Medicare: Need To Strengthen Home Health Care Payment Controls and Address Unmet Needs
HRD-87-9
Published: Dec 02, 1986. Publicly Released: Jan 02, 1987.
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Highlights
Pursuant to a congressional request, GAO provided information on the Medicare home health program, specifically: (1) the status of efforts to strengthen internal controls to prevent payment for services Medicare does not cover; and (2) how many chronically ill elderly persons have home care needs that Medicare and other providers do not meet.
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, Health Care Financing Administration (HCFA), to implement the recommendations in the 1981 GAO report to develop national prepayment utilization review screens for home health and clarify coverage criteria. |
Closed – Implemented
HHS has developed utilization review screens for home health and is currently using them at several intermediaries. In addition, it has held meetings with regional intermediaries to clarify coverage criteria. A followup report on the home health program is currently being prepared.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to revise the home health postpayment utilization review program guidance to require intermediaries to use statistically valid sampling techniques for identifying and projecting the amount of noncovered care to the universe of claims paid. |
Closed – Not Implemented
HHS stated that the waiver of liability makes it inappropriate to project overpayments for home health agencies. GAO continues to believe that it is imperative that statistically valid techniques be used to project the amount of noncovered care. Continuing problems in calculating denial rates were addressed in a recent report.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to expand the assessment of intermediary performance under the contractor performance evaluation program to include an assessment of the accuracy of intermediary home health coverage determinations. |
Closed – Implemented
HHS has revised the contractor performance evaluation program to more closely assess performance of home health coverage determinations.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should do further studies to evaluate factors contributing to unmet needs for home care assistance and options for meeting the future home care needs of the elderly. |
Closed – Implemented
HHS cited a number of actions taken, or underway, which address unmet needs. Further analysis will be contained in a forthcoming report on home health.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should include the internal control weaknesses in the Medicare home health program in the next annual report under the Federal Managers' Financial Integrity Act (FMFIA) and set a timetable for completing actions to correct the deficiencies. |
Closed – Not Implemented
HHS did not agree that reporting under FMFIA was appropriate given the actions taken and planned.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should identify the limited assessment of the appropriateness of intermediaries' home health payment decisions as a material internal control weakness in the annual report under FMFIA and establish a timetable for prompt corrective action. |
Closed – Not Implemented
HHS did not believe that an internal control weakness exists inlight of planned actions.
|
Full Report
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Topics
Aid for the elderlyElder careElderly personsMedicareFunds managementHealth care cost controlHome health care servicesInternal controlsMedicaidProgram managementPublic assistance programs