Medicare Home Health Benefit: Congressional and HCFA Actions Begin to
Address Chronic Oversight Weaknesses (Testimony, 03/19/98,
GAO/T-HEHS-98-117).

Home health care is an important Medicare benefit, allowing
beneficiaries with acute-care needs, such as recovery from hip
replacement, and chronic conditions, such as congestive heart failure,
to receive care in their homes rather than in more costly settings, such
as nursing homes and hospitals. Drawing on past and ongoing GAO work on
the home health care industry, this testimony summarizes (1) the general
nature of beneficiary eligibility criteria, which opportunists exploit
to provide excessive services; (2) diminished Medicare contractor review
and audit effort, which makes it less likely that abusers will be
caught; (3) weaknesses in Medicare's home health provider certification
process; and (4) new tools that Congress has provided to strengthen
oversight of the home health benefit, including provisions of the Health
Insurance Portability and Accountability Act of 1996 and the Balanced
Budget Act of 1997.

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

 REPORTNUM:  T-HEHS-98-117
     TITLE:  Medicare Home Health Benefit: Congressional and HCFA 
             Actions Begin to Address Chronic Oversight Weaknesses
      DATE:  03/19/98
   SUBJECT:  Fraud
             Health care programs
             Program abuses
             Home health care services
             Medical expense claims
             Eligibility criteria
             Claims processing
             Erroneous payments
IDENTIFIER:  Medicare Program
             HHS Operation Restore Trust
             
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Cover
================================================================ COVER


Before the Subcommittee on Oversight and Investigations, Committee on
Commerce, House of Representatives

For Release on Delivery
Expected at 10:00 a.m.
Thursday, March 19, 1998

MEDICARE HOME HEALTH BENEFIT -
CONGRESSIONAL AND HCFA ACTIONS
BEGIN TO ADDRESS CHRONIC OVERSIGHT
WEAKNESSES

Statement of Laura A.  Dummit, Associate Director
Health Financing and Systems Issues
Health, Education, and Human Services Division

GAO/T-HEHS-98-117

GAO/HEHS-98-117T


(101731)


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

  BBA - ABC
  HCFA - ABC
  HHS - ABC
  HIPAA - ABC
  RHHI - ABC

MEDICARE HOME HEALTH BENEFIT: 
CONGRESSIONAL AND HCFA ACTIONS
BEGIN TO ADDRESS CHRONIC OVERSIGHT
WEAKNESSES
============================================================ Chapter 0

Mr.  Chairman and Members of the Subcommittee: 

Thank you for inviting us today as you discuss fraud and abuse in the
home health industry.  As you know, home health care is an important
Medicare benefit enabling beneficiaries with acute-care needs, such
as recovery from hip replacement, and chronic-care conditions, such
as congestive heart failure, to receive care in their homes rather
than in more costly settings, such as nursing homes and hospitals. 
However, home health care has attracted much attention because of the
publicized abuses of certain providers. 

Periodically, we have reported on Medicare's vulnerabilities with
regard to oversight of the home health benefit.  Today, I would like
to provide a synopsis of this work as a prelude to the specific
problems identified by the case that my colleague in our Office of
Special Investigations is about to discuss.\1 In doing so, I will
focus on (1) the general nature of beneficiary eligibility criteria,
which opportunists exploit to provide excessive services; (2)
diminished Medicare contractor review and audit effort, which makes
it less likely that abusers will be caught; (3) weaknesses in
Medicare's home health provider certification process; and (4) new
tools the Congress provided to strengthen oversight of the home
health benefit.  My remarks are based on our issued and ongoing work
on Medicare's home health services.  (See Related GAO Products list
at the end of this statement.)

In brief, several historical factors have produced an environment
that, until recently, has enabled improper billing and cost-reporting
practices to grow unchecked.  First, legislation and coverage policy
changes in response to court decisions in the 1980s made it easier
for beneficiaries to obtain home health coverage and harder for
Medicare claims reviewers to deny questionable claims.  Second, from
1989 until recently, the volume of claims reviews and cost-report
audits plummeted, reducing the likelihood that improprieties would be
detected.  Third, because of the laxity of Medicare's survey and
certification process, agencies with no experience or proof of
capability were certified as providers.  Moreover, home health
agencies were unlikely to be terminated or penalized even when they
were cited repeatedly for providing substandard care or otherwise
failed to comply with conditions of participation. 

