Medicare: Improper Handling of Beneficiary Complaints of Provider Fraud and Abuse
HRD-92-1
Published: Oct 02, 1991. Publicly Released: Oct 02, 1991.
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Highlights
Pursuant to a congressional request, GAO provided information on Medicare's responsiveness to beneficiary complaints that carriers were not acting on complaints of provider fraud and abuse, focusing on the: (1) extent to which Medicare carrier personnel identify and refer beneficiary complaints to carrier investigative units; (2) thoroughness of carriers' investigations of complaints; and (3) impact of proposed budget cutbacks on those activities.
Recommendations
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 implement draft instructions to carriers for identifying and referring beneficiary complaints of provider fraud and abuse to carrier investigative units. |
Closed – Implemented
Instructions were implemented as recommended in February 1992.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to establish clear guidance to carriers for thoroughly investigating beneficiary complaints. |
Closed – Implemented
HCFA issued recommended guidance to carriers in February 1992.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to require that annual HCFA carrier evaluations be used to monitor a sample of beneficiary telephone calls to ensure that complaints of fraud and abuse are: (1) properly identified by carrier staff who initially receive them; and (2) referred to carrier investigative units. |
Closed – Not Implemented
HCFA does not believe that it is feasible to implement this recommendation. However, HCFA actions to implement other GAO recommendations will likely minimize the need to monitor beneficiary telephone calls.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to examine the adequacy of carrier funding for fraud and abuse detection efforts and, if necessary, seek additional funding. |
Closed – Implemented
In its fiscal year 1993 budget submission, HCFA proposed that fraud and abuse be designated as a specific line item in the budget under payment safeguards. HCFA also requested a substantial increase in its budget for fraud and abuse activities from $10 million in fiscal year 1992 and $24 million in fiscal year 1993.
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Topics
BeneficiariesBudget cutsErroneous paymentsFraudHealth insurance cost controlInvestigations by federal agenciesMedical expense claimsMedicareOverpaymentsRisk management