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 2000-04-06 monographic deposited born digital 8 p. GA 1.13:T-HEHS-00-93 https://www.govinfo.gov/app/details/GAOREPORTS-T-HEHS-00-93 P0b002ee18038219e f:he00093t DGPO 2010-08-12 2011-03-28 GAOREPORTS-T-HEHS-00-93 machine generated eng fdlp REPORT GAOREPORTS-T-HEHS-00-93 T-HEHS-00-93 Medical information systems Health care programs Internal controls Fraud Claims processing Program abuses Health insurance Medical expense claims Reporting requirements HCFA Provider Enrollment Chain and Ownership System Medicare Program Testimony HEHS Pursuant to a congressional request, GAO discussed the effectiveness of the Health Care Financing Administration's (HCFA) efforts to prevent fraud by third-party billing companies that submit claims to Medicare on behalf of providers.<p/>GAO noted that: (1) third-party billing companies often have access to billing information about multiple health care providers and many of their patients; (2) as a result, unscrupulous operators of such businesses have an opportunity to submit false claims; (3) even when HCFA or its contractors suspect that providers' claims are abusive, they are often unable to tell that the claims were submitted by a third-party biller; (4) this is due to limitations in both the systems for processing electronic claims and the complete lack of identifying information on paper claims; (5) while HCFA has established a process to monitor the source of electronic claims, no such process exists for paper claims; (6) paper claim forms include a section or space to identify the provider but not the biller; (7) an Office of Inspector General (OIG) official who has investigated several cases of Medicare fraud by third-party billing companies told GAO that when billing companies used paper claims, it was difficult for the OIG to identify all providers using a given biller; (8) HCFA has no routine registration process to collect comprehensive information about third-party billers; (9) HCFA has made efforts to obtain information on third-party billers, but it still cannot routinely match a third-party biller with all of the providers it represents; (10) in an attempt to gather updated and comprehensive information about providers, HCFA is drafting a regulation to require providers that enrolled in Medicare before May 1996 to complete the new enrollment form to fill this information gap; (11) providers would also be required to recertify the information on their enrollment form every 3 years; (12) HCFA plans to have the regulation in effect by October 1, 2000, and begin requiring providers to update their enrollment information shortly thereafter; (13) this process involves self-reported data that typically will not be validated or updated by the contractors; (14) to make provider and third-party biller information more accessible to the contractors, HCFA is developing a new automated system to access the provider enrollment database; (15) HCFA intends that the system, known as the Provider Enrollment, Chain and Ownership System will provide a complete history of a Medicare provider based on the information in the provider enrollment application; and (16) initially, HCFA plans to incorporate currently available provider information into the system, and, according to HCFA officials, will include updated information from all providers in the future. https://www.govinfo.gov/content/pkg/GAOREPORTS-T-HEHS-00-93/html/GAOREPORTS-T-HEHS-00-93.htm https://www.govinfo.gov/content/pkg/GAOREPORTS-T-HEHS-00-93/pdf/GAOREPORTS-T-HEHS-00-93.pdf GAO/T-HEHS-00-93 https://www.govinfo.gov/app/details/GAOREPORTS-T-HEHS-00-93 Testimony GAO/T-HEHS-00-93; Medicare: Concerns About HCFA's Efforts to Prevent Fraud; Medical information systems Health care programs Internal controls Fraud Claims processing Program abuses Health insurance Medical expense claims Reporting requirements HCFA Provider Enrollment Chain and Ownership System Medicare Program