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 1999-07-14 monographic deposited born digital 84 p. GA 1.13:HEHS-99-115 https://www.govinfo.gov/app/details/GAOREPORTS-HEHS-99-115 P0b002ee1803a0691 f:he99115 DGPO 2010-08-12 2011-03-24 GAOREPORTS-HEHS-99-115 machine generated eng fdlp REPORT GAOREPORTS-HEHS-99-115 HEHS-99-115 Contract oversight Claims processing Contractor violations Program abuses Fraud Health insurance Internal controls Reporting requirements Overpayments Fines (penalties) Medicare Contractor Performance Evaluation Program Medicare Integrity Program HCFA Performance Improvement Plan Medicare Secondary Payer Program Medicare Program Medicare Fee-for-Service Program Chapter Report HEHS

Pursuant to a congressional request, GAO reviewed the Health Care Financing Administration's (HCFA) oversight of its claims administration contractors, focusing on whether: (1) there are weaknesses in HCFA's contractor oversight activities that may make Medicare more vulnerable to fraud, waste, or abuse; and (2) changes in HCFA's contracting authority that may improve its ability to manage its contractors.<p/>GAO noted that: (1) despite its efforts, HCFA's oversight of Medicare claims administration contractors has significant weaknesses that leave the agency without assurance that contractors are paying providers appropriately; (2) since 1993, six contractors have settled civil and criminal charges following allegations that they did not check claims to ensure proper payment or allowed Medicare to pay claims that should have been paid by other insurers; (3) even though inadequate management controls and falsified data are a common theme in these cases, GAO found that HCFA still does not regularly check contractors' internal management controls, management and financial data, and key program safeguards to prevent payment errors; (4) furthermore, HCFA's headquarters office generally has not set oversight priorities, leaving such decisions almost entirely to regional office reviewers; (5) this has led to uneven contractor evaluations by regional reviewers, making it more difficult for HCFA to determine which contractors are performing effectively; (6) HCFA's organizational structure contributes to the problem by dividing responsibilities for contractor oversight between the regions and headquarters without assigning overall accountability to one office; (7) HCFA officials believe that increased competition among contractors could enhance contractor performance but that statute and regulations limit its authority to contract; (8) the statutory limitations were enacted for easier initial implementation of Medicare, but the program now has over 30 years of operational experience; (9) consequently, HCFA is seeking new or explicit authority from Congress that would allow it to: (a) choose its intermediaries, rather than having providers nominate them, and contract with non-health insurance companies; (b) contract separately for specific functions; and (c) use payment methods that would allow contractors to earn profits on their Medicare business, rather than reimbursing contractors only for their costs up to a present target; and (10) while these changes might broaden the pool of contractors HCFA could choose from and would increase its flexibility in contracting for specific functions, past experience with other efforts to change the program has shown that HCFA will need several years to carefully plan, properly implement, and conduct a postimplementation review of any new contracting initiatives. https://www.govinfo.gov/content/pkg/GAOREPORTS-HEHS-99-115/html/GAOREPORTS-HEHS-99-115.htm https://www.govinfo.gov/content/pkg/GAOREPORTS-HEHS-99-115/pdf/GAOREPORTS-HEHS-99-115.pdf GAO/HEHS-99-115 https://www.govinfo.gov/app/details/GAOREPORTS-HEHS-99-115 Chapter Report GAO/HEHS-99-115; Medicare Contractors: Despite Its Efforts, HCFA Cannot; Contract oversight Claims processing Contractor violations Program abuses Fraud Health insurance Internal controls Reporting requirements Overpayments Fines (penalties) Medicare Contractor Performance Evaluation Program Medicare Integrity Program HCFA Performance Improvement Plan Medicare Secondary Payer Program Medicare Program Medicare Fee-for-Service Program Title 31 Section 3729-3733 31 U.S.C. 3729-3733