Recent legislation has enhanced the Health Care Financing
Administration's (HCFA) ability to improve its oversight of the home
health benefit.  In 1995, a multiagency government effort known as
Operation Restore Trust launched a new anti-fraud-and-abuse campaign,
targeting home health services, among others, for investigation.  The
following year, the Health Insurance Portability and Accountability
Act of 1996 (HIPAA), P.L.  104-191, provided dedicated funding to
finance, in part, the investigative efforts of the Department of
Health and Human Services' (HHS) Office of the Inspector General and
other federal agencies.  A year later, the Balanced Budget Act of
1997 (BBA) mandated reforming Medicare's method of paying for home
health services and contained additional provisions designed to
tighten the use and oversight of the home health benefit. 


--------------------
\1 Medicare:  Improper Activities by Mid-Delta Home Health
(GAO/T-OSI-98-6, Mar.  19, 1998; GAO/OSI-98-5, Mar.  12, 1998). 


   BACKGROUND
---------------------------------------------------------- Chapter 0:1

The Medicare statute divides benefits into two parts:  (1) "hospital
insurance," or part A, which covers inpatient hospital, skilled
nursing facility, hospice, and certain home health care services, and
(2) "supplementary medical insurance," or part B, which covers
physician and outpatient hospital services, diagnostic tests, and
ambulance and other medical services and supplies.  Part B can also
cover home health services under certain conditions. 

In 1996, Medicare paid approximately $18 billion for both part A and
part B home health services.  By fiscal year 1998, Medicare's home
health spending is estimated to total nearly $22 billion,
representing a 700-percent increase from 1989 when spending was $2.7
billion.  During this period, coverage requirements changed so that
more beneficiaries qualified for home health services.  In addition,
advances in medical technologies and changes in practice patterns
resulted in more beneficiaries needing these services.  The number of
home health agencies certified to care for Medicare beneficiaries has
also grown rapidly since 1989--from 5,700 to more than 10,000 in
September 1997. 


      MEDICARE'S COVERAGE OF THE
      HOME HEALTH BENEFIT
-------------------------------------------------------- Chapter 0:1.1

To qualify for home health care, individuals must be homebound, that
is, confined to their residences; be under a physician's care; and
need intermittent skilled nursing care or physical or speech therapy. 
Once qualified, beneficiaries may receive those services and visits
by home health aides, medical social workers, and occupational
therapists on a part-time or intermittent basis.  Required medical
supplies are also covered.\2

Services must be furnished under a plan of care prescribed and
periodically reviewed by a physician.  As long as the care is
reasonable and necessary, there are no limits on the number of visits
or length of coverage.  Medicare does not require copayments or
deductibles for home health care except for durable medical
equipment. 


--------------------
\2 For purposes of qualifying for intermittent skilled care,
"intermittent" is defined as skilled nursing care that is either
provided or needed on fewer than 7 days each week or less than 8
hours of each day for periods of 21 days or less (with extensions in
exceptional circumstances).  For purposes of receiving home health
services, "part-time or intermittent" is defined as skilled nursing
and home health aide services furnished any number of days per week
as long as they were furnished (combined) less than 8 hours each day
and 28 or fewer hours each week (with extensions in exceptional
circumstances). 


      OVERSIGHT OF THE HOME HEALTH
      BENEFIT
-------------------------------------------------------- Chapter 0:1.2

HCFA, the agency within HHS responsible for administering Medicare,
uses six regional claims processing contractors (which are insurance
companies) to process and pay home health claims.  These
contractors--called regional home health intermediaries
(RHHI)--process the claims submitted by the 10,000-strong home health
agencies, which are paid on the basis of the costs they incur up to
predetermined cost limits. 

RHHIs are responsible for ensuring that Medicare does not pay home
health claims when beneficiaries do not meet the Medicare home health
criteria, when services claimed are not reasonable or necessary, or
when the volume of services exceeds the level called for in an
approved plan of treatment.  They carry out these responsibilities
through medical reviews of claims.  HHS' Office of the Inspector
General has emphasized the importance of medical reviews.  In the
Office's sampling of claims--which included not just home health but
all Medicare services--it found that 99 percent of the improper
payments the Office identified appeared to be correct on the surface
and were detected only through medical record reviews.\3

Medical reviews can be performed either before or after a claim is
approved for payment.  Occasionally, RHHIs conduct site visits--a
postpayment review at the home health agency where reviewers can
examine plans of care and other medical documentation; RHHIs may also
visit beneficiaries under the care of the agency.  In principle,
RHHIs target their reviews on providers that have unexplained
utilization patterns.  A similar kind of analysis led our Office of
Special Investigations to identify the case being discussed today. 


