Medicare: Recent Legislation to Minimize Fraud and Abuse Requires
Effective Implementation (Testimony, 10/09/97, GAO/T-HEHS-98-9).

Pursuant to a congressional request, GAO discussed recent legislative
efforts to address fraud and abuse in the Medicare program.

GAO noted that: (1) both the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) and the Balanced Budget Act of 1997
(BBA) directly address Medicare fraud and abuse and provide
opportunities to improve program management; (2) both acts offer civil
and criminal penalties; (3) they also introduce opportunities to deploy
new program safeguards; (4) for example, on the fee-for-service side of
the program, BBA introduces prospective payment methods for skilled
nursing facility and home health services, in part to halt opportunists
from overbilling Medicare; (5) these are among Medicare's
fastest-growing components: from 1989 to 1996, spending for home health
care and skilled nursing facility care averaged, respectively, a
33-percent and 22-percent annual rise; (6) HIPAA also ensures a stable
source of funding for anti-fraud-and-abuse activities, authorizes the
Health Care Financing Administration (HCFA) to contract for improved
claims reviews, enhances law enforcement coordination, and calls for
data collection improvements; (7) on the managed care side, BBA's
Medicare+Choice program, which broadens beyond health maintenance
organizations (HMO) the private health plans available to Medicare
beneficiaries, includes several provisions addressing the marketing,
enrollment, and quality of care issues raised in GAO's reports and those
of the Inspector General; (8) as always, however, the success of any
reform legislation is contingent on its implementation; (9) the Congress
has provided the Department of Health and Human Resources (HHS) and
HCFA, the Department's administrator of the Medicare program, with many
new statutory requirements governing traditional fee-for-service
Medicare; some require little effort to carry out, whereas others, such
as prospective payment system development, will require extensive time
and resources to implement effectively; (10) in addition, the
Medicare+Choice program will add considerably to HCFA's private plan
monitoring workload; (11) the project to modernize Medicare's claims
processing systems, which are at the core of many fraud and abuse
detection efforts, has recently been halted; (12) this brings into
question the ability of HCFA and its contractors to perform
expeditiously the data-intensive analyses needed to spot and counteract
abusive billing schemes; and (13) HCFA agrees that the tasks associated
with implementing HIPAA and BBA mandates are considerable and plans to
report routinely to HHS officials and to the Congress on HCFA's progress
implementing the legislation.

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

 REPORTNUM:  T-HEHS-98-9
     TITLE:  Medicare: Recent Legislation to Minimize Fraud and Abuse 
             Requires Effective Implementation
      DATE:  10/09/97
   SUBJECT:  Managed health care
             Program abuses
             Fraud
             Overpayments
             Health care programs
             Health care cost control
             Claims processing
IDENTIFIER:  Medicare Program
             Medicare Choice Program
             HCFA Medicare Transaction System
             
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Cover
================================================================ COVER


Before the Subcommittee on Health, Committee on Ways and Means, House
of Representatives

For Release on Delivery
Expected at 10:00 a.m.
Thursday, October 9, 1997

MEDICARE - RECENT LEGISLATION TO
MINIMIZE FRAUD AND ABUSE REQUIRES
EFFECTIVE IMPLEMENTATION

Statement of William J.  Scanlon, Director
Health Financing and Systems Issues
Health, Education, and Human Services Division

GAO/T-HEHS-98-9

GAO/HEHS-98-9T


(101598)


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

  GTE - x
  HCFA - x
  MTS - x
  HMO - x
  PPO - x
  PSO - x
  BBA - x
  HIPAA - x
  HHS - x
  SNF - x
  MSA - x

MEDICARE:  RECENT LEGISLATION TO
MINIMIZE FRAUD AND ABUSE REQUIRES
EFFECTIVE IMPLEMENTATION
============================================================ Chapter 0

Mr.  Chairman and Members of the Subcommittee: 

We are pleased to be here as you discuss recent legislative efforts
to address fraud and abuse in the Medicare program.  In response to
heightened concern about the exploitation of Medicare, the Congress
enacted as part of the Balanced Budget Act of 1997 (BBA) (P.L. 
105-33) a number of provisions designed to control fraud and abuse. 
At your request, we have sent correspondence to the Subcommittee
today that discusses the provisions of the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) (P.L.  104-191)
and BBA that address anti-fraud-and-abuse recommendations that we and
the Inspector General of the Department of Health and Human Services
(HHS) have made.\1 We also included in the correspondence our
remaining open recommendations and those from the Inspector General. 

