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 1995-06-15 monographic deposited born digital GA 1.13:T-HEHS-95-183 https://www.govinfo.gov/app/details/GAOREPORTS-T-HEHS-95-183 P0b002ee18039f7c6 f:the95183 DGPO 2010-08-12 2011-03-24 GAOREPORTS-T-HEHS-95-183 machine generated eng fdlp REPORT GAOREPORTS-T-HEHS-95-183 T-HEHS-95-183 Medicare programs Health care cost control Claims processing Questionable payments Fraud Program abuses Medical expense claims Medical services rates Overpayments Risk management Testimony HEHS Medicare's vulnerability to provider exploitation of its billing system stems from a combination of factors: (1) higher-than-market rates for some services, (2) inadequate checks for detecting fraud and abuse, (3) superficial criteria for confirming the authenticity of providers billing the program, and (4) weak enforcement efforts. Various health care management techniques help private payers avoid these problems, but Medicare generally does not use these techniques. The program's pricing methods and controls over utilization have not kept pace with changes in health care financing and delivery. To some extent, the predicament inherent in public programs--the uncertain line between adequate managerial control and excessive government intervention--helps explains the dissimilarity in the ways in which Medicare and private health insurers run their respective "plans." GAO believes that a viable strategy for remedying the program's weaknesses consists of adapting the health care management approach of private payers to Medicare's public payer role. This would entail (1) more competitively developed payment rates, (2) beefed-up fraud and abuse detection that uses modern information systems, and (3) more rigorous criteria for granting authorization to bill the program. https://www.govinfo.gov/content/pkg/GAOREPORTS-T-HEHS-95-183/html/GAOREPORTS-T-HEHS-95-183.htm GAO/T-HEHS-95-183 https://www.govinfo.gov/app/details/GAOREPORTS-T-HEHS-95-183 Testimony GAO/T-HEHS-95-183; Medicare: Modern Management Strategies Needed to Curb Program Exploitation; Medicare programs Health care cost control Claims processing Questionable payments Fraud Program abuses Medical expense claims Medical services rates Overpayments Risk management