Medicare: HCFA Needs to Take Stronger Actions Against HMOs Violating Federal Standards
HRD-92-11
Published: Nov 12, 1991. Publicly Released: Nov 12, 1991.
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Highlights
Pursuant to a congressional request, GAO examined media allegations regarding widespread compliance problems with Medicare's largest health maintenance organization (HMO) contractor, focusing on: (1) federal oversight of the contractor; (2) whether the Department of Health and Human Services (HHS) had identified the alleged problems; and (3) whether the Health Care Financing Administration (HCFA) took prompt and effective actions to resolve the alleged problems.
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 establish policies that specify the circumstances and timing regarding when it will impose sanctions on HMO with Medicare risk contracts that are violating Medicare requirements. |
Closed – Implemented
The HCFA Office of Prepaid Health Care Operations and Oversight has issued policies setting forth the process for initiating sanctions. But, these policies do not clearly specify the circumstances under which the sanctions will be imposed. HCFA has no plans to further clarify its process for initiating sanctions.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to develop and publish standards that will enable HCFA to require contracting HMO to pay accurately as well as in a timely manner. |
Closed – Implemented
HCFA has issued standards which require contracting HMO to meet standards of accuracy as well as timeliness of payment.
|
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Topics
Claims settlementHealth care cost controlHealth maintenance organizationsHealth services administrationMarketingMedicareMonitoringNoncomplianceRisk managementSanctionsQuality of care