--------------------
\3 Medicare Fraud and Abuse, testimony of John E.  Hartwig, Deputy
Inspector General for Investigations, HHS, before the Senate
Committee on Governmental Affairs, Permanent Subcommittee on
Investigations (Washington, D.C.:  HHS, Office of the Inspector
General, Jan.  29, 1998). 


   ELIGIBILITY CRITERIA PERMIT
   EASY ACCESS TO THE HOME HEALTH
   BENEFIT
---------------------------------------------------------- Chapter 0:2

Since Medicare's inception, the home health benefit has undergone
several changes in which coverage criteria and their enforcement have
alternately tightened and relaxed.  The net effect of the changes was
that home health care became available to more beneficiaries, for
less acute conditions, and for longer periods of time. 

The benefit was legislatively liberalized in 1980 when limits on the
number of services and cost-sharing requirements were eliminated. 
When prospective payment for hospital services was initiated in 1983,
the use of home health services was expected to increase
significantly because of incentives for hospitals to discharge
patients more quickly.  However, HCFA's relatively stringent
interpretation of coverage criteria and emphasis on medical record
review kept home health growth in check. 

Then in 1989, coverage rules relaxed following a court case brought
in 1988 that challenged HCFA's interpretation that individuals had to
satisfy both the part-time and intermittent criteria to qualify for
the home health benefit (Duggan v.  Bowen).\4

HCFA was obliged to revise its coverage guidelines to allow
individuals to qualify by satisfying either criterion, which, as we
reported in 1996,\5 enabled home health agencies to increase the
frequency of home visits.  The requirements were also changed so that
patients qualified for skilled observation by a nurse or therapist if
a reasonable potential for complications or possible need to change
treatment existed.  The skilled observation, in turn, qualified the
beneficiary for home health aide visits.  The benefit also allowed
maintenance therapy when therapy services were required to simply
maintain function; previously, patients had to show improvement from
such services to be covered. 

In that same report, we also noted problems interpreting the
definition of "homebound." HCFA's Medicare Home Health Agency Manual
qualifies the concept of "confined to the home" as follows: 

     An individual does not have to be bedridden.  .  .  .[But] the
     condition of these patients should be such that there exists a
     normal inability to leave home, and, consequently, leaving their
     homes would require a considerable and taxing effort.  If the
     patient does in fact leave the home, the patient may
     nevertheless be considered homebound if the absences from the
     home are infrequent or for periods of relatively short duration
     or are attributable to the need to receive medical treatment. 

In our interviews for the 1996 study, HCFA and intermediary officials
said that few denials were made on the basis that the beneficiary was
not homebound.  In particular, the "infrequent" and "short duration"
language qualifying permissible absences from the home would likely
result in the reversal of homebound-criterion-based denials at the
reconsideration or appeals level.\6 My colleague's statement on
improper activities by Mid-Delta Home Health describes patients whose
eligibility on the basis of being homebound was highly questionable. 


--------------------
\4 Duggan v.  Bowen, 691 F.  Supp.  1487 (D.D.C.  1988). 

\5 See Medicare:  Home Health Utilization Expands While Program
Controls Deteriorate (GAO/HEHS-96-16, Mar.  27, 1996). 

\6 As we noted in the 1996 report, HCFA in 1991 attempted to develop
numerical parameters to better define the terms "infrequent," "short
duration," and "confined to the home." However, HCFA's proposal
received so many negative responses during the comment period--from
intermediaries as well as home health agencies--that this proposal
was never implemented.  Many home health agencies expressed concerns
that such absolute limits would rob them of flexibility in
interpreting the benefit. 


   DIMINISHED OVERSIGHT RIPENED
   OPPORTUNITY FOR EXPLOITATION
---------------------------------------------------------- Chapter 0:3

The relationship between the funding levels for payment safeguard
activities and the proportion of claims reviewed helps explain the
weak oversight of Medicare's home health benefit in the 1990s.  In
1985, legislation more than doubled funding for contractors to
conduct claims reviews, enabling intermediaries to review over 60
percent of the home health claims processed in 1986 and 1987.  By
1995, however, when payment safeguard funding for medical review of
all Medicare-covered part A services had substantially declined (from
$61 million in 1989 to $33 million in 1995), RHHIs reviewed about 1
percent of home health claims.  As a result of decreased review,
agencies were less likely to be caught if they abused the home health
benefit.  During this period, however, the number of home health
agencies participating in Medicare increased by more than a third,
and the volume of home health claims processed more than tripled.  In
January 1998, HCFA announced an increase in the number of claims
reviews to about 1.3 percent--still far short of the peak levels of
the mid-1980s. 


