Medicare: Modern Management Strategies Could Curb Fraud, Waste, and Abuse
(Testimony, 07/31/95, GAO/T-HEHS-95-227).

Medicare's vulnerability to waste, fraud, and abuse stems from several
factors:  (1) higher-than-market rates for some services, (2) inadequate
checks for detecting fraud and abuse, (3) superficial criteria for
confirming the authenticity of providers billing the program, and (4)
weak enforcement efforts.  Various health care management techniques
help private payers overcome these programs, but Medicare generally does
not use these methods. The program;s pricing methods and controls over
utilization have not kept pace with financing and delivery changes
during the past 30 years.  To some extent, the predicament inherent in
public programs--the uncertain line between adequate managerial control
and excessive government intervention--helps explain the dissimilarity
in the ways that Medicare and private health insurers run their
respective "plans." GAO believes that a viable strategy for remedying
the program;s weaknesses involved adapting the health care management
approach of private payers to Medicare's public payer role.

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

 REPORTNUM:  T-HEHS-95-227
     TITLE:  Medicare: Modern Management Strategies Could Curb Fraud, 
             Waste, and Abuse
      DATE:  07/31/95
   SUBJECT:  Medicare programs
             Fraud
             Program abuses
             Health maintenance organizations
             Medical expense claims
             Medical services rates
             Claims processing
             Internal controls
             Billing procedures
             Overpayments
IDENTIFIER:  Medicaid Program
             
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