High-Risk Series: Medicare (Letter Report, 02/01/97, GAO/HR-97-10).

GAO reviewed the challenges the federal government faces in safeguarding
Medicare, the government's second largest social program.

GAO found that: (1) since GAO's last high-risk report in 1995, the
government has made important strides in efforts to protect Medicare
from exploitation; (2) recent legislation, the Health Insurance
Portability and Accountability Act of 1996, increases funding for
program safeguards, although per-claim expenditures will remain below
the level of 1989 after adjusting for inflation; (3) in addition, the
Health Care Financing Administration (HCFA) anticipates that it will
gain enhanced oversight capacity and reduced administrative costs when
the next-generation claims processing system, the Medicare Transaction
System (MTS), is fully implemented, which HCFA expects to occur after
the year 2000; (4) the Health and Human Services Inspector General and
other federal and state agencies have banded together to fight fraud in
five states in an effort called Operation Restore Trust; (5) after the
first year of operation, the effort yielded more than $40 million in
recoveries of payments for claims that were not allowed under Medicare
rules, as well as convictions for fraud, impositions of civil monetary
penalties, and the exclusion of providers from the program; (6) the act
gives HCFA additional flexibility to contract with firms specializing in
utilization reviews and makes more severe the penalties for Medicare
fraud; (7) in addition, HCFA is improving its credentialing process for
Medicare providers and is currently evaluating commercially available
software for its potential to screen out some types of inappropriate
claims; (8) judicious changes in Medicare's day-to-day operations
entailing HCFA's improved oversight and leadership, its appropriate
application of new anti-fraud-and-abuse funds, and the mitigation of MTS
acquisition risks are necessary to reduce substantial future losses; and
(9) as Medicare's managed care enrollment grows, HCFA must ensure that
payments to health maintenance organizations (HMO) better reflect the
cost of beneficiaries' care, that beneficiaries receive information
about HMOs sufficient to make informed choices, and that its expanded
authority to enforce HMO compliance with federal standards is used.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HR-97-10
     TITLE:  High-Risk Series: Medicare
      DATE:  02/01/97
   SUBJECT:  Health care programs
             Health maintenance organizations
             Managed health care
             Program abuses
             Fraud
             Cost control
             Claims processing
             Risk management
             Erroneous payments
             Medical expense claims
IDENTIFIER:  Medicare Health Maintenance Organizations Program
             Medicare Program
             HCFA Medicare Transaction System
             HHS Operation Restore Trust
             High Risk Series 1997
             
******************************************************************
** This file contains an ASCII representation of the text of a  **
** GAO report.  Delineations within the text indicating chapter **
** titles, headings, and bullets are preserved.  Major          **
** divisions and subdivisions of the text, such as Chapters,    **
** Sections, and Appendixes, are identified by double and       **
** single lines.  The numbers on the right end of these lines   **
** indicate the position of each of the subsections in the      **
** document outline.  These numbers do NOT correspond with the  **
** page numbers of the printed product.                         **
**                                                              **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced.  Tables are included, but    **
** may not resemble those in the printed version.               **
**                                                              **
** Please see the PDF (Portable Document Format) file, when     **
** available, for a complete electronic file of the printed     **
** document's contents.                                         **
**                                                              **
** A printed copy of this report may be obtained from the GAO   **
** Document Distribution Center.  For further details, please   **
** send an e-mail message to:                                   **
**                                                              **
**                                            **
**                                                              **
** with the message 'info' in the body.                         **
******************************************************************


Cover
================================================================ COVER


High-Risk Series

February 1997

MEDICARE

GAO/HR-97-10

Medicare


Abbreviations
=============================================================== ABBREV

  HMO - health maintenance organization
  HCFA - Health Care Financing Administration
  HHS - Department of Health and Human Services
  MTS - Medicare Transaction System
  HEDIS 3.0 - Health Plan Employer Data and Information Set

Letter
=============================================================== LETTER



February 1997

The President of the Senate
The Speaker of the House of Representatives

In 1990, the General Accounting Office began a special effort to
review and report on the federal program areas its work identified as
high risk because of vulnerabilities to waste, fraud, abuse, and
mismanagement.  This effort, which was supported by the Senate
Committee on Governmental Affairs and the House Committee on
Government Reform and Oversight, brought a much-needed focus on
problems that were costing the government billions of dollars. 

In December 1992, GAO issued a series of reports on the fundamental
causes of problems in high-risk areas and, in a second series in
February 1995, it reported on the status of efforts to improve those
areas.  This, GAO's third series of reports, provides the current
status of designated high-risk areas. 

This report discusses the challenges that the federal government
faces in safeguarding Medicare, the government's second largest
social program.  Since the issuance of GAO's 1995 high-risk report,
both the Congress and the Health Care Financing Administration, the
agency responsible for running Medicare, have made important
legislative and administrative changes addressing chronic payment
safeguard problems.  However, because of the hundreds of billions of
dollars at stake, GAO believes that the government will need to
exercise constant vigilance and effective management to protect
Medicare from waste, fraud, abuse, and mismanagement. 

Copies of this report series are being sent to the President, the
congressional leadership, all other Members of the Congress, the
Director of the Office of Management and Budget, and the heads of
major departments and agencies. 

James F.  Hinchman
Acting Comptroller General
of the United States


OVERVIEW
=========================================================== Appendix 0

Medicare provides health care insurance for nearly all elderly
Americans (those age 65 and older) and many of the nation's disabled. 
It is one of the largest entitlement programs in the federal budget. 
In fiscal year 1996, federal spending for Medicare was $197 billion. 
Program expenditures have been growing at about 9 percent per year. 
While growth has moderated somewhat during the last 2 years, many
view even the lower growth rates as unsustainable.  Moreover, the
trust fund that pays for hospital and other institutional services is
projected to be depleted within 5 years.  The Congress and the
President have been seeking to introduce changes to Medicare to help
control program costs.  At the same time, they are concerned that
significant amounts of these costs are lost to fraudulent and
wasteful claims. 

Although no one can claim with precision how much Medicare loses each
year, our work suggests that by reducing unnecessary or inappropriate
payments, the federal government would realize large savings and help
dampen the growth in Medicare costs.  The hidden nature of improper
billing and health care crimes precludes a rigorously quantified
estimate of expenditures attributable to fraud and abuse.  Estimates
of the costs of fraud and abuse ranging from 3 to 10 percent have
been cited for health expenditures nationwide, so applying this range
to Medicare suggests that such losses in fiscal year 1996 could have
been from $6 billion to as much as $20 billion. 