In noting the comprehensive legislation that the Congress enacted, in
part, to grapple with program fraud and abuse, my statement today
focuses on the work it will likely take to realize the potential
benefits of HIPAA and BBA in three areas--in traditional
fee-for-service Medicare, the new Medicare+Choice plans, and
information management systems.  My remarks are based on the work we
have done to prepare today's correspondence and relevant GAO studies. 
(See the list of related products at the end of this statement.)

In summary, both HIPAA and BBA directly address Medicare fraud and
abuse and provide opportunities to improve program management.  Both
acts offer civil and criminal penalties.  They also introduce
opportunities to deploy new program safeguards.  For example, on the
fee-for-service side of the program, BBA introduces prospective
payment methods for skilled nursing facility and home health
services, in part to halt opportunists from overbilling Medicare. 
These are among Medicare's fastest-growing components:  From 1989 to
1996, spending for home health care and skilled nursing facility care
averaged, respectively, a 33-percent and 22-percent annual rise. 
HIPAA also ensures a stable source of funding for
anti-fraud-and-abuse activities, authorizes HCFA to contract for
improved claims reviews, enhances law enforcement coordination, and
calls for data collection improvements.  On the managed care side,
BBA's Medicare+Choice program, which broadens beyond health
maintenance organizations (HMO) the private health plans available to
Medicare beneficiaries, includes several provisions addressing the
marketing, enrollment, and quality of care issues raised in our
reports and those of the Inspector General. 

As always, however, the success of any reform legislation is
contingent on its implementation.  The Congress has provided HHS and
the Health Care Financing Administration (HCFA), the Department's
administrator of the Medicare program, with many new statutory
requirements governing traditional fee-for-service Medicare; some
require little effort to carry out, whereas others, such as
prospective payment system development, will require extensive time
and resources to implement effectively.  In addition, the
Medicare+Choice program will add considerably to HCFA's private plan
monitoring workload.  Finally, the project to modernize Medicare's
claims processing systems, which are at the core of many fraud and
abuse detection efforts, has recently been halted.  This brings into
question the ability of HCFA and its contractors to perform
expeditiously the data-intensive analyses needed to spot and
counteract abusive billing schemes.  HCFA agrees that the tasks
associated with implementing HIPAA and BBA mandates are considerable
and plans to report routinely to HHS officials and to the Congress on
HCFA's progress implementing the legislation. 

As we stated in our 1997 High-Risk Series report on Medicare,
fraudulent and abusive schemes are inherently dynamic, as
unprincipled entrepreneurs continually seek ways to dodge program
safeguards.\2 As a result, fortifying Medicare against fraud and
abuse will require a concerted and ongoing effort by Medicare program
managers and federal law enforcement agencies to keep pace with new
attempts to exploit the program.  It will also likely require
additional congressional oversight to encourage timely and effective
program management. 


--------------------
\1 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). 

\2 High-Risk Series:  Medicare (GAO/HR-97-10, Feb.  1997). 


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

Established under the Social Security Amendments of 1965, Medicare is
a two-part program:  (1) "hospital insurance," or part A, which
covers inpatient hospital services and skilled nursing facility,
hospice, and 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.  In fiscal year 1997, part A will have covered
an estimated 38.1 million aged and disabled beneficiaries, including
those with chronic kidney disease.  Total outlays for parts A and B
are estimated at $212 billion for fiscal year 1997. 

In Medicare's fee-for-service program, which is used by almost 90
percent of the program's beneficiaries, physicians, hospitals, and
other providers submit claims for services rendered to Medicare
beneficiaries.  HCFA administers the fee-for-service program largely
through claims processing contractors.  Insurance companies--like
Blue Cross and Blue Shield plans, Mutual of Omaha, and CIGNA--process
and pay Medicare claims, which totaled an estimated 900 million in
fiscal year 1997.  As Medicare contractors, these companies use
federal funds to pay health care providers and beneficiaries and are
reimbursed for the administrative expenses incurred in performing the
Medicare work.  Over the years, HCFA has consolidated some of
Medicare's operations, and the number of contractors has fallen from
a peak of about 130 to about 65 in 1997. 

Generally, intermediaries are the contractors that handle claims
submitted by "institutional providers" (hospitals, skilled nursing
facilities, hospices, and home health agencies); carriers generally
handle claims submitted by physicians, laboratories, equipment
suppliers, and other practitioners.  HCFA has guarded against
inappropriate payments largely through contractor-managed operations,
leaving the intermediaries and carriers broad discretion over how to
protect Medicare program dollars.  As a result, contractors'
implementation of Medicare payment safeguard policies varies
significantly. 

