Certifying health conditions: The National Institute for Occupational Safety and Health (NIOSH)--an agency within the Department of Health and Human Services that administers the World Trade Center (WTC) Health Program--has developed policies, procedures, and guidance necessary for Health Program clinics and NIOSH to certify enrollees' WTC-related health conditions as being eligible for treatment

The Department of Veterans Affairs (VA) completed processing about 11,400 Gulf War Illness (GWI) claims in fiscal year 2015, which was more than double the 4,800 claims processed in fiscal year 2010. GWI is a collective term for certain medical conditions among veterans who have served in Southwest Asia since 1990. Symptoms of GWI can include joint pain, gastrointestinal problems, fatigue, and ne

The appeals process for Medicare fee-for-service (FFS) claims consists of four administrative levels of review within the Department of Health and Human Services (HHS), and a fifth level in which appeals are reviewed by federal courts. Appeals are generally reviewed by each level sequentially, as appellants may appeal a decision to the next level depending on the prior outcome. Under the administ

The Centers for Medicare & Medicaid Services (CMS) uses different types of contractors to conduct prepayment and postpayment reviews of Medicare fee-for-service claims at high risk for improper payments. Medicare Administrative Contractors (MAC) conduct prepayment and postpayment reviews; Recovery Auditors (RA) generally conduct postpayment reviews; and the Supplemental Medical Review Contractor

GAO's recent work has found significant weaknesses in the Department of Veterans Affairs' (VA) monitoring and oversight of its Non-VA Medical Care Program. Through this program, care is provided to veterans by non-VA providers in non-VA facilities. As GAO reported in May 2013, VA did not collect data on wait times veterans face in obtaining care from non-VA providers. Having data on wait times fo

The Centers for Medicare & Medicaid Services (CMS)--the agency within the Department of Health and Human Services (HHS) that oversees Medicare--has made progress in implementing several key strategies GAO identified or recommended in prior work as helpful in protecting Medicare from fraud; however, implementing other important actions that GAO recommended could help CMS and its program integrity

The Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) provides information and updates on covered health care services to beneficiaries enrolled in its spina bifida program, but has conducted limited outreach with key stakeholder organizations. VHA provides information on health care benefits to enrolled beneficiaries through the program website, for example. However, VHA

The Office of Personnel Management (OPM) Healthcare & Insurance--Federal Employee Insurance Operations office, which we refer to as OPM's contracting office, monitors Federal Employees Health Benefits Program (FEHBP) carriers' compliance with requirements and other guidance for preventing, detecting, and eliminating fraud and abuse. These requirements include establishing a program to assess vuln

The Medicaid Integrity Group's (MIG) hiring of separate review and audit contractors for its National Medicaid Audit Program (NMAP) was inefficient and led to duplication because key functions were performed by both entities. Review contractors analyze state claims data to identify aberrant claims or billing anomalies while audit contractors conduct postpayment audits to determine if payments to