      LITTLE SCRUTINY OF CLAIMS ON
      A PREPAYMENT BASIS
-------------------------------------------------------- Chapter 0:3.1

For years, we have reported on the need for HCFA to improve the
strategies and methods contractors use to review claims prior to
payment.  Contractors are largely autonomous in their prepayment
claims screening efforts, and HCFA has not routinely given guidance
on best practices.  For example, HCFA has not issued any guidance
suggesting that claims for unusually high dollar amounts per
beneficiary trigger prepayment reviews.  In a recent study of home
health claims reviews,\7 we conducted a test of 80 high-dollar claims
at one RHHI.  The RHHI had initially processed and approved the
claims without review but denied them subsequent to our test.  The
following examples illustrate the importance of careful prepayment
review: 

  -- Of $18,132 in charges for the care of a beneficiary's decubitus
     ulcer (open wound) for 30 days, more than a third
     ($6,483)--including the charges for almost half of the skilled
     nursing visits (four per day)--were for services not considered
     medically necessary. 

  -- Of $4,100 in charges for supplies related to care provided over
     4 weeks, 31 percent were denied because they were not adequately
     documented in the medical records or should have been included
     as part of the nurse's visit and not billed separately.  About
     half the amount denied was for supplies never received by the
     beneficiary. 

  -- Of $17,953 in charges for medical supplies related to the
     treatment of a beneficiary's salivary gland disease, the
     intermediary denied the entire amount because the medical
     documentation was not consistent with the itemized list of
     supplies provided, thus failing to support the claims for
     supplies the agency billed for. 

Nine of the 80 claims tested--representing nearly half ($61,250) of
the total dollars disapproved--were denied because the home health
agency did not submit any of the medical records the intermediary had
requested for the review. 


--------------------
\7 Medicare:  Need to Hold Home Health Agencies More Accountable for
Inappropriate Billings (GAO/HEHS-97-108, June 13, 1997). 


      POSTPAYMENT REVIEWS
      INADEQUATE RELATIVE TO
      VOLUME OF IMPROPER PAYMENTS
-------------------------------------------------------- Chapter 0:3.2

Postpayment oversight activity also waned in the 1990s--including
on-site medical record reviews of home health agencies and audits of
cost reports.  Medical reviews are used to identify noncovered
services paid by Medicare.  Reviews conducted at the site of the home
health agency give contractor staff ready access to such records as
providers' plans of care and documentation of visits.  In fiscal year
1994, fewer than 1 percent of all Medicare-certified home health
agencies had received on-site medical record reviews, and although
more recent data on on-site agency reviews are not readily available,
there is no evidence to suggest that this level would have increased
before the recent infusion of new payment safeguard funds through
HIPAA. 

Cost-report audits help identify providers' attempts to shift
inappropriate or unnecessary costs to the program.  Providers paid
under Medicare's cost-based reimbursement systems--including 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, subject to certain limits. 

RHHIs reimburse cost providers in several steps, including making
periodic interim payments based on the provider's historical costs
and current cost estimates, determining an end of the year tentative
settlement based on a report the provider submits that details
operating costs and the share related to the provision of Medicare
services, and--in relatively few cases--conducting a detailed review
(audit) of the cost report to determine the appropriate final
settlement amounts. 

Between 1991 and 1996, the chances, on average, that a provider's
cost report would be subject to an audit fell from about 1 in 6 to
about 1 in 13.  Much of our statement on Mid-Delta Home Health
centers on improperly claimed and reimbursed costs included in cost
reports that had not received an in-depth audit until our
investigation prompted a closer look.  In January 1998, HCFA
announced its plans to double the number of comprehensive home health
agency audits it performs each year--from about 900 to 1,800. 


      LITTLE MONITORING OF CARE
      PROVIDED
-------------------------------------------------------- Chapter 0:3.3

HCFA conducts almost no oversight of the actual care provided.  Such
oversight is particularly difficult because these services are not
provided in a traditional health care setting.  The sheer volume of
Medicare's home health claims and scarce funds for monitoring have
resulted in an approach that relies substantially on the home health
agencies themselves.  In 1996, more than 10 percent of Medicare
beneficiaries--roughly 4 million people--received home health
services.  To cope with this caseload, HCFA relies on the home health
agencies and attending physicians to monitor patient progress, the
proper development and periodic review of plans of care, and the
medical necessity of services delivered.  Although the physician's
signature on a plan of care is intended to serve as a quality
control, in practice, the certifying physician may not have ever seen
the patient for whom the care plan is designed.  Moreover, updated
plans of care--required at least every 62 days--are not routinely
reviewed by an independent party, such as Medicare's RHHIs. 


