Medicare:

Improper Handling of Beneficiary Complaints of Provider Fraud and Abuse

T-HRD-92-2: Published: Oct 2, 1991. Publicly Released: Oct 2, 1991.

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GAO discussed Medicare's responsiveness to beneficiary complaints of provider fraud and abuse, focusing on: (1) weaknesses in Medicare carriers' fraud and abuse detection efforts; and (2) the Health Care Financing Administration's (HCFA) oversight of those carrier operations. GAO noted that: (1) carriers often told beneficiaries to submit their complaints in writing or to resolve them with providers, even though the beneficiary described the complaint in detail over the telephone; (2) 15 of the 155 cases included substantial indications of potential fraud and abuse in that the provider had 2 or more similar, substantiated complaints within the last 2 years, or the current complaint, on its own, strongly suggested fraudulent or abusive behavior; (3) HCFA has not developed instructions for carrier staff on how to identify and refer complaints for investigation; (4) annual HCFA evaluations of carrier fraud and abuse detection efforts were inadequate for the five carriers reviewed; (5) carrier officials complained that they lacked sufficient resources to thoroughly investigate all complaints of provider fraud and abuse; and (6) budget reductions in the program safeguard area are undermining fraud and abuse detection activities and resulting in large program losses, but HCFA officials believe that funds for carrier personnel who answer complaints will be reallocated within the fiscal year 1992 budget.

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