Identifying Third-Party Billing Companies Submitting Claims

HEHS-99-127R: Published: Jun 2, 1999. Publicly Released: Jun 2, 1999.

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William J. Scanlon
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Pursuant to a congressional request, GAO described how the Health Care Financing Administration (HCFA) and its contractors monitor third-party billing companies' involvement in the submission of claims to Medicare.

GAO noted that: (1) providers are ultimately responsible for the claims that they submit or that are submitted on their behalf; (2) despite this, HCFA has an interest in tracking claims submitted by third-party billers as one way of targeting its program safeguard resources and determining the source of inappropriate or fraudulent claims; (3) GAO found that HCFA cannot identify when third-party billers were involved in the more than 700 million electronic claims in fiscal year 1998, because its systems identify only one of the many possible entities involved in preparing a claim; (4) further, paper claims--146 million in 1998--do not have any identifying information that would indicate whether third-party billers submitted them; (5) GAO also found weaknesses in HCFA's efforts to obtain information about third-party billers; (6) HCFA issued a new enrollment form for providers first enrolling in Medicare after May 1996; (7) this form obtains the identity of third-party billers that the enrolling providers use; (8) however, since 96 percent of Medicare's providers enrolled in Medicare before 1996, HCFA has no information on billing arrangements for most providers; (9) HCFA is proceeding with plans to develop a national system to capture this information on the enrollment form, even though the system would initially contain data for only a fraction of all Medicare providers; and (10) although HCFA's plans for implementing this system are not final, HCFA officials told GAO they plan to complete it after addressing computer systems work needed to prepare for year 2000.

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