Medicare Claims Billing Abuse: Commercial Software Could Save Hundreds of
Millions Annually (Testimony, 05/05/95, GAO/T-AIMD-95-133).

With an investment of only $20 million in off-the-shelf commercial
software, Medicare could save nearly $4 billion over five years by
detecting fraudulent claims by physicians--primarily manipulation of
billing codes.  On the basis of a test in which four commercial firms
reprocessed samples of more than 20,000 paid Medicare claims, GAO
estimates that the software could have saved $603 million in 1993 and
$640 million in 1994.  In addition, GAO estimates that because
beneficiaries are responsible for about 22 percent of the payment
amounts--mainly in the form of deductibles and copayments--Medicare
could have saved an additional $134 million in 1993 and $142 million in
1994.  The test results indicate that only a small proportion of
providers are responsible for most of the abuses: less than 10 percent
of providers in the sample had miscoded claims.

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

 REPORTNUM:  T-AIMD-95-133
     TITLE:  Medicare Claims Billing Abuse: Commercial Software Could 
             Save Hundreds of Millions Annually
      DATE:  05/05/95
   SUBJECT:  Medicare programs
             Program abuses
             Billing procedures
             Overpayments
             Medical expense claims
             Health care cost control
             Claims processing
             Medical information systems
             Cost effectiveness analysis
             Application software
IDENTIFIER:  Physicians Current Procedural Terminology System
             CHAMPUS
             Civilian Health and Medical Program of the Uniformed 
             Services
             
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