Medicare Part B: Regional Variation in Denial Rates for Medical Necessity
PEMD-95-10
Published: Dec 19, 1994. Publicly Released: Dec 19, 1994.
Skip to Highlights
Highlights
Pursuant to a congressional request, GAO reviewed Medicare Part B claims processing, focusing on the: (1) differences in carriers' denial rates for lack of medical necessity; and (2) factors that contribute to intercarrier variations in denial rates.
Recommendations
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Health Care Financing Administration | To improve its oversight of the Medicare Part B program, HCFA should issue instructions to carriers on how to classify the reason for denial when reporting this information. |
No action has been taken.
|
| Health Care Financing Administration | To improve its oversight of the Medicare Part B program, HCFA should analyze intercarrier screen usage (including the stringency of screen criteria), identify effective screens, and disseminate this information to all carriers. |
No action has been taken.
|
| Health Care Financing Administration | To improve its oversight of the Medicare Part B program, HCFA should direct carriers to profile the subpopulation of providers responsible for a disproportionate share of medical necessity denials in order to devise a strategy for addressing this problem. |
No action has been taken.
|
Full Report
Public Inquiries
Topics
BeneficiariesClaims processingClaims settlementHealth care cost controlHealth care servicesInsurance companiesMechanizationMedical expense claimsMedical information systemsMedicare