

Recommendations

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Health and Human Services The Secretary of Health and Human Services should instruct the Administrator, HCFA, to ensure that in future PRO evaluations, the evaluation process has sufficient internal controls to ensure that evaluations are consistently applied and that decisions resulting from them are adequately documented.
Closed – Implemented
The Department of Health and Human Services (HHS) agreed with this recommendation and took several actions to tighten controls over the evaluation process.
Department of Health and Human Services The Secretary of Health and Human Services should direct the Administrator, HCFA, to provide criteria to enable HCFA personnel to differentiate between acceptable and unacceptable performance in the routine monitoring of PRO activities.
Closed – Implemented
HHS stated that it was in general agreement with this recommendation and would provide additional training to the project officers who monitor PRO performance.
Department of Health and Human Services The Secretary of Health and Human Services should direct the Administrator, HCFA, to determine the scope of review needed to adequately meet the program's intent and use this as the starting point for determining the program's funding level.
Closed – Not Implemented
HHS commented that it believed its PRO budget process was already meeting the intent of the recommendation.
Department of Health and Human Services The Secretary of Health and Human Services should direct the Administrator, HCFA, to collect and use adequate cost and performance data to set each PRO contract funding at a level sufficient to provide the coverage determined to be necessary.
Closed – Implemented
HHS agreed with this recommendation and stated that it would be collecting better data to use in setting individual PRO funding levels. HHS has actions in the latest round of PRO contracts to accomplish this.

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Topics

Contract costsContract oversightContract performanceEvaluation methodsHealth care cost controlInternal controlsService contractsMedicareBeneficiariesSanctions