Most Medicare services are provided through the fee-for-service
sector, where any qualified provider can bill the program for each
covered service rendered.  In recent years, greater numbers of
Medicare beneficiaries have enrolled in health maintenance
organizations (HMO) to receive covered services.  The most recent
figures show, however, that almost 90 percent of beneficiaries remain
under the fee-for-service program.  Each of these delivery systems
has its unique set of problems. 

In 1992 and again in 1995, GAO reported on Medicare as one of several
government programs highly vulnerable to waste, fraud, abuse, and
mismanagement.\1 Since the first report in the series, the Health
Care Financing Administration (HCFA), the Department of Health and
Human Services' (HHS) agency responsible for running the Medicare
program, has made some regulatory and administrative changes aimed at
curbing fraudulent and unnecessary payments.  However, in recent
years, sizable cuts in the budget for program safeguards, where most
of the funding for the fight against abusive billing is centered,
have diminished efforts to thwart improper billing practices. 

PROBLEMS

Problems in funding program safeguards and HCFA's limited oversight
of contractors continue to contribute to fee-for-service program
losses.  While HCFA expects a major system acquisition project to
reduce certain weaknesses, the project itself has several risks that
may keep HCFA from attaining its goals.  In addition, the managed
care program suffers from excessive payment rates to HMOs and weak
HCFA oversight of the HMOs it contracts with.  These flaws leave
beneficiaries without information essential to guide their HMO
selection and without assurance that HMOs are adequately screened and
disciplined for unacceptable care. 

PROGRESS

Since GAO's last high-risk report in 1995, the government has made
important strides in efforts to protect Medicare from exploitation. 
Recent legislation--the Health Insurance Portability and
Accountability Act of 1996 (P.L.  104-191), popularly known as the
Kassebaum-Kennedy Act--increases funding for program safeguards,
although per-claim expenditures will remain below the level of 1989
after adjusting for inflation.  Nevertheless, we expect that the
increase, if properly applied, can significantly improve
anti-fraud-and-abuse efforts.  In addition, HCFA anticipates that it
will gain enhanced oversight capacity and reduced administrative
costs when the next-generation claims processing system--the Medicare
Transaction System (MTS), now progressing through its design
phase--is fully implemented, which HCFA expects to occur after the
year 2000.  Further, the HHS Inspector General and other federal and
state agencies have banded together to fight fraud in five states in
an effort called Operation Restore Trust.  After the first year of
operation, the effort yielded more than $40 million in recoveries of
payments for claims that were not allowed under Medicare rules, as
well as convictions for fraud, impositions of civil monetary
penalties, and the exclusion of providers from the program. 

Progress is also being made in addressing program management issues. 
For example, the Health Insurance Portability and Accountability Act
gives additional flexibility to HCFA to contract with firms
specializing in utilization reviews and makes more severe the
penalties for Medicare fraud.  In addition, HCFA is improving its
credentialing process for Medicare providers and is currently
evaluating commercially available software for its potential to
screen out some types of inappropriate claims.  Finally, the new
Health Insurance Portability legislation and several planned consumer
information efforts offer the potential for improved HCFA oversight
of HMOs. 

OUTLOOK FOR THE FUTURE

Many of Medicare's vulnerabilities are inherent in its size and
mission, making the government's second largest social program a
perpetually attractive target for exploitation.  That wrongdoers
continue to find ways to dodge safeguards illustrates the dynamic
nature of fraud and abuse and the need for constant vigilance and
increasingly sophisticated ways to protect against gaming the system. 
Judicious changes in Medicare's day-to-day operations entailing
HCFA's improved oversight and leadership, its appropriate application
of new anti-fraud-and-abuse funds, and the mitigation of MTS
acquisition risks--these are necessary ingredients to reduce
substantial future losses.  Moreover, as Medicare's managed care
enrollment grows, HCFA must ensure that payments to HMOs better
reflect the cost of beneficiaries' care, that beneficiaries receive
information about HMOs sufficient to make informed choices, and that
the agency's expanded authority to enforce HMO compliance with
federal standards is used.  To adequately safeguard the Medicare
program, HCFA needs to meet these important challenges promptly. 


--------------------
\1 High-Risk Series:  Medicare Claims (GAO/HR-93-6, Dec.  1992) and
High-Risk Series:  Medicare Claims (GAO/HR-95-8, Feb.  1995). 


BACKGROUND
=========================================================== Appendix 1

Congressional attention has recently been focused on the impending
depletion of Medicare's Federal Hospital Insurance Trust Fund. 
Payroll taxes credited to the hospital trust fund finance the bulk of
Medicare's "hospital insurance," or part A, which covers nursing
facility, hospice, and home health care in addition to inpatient
hospital services.  Current projections by the fund's trustees
indicate that, absent action, it will be insolvent by 2001. 
Beneficiaries' premium contributions and general revenues finance
Medicare's "supplementary medical insurance," or part B, which covers
physician and outpatient hospital services, diagnostic tests, and
ambulance and other medical services and supplies.  Although the part
B trust fund's link to the Treasury shields it from the danger of
bankruptcy, part B expenditures comprise a growing share of the
federal budget. 

HCFA administers Medicare largely through an administrative structure
of claims processing contractors.  In 1965, when the Medicare program
was enacted, the law called for insurance companies--like Blue Cross
and Blue Shield, Travelers, and Aetna--to process and pay claims
because of their expertise in performing these functions.  As
Medicare contractors, these companies use federal funds to pay health
care providers and beneficiaries and are reimbursed for their
administrative expenses incurred in performing the work.  Over the
years, HCFA has consolidated some of Medicare's operations, and the
number of contractors has fallen from about 130 to about 70 in 1996. 
Generally, intermediaries are the contractors that handle part A
claims submitted by "institutional providers" (hospitals, skilled
nursing facilities, hospices, and home health agencies); carriers are
those handling part B claims submitted by physicians, laboratories,
equipment suppliers, and other practitioners. 

HCFA's efforts to guard against inappropriate payments have been
largely contractor-managed operations, permitting the carriers and
fiscal intermediaries broad discretion in acting to protect Medicare
program dollars.  As a result, there are significant variations in
contractors' implementation of Medicare's payment safeguard policies. 
In 1996, the budget for contractors to administer Medicare was
approximately $1.6 billion, with 24 percent devoted to payment
safeguard activities. 

