United States Government Publishing Office publisher pbl distributor dst United States Government Accountability Office Program Evaluation and Methodology Division author aut Government Organization text government publication eng GAOREPORTS Legislative Agency Publications gao legislative 2010-08-12 U.S. Government Printing Office 1994-03-29 monographic deposited born digital GA 1.13:T-PEMD-94-17 https://www.govinfo.gov/app/details/GAOREPORTS-T-PEMD-94-17 P0b002ee180372380 f:tpe94017 DGPO 2010-08-12 2011-03-28 GAOREPORTS-T-PEMD-94-17 machine generated eng fdlp REPORT GAOREPORTS-T-PEMD-94-17 T-PEMD-94-17 Medicare programs Beneficiaries Health care services Medical services rates Medical expense claims Entitlement programs Claims processing Elderly persons Health services administration Billing procedures California North Carolina South Carolina Illinois Wisconsin Testimony PEMD GAO discovered large disparities in a probe of how many Medicare claims are being rejected for medical reasons in different parts of the country. The study looked at six carriers: California Blue Shield, California-Occidental, Illinois Blue Shield, Wisconsin Physician Services, North Carolina-Connecticut General, and South Carolina Blue Shield. In Southern California, for example, the insurance carrier handling Medicare claims rejects as medically unnecessary 54 of every 1,000 claims for mammograms. In contrast, in Northern California, only three claims in 10,000 for the same procedure are turned down. GAO discovered (1) sizable differences among the carriers with respect to denial rates for the services screened for medical necessity; (2) that the number of services that carriers screened for medical necessity varied markedly; and (3) that the overall denial rate for medical necessity also differed among the six carriers reviewed. At one extreme, one carrier denied as few as one service per 1,000 allowed, while at the other extreme, another carrier denied 23 services per 1,000 allowed. Medicare is a national program under which beneficiaries in different geographic areas should be receiving similar benefits. Although it may be essential for Medicare to allow for local determination of medical policy, GAO concludes that this allowance, left to itself, results in inconsistent treatment of beneficiaries and providers. https://www.govinfo.gov/content/pkg/GAOREPORTS-T-PEMD-94-17/html/GAOREPORTS-T-PEMD-94-17.htm GAO/T-PEMD-94-17 https://www.govinfo.gov/app/details/GAOREPORTS-T-PEMD-94-17 Testimony GAO/T-PEMD-94-17; Medicare Part B: Inconsistent Denial Rates for Medical Necessity Across Six Carriers; Medicare programs Beneficiaries Health care services Medical services rates Medical expense claims Entitlement programs Claims processing Elderly persons Health services administration Billing procedures California North Carolina South Carolina Illinois Wisconsin