Medicare: Experience Shows Ways to Improve Oversight of Health Maintenance Organizations
HRD-88-73
Published: Aug 17, 1988. Publicly Released: Aug 17, 1988.
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Highlights
In response to a congressional request, GAO reviewed the Health Care Financing Administration's (HCFA) efforts to deal with health maintenance organizations' (HMO) compliance problems, specifically: (1) the adequacy of data to determine the quality and cost of HMO care; (2) the adequacy of HCFA staff levels to monitor HMO; and (3) HCFA willingness to act when HMO fail to meet federal requirements.
Recommendations
Matter for Congressional Consideration
| Matter | Status | Comments |
|---|---|---|
| The House Committee on Ways and Means, Subcommittee on Health, should consider increasing HCFA discretion in applying its authority to suspend Medicare enrollments. Specifically, the Subcommittee should consider developing legislation to give HCFA discretion to suspend Medicare enrollments in HMO that fail to respond to notices of noncompliance in a timely manner, have recurring compliance problems, or are encountering financial difficulties or failing to meet financial solvency requirements and not showing substantial progress in improving from one reporting period to the next. |
Closed – Implemented
|
Public Law 101-239, the Omnibus Budget Reconciliation Act of 1989, amended the Social Security Act to give the Secretary of Health and Human Services additional authority to apply sanctions, including restricting enrollment, applying civil monetary penalties, and suspending payment. The Secretary issued implementing regulations in July 1994. |
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, HCFA, to issue regulations specifying the purpose of retroactive disenrollments and the circumstances, criteria, and procedures that must be met in authorizing such actions. |
Closed – Implemented
As of July 27, 1998, new HCFA regulations codified the purpose and criteria for granting retroactive disenrollments.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to establish a formal system for tracking through final resolution HCFA requests for corrective actions and HMO corrective actions. |
Closed – Implemented
HHS completed testing of the Compliance Activity Tracking System, which became fully operational in June 1990.
|
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Topics
Health care costsHealth care servicesHealth maintenance organizationsHealth services administrationInternal controlsMedical information systemsMedicareMonitoringNoncomplianceProposed legislation