From a management perspective, Medicare consists of two
programs--fee-for-service and managed care.  The fee-for-service
program covers most of the program's beneficiaries--almost 90
percent, or 33 million individuals in 1996.  Physicians, hospitals,
and other providers submit claims to Medicare to receive
reimbursement.  In contrast, Medicare's managed care program covers a
much smaller number of beneficiaries--nearly 5 million in 1996.  It
is funded from the part A and part B trust funds.  The managed care
program consists mostly of risk contract HMOs,\2 which enrolled about
4 million Medicare beneficiaries in 1996.  Physicians, hospitals, and
other providers serving these HMOs' enrollees do not submit a
per-service claim for reimbursement.  Instead, they are paid by the
HMO, which in turn is paid a monthly amount by Medicare for each
beneficiary enrolled.  This amount is fixed in advance.  In this
sense, the HMO has a "risk" contract because regardless of what it
spends for each enrollee's care, the HMO assumes the financial risk
of providing health care within a fixed budget.  HMOs profit if their
cost of providing services is lower than the predetermined payment
but lose if their cost is higher than the payment. 


--------------------
\2 Other Medicare HMOs include cost contracts and health care
prepayment plans.  Cost contract HMOs allow beneficiaries to choose
health services from an HMO network or outside providers.  Health
care prepayment plans may cover only part B services.  Together, they
enroll fewer than 2 percent of the Medicare population. 


FEE-FOR-SERVICE PROGRAM RISKS
=========================================================== Appendix 2

The depletion of Medicare's hospital trust fund and the projected
growth in Medicare's share of the federal budget have focused
congressional attention on making broad program reforms.  Although
the consensus to make changes is clearly building, there is less
agreement about what the changes will be, when they will be
implemented, and whether they will be comprehensive or incremental. 
For the near term, Medicare's current structure is likely to remain
in place; therefore, we have made the existing program's day-to-day
management the focus of this report. 

Certain factors make Medicare's fee-for-service program inherently
high risk.  For one thing, health care consumers are less alert to
provider charges when a third party pays most of their bill.  In
Medicare, even when patients receive a notice of what services their
provider billed, the computer-generated notices can be difficult to
follow. 

In addition, guarding against waste, fraud, and abuse in a program
the size of Medicare would task any payer:  fee-for-service Medicare
serves about 33 million beneficiaries and processes a high volume of
claims--over 800 million in 1996--from hundreds of thousands of
providers.  Individually, the claims tend to be for relatively low
dollar amounts, so balancing the extent of scrutiny given each claim
against the costs and benefits obtained is important. 

Compounding these difficulties has been a pattern since 1989 of
unstable funding for anti-fraud-and-abuse activities.  However,
passage of the Health Insurance Portability and Accountability Act
adds new funds--starting in 1997--to fight fraud and abuse.  By 2003,
funding for anti-fraud-
and-abuse activities will have increased over the 1996 level by about
80 percent.  This increased funding offers the promise of much-needed
improvements. 

DECLINE IN FUNDS FOR SAFEGUARDING
PAYMENTS WEAKENED EFFORTS TO DENY
IMPROPER CLAIMS, DETER ABUSE

Since 1989, the number of Medicare claims has climbed 70 percent to
822 million in 1996.  During that same period, however, resources
committed to claims review, both before and after payment, without
adjusting for inflation, grew less than 11 percent.  Under these
circumstances, the amount contractors could spend for reviewing
claims shrank from 74 cents to 48 cents per claim, at a time when
payments for part A benefits more than doubled.  In 1995, only about
3 percent of Medicare's part A claims on average received more than
superficial screening before being paid.  This scarcity of resources
seriously hampered the Medicare contractors' efforts to (1) conduct
various reviews of claims to verify beneficiaries' needs for the
services billed and (2) audit providers' cost reports to ensure that
reimbursed costs meet standards for reasonableness and
appropriateness. 

The inadequate funding of Medicare's claims scrutiny activities has
hurt contractors' efforts to review the medical necessity of services
billed to the program.  Contractors review some portion of their
total claims volume at both the prepayment stage--while the claims
are being processed--and at postpayment--after the payment checks
have been sent out.  Medicare's review of home health claims
illustrates the effect of reduced review that resulted from
constraints on the contractors' payment safeguard budgets since 1989. 

In 1985, legislation more than doubled the funds available for
reviewing home health and other claims.  Contractors reviewed for
medical necessity 62 percent of home health claims processed in
fiscal years 1986 and 1987.  In contrast, since 1989, contractors'
claims review target was lowered to 3.2 percent (or even lower,
depending on available resources, to a required minimum of 1
percent).  At the same time, the home health claims volume more than
tripled between 1989 and 1994, from 5.5 million to 16.6 million. 

In 1996, we reported that, because of the small number of claims
selected for review, home health agencies billing for noncovered
services were less likely to be caught.  Besides covering so few
claims, prepayment reviews of home health claims done at the
contractor's office are simply paper reviews and, therefore, limited
in their ability to detect noncovered care.  If billing codes appear
valid, forms appear to be filled out correctly, and the services
billed have not been flagged for additional attention based on the
results of other analyses, the claim goes through without further
scrutiny.  In the case of a large home health organization we
investigated, claims passed review scrutiny even for visits never
made, because company staff allegedly falsified the medical records. 
Contractors have also noticed instances where the wrong diagnosis has
been put on the claim form to give the impression that beneficiaries
are sicker and in need of more care than is actually the case. 

The lack of adequate resources also prevented contractors from
conducting effective postpayment reviews of home health claims.  In
Medicare, comprehensive medical reviews are an essential component of
postpayment reviews of home health agencies and entail evaluations of
claims and medical records, such as plans of care and documentation
of visits.  In 1994, fewer than 1 percent of all Medicare-certified
home health agencies received on-site comprehensive reviews.  Because
these reviews are resource intensive and because contractors are
required to do only 10 annually for all provider types combined--
including outpatient, skilled nursing, and rehabilitation
facilities--a contractor may not do any for home health agencies if
they account for a relatively small portion of the contractor's total
claims volume.  In fiscal year 1994, for example, the number of
on-site audits ranged from none to 15 among the nine contractors
responsible for reviewing home health claims.  Declines in funding
also weakened the efforts of contractors to do prepayment reviews of
part B claims.  In 1991, HCFA required contractors to conduct
prepayment reviews of 15 percent of part B claims, whereas by 1995
the required level had sunk to 4.6 percent. 

A successful HCFA demonstration project, which we reported on in
1994, helps explain how adequate funding of part B contractors'
claims review activities can reduce program losses.  In the
demonstration, HCFA gave three part B Medicare carriers a 12-percent
increase in funds to do claims review activities, while two
"comparison" carriers received no additional funding.  Over the life
of the project, each demonstration carrier saved about twice as much
as the two comparison carriers in the project, or $2.84 per claim
compared with $1.34 per claim.  The financial investment in claims
review permitted the demonstration carriers to employ over twice the
number of claims review staff employed by the comparison carriers and
to employ staff technically qualified to do data analyses, use four
times more computerized controls to flag questionable claims for
review, and review before payment nearly four times the volume of
claims. 

