HCFA Monitoring of the Quality of Part B Claims Processing

T-PEMD-92-14: Published: Sep 23, 1992. Publicly Released: Sep 23, 1992.

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GAO discussed the Health Care Financing Administration's (HCFA) review of Medicare carrier performance, focusing on its methodological quality. GAO noted that: (1) HCFA has two methods to evaluate carriers' contract performance; (2) the quality assurance program assesses the number of processing errors and payment/deductible errors, which quantify the corresponding dollar amount of processing errors, from a random sample of a carrier's claims; (3) the quality assurance program only assesses the evaluation criteria's reliability and not their appropriateness; (4) the quality assurance program does not directly measure the extent of claim underpayments; (5) the contractor performance evaluation program rates the timeliness and accuracy of claims processing, payment safeguards, compliance with applicable laws, administrative management, and program efficiency; (6) the performance evaluation uses the payment/deductible error rate from the quality assurance assessment, but does not use the number of inaccurately processed claims; (7) the performance evaluation does measure the validity of the carriers' medical screens; and (8) HCFA has not developed a systematic analysis of reversed claims appeals.

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