Medicare:

HCFA Can Reduce Paperwork Burden for Physicians and Their Patients

HRD-90-86: Published: Jun 20, 1990. Publicly Released: Jun 20, 1990.

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Pursuant to a congressional request, GAO reviewed the claims process for Medicare physician services to determine whether: (1) opportunities exist to help providers submit more complete claims; (2) notices to beneficiaries explain claims decisions clearly; and (3) electronic services, such as electronic mail, could reduce paperwork.

GAO found that: (1) in 1989, providers and beneficiaries filed 45 million incomplete claim forms; (2) incomplete claim forms were more costly to process than complete claim forms; (3) service descriptions and provider names on benefit notices were vague; (4) mathematical calculations and explanations of beneficiary liability were difficult to understand; and (5) reasons for service denial were not sufficiently precise. GAO also found that: (1) the Health Care Financing Administration (HCFA) could make filing claims easier by using electronic technologies to automate the process; (2) electronic technologies would reduce Medicare administrative costs and alleviate providers' cost and paperwork; and (3) some contractors and commercial insurers had already developed systems to simplify the claims process and make electronic filing available to more providers.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: HCFA has submitted legislative proposals to encourage increased numbers of submissions of electronic claims. HCFA proposed that electronic claims be paid 10 to 14 days faster than paper claims. The FY 1993 appropriations bill was passed with a provision for paying electronic claims 13 days faster.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to assume a leadership role in further automating the claims process and specifically identify the innovations in electronic claims filing systems and electronic communications that Medicare carriers and commercial insurers have instituted.

    Agency Affected: Department of Health and Human Services

  2. Status: Closed - Implemented

    Comments: HCFA requires that carriers send an explanation of Medicare benefits (EOMB) to beneficiaries in all cases except for laboratory charges. Because of funding restraints, HCFA does not require carriers to send EOMB for laboratory charges due to the large volume of claims. If funding becomes available, HCFA would require that EOMB be sent for laboratory charges; however increased funding is unlikely.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to initiate a concerted effort with carriers and beneficiaries to improve the quality of notices and messages. Specifically, HCFA should monitor carriers to ensure that notices are sent to beneficiaries in all required cases so that beneficiaries will have the opportunity to detect potential payment errors or fraudulent claims.

    Agency Affected: Department of Health and Human Services

  3. Status: Closed - Implemented

    Comments: HCFA has initiated a significant effort to redesign the form and content of EOMB. HCFA contracted with a design firm to revise EOMB. The design firm held meetings with focus groups (beneficiaries, AARP, etc.) to solicit their suggestions. A new EOMB was implemented in late 1991.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to initiate a concerted effort with carriers and beneficiaries to improve the quality of notices and messages. Specifically, HCFA should, during annual carrier evaluations, examine the messages used on benefit notices to ensure that information is clear and necessary.

    Agency Affected: Department of Health and Human Services

  4. Status: Closed - Implemented

    Comments: HCFA initiated a significant effort to redesign the form and content of the explanation of Medicare benefits (EOMB). HCFA contracted with a design firm to revise EOMB. The design firm held meetings with focus groups (beneficiaries, AARP, etc.) to solicit their suggestions. A new EOMB was implemented in late 1991.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to initiate a concerted effort with carriers and beneficiaries to improve the quality of notices and messages. Specifically, HCFA should establish a formal mechanism to solicit feedback from carriers and beneficiaries on benefit notice problems and use the feedback to improve notices and messages.

    Agency Affected: Department of Health and Human Services

  5. Status: Closed - Implemented

    Comments: HCFA has revised the 1500 claim form plus instructions. This should help providers to complete claim forms more accurately. The new form and instructions were issued late in 1991. Providers are required to answer questions on the 1500 claim form regarding other insurance, effective October 1, 1991. Claims submitted after April 1, 1992 with this information missing will be denied.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to: (1) identify effective techniques for reducing the number of incomplete claims filed by providers; and (2) encourage carriers to adopt those techniques when appropriate.

    Agency Affected: Department of Health and Human Services

  6. Status: Closed - Implemented

    Comments: HCFA has submitted legislative proposals to encourage increased numbers of submissions of electronic claims. The FY 1993 appropriations bill was passed with such a provision setting a 14-day floor for electronic media claims versus a 27-day floor for paper claims. It is effective for FY 1993 and 1994 so HCFA has included a permanent provision in its FY 1994 appropriations bill.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to assume a leadership role in further automating the claims process and specifically disseminate information on such innovations to carriers to facilitate the implementation of these innovations throughout Medicare.

    Agency Affected: Department of Health and Human Services

 

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