Another payment safeguard activity impaired by funding declines
involves cost report audits, which are Medicare's principal weapon to
fight the shifting of inappropriate or unnecessary costs to the
program.  Providers paid under Medicare's cost-based reimbursement
systems--such as hospital outpatient departments, skilled nursing
facilities, and home health agencies--are reimbursed not on the basis
of a fee schedule or the charge for a service but on the basis of the
actual cost to provide the service. 

Reimbursement to institutional providers occurs in several steps. 
First, Medicare contractors make periodic "interim" payments based on
the provider's historical costs and current cost estimates.  These
payments help defray the ongoing costs of providing services to
Medicare beneficiaries.  Second, at the end of each year, the
providers submit reports that detail their operating costs throughout
the preceding year and specify the share related to the provision of
Medicare services.  Using this information, intermediaries make
tentative settlement payments or recover excessive payments based on
the total amount claimed and the amounts already paid in interim
payments.  Third, the intermediary can conduct a more detailed review
of the cost reports to determine the appropriate final settlement
amounts, but in practice, only a fraction of providers is subject to
such reviews and the number has declined in recent years.  Between
1991 and 1996, the chances, on average, that an institutional
provider would be subject to a detailed review fell from about 1 in 6
to about 1 in 13. 

Furthermore, because of the time needed to schedule and conduct
audits, intermediaries can take 2 years or more to make this review
and final settlement.  Tentative settlements that differ
substantially from the amount ultimately determined to be due a
provider cause underpayments or excessive payments that can remain
outstanding for 2 years or more.  When excessive payments occur,
Medicare loses interest income because it has less surplus trust fund
money to invest in government securities. 

SIGNIFICANT MANAGEMENT PROBLEMS
REMAIN, INDEPENDENT OF FUNDING
ADEQUACY ISSUES

As we noted in reports and testimonies in recent years, HCFA has been
less than aggressive in managing the Medicare claims processing
function.  HCFA has not taken a leadership role, for example, in
managing how contractors select the criteria used to identify claims
that may not be eligible for payment or in assisting contractors in
this task.  In addition, HCFA's acquisition of a major new claims
processing system has several flaws that, if not corrected, put the
system at risk of not meeting touted expectations.  Interim
information management activities also pose certain risks. 


      ABSENCE OF COORDINATED
      CLAIMS SCREENING STRATEGY
------------------------------------------------------- Appendix 2:0.1

Generally, when contractors process Medicare claims, the claims are
run through computerized screens, or edits, to detect such problems
as incomplete or inaccurate provider billing numbers and beneficiary
identification numbers, duplicate claims, and beneficiary
ineligibility.  Contractors have additional "medical necessity"
screens that flag claims for not meeting certain diagnosis or
frequency-of-treatment criteria and suspend payment until further
review.  The criteria are established in contractors' medical
policies, which, with some exceptions, are developed locally and vary
greatly among contractors. 

HCFA has not systematically aggregated information on contractors'
medical policies or their related use of prepayment screens.  As a
result, HCFA has not adequately assessed the relative performance of
contractors or helped share with all contractors the experience of
some in using effective claims screening controls.  HCFA's current
approach is to rely on contractors to focus their reviews on
overutilization problems that are local. 

Our 1995 review of 17 contractors' use of medical necessity screens
for Medicare's high-volume medical procedures illustrates HCFA's lack
of a coordinated approach.  For example, 10 of the 17 contractors
reviewed lacked screens for echocardiography, which in fiscal year
1994 was the most costly diagnostic test in terms of total Medicare
payments and which increased in use nationwide by over 50 percent
between 1992 and 1994.  Eleven of the contractors were not screening
colonoscopy claims by the end of 1994, despite the advice of the HHS
Inspector General in 1991 to monitor the use of colonoscopies and
deny claims that were not indicated by medical symptoms or supported
with documentation.  We estimated that Medicare could have denied at
least $10.5 million in echocardiography payments and $5.8 million in
colonoscopy payments made in 1993 if just seven contractors that did
not screen these procedures had applied the medical necessity screens
used by the other contractors.  We also estimated that medical
necessity screens for all six procedures tested--eye exams, chest X
rays, yttrium aluminum garnet (YAG) laser surgery, and duplex scan of
extracranial arteries in addition to echocardiography and
colonoscopy--could have saved Medicare from $29 million to $150
million in payments made by these seven contractors for services that
may have been medically unnecessary.  The range reflects the
variation in contractors' criteria for identifying medically
unnecessary services. 


      IMPLEMENTATION OF MAJOR
      CLAIMS PROCESSING SYSTEM AT
      RISK
------------------------------------------------------- Appendix 2:0.2

We have also reported in recent years on HCFA's acquisition and
development of a claims processing system called the Medicare
Transaction System.  HCFA intends MTS to replace the nine different
claims processing systems it currently uses by the year 2000.  The
goals of MTS are to provide enhanced claims processing capabilities,
increased levels of beneficiary and provider service, and greater
capabilities to provide program safeguards.  Overall, HCFA expects
the system to process over 1 billion claims and pay $288 billion in
benefits in the year 2000. 

In January 1994 and November 1995, we reported on risks associated
with the MTS project.  In response to our work, HCFA revised its
initial MTS approach from developing and installing the system in a
single stage to developing, testing, and implementing MTS through a
number of clearly defined system releases, thereby reducing the
potential for problems stemming from large-scale system failures. 
While this new approach should facilitate managing the MTS project,
we identified critical management and technical risks that could
result in a system that does not meet HCFA's needs.  First,
difficulties in defining requirements have led HCFA to redirect its
approach to this effort twice.  HCFA is now working to completely
define its requirements.  Inadequately defined requirements could
cause technical problems.  Second, HCFA's MTS development schedule
showed significant overlap among the various system-development
phases.  Progressing with succeeding phases before the previous phase
has been completed also increases the risk that technical problems
will occur.  Finally, our previous review of HCFA's cost benefit
analysis of MTS found it flawed and warranting corrections before
HCFA can use it to make effective management decisions. 

HCFA is working on the reported deficiencies.  We plan to evaluate
HCFA's efforts after it completes this work. 