Medicare's managed care program covers a growing number of
beneficiaries--more than 5 million as of September 1997--who have
chosen to enroll in a prepaid health plan rather than purchase
medical services from individual providers.  The managed care
program, which is funded from both the part A and part B trust funds,
consists mostly of risk contract HMOs that enrolled nearly 5 million
Medicare beneficiaries as of September 1997.\3 Medicare pays these
HMOs a monthly amount, fixed in advance, for each beneficiary
enrolled.  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 in return for the
payments received.  An HMO profits if its cost of providing services
is lower than the predetermined payment but loses if its cost is
higher than the payment. 


--------------------
\3 The Medicare managed care program also includes cost contract HMOs
and health care prepayment plans.  Cost contract HMOs allow
beneficiaries to choose health services from their HMO network or
outside providers.  Health care prepayment plans may cover only part
B services.  Together, both types of plans enroll fewer than 2
percent of the Medicare population. 


   IMPLEMENTING NEW LAWS AFFECTING
   FEE-FOR-SERVICE MEDICARE WILL
   REQUIRE SUSTAINED EFFORT TO
   REALIZE BENEFITS
---------------------------------------------------------- Chapter 0:2

The Congress provided important new resources and tools to fight
health care fraud and abuse when it enacted HIPAA and BBA.  To
address problems in traditional fee-for-service Medicare, various
provisions require HCFA to change outmoded payment methods, largely
by establishing new prospective payment systems and by imposing fee
caps, reductions, and updates to contain unnecessary expenditures. 
Certain provisions offer the potential to improve claims
reviews--mandating specific increases in reviews and providing HCFA
new contracting authority to acquire technical expertise. 

Enactment of the legislation represents an important first step
toward the realization of program integrity goals.  As we have noted
in previous testimony, the legislation process sets forth the broad
concepts while the administering agencies implement the legislation
through planning, design, and execution.\4 In the case of HIPAA, now
more than a year old, HCFA and the HHS Inspector General have been
developing plans on many fronts, but actual implementation is just
beginning.  In the case of BBA, less than 3 months old, the "to-do"
list is long.  Three examples relating to both acts illustrate the
situation. 

First, HIPAA, enacted over a year ago, grants HCFA the authority to
use contractors other than the insurers serving as Medicare
intermediaries and carriers to conduct medical and utilization
review, audit cost reports, and carry out other program safeguard
activities.  The purpose is to enhance HCFA's oversight of claims
payment operations by increasing contractor accountability, enhancing
data analysis capabilities, and avoiding potential contractor
conflicts of interest. 

HCFA's target date for awarding the first program safeguard contract
is in fiscal year 1999, more than a year from now.  HCFA officials
are preparing for public comment a notice of proposed rulemaking that
would ultimately govern the selection of contractors to perform
safeguard functions, but they are not able to specify when the
contract award rules will be final. 

Second, to allow greater information-sharing among federal and state
government agencies and health plans, HIPAA mandates the creation of
a national data collection program under which information on final
adverse actions against health care providers will be maintained. 
Officials from the Office of the Inspector General are working with
the Health Resources and Services Administration to develop the
database.  On the basis of past experiences with database
development, it could be several years before the system can be fully
operational. 

Distinct from its predecessor system, the National Provider Data
Bank, this data collection program is expected to maintain
information on civil judgments, criminal convictions, licensing and
certification actions on suppliers and providers, exclusions, and
other adjudicated adverse actions--involving the collection of data
from state and local governments.  The program must also be
self-supporting, requiring market research to assess the needs and
preferences of potential users.  Finally, because existing federal
and state statutes and regulations may impede the collection and
dissemination of the information required, new federal regulations
may be necessary, requiring the publication of proposed rules, a
60-day period for receipt of public comments, and an indeterminate
period for making the regulations final. 

Third, BBA requires the implementation of several prospective payment
systems to replace cost-based reimbursement methods.  Depending on
their design, prospective payment systems can remove the incentive to
provide services unnecessarily.  For example, prospective payment for
skilled nursing facilities (SNF) should make it more difficult to
increase payments by manipulating Medicare's billing rules for
ancillary services provided to beneficiaries in these facilities, an
issue often raised in our reports and testimonies.  However, a
considerable amount of work will be involved.  Establishing rates
that will enable efficient providers to furnish adequate services
without overcompensating them will require (1) accounting for the
varying needs of patients for routine and ancillary services and (2)
collecting reliable cost and utilization data to compute the rates
and the needed health status adjustment factors.  Earlier this year
in testimony before this Committee on prospective payment proposals,
we suggested that HCFA use the results of audits of a projectable
sample of SNF cost reports when setting base rates to avoid
incorporating the inflated costs found in the HHS Inspector General's
reviews of SNF cost reports.  We also discussed the need for systems
to adequately monitor prospective payments to help ensure that
providers do not skimp on services to increase profits at the expense
of quality care.\5

In general, reforming payment methods entails developing payment
methodology components that require data-intensive studies,
developing the implementing regulations, publishing the proposed
regulations for public comment, and issuing final regulations.  For
example, it took HCFA 4 years--from the time a task force was
established in 1993--to issue proposed salary guideline regulations
for rehabilitation therapy services.  To meet the requirements of
BBA, HCFA will have to develop, concurrently, separate prospective
payment systems for services delivered through inpatient
rehabilitation facilities, home health agencies, skilled nursing
facilities, and hospital outpatient departments. 

