United States Government Publishing Office publisher pbl distributor dst United States Government Accountability Office Health, Education, and Human Services Division author aut Government Organization text government publication eng GAOREPORTS Legislative Agency Publications gao legislative 2010-08-12 U.S. Government Printing Office 1995-09-19 monographic deposited born digital 28 p. GA 1.13:HEHS-95-210 https://www.govinfo.gov/app/details/GAOREPORTS-HEHS-95-210 P0b002ee180398523 f:he95210 DGPO 2010-08-12 2011-03-28 GAOREPORTS-HEHS-95-210 machine generated eng fdlp REPORT GAOREPORTS-HEHS-95-210 HEHS-95-210 Medicare programs Health care cost control Medical services rates Fraud Internal controls Questionable payments Health maintenance organizations Billing procedures Medical expense claims HCFA Medicare Transaction System Medicaid Program CHAMPUS Civilian Health and Medical Program of the Uniformed Services Letter Report HEHS

Pursuant to a congressional request, GAO examined Medicare's vulnerability to provider exploitation and ways to remedy Medicare fraud and abuse.<p/>GAO found that Medicare is vulnerable to billions of dollars in unnecessary payments, since Medicare: (1) pays higher than market rates for certain services and supplies; (2) anti-fraud and abuse controls do not systematically prevent the payment of claims for improbably high charges or manipulated billing codes; and (3) checks on the legitimacy of providers do not adequately detect the potential for fraud. In addition, GAO found that: (1) Medicare has not used the health care management strategies that have helped private payers alleviate weaknesses; (2) Medicare pricing methods and utilization controls have not adapted to current health care financing and delivery changes; (3) the uncertain line between adequate managerial control and excessive government intervention explains the differences in the ways Medicare and private health insurers administer their respective plans; and (4) Medicare should implement a strategy to remedy its weaknesses that includes competitive payment rates, enhanced fraud detection, and more rigorous criteria for granting authorization to bill the program. https://www.govinfo.gov/content/pkg/GAOREPORTS-HEHS-95-210/html/GAOREPORTS-HEHS-95-210.htm https://www.govinfo.gov/content/pkg/GAOREPORTS-HEHS-95-210/pdf/GAOREPORTS-HEHS-95-210.pdf GAO/HEHS-95-210 https://www.govinfo.gov/app/details/GAOREPORTS-HEHS-95-210 Letter Report GAO/HEHS-95-210; Medicare Spending: Modern Management Strategies Needed to Curb Billions in Unnecessary Payments; Medicare programs Health care cost control Medical services rates Fraud Internal controls Questionable payments Health maintenance organizations Billing procedures Medical expense claims HCFA Medicare Transaction System Medicaid Program CHAMPUS Civilian Health and Medical Program of the Uniformed Services Title 42 Section 1320a-7 Title 42 Section 1395a Title 42 Section 1395 Title 42 Section 1395f Title 42 Section 1395h Title 42 Section 1395m(a)(10)(B) Title 42 Section 1395m(i) Title 42 Section 1395mm Title 42 Section 1395u Title 42 Section 1395u(b)(8) Title 42 Section 1395x(e)(9) Title 42 Section 1395x(v) 42 U.S.C. 1320a-7 42 U.S.C. 1395a 42 U.S.C. 1395 42 U.S.C. 1395f 42 U.S.C. 1395h 42 U.S.C. 1395m(a)(10)(B) 42 U.S.C. 1395m(i) 42 U.S.C. 1395mm 42 U.S.C. 1395u 42 U.S.C. 1395u(b)(8) 42 U.S.C. 1395x(e)(9) 42 U.S.C. 1395x(v)