      OTHER POTENTIALLY
      TROUBLESOME INFORMATION
      MANAGEMENT ISSUES
------------------------------------------------------- Appendix 2:0.3

Before MTS is completed, HCFA must oversee several essential
information management transitions in the Medicare claims processing
environment.  One transition involves the shifting of claims
processing workloads, either because a contractor, for business
reasons, has opted to leave the program or because HCFA will have
closed some claims processing sites and moved the work to remaining
sites in an upcoming effort to consolidate claims processing.  In
1992 and 1994, we reported on the consequences of poor planning when
HCFA shifted an outgoing contractor's claims processing workload to
another contractor's automated system.  There were serious
disruptions in getting claims processed and payments made to
physicians, an increase in erroneous payments, and a decrease in
payment safeguards that may have resulted in overpayments.  In a
second transition, to facilitate the implementation of MTS while
reducing system maintenance costs, HCFA is planning to convert the
contractors' claims processing systems--currently three part A and
six part B systems--into a single part A system and a single part B
system.  This will involve several major software conversions.  A
third transition involves the "millennium" problem--revising
computerized systems to accommodate the year-digit change to 2000. 
HCFA does not yet have plans for monitoring contractors' progress in
making their systems "millennium compliant." Each of these
information management transitions will require HCFA's careful
planning and focused attention. 

NEW HEALTH INSURANCE ACT, OTHER
INITIATIVES IMPROVE HCFA'S ARSENAL
FOR FIGHTING FRAUD AND ABUSE

The outlook for Medicare's program safeguards budget appears brighter
largely due to gradual funding increases provided for in the 1996
Health Insurance Portability and Accountability Act.  In addition,
Operation Restore Trust, an HHS antifraud initiative, has been
implemented to identify and recover overpayments from providers who
improperly billed Medicare.  Other changes underway include HCFA's
improved screening of Medicare providers and more focused attention
on both hardware and software aspects of Medicare's claims processing
system.  (See table 1.)



                                     Table 1
                     
                     Summary of Major Government Initiatives
                       to Improve Medicare Fee-for-Service

Problem area        Actions taken
------------------  ------------------------------------------------------------
Budget for anti-    Health Insurance Portability and Accountability Act:
fraud-and-abuse     increases funding to investigate Medicare fraud and abuse
activities          and pursue the recovery of inappropriate payments.

                    Operation Restore Trust: multiagency antifraud effort
                    targeting high-use services provides increased funding for a
                    2-year period.

Prepayment,         HCFA's contract to acquire commercially developed software:
prevention, and     explores whether the Medicare program can apply off-the-
utilization review  shelf software designed to detect unacceptable or
efforts             inappropriately coded claims.

                    Los Alamos interagency agreement: the Department of Energy's
                    Los Alamos, New Mexico, National Laboratory is to provide
                    HCFA with analytical and computer support to develop fraud
                    and abuse detection methods, including enhancements in
                    prepayment claims screening and postpay analyses.

                    National Provider Identifier: HCFA has assigned numbers to
                    every Medicare provider and supplier; effective in 1997,
                    these numbers will be required for Medicare billing
                    purposes.

Contractor          Health Insurance Portability and Accountability Act: makes
management and      HCFA's authority explicit to contract with companies that
oversight           specialize in utilization review, provider audit, and other
                    safeguard activities to perform these functions for
                    Medicare.
--------------------------------------------------------------------------------

      HEALTH INSURANCE PORTABILITY
      AND ACCOUNTABILITY ACT OF
      1996
------------------------------------------------------- Appendix 2:0.4

Most significantly, the Health Insurance Portability and
Accountability Act increases the funding level for pursuing health
care fraud and abuse, including HCFA's audit and related activities. 
For fiscal year 1997, the act boosts the contractors' budget for
program safeguard activities to 10 percent higher than in 1996; by
2003, the level will be 80 percent higher than for 1996, after which
it remains constant.  These additional amounts, however, will leave
per-claim safeguard expenditures at about one-half the level of 1989
after adjusting for inflation (see fig.  1). 

   Figure 1:  HCFA's Actual and
   Projected Per-Claim Program
   Safeguard Spending, FYs
   1989-2003

   (See figure in printed
   edition.)

Source:  Justification of Estimates for Appropriations Committees,
Fiscal Year 1996, HHS, HCFA (Washington, D.C.:  1996), section III,
p.  58 and Economic Report of the President (Washington, D.C.: 
1996), table B-56, p.  343. 

In addition to funding, the act has several other provisions to
improve vigilance over Medicare benefit dollars, including the
following: 

  -- It allows HCFA to use additional contractors to perform
     utilization review, provider audit, and other safeguard
     activities as functions distinct from basic claims processing
     activities.  The act permits HCFA to use separate claims
     processing and utilization review entities to avoid any conflict
     of interest and is intended to increase accountability and
     enhance data analysis capability. 

  -- It establishes a program run jointly by the Department of
     Justice and HHS to coordinate federal, state, and local law
     enforcement efforts against fraud in Medicare and other health
     care payers.  The program is to be funded by a new subaccount in
     the Medicare trust fund and the expenditure offset by having
     fines, forfeitures, and damages received as a result of the
     coordinated anti-fraud-and-abuse efforts transferred into the
     trust fund. 

  -- It calls for greater information-sharing on health care fraud
     and abuse, including the establishment of a national health care
     fraud data collection program. 

  -- It establishes enhanced penalties and specifies health care
     fraud as a separate criminal offense. 


      OPERATION RESTORE TRUST
------------------------------------------------------- Appendix 2:0.5

Operation Restore Trust is a 2-year antifraud initiative involving
three HHS agencies--the Office of the Inspector General, HCFA, and
the Administration on Aging--as well as the Department of Justice and
various state and local agencies.  HHS has designated an
interdisciplinary project team of federal and state government
representatives to target Medicare abuse and misuse in California,
Florida, Illinois, New York, and Texas--
states that together account for over one-third of all Medicare
beneficiaries.  The team has focused on three of the fastest-
growing spending components:  home health, nursing homes, and medical
equipment and supplies. 

In its first year, Operation Restore Trust reported recovering $42.3
million in inappropriate payments:  $38.6 million were returned to
the Medicare trust fund and $3.7 million to the Treasury as a result
of these efforts.  It also resulted in 46 convictions, imposed 42
fines, and excluded 119 fraudulent providers.  Inspector General
officials believe that the major achievement of this initiative will
be continued coordination among the various agencies involved and a
heightened awareness of the effectiveness of constant vigilance.  For
example, as a result of improved coordination between HCFA
contractors and state surveyors in the project's several states, many
of the targeted home health agencies were decertified and substantial
sums in inappropriate payments were recovered.  Operation Restore
Trust is scheduled to be closed out as a demonstration project in May
1997. 


