District Needs To Improve the Process for Identifying Misuse of Its Medicaid Program

GGD-81-78: Published: Jul 13, 1981. Publicly Released: Jul 13, 1981.

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GAO reviewed the effectiveness of the District of Columbia's Department of Human Services (DHS) surveillance and utilization review procedures in identifying and controlling misuse and abuse of medical services.

The DHS Surveillance and Utilization Review (SUR) program, which was designed to identify and safeguard against Medicaid fraud, misuse, and abuse, could be improved. DHS has not established and implemented effective methods and procedures to identify and safeguard against recipient misuse and abuse of medical services. As a result, the Department could not determine the extent of recipient misuse or abuse. Since audits are not made of all providers' records, some overpayments could exist that are not identified. The GAO review showed that there was a need for: (1) a better system to identify potential misuse/abuse cases for review; (2) more effective procedures for counseling, monitoring, and controlling persons misusing or abusing medical services; (3) more effective controls for processing cases and an improved reporting system to facilitate management reviews; and (4) improved procedures for recovering improperly billed Medicaid payments. A new Medicaid Management Information System, expected to be operational in mid-1981, will correct some of the deficiencies noted in the review. However, to realize the full benefits of the system, other operational improvements should be made.

Recommendation for Executive Action

  1. Status: Closed - Implemented

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: The Director of the Department of Human Services should establish and implement effective procedures to require that (1) all recipients referred to the Health Education Section are counseled and (2) where appropriate, their future medical service use is monitored. Additionally, the Director should: (1) take action to implement a policy to restrict identified misusers/abusers of medical services; (2) prescribe reasonable standards and controls to assure timely processing of cases; (3) establish a system for effective reporting on the Surveillance and Utilization Review (SUR) operations; and (4) require that complete and accurate records be maintained on all cases reviewed and processed by SUR.

    Agency Affected: District of Columbia: Department of Human Services


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