Guidance and Information Needed on the Use of Machine Readable Claims Under Medicare and Medicaid
HRD-82-30
Published: Dec 16, 1981. Publicly Released: Dec 16, 1981.
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Highlights
GAO surveyed the: (1) extent that Medicare and Medicaid providers use machine readable claims and billing service companies; and (2) implications of their use on claims processing agent operations such as administrative costs, utilization and quality control reviews, and reimbursement determinations. GAO was also interested in whether there were any potential conflicts of interest between claims processing agents and billing service companies.
Recommendations
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Health Care Financing Administration | The Administrator, HCFA, should gather and analyze sufficient data on the different types of machine readable claims systems used by Medicare and Medicaid claims processing agents to determine their relative costs and benefits so that policies encouraging the most effective and efficient systems for Medicare and Medicaid can be developed. |
Closed – Implemented
HCFA contracted for a study of the various systems used by claims processing agents. Because of tight budgets, HCFA does not plan to encourage those agents to buy new systems.
|
| Health Care Financing Administration | The Administrator, HCFA, should establish an acceptable error rate for machine readable claims and revise current policy on onsite verification audits to allow less frequent audits of providers demonstrating compliance rates that meet the established requirements. Medicaid requirements should be made compatible with Medicare requirements so that a single audit for both programs would be possible. |
Closed – Implemented
HCFA established an acceptable error rate for Medicare part A claims, but does not intend to do so for Medicare part B nor for Medicaid.
|
| Health Care Financing Administration | The Administrator, HCFA, should issue guidance similar to that under Medicare which will assist state Medicaid agencies in implementing machine readable claim systems and in establishing controls for their use. |
Closed – Not Implemented
HCFA does not plan any action; however, GAO believes the recommendation is valid and implementation of it would provide more assurance that only valid Medicaid claims are paid.
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Topics
Billing proceduresMedicareClaims settlementConflict of interestsCost controlstate relationsHealth care servicesInformation systemsMedicaidElectronic data processing