      HCFA'S EFFORTS TO ADOPT
      FRAUD AND ABUSE DETECTION
      SOFTWARE
------------------------------------------------------- Appendix 2:0.6

HCFA has taken several actions to improve Medicare's fraud detection
activities.  In a 1995 study, we found that commercial systems, which
analyze paid claims for patterns that identify potentially fraudulent
providers, could significantly improve HCFA's ability to detect and
prevent potential Medicare fraud.  Our study found that Medicare's
largest part B contractor had acquired this type of commercial
antifraud technology and identified over $6 million in potentially
fraudulent payments.  We also noted that although this technology had
potential benefits, it was not being widely used in the Medicare
program.  Recently, HCFA expanded the use of commercial antifraud
systems by providing about $1 million to fund this technology at
three additional Medicare contractor sites. 

HCFA is aggressively pursuing another effort to strengthen Medicare
fraud detection.  This initiative, intended to reduce Medicare's
vulnerability to fraud, involves an interagency agreement with the
Department of Energy's Los Alamos National Laboratory.  This 2-year
$6-million interagency agreement specifically calls for the
development of prepayment antifraud methods that could be used to
produce software suitable for inclusion in MTS.  Because this effort
is not expected to be completed until September 1997, it is too early
to determine its effect on reducing Medicare fraud. 

Finally, HCFA has also taken the initiative to strengthen Medicare's
payment controls by awarding a $1.6 million contract to test
commercial software that detects billing abuse.  In another 1995
study, we reported that commercially available software could improve
HCFA's ability to prevent losses from inappropriately coded claims
submitted for payment.  In this study, a test using commercial
software programs to detect code manipulation--one form of billing
abuse--estimated that these programs could have reduced Medicare
costs by over $600 million annually for 1993 and 1994.  HCFA's
initial plans for this technology are to assess, customize, and test
a commercial software package at the Iowa Blue Cross and Blue Shield
part B carrier to determine whether the software meets Medicare's
needs and should be considered for inclusion at other sites and in
MTS. 


      NATIONAL PROVIDER IDENTIFIER
------------------------------------------------------- Appendix 2:0.7

HCFA has taken another important step to reduce Medicare's
vulnerability to abusive billing and prevent fraudulent or excluded
providers from continuing to bill the program.  In May 1996, HCFA
extended its existing system of physician identification numbers and
registration procedures to new Medicare providers and suppliers. 
Medicare contractors are now required to verify professional and
business license, certification, and registration information, and
billing agency and subcontractor agreements.  Contractors must also
check each owning and managing employee against the HHS Inspector
General's list of currently sanctioned providers and suppliers.  Our
earlier work identified problems with the completeness of this list,
but, if corrected, this check should preclude fraudulent and
incompetent providers from billing Medicare.  HCFA will assign new
identification numbers--National Provider Identifiers--to every
provider and supplier in the Medicare program and, effective February
1997, will require the use of these numbers for billing purposes. 
The numbers will be unique to each provider or supplier and will stay
with them for the length of their Medicare participation regardless
of relocations or changes in medical specialties. 


MANAGED CARE PROGRAM RISKS
=========================================================== Appendix 3

Most recent legislative proposals to reform Medicare would expand the
program's use of prepaid health plans.  Risk contract HMOs,
Medicare's principal managed care option, are one version of these
plans.  They currently enroll about 10 percent of Medicare's
population and have shown rapid enrollment growth in recent years. 
The Congressional Budget Office projects that, under one Medicare
reform scenario, enrollment in risk HMOs and other prepaid plans
could grow to 25 percent of all Medicare beneficiaries by 2002. 
Because prepayment of health benefits has helped private sector
payers contain health care costs and limit the excess utilization
encouraged by fee-for-service reimbursement, prepaid plans have
cost-control appeal for Medicare, while offering potential advantages
to beneficiaries. 

However, our recent studies reveal shortcomings in Medicare's risk
contract program that affect both taxpayers and beneficiaries. 
First, due to difficulties in establishing capitation rates, Medicare
each year overpays some HMOs, thereby needlessly spending at least
hundreds of millions of dollars annually from the program's trust
funds.  Second, HCFA has not adequately enforced or kept
beneficiaries apprised of HMOs' compliance with federal standards and
other pertinent information about HMOs. 

GROWING ENROLLMENT IN HMOS
COMPOUNDS PROBLEM OF EXCESSIVE
PAYMENTS

The Medicare risk contract program is designed to limit the federal
government's financial liability for covering health care costs.  To
do this, Medicare pays the risk HMOs it contracts with a flat,
per-beneficiary fee, regardless of whether the HMO spends more or
less for each enrollee's care.  This capitated payment method breaks
the linkage between payment and usage.  However, a deficiency in
Medicare's formula for setting HMO payment rates keeps the government
from realizing managed care's potential savings.  As with most
financing problems, the devil is in the details; a simplified view of
the problem follows. 

HMOs tend to attract Medicare beneficiaries whose need for costly
care when joining is low.  In this way, HMOs are said to attract a
"favorable selection" of Medicare beneficiaries.  The formula
includes a crude "risk adjustor" to correct for favorable selection,
but it is not precise enough to account for its full effect.  HCFA
analysts as well as independent researchers acknowledge this problem,
and studies of the favorable selection phenomenon have been conducted
for over a decade.  However, determining exactly how much less costly
new HMO enrollees are compared to fee-
for-service beneficiaries is difficult and complicated, thwarting
efforts to devise a formula that will make adjustments precise enough
to reflect enrollees' better health status. 

When several studies reporting this problem appeared roughly a decade
ago, less than 3 percent of Medicare beneficiaries were enrolled in
risk contract HMOs.  Today, however, such enrollment is much higher
and in some parts of the country, growing rapidly.  In just 2
years--between August 1994 and August 1996--the number of risk HMOs
nationwide rose from 141 to 229 and enrollment in these HMOs grew by
over 80 percent, from about 2.1 million to 3.8 million beneficiaries. 

Research on improved payment methods has failed to develop an
administratively feasible system of adjusting payments to eliminate
the problem of excessive payments.  However, in a forthcoming report
we discuss a method that would at least lower the excess payments
made to some HMOs.  Unlike other formula adjustment methods being
developed today, this method is one that HCFA could implement right
away.  It is not designed to eliminate all the excess paid to each
HMO for their healthier-than-average beneficiaries.  Therefore,
HCFA's implementation of this method would not likely result in
underpaying any one HMO.  Immediate implementation could save
Medicare hundreds of millions of dollars annually. 

