Medicare Provider Enrollment:
Opportunities to Enhance Program Integrity Efforts
GAO-03-185: Published: Mar 17, 2003. Publicly Released: Mar 17, 2003.
Additional Materials:
- Highlights Page:
- Full Report:
- Accessible Text:
Contact:
(312) 220-7767
contact@gao.gov
Office of Public Affairs
(202) 512-4800
youngc1@gao.gov
Staffing companies that contract with physicians to staff hospital departments--including emergency departments--are not permitted to bill Medicare. In the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, Congress directed GAO to assess the program integrity implications of enrolling these companies and allowing them to bill Medicare. GAO reviewed about 2.8 million emergency department claims for 2000 from five states and assessed whether contractor physicians retained by staffing companies billed Medicare comparably to other emergency department physicians. GAO also evaluated how the lack of information on staffing companies affects efforts to assure Medicare program integrity.
Contractor physicians associated with staffing companies billed Medicare for complex and costly, higher-level emergency department services at rates similar to emergency department physicians with other affiliations, such as those practicing in partnerships, medical groups, or employee-based staffing companies. In addition, the patients treated by contractor physicians received diagnostic tests, were admitted to the hospital, and used ambulance transport at rates similar to patients treated by other emergency department physicians. Staffing companies that retain contractor physicians remain largely invisible to the oversight efforts of the Centers for Medicare & Medicaid Services (CMS) because these companies are not enrolled in Medicare. Although CMS has information on the individual physicians, it has no information on the companies themselves. This may hinder oversight because contractor physicians provided a significant share of emergency care to Medicare beneficiaries. For example, in four of the five states studied, 27 to 58 percent of the physicians with substantial emergency department practices were contractor physicians retained by staffing companies. CMS does not permit the enrollment of staffing companies that retain contractor physicians because, under current law, these companies may not be reassigned Medicare benefits. This limits CMS's ability to monitor claims. CMS cannot identify claims submitted by these companies on behalf of their contractor physicians nor can it subject the claims to the same systematic scrutiny given to enrolled groups. Consequently, it cannot evaluate the billing patterns of specific companies nor assess the aggregate impact of these companies on Medicare program integrity.
Matters for Congressional Consideration
Status: Closed - Implemented
Comments: The recently enacted Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (P.L. 108-173), included a provision permitting the reassignment of benefits to staffing companies that retain contractor physicians.
Matter: In order to enhance Medicare's program integrity, Congress may wish to amend the Social Security Act to permit the reassignment of benefits to staffing companies that retain contractor physicians to treat Medicare beneficiaries so that CMS may enroll these companies if they meet appropriate criteria.
Status: Closed - Not Implemented
Comments: The recently enacted Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (P.L. 108-173), included a provision permitting, but not requiring, the reassignment of benefits to staffing companies that retain contractor physicians.
Matter: In order to enhance Medicare's program integrity, Congress may wish to amend the Social Security Act to require these staffing companies to seek enrollment in Medicare.
Recommendation for Executive Action
Status: Closed - Not Implemented
Comments: The recently enacted Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (P.L. 108-173), contained a provision permitting the reassignment of benefits to staffing companies that retain contractor physicians. As a result, there is no need for the CMS Administrator to propose legislation.
Recommendation: To facilitate improvements in program integrity, the CMS Administrator should propose legislation permitting the reassignment of benefits to staffing companies that retain contractor physicians to treat Medicare beneficiaries and requiring that these companies seek enrollment in Medicare.
Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services
Explore the full database of GAO's Open Recommendations
»
Jan 14, 2021
-
Medicaid:
Data Completeness and Accuracy Have Improved, Though Not All Standards Have Been MetGAO-21-196: Published: Jan 14, 2021. Publicly Released: Jan 14, 2021.
Jan 4, 2021
-
Medicare Severe Wound Care:
Spending Declines May Reflect Site of Care Changes; Limited Information Is Available on QualityGAO-21-92: Published: Jan 4, 2021. Publicly Released: Jan 4, 2021.
Dec 22, 2020
-
Defense Health Care:
Efforts to Ensure Beneficiaries Access Specialty Care and Receive Timely and Effective CareGAO-21-143: Published: Dec 22, 2020. Publicly Released: Dec 22, 2020.
Dec 16, 2020
-
Medicaid Long-Term Services and Supports:
Access and Quality Problems in Managed Care Demand Improved OversightGAO-21-49: Published: Nov 16, 2020. Publicly Released: Dec 16, 2020.
Dec 14, 2020
-
Drug Pricing Program:
HHS Uses Multiple Mechanisms to Help Ensure Compliance with 340B RequirementsGAO-21-107: Published: Dec 14, 2020. Publicly Released: Dec 14, 2020. -
Substance Use Disorder:
Reliable Data Needed for Substance Abuse Prevention and Treatment Block Grant ProgramGAO-21-58: Published: Dec 14, 2020. Publicly Released: Dec 14, 2020.
Dec 10, 2020
-
Indian Health Service:
Actions Needed to Improve Oversight of Provider Misconduct and Substandard PerformanceGAO-21-97: Published: Dec 10, 2020. Publicly Released: Dec 10, 2020. -
Clinical Labs:
Studies Suggest Biopsy Specimen Misidentification and Contamination Errors Are InfrequentGAO-21-59: Published: Nov 10, 2020. Publicly Released: Dec 10, 2020.
Dec 7, 2020
-
Medicaid:
CMS Needs More Information on States' Financing and Payment Arrangements to Improve OversightGAO-21-98: Published: Dec 7, 2020. Publicly Released: Dec 7, 2020.
Dec 1, 2020
-
Military Health Care:
Defense Health Agency Processes for Responding to Provider Quality and Safety ConcernsGAO-21-160R: Published: Dec 1, 2020. Publicly Released: Dec 1, 2020.
Looking for more? Browse all our products here