Developing prospective payment systems, moreover, represents only a
fraction of the design and implementation work that HIPAA and BBA
require.  Conducting demonstration projects and reporting to the
Congress constitute another portion of work mandated by the
legislation. 


--------------------
\4 "Administration's Proposed Budget Cuts Affecting the Medicare
Program," hearing before the House Subcommittee on Health, Committee
on Ways and Means, March 2 and June 15, 1982, serial 97-53, pp. 
331-38. 

\5 Medicare Post-Acute Care:  Cost Growth and Proposals to Manage It
Through Prospective Payment and Other Controls (GAO/T-HEHS-97-106,
Apr.  9, 1997). 


   MEDICARE'S NEW CHOICE PLANS
   PRESENT UNKNOWN CHALLENGES FOR
   PROGRAM MANAGERS
---------------------------------------------------------- Chapter 0:3

Among the more challenging of BBA's provisions to implement are those
establishing the Medicare+Choice program, which expands
beneficiaries' private plan options to include preferred provider
organizations (PPO), provider sponsored organizations (PSO), and
private fee-for-service plans.  It also makes medical savings
accounts (MSA) available to a limited number of beneficiaries under a
demonstration program.  The reforms the Congress embodied in these
provisions are major, helping Medicare adapt to and capitalize on
changes in the health care market. 

However, each of these options will have to be carefully monitored to
identify and correct vulnerabilities.  Our observations of HCFA's
oversight of Medicare's risk contract HMOs, which have been the chief
alternative to traditional fee-for-service Medicare, raise concerns. 
In our 1997 High-Risk Series report, we noted that HCFA's monitoring
of HMOs has been historically weak.  HCFA has allowed some plans with
a history of abusive sales practices, delays in processing
beneficiaries' appeals of HMO decisions to deny coverage, and
patterns of poor-quality care to receive little more than a slap on
the wrist.  We also noted that HCFA had done little to inform
beneficiaries of HMO performance and did not publish available data
on such satisfaction indicators as rapid disenrollment rates compared
across Medicare HMOs within a given market.\6

BBA addresses many of these problems.  For example, the legislation
calls for all Medicare+Choice plans to, among other things, obtain
external review from an independent quality assurance organization,
such as a peer review organization, that would assess such factors as
the quality of the plan's inpatient and outpatient services and the
adequacy of the plan's response to written complaints about
poor-quality care.  These and other mandates should help improve
oversight.  The act also requires HHS to disseminate to all
beneficiaries within a market area consumer information on the area's
Medicare+Choice plans, including, for example, disenrollment rates,
health outcomes, and compliance with program requirements. 
Collectively, these consumer information requirements enlist market
forces to help improve HMO performance. 

We remain concerned that HCFA will have to be attentive to new issues
raised by expanded choice for beneficiaries.  The implementation
challenge for HCFA will be to strike a judicious balance between
encouraging plan growth and development and adequately protecting
beneficiaries' quality of care.  For example, under BBA, requirements
for minimum enrollment levels--aimed at achieving an adequate
spreading of risk to ensure a plan's financial solvency--can be
waived for new Choice plans in their first 3 years of operation.  In
addition, the recent authorization of higher HMO rates in rural areas
may well increase the total number of risk contract HMOs.  If the
number of Medicare managed care organizations grows, HCFA may not be
equipped to make site visits at the current rate of every other year. 
Finally, all the Medicare+Choice plans, including PPOs, PSOs, and
private fee-for-service plans, will have to submit new marketing
materials for HHS approval; with an escalating workload, however,
these materials could be approved without adequate scrutiny.  Under
the law, marketing materials are approved automatically if HHS does
not disapprove them within 45 days of their submission to the
Department. 


--------------------
\6 Our in-depth study on this subject is entitled Medicare:  HCFA
Should Release Data to Aid Consumers, Prompt Better HMO Performance
(GAO/HEHS-97-23, Oct.  22, 1996). 


