Medicare Part A Reimbursements:

Processing of Appeals Is Slow

HRD-90-23BR: Published: Feb 9, 1990. Publicly Released: Mar 15, 1990.

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Pursuant to a legislative requirement, GAO assessed the adequacy of the Provider Reimbursement Review Board's (PRRB) staffing levels, focusing on: (1) whether the Health Care Financing Administration's (HCFA) limited staff allocations impaired PRRB ability to process health care agencies' appeals of denied Medicare reimbursement claims by limiting staff allocations; and (2) PRRB timeliness in processing those cases.

GAO found that: (1) PRRB and HCFA functioned in a manner consistent with their legislatively prescribed roles for administering Medicare hospital insurance; (2) while HCFA allocation of limited resources impaired PRRB ability to process appeals, there was no evidence that HCFA deliberately set staffing levels, or denied PRRB requests for additional staff, to impair PRRB effectiveness; (3) HCFA provided PRRB with contract funds for data processing support; (4) the number of cases PRRB resolved steadily increased between fiscal years (FY) 1975 and 1987, and decreased between FY 1987 and 1988; (5) most PRRB cases were concentrated in the early prehearing steps of the appellate process, and many cases remained in those steps for time periods that exceeded PRRB-established criteria; (6) the PRRB-reported inventory of about 4,000 cases was inaccurate; (7) PRRB did not assess the number of staff it needed, and may not have set realistic time frames for each step in the appellate process; and (8) the Department of Health and Human Services' (HHS) annual appropriations request did not identify PRRB monetary needs separately from those of HCFA.

Matter for Congressional Consideration

  1. Status: Closed - Not Implemented

    Comments: Congress has not yet responded to this matter for consideration, but has mandated that a related board be established in HHS which may accomplish the intent of the recommendation. No further action on this matter is expected.

    Matter: If the Senate Committee on Appropriations wishes to directly monitor the level of resources requested for PRRB operations, it may wish to consider directing that PRRB be identified separately in the HHS appropriation request.

Recommendation for Executive Action

  1. Status: Closed - Implemented

    Comments: The agency has taken the position that it has responded to the recommendation and that no further actions are needed. While GAO does not believe it has been fully reponsive. No further agency action should be anticipated.

    Recommendation: The Secretary of Health and Human Services should direct that HCFA and PRRB work together to establish an accurate case inventory, determine the number of staff needed to process cases, and reevaluate time frames for each step in the process.

    Agency Affected: Department of Health and Human Services


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