Improved Efforts Needed To Relieve Medicaid From Paying for Services Covered by Private Insurers
HRD-85-10
Published: Feb 12, 1985. Publicly Released: Feb 12, 1985.
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Highlights
GAO reviewed six states' administration of Medicaid programs to assess the extent and effectiveness of their efforts to reduce Medicaid program costs by using other available health care resources. In addition, GAO described how state Medicaid practices for identifying and collecting private health insurance could be improved through more oversight by the Health Care Financing Administration (HCFA).
Recommendations
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to implement one of two options. One alternative is to use the HCFA quality control program to influence states to improve their practices for identifying and applying health and liability insurance by: (1) developing quality control program sampling procedures that would determine the amount of erroneous payments due to unrecovered health and liability insurance; and (2) determining an acceptable level of performance, after a base error rate is established, and requiring that states not meeting these performance standards lose the federal share of erroneous payments exceeding the target error rates. |
Closed – Implemented
The Consolidated Omnibus Budget Reconciliation Act of 1985 included a provision requiring the Secretary, HHS, to issue regulations for financially penalizing states for not collecting required insurance information or not following through with the agreed collection plan.
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| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to implement one of two options. One alternative is to strengthen the HCFA oversight of state practices for using available health and liability insurance resources by issuing regulations that require specific practices that include: (1) using interview forms that ask the Medicaid applicants a series of questions designed to detect available insurance resources; (2) establishing procedures for obtaining needed information about the Medicaid applicants' insurance coverage; (3) requiring states to use their available state automated databases to identify sources of insurance available to Medicaid recipients; (4) using effective follow-up procedures to recover from insurers responsible for paying claims covering accident-related injuries; and (5) using a cost avoidance system that avoids paying claims where states have indications that health insurance resources are available to pay the claims. |
Closed – Implemented
The Consolidated Omnibus Budget Reconciliation Act of 1985 included provisions requiring HHS to publish regulations establishing the GAO recommended action. HHS also published regulations in November 1985 requiring states to use cost avoidance systems when the probable existance of third-party liability is established at the time a claim is made.
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Topics
Collection proceduresstate relationsHealth care cost controlHealth insuranceInteragency relationsMedicaidMonitoringProgram managementSupplemental security incomeQuality control