   DELAYS IN MODERNIZING
   MEDICARE'S CLAIMS PROCESSING
   SYSTEMS COULD HAMPER PROGRAM
   INTEGRITY EFFORTS
---------------------------------------------------------- Chapter 0:4

Another implementation concern is related to HCFA's information
management systems.  As you know, HCFA's major project to modernize
its information systems--the Medicare Transaction System (MTS)--all
but collapsed as of August 15, 1997.\7 This is a significant setback
for HCFA's efforts to prevent and detect fraud and abuse.  For
example, HCFA intended MTS to replace nine separate automated
information systems with a single, unified system.  It was expected
to provide an on-line database that could integrate data on part A
and part B services and payments that are currently stored
separately.  Ideally, such a system would enable the comparison of
claims against other claims already submitted on behalf of the
beneficiary, other claims submitted by the provider, and other claims
for the same procedure or item.  Work is still underway to develop a
new system for collecting payment and other information related to
risk contract HMOs, but the MTS contract has been terminated. 

HCFA is in the process of consolidating its nine separate systems
into one part A claims system and one part B claims system.  While
having a single system for each part should allow better claims
editing, it would not provide all the benefits that had been expected
from MTS, including the ability to ensure routinely, before payments
are made, that an item or service billed to part A has not also been
billed to part B and vice versa.  Other anti-fraud-and-abuse software
development discussed in our High-Risk report--namely, algorithms
under development by the Los Alamos National Laboratory for
generating prepayment claims screens and commercial off-the-shelf
software controls being tested at one contractor--are years away from
implementation nationwide.\8


--------------------
\7 On that day, an internal HCFA memo was issued stating, "Today,
HCFA formally notified GTE of our decision to close down the contract
by January 1998.  This contract action results from the stop work
order that we issued to GTE on April 4, 1997."

\8 For a more detailed discussion of this work, see Medicare
Automated Systems:  Weaknesses in Managing Information Technology
Hinder Fight Against Fraud and Abuse (GAO/T-AIMD-97-176, Sept.  29,
1997). 


   HCFA DEDICATES STAFF TO
   IMPLEMENT BBA MANDATES
---------------------------------------------------------- Chapter 0:5

Aware of the need for agencywide coordination and planning to
implement BBA's multiple provisions, HCFA has established an
infrastructure to track and monitor the tasks associated with BBA
mandates.  Staff organized into functional teams will be led by a
project management team tasked with reporting to agency executives,
including the HCFA Administrator.  According to a HCFA official, the
agency has plans to keep Department officials and the Congress
routinely informed of the agency's progress. 


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

With the enactment of HIPAA and BBA, the Congress has provided
significant opportunities to strengthen several of Medicare's areas
of vulnerability.  How HHS and HCFA will use the authority of HIPAA
and BBA to improve its vigilance over Medicare benefit dollars
remains to be seen.  The outcome largely depends on how promptly and
effectively HCFA implements the various provisions.  HCFA's past
efforts to implement regulations, oversee Medicare managed care
plans, and acquire a major information system have often been slow or
ineffective.  Now that many more requirements have been placed on
HCFA, we are concerned that the promise of the new legislation to
combat health care fraud and abuse could at best be delayed or not be
realized at all without sustained efforts at implementation. 

Mr.  Chairman, this concludes my statement.  I will be happy to
answer your questions. 

RELATED GAO PRODUCTS

Medicare Automated Systems:  Weaknesses in Managing Information
Technology Hinder Fight Against Fraud and Abuse (GAO/T-AIMD-97-176,
Sept.  29, 1997). 

Medicare Home Health Agencies:  Certification Process Is Ineffective
in Excluding Problem Agencies (GAO/T-HEHS-97-180, July 28, 1997). 

Medicare:  Control Over Fraud and Abuse Remains Elusive
(GAO/T-HEHS-97-165, June 26, 1997}. 

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

Medicare Transaction System:  Success Depends Upon Correcting
Critical Managerial and Technical Weaknesses (GAO/AIMD-97-78, May 16,
1997). 

Nursing Homes:  Too Early to Assess New Efforts to Control Fraud and
Abuse (GAO/T-HEHS-97-114, Apr.  16, 1997). 

Medicare Post-Acute Care:  Cost Growth and Proposals to Manage It
Through Prospective Payment and Other Controls (GAO/T-HEHS-97-106,
Apr.  9, 1997). 

Medicaid Fraud and Abuse:  Stronger Action Needed to Remove Excluded
Providers From Federal Health Programs (GAO/HEHS-97-63, Mar.  31,
1997). 

High-Risk Series:  Medicare (GAO/HR-97-10, Feb.  1997). 

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

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

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

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


*** End of document. ***