Medicare:

Internal Controls Over Electronic Claims for Anesthesia Services Are Inadequate

HRD-90-49: Published: Dec 18, 1989. Publicly Released: Dec 18, 1989.

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Pursuant to a legislative requirement, GAO reviewed Medicare payments to anesthesiologists and verified the anesthesia times claimed.

GAO found that: (1) all eight Medicare carriers GAO reviewed required anesthesia times on all paper claims for anesthesia services and did not process paper claims until providers submitted such times, but seven of the eight carriers paid electronic claims for services that did not show anesthesia times; (2) carriers lacked adequate assurance that providers billing electronically had correctly computed their anesthesia time units, and did not reconcile time units claimed with anesthesia times reported on the claims, sometimes resulting in overpayments; (3) the Health Care Financing Administration (HCFA) did not ensure that organizations adopted internal controls over the use of federal funds; and (4) HCFA annual contractor evaluations did not determine whether carriers subjected electronic claims to the same prepayment reviews as paper claims.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: HCFA issued instructions to intermediaries and carriers on proper processing procedures for electronic claims in its 1992 update of electronic media claims manual instructions.

    Recommendation: The Acting Administrator, HCFA, should reemphasize to carriers that electronic media claims for anesthesia services must show anesthesia times and receive the same prepayment reviews as paper claims.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

  2. Status: Closed - Not Implemented

    Comments: The Omnibus Budget Reconciliation Act (OBRA) 1989 required that anesthesia providers be paid based on actual time. HCFA implementation of this requires anethesia providers to submit times and carriers to calculate the time units. (Fed. Reg., August 7, 1990, p. 32083).

    Recommendation: The Acting Administrator, HCFA, should require that carriers systematically reconcile time units claimed with anesthesia times reported on the claims.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

  3. Status: Closed - Implemented

    Comments: HCFA initiated reviews of contractor compliance with electronic media processing requirements.

    Recommendation: The Acting Administrator, HCFA, should include periodic assessment of compliance with electronic media processing requirements in HCFA contractor evaluations.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

 

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