HCFA HAS BEEN LAX IN ENFORCING HMO
REQUIREMENTS, WHILE NOT KEEPING
BENEFICIARIES ADEQUATELY INFORMED

In 1995, we reported on the need for HCFA to be a more active agent
for beneficiaries enrolling in Medicare HMOs.  Despite efforts to
improve its HMO monitoring, HCFA conducted only paper reviews of
HMOs' quality assurance plans, examining only the description rather
than the implementation of HMOs' quality assurance processes. 
Moreover, the agency was reluctant to take action against HMOs that
subjected beneficiaries to abusive sales practices, unduly delayed
beneficiaries' appeals of HMOs' decisions to deny coverage, or
exhibited patterns of poor quality care. 

Historically, HCFA has been unwilling to place sanctions against
HMOs, even those it cites repeatedly for violations found during site
monitoring visits.  In 1988, 1991, and 1995, we reported on the
agency's pattern of ineffective oversight of HMOs violating federal
standards.  In the case of one Florida HMO, for example, HCFA
found--in 1991, 1992, 1994, and 1996--some combination of
deficiencies in marketing, enrollment, quality assurance systems,
grievance and appeals procedures, and access to health services. 
Despite the repeated findings of standards violations at this HMO,
HCFA's strongest regulatory action was to require, after each
inspection, a corrective action plan. 

HCFA also misses the opportunity to supplement its regulatory efforts
by not keeping the Medicare beneficiary population well-informed
about competing HMOs.  As we reported in 1996, HCFA has a wealth of
data, collected for program administration and contract oversight
purposes, that it does not package or disseminate for consumer use. 
For example, HCFA does not provide beneficiaries with any of the
comparative consumer guides that the federal government and other
employer-based health insurance programs routinely distribute to
their employees and retirees.  Such guides are typically summary
charts comparing the benefit packages and premium rates of available
area plans.  Instead, HCFA collects information only for its internal
use--records of each HMO's premium requirements and benefit
offerings, disenrollment data (monthly reports specifying for each
HMO the number of beneficiaries that joined and left that month),
records of enrollees' complaints, and results of certification visits
to HMOs. 

Public disclosure of such comparative information as disenrollment
rates could help beneficiaries choose among competing HMOs and
encourage HMOs to do a better job of marketing their plans and
serving enrollees.  Because Medicare beneficiaries enrolled in HMOs
can, each month, switch plans or return to fee-for-service, comparing
plans' disenrollment rates can suggest beneficiaries' relative
satisfaction with competing HMOs.  Our 1996 analysis of HCFA's
disenrollment data showed that Medicare HMOs' ability to retain
beneficiaries varied widely among HMOs in the same market. 

The substantial variation we found in the rate at which beneficiaries
disenrolled from plans within the first 3 months of joining suggested
that some HMOs do a better job than others of representing their
plans to potential enrollees.  Similarly, the HHS Inspector General
found, in a 1991 study of one market's plans, that beneficiaries from
the plan with the highest rate of disenrollment within a year were
much more likely than other plans' enrollees to misunderstand either
that they were in an HMO or that they were restricted in provider
choice. 

NEW HEALTH INSURANCE ACT, OTHER
INITIATIVES INTENDED TO ADDRESS
RISK CONTRACT PROGRAM PROBLEMS

HCFA acknowledges the problems that persist in Medicare's risk
contract program.  To tackle the difficulties in setting capitation
rates, HCFA has been conducting several demonstration projects that
examine ways to modify or replace the current method of determining
HMO payment rates.  In addition, the Health Insurance Portability and
Accountability Act amended HCFA's sanction authority in cases where
HMOs have not complied with federal standards.  Finally, HCFA is
developing several consumer information efforts, including the
dissemination of comparative information on competing HMOs, a
beneficiary satisfaction survey, and a requirement for HMOs to report
on aspects of patient care. 



                                     Table 2
                     
                     Summary of Major Government Initiatives
                         to Improve Medicare Managed Care

Problem area        Actions taken
------------------  ------------------------------------------------------------
HMO payment rates   HCFA demonstrations underway to improve risk adjustment or
                    find alternative HMO payment methods include (1) research on
                    two health status measures to determine their potential to
                    account more precisely for favorable selection and (2)
                    proposed use of competitive bids to establish HMO payment
                    rates; now seeking a test site.

Efforts to          Health Insurance Portability and Accountability Act:
regulate HMOs       clarifies and extends the conditions under which HCFA can
                    impose intermediate sanctions.

Publication of      HCFA plans electronic posting of comparative information.
comparative
information         HCFA is developing standard member satisfaction survey that
on competing HMOs   some HMOs are required to administer as of January 1997.

                    Independent HMO industry organization has developed
                    Medicare-specific clinical effectiveness measures of HMO
                    performance; HCFA requires HMOs, as of January 1997, to
                    report data related to these measures; HCFA intends to
                    publish results.
--------------------------------------------------------------------------------

      HEALTH INSURANCE PORTABILITY
      AND ACCOUNTABILITY ACT
------------------------------------------------------- Appendix 3:0.1

The Health Insurance Portability and Accountability Act gives HCFA
more flexible sanction authority while providing HMOs the statutory
right to greater procedural safeguards.  In addition to existing
authority to terminate an HMO's contract if the HMO did not meet
requirements, HCFA now has the option of imposing lesser sanctions,
such as suspending the HMO's right to enroll Medicare beneficiaries
until the deficiencies are corrected.  Before imposing a sanction,
however, HCFA is required to provide the HMO with a reasonable
opportunity to develop and implement a corrective action plan. 
Before the act made this a requirement, HCFA routinely requested
corrective action plans of HMOs that violated federal standards. 


      ELECTRONIC POSTING OF
      COMPARATIVE INFORMATION
------------------------------------------------------- Appendix 3:0.2

HCFA has plans to produce HMO comparison charts that will initially
specify HMO costs and benefits covered and later may also include
other plan-specific information--
such as the results of HMOs' satisfaction surveys.  HCFA expects
advocates and insurance counselors, not beneficiaries, to be the
primary users of this information.  HCFA plans to make the charts
"available to any individual or organization with electronic access,"
because "the materials will primarily reside in an electronic format,
which is easily updatable and economical." Providing the information
in an electronic format, however, rather than in print, may make it
less accessible to the very individuals who would find it useful. 
The information, according to HCFA, will have to be "downloaded and
customized for local consumption."