   CERTIFICATION PROCESS
   INEFFECTIVE IN EXCLUDING
   PROBLEM PROVIDERS
---------------------------------------------------------- Chapter 0:4

In our December 1997 report on the home health survey and
certification process,\8 we noted that becoming a Medicare-certified
home health agency has been too easy, particularly in light of the
number of problem agencies identified in various studies in recent
years.  Until recently, there was little screening of those seeking
Medicare certification.  We found that the initial survey of an
applicant occurred too soon after the agency began operating,
offering little assurance that the agency was providing or capable of
providing quality care.  For example, Medicare certified an agency
owned by an individual with no home health experience who turned out
to be a convicted drug felon and who later pled guilty with an
associate to having defrauded Medicare of over $2.5 million. 

Rarely were new home health agencies found to fail Medicare's
certification requirements, which call for agencies to (1) be
financially solvent, (2) comply with antidiscrimination provisions in
title VI of the Civil Rights Act of 1964, and (3) meet Medicare's
conditions of participation.  Home health agencies self-certify their
solvency, agree to comply with the act, and undergo a very limited
survey that few fail.  Until less than a year ago, HCFA had been
certifying about 100 new home health agencies each month.  Once
certified, it was unlikely that home health agencies would be
terminated from the program or otherwise penalized, even when they
had been repeatedly cited for not meeting Medicare's conditions of
participation or for providing substandard care. 

From September 15, 1997, until January 13, 1998, the Administration
placed a moratorium on admitting new agencies into the Medicare
program.  The moratorium was intended to stop the admission of
untrustworthy providers while HCFA strengthened its requirements for
entering the program.  HCFA used this period of time to develop new
surety bond regulations (as mandated by BBA), capital requirements to
ensure adequate operating funds, and procedures to better scrutinize
the integrity of home health agency applicants.  HCFA plans to issue
additional provider certification and renewal regulations in the
coming months. 


--------------------
\8 Medicare Home Health Agencies:  Certification Process Ineffective
in Excluding Problem Agencies (GAO/HEHS-98-29, Dec.  16, 1997). 


   RECENT LEGISLATION FOSTERS
   GREATER OVERSIGHT, INTRODUCES
   PAYMENT REFORMS
---------------------------------------------------------- Chapter 0:5

With the passage of HIPAA and BBA, the Congress recently provided
important new resources and tools to fight fraud and abuse in general
and home health care offenses in particular.  In addition to
earmarking funds for anti-fraud-and-abuse activities, the legislation
offers specific civil and criminal penalties against health care
fraud as well as opportunities to improve detection capabilities. 
For example, HIPAA makes health care fraud a separate criminal
offense and establishes fines and other penalties for federal health
care offenses.  BBA stiffens the exclusion penalties for individuals
convicted of health care fraud.  It also establishes civil monetary
penalties for such offenses as contracting with an excluded provider,
failing to report adverse actions under the new health care data
collection program, and violating the antikickback statute. 

With respect to the home health benefit in particular, BBA targets
historical abuses.  For example, in an egregious case of home health
fraud that our Office of Special Investigations reported on in 1995,
the HHS Inspector General charged ABC Home Health Care with billing
Medicare for items that were solely for the owner's or his family's
personal use, including condominium utility expenses, maid services,
and automobile lease payments.\9 BBA mandates the elimination of
cost-based reimbursement and its replacement by a prospective payment
method.  Under this method, home health providers will be expected to
deliver care for a fixed payment, thus breaking the link in the
future between the home health agency's costs and Medicare's
payments. 

While closing off some opportunities for exploitation, however,
prospective payment creates others.  As we stated before this
Subcommittee last October,\10 several design issues have implications
for beneficiary and taxpayer protection, as follows: 

  -- Unit of service:  If an episode of care rather than a visit is
     used when paying for home health prospectively, the system's
     design will need to guard against the incentive to lower the
     number of visits per episode and the incentive to pad patient
     volume with individuals who need relatively few services, some
     of whom may not even qualify for benefits. 

  -- Case-mix adjuster:  The system design will need to incorporate a
     method for adjusting payments to account for the differences in
     the kinds of patients treated by home health agencies; an
     effective case-mix adjuster is needed to protect against the
     incentive to shun patients needing a high level of care in favor
     of those who would be less expensive to treat.  The adjuster
     would not only protect access to care but would also help ensure
     that Medicare was paying agencies more appropriately. 

  -- Base-rate development:  Because HCFA intends to use historical
     data on cost of services to calculate a base rate of an episode
     of care, it must take care to avoid incorporating the inflated
     costs identified in the cost reports of problem home health
     agencies.  For example, in 1995 we reported on a number of
     problems with payments by intermediaries for surgical dressing
     supplies, indicating that excessive costs are being included and
     not removed from home health agency cost reports.\11 We have
     suggested at several hearings that HCFA audit thoroughly a
     projectable sample of home health agency cost reports so that
     the results could be used to adjust HCFA's cost database to help
     ensure that unallowable costs are not included in the base for
     setting prospective rates. 

Until October 1999, when the law requires prospective payment for
home health services to be implemented, Medicare will continue to
reimburse for home health services on a cost basis.  Addressing this
situation, BBA prohibits Medicare payments for items that have
historically been associated with inflated cost reports, such as
entertainment, gifts, donations, educational expenses, and the
personal use of automobiles.  It also tightens per-visit limits and
imposes new ones based on historical per-beneficiary costs. 

Other BBA provisions designed to improve home health oversight
include clarifying the terms "part-time" and "intermittent" nursing
care; requiring the HHS Secretary to recommend by October 1, 1998,
criteria to clarify the term "homebound"; and requiring a
$50,000-minimum surety bond from home health agencies. 


--------------------
\9 Medicare:  Allegations Against ABC Home Health Care
(GAO/OSI-95-17, July 19, 1995). 

\10 Medicare Home Health:  Success of Balanced Budget Act Cost
Controls Depends on Effective and Timely Implementation
(GAO/T-HEHS-98-41, Oct.  29, 1997). 

\11 Medicare:  Excessive Payments for Medical Supplies Continue
Despite Improvements (GAO/HEHS-95-171, Aug.  8, 1995). 


   CONCLUSIONS
---------------------------------------------------------- Chapter 0:6

The very nature of the home health benefit makes judgments on
eligibility difficult and overseeing services provided in the home
problematic.  Our Office of Special Investigation's inquiry into the
operations of a home health agency in Mississippi graphically
illustrates how agencies find creative ways to add patients of
questionable eligibility to their rolls and include questionable
items in their cost reports.  This is consistent with our findings. 
Scant medical reviews of claims and lack of cost-report auditing have
allowed opportunists to receive improper payments with little chance
of their being caught.  Untrustworthy providers have been admitted to
Medicare because of little scrutiny during the certification process. 
While HIPAA and BBA have given HCFA greater resources and tools to
fight fraud and abuse, the home health benefit will continue to
require concerted oversight. 


-------------------------------------------------------- Chapter 0:6.1

Mr.  Chairman, this concludes my prepared statement.  I would be
pleased to answer any questions you or the Subcommittee Members may
have. 

RELATED GAO PRODUCTS

Medicare:  Improper Activities by Mid-Delta Home Health
(GAO/T-OSI-98-6, Mar.  19, 1998; GAO/OSI-98-5, Mar.  12, 1998). 

Long-Term Care:  Baby Boom Generation Presents Financing Challenges
(GAO/T-HEHS-98-107, Mar.  9, 1998). 

Medicare Home Health Agencies:  Certification Process Ineffective in
Excluding Problem Agencies (GAO/HEHS-98-29, Dec.  16, 1997). 

Medicare Home Health:  Success of Balanced Budget Act Cost Controls
Depends on Effective and Timely Implementation (GAO/T-HEHS-98-41,
Oct.  29, 1997). 

Medicare Fraud and Abuse:  Summary and Analysis of Reforms in the
Health Insurance Portability and Accountability Act of 1996 and the
Balanced Budget Act of 1997 (GAO/HEHS-98-18R, Oct.  9, 1997). 

Medicare:  Need to Hold Home Health Agencies More Accountable for
Inappropriate Billings (GAO/HEHS-97-108, Jun.  13, 1997). 

Medicare:  Home Health Cost Growth and Administration's Proposal for
Prospective Payment (GAO/T-HEHS-97-92, Mar.  5, 1997). 

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

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). 


*** End of document. ***