      BENEFICIARY SATISFACTION
      SURVEY
------------------------------------------------------- Appendix 3:0.3

HCFA is developing a standard survey, through HHS' Agency for Health
Care Policy and Research, to obtain beneficiaries' perceptions of
their managed care plans.  This effort aims to standardize surveys
and report formats to yield comparative information about, for
example, enrollees' experiences with access to services, interactions
with providers, continuity of care, and perceived quality of care. 
HCFA does not expect preliminary results before the end of 1997. 


      OTHER CONSUMER-ORIENTED
      INFORMATION INITIATIVES
------------------------------------------------------- Appendix 3:0.4

HCFA is working with the managed care industry, other purchasers,
providers, public health officials, and consumer advocates to develop
a new version of the Health Plan Employer Data and Information Set
(HEDIS 3.0) that will incorporate measures relevant to the elderly
population.  The measures will enable comparisons to be made among
plans of the enrollees' use of such prevention and screening services
as flu shots, mammography, and eye exams for diabetics.  As of
January 1997, Medicare HMOs are required, from the time they renew
their contract, to report on HEDIS 3.0 clinical effectiveness
measures.  HCFA intends to summarize the results and include them in
comparability charts being developed.  HCFA is also working with the
Foundation for Accountability, an independent organization composed
of consumers and public and private health care payers, to develop
more patient-oriented measures of health care quality.  This may
require new data collection efforts by plans, and its implementation
may therefore be years away. 


WHAT NEEDS TO BE DONE
=========================================================== Appendix 4

Adequate funding of anti-fraud-and-abuse activities coupled with
strong HCFA oversight of its fee-for-service and managed care
contracts constitute the foundation for managing a program that is
permanently vulnerable to exploitation.  The Health Insurance
Portability and Accountability Act puts the cornerstone of this
foundation in place by providing HCFA an opportunity both to
stabilize its scrutiny of Medicare claims and more effectively
regulate risk contract HMOs.  In addition, the successful
implementation of MTS is expected to help address various Medicare
problems, including better controls over fraud and abuse.  However,
HCFA needs to mitigate the risks associated with the acquisition of
this system.  As HCFA faces this challenge as well as those presented
by the growing and complex Medicare program, it needs to apply
continued vigilance over day-to-day operations, make additional
technological improvements, and exhibit strong leadership to
effectively manage the program, thereby controlling the risks to both
the taxpayers and beneficiaries. 


RELATED GAO PRODUCTS
=========================================================== Appendix 5

MEDICARE FEE-FOR-SERVICE

Fraud and Abuse:  Providers Excluded From Medicaid Continue to
Participate in Federal Health Programs (GAO/HEHS-96-205, Sept.  5,
1996). 

Medicare:  Private Payer Strategies Suggest Options to Reduce Rapid
Spending Growth (GAO/T-HEHS-96-138, Apr.  30, 1996). 

Medicare:  Home Health Utilization Expands While Program Controls
Deteriorate (GAO/HEHS-96-16, Mar.  27, 1996). 

Medicare:  Millions Can Be Saved by Screening Claims for Overused
Services (GAO/HEHS-96-49, Jan.  30, 1996). 

Fraud and Abuse:  Providers Target Medicare Patients in Nursing
Facilities (GAO/HEHS-96-18, Jan.  24, 1996). 

Medicare Transaction System:  Strengthened Management and Sound
Development Approach Critical to Success (GAO/T-AIMD-96-12, Nov.  16,
1995). 

Fraud and Abuse:  Medicare Continues to Be Vulnerable to Exploitation
by Unscrupulous Providers (GAO/T-HEHS-96-7, Nov.  2, 1995). 

Medicare Spending:  Modern Management Strategies Needed to Curb
Billions in Unnecessary Payments (GAO/HEHS-95-210,
Sept.  19, 1995). 

Medicare:  Antifraud Technology Offers Significant Opportunity to
Reduce Health Care Fraud (GAO/AIMD-95-77, Aug.  11, 1995). 

Medicare:  Excessive Payments for Medical Supplies Continue Despite
Improvements (GAO/HEHS-95-171, Aug.  8, 1995). 

Medicare:  Allegations Against ABC Home Health Care (GAO/OSI-95-17,
July 19, 1995). 

Medicare:  Commercial Technology Could Save Billions Lost to Billing
Abuse (GAO/AIMD-95-135, May 5, 1995). 

Medicare and Medicaid:  Opportunities to Save Program Dollars by
Reducing Fraud and Abuse (GAO/T-HEHS-95-110, Mar.  22, 1995). 

Medicare:  High Spending Growth Calls for Aggressive Action
(GAO/T-HEHS-95-75, Feb.  6, 1995). 

Medicare:  Inadequate Review of Claims Payments Limits Ability to
Control Spending (GAO/HEHS-94-42, Apr.  28, 1994). 

Medicare:  Greater Investment in Claims Review Would Save Millions
(GAO/HEHS-94-35, Mar.  2, 1994). 

Medicare:  New Claims Processing System Benefits and Acquisition
Risks (GAO/HEHS/AIMD-94-79, Jan.  25, 1994). 

MEDICARE MANAGED CARE

Medicare:  HCFA Should Release Data to Aid Consumers, Prompt Better
HMO Performance (GAO/HEHS-97-23, Oct.  22, 1996). 

Medicare Managed Care:  Growing Enrollment Adds Urgency to Fixing HMO
Payment Problem (GAO/HEHS-96-21, Nov.  8, 1995). 

Medicare:  Increased HMO Oversight Could Improve Quality and Access
to Care (GAO/HEHS-95-155, Aug.  3, 1995). 

Medicare:  Changes to HMO Rate Setting Method Are Needed to Reduce
Program Costs (GAO/HEHS-94-119, Sept.  2, 1994). 


1997 HIGH-RISK SERIES
=========================================================== Appendix 6

An Overview (GAO/HR-97-1)

Quick Reference Guide (GAO/HR-97-2)

Defense Financial Management (GAO/HR-97-3)

Defense Contract Management (GAO/HR-97-4)

Defense Inventory Management (GAO/HR-97-5)

Defense Weapon Systems Acquisition (GAO/HR-97-6)

Defense Infrastructure (GAO/HR-97-7)

IRS Management (GAO/HR-97-8)

Information Management and Technology (GAO/HR-97-9)

Medicare (GAO/HR-97-10)

Student Financial Aid (GAO/HR-97-11)

Department of Housing and Urban Development (GAO/HR-97-12)

Department of Energy Contract Management (GAO/HR-97-13)

Superfund Program Management (GAO/HR-97-14)

























The entire series of 14 high-risk reports can be ordered by using the
order number GAO/HR-97-20SET. 


*** End of document. ***