Waste and Inequity: A Call for Improved Management of Medicare's Private Insurance Contractors : Hearing Before the Subcommittee on Regulation, Business Opportunities, and Technology of the Committee on Small Business, House of Representatives, One Hundred Third Congress, Second Session, Washington, DC, December 19, 1994, Volume 4U.S. Government Printing Office, 1995 - 147 pages |
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1,000 services allowed 74 services Accounting Office APPENDIX ARCHER billing practices Calif carrier denial rates Carriers Differed Chairman WYDEN chest x-ray chiropractic claims processing Code Description Colonoscopy CONGRESS THE LIBRARY coronary coverage policies develop diagnostic screen doctors DOWDAL durable medical equipment echocardiography established patient example Financing Administration fiscal intermediaries HCFA's Health Care Financing HEDRICK highest denial rates HMO's home health identify Illinois incomplete claims issue LIBRARY OF CONGRESS low denial rates mammography MBDF medical necessity denial medical policies medical practice medical services medically unnecessary Medicare beneficiaries Medicare carriers Medicare claims Medicare coverage Medicare HMO Medicare patients Medicare pays Medicare program medigap national coverage standards noncovered North Carolina number of services outpatient visit payment physician prepayment screens problem procedures Radiologic exam Rates for Medical seniors services denied Sharma six carriers Southern California Subcommittee on Regulation support the need Total Transamerica variation in denial VLADECK Wisconsin
Fréquemment cités
Page 57 - In accordance with title XVIII of the Social Security Act, as amended, HCFA contracts with 34 private insurance carriers to process and issue benefit payments on claims submitted under Part B coverage. Carriers are required to process claims in a timely, efficient, effective, and accurate manner. During fiscal year 1993, carriers processed about 576 million Part B claims submitted by about 780,000 physicians and 136,000 suppliers.
Page 1 - Washington, DC. The subcommittee met, pursuant to notice, at 10:10 am, in room 2237, Rayburn House Office Building, Hon.
Page 75 - Notwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for items or services — (1) which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member...
Page 69 - ... national coverage standards across carriers, differences in the way carriers treated claims with missing information, and reporting inconsistencies helped explain variation in carrier denial rates. We did not attempt to assess whether low or high medical necessity denial rates for individual carriers were appropriate. Low denial rates are desirable from the standpoint that they imply less annoyance and inconvenience for providers and beneficiaries. However, low denial rates are desirable only...
Page 74 - ... reason of the dollar amount denied was as follows: duplicate claim (30 percent), service not covered (14 percent), claimant ineligible (8 percent), missing information (10 percent), rebundled (6 percent), filing limit exceeded (1 percent), Medicare secondary payer (6 percent), and other (16 percent). Services deemed not medically necessary constituted about 9 percent of the dollar amount denied by carriers.
Page 102 - ... for examining intraregional variation in medical policies. In terms of the number of claims processed, the frequency distribution of carriers is essentially bimodal — that is, there are two large clusters of carriers, those that annually process between 2 and 13 million claims and those that process between 18 and 29 million claims (2 carriers processed over 46 million claims each). Our sample included two carriers from the former cluster and four from the latter. APPENDIX I APPENDIX I Table...
Page 100 - ... denials in order to devise a strategy for addressing this problem. Agency Comments At your request, we did not obtain agency comments on a draft of this report If you or your staff have any questions about this report or would like additional information, please call me at (202) 512-2900 or Kwai-Cheung Chan, Director for Program Evaluation in Physical Systems Areas, at (202) 512-3092. Major contributors to this report are listed in appendix V. Sincerely yours, Terry E. Hedrick Assistant Comptroller...
Page 63 - HCFA requires that carriers assess the necessity of visits in excess of 12 per year, but carriers diverged in how they assessed such treatments. One carrier stated that, after 12 visits, additional documentation on medical necessity would be required. Another carrier based the number of additional visits allowed on the injured area of the spine.
Page 57 - ... claims in a timely, efficient, effective, and accurate manner. During fiscal year 1993, carriers processed about 576 million Part B claims submitted by about 780,000 physicians and 136,000 suppliers. The Social Security Act mandates that carriers pay only for services that are covered, and reject the claim if they determine that the services were not medically necessary. In fiscal year 1993, carriers denied 112 million Part B claims in whole or part...
Page 75 - ... routine physical checkups and cosmetic surgery. Medicare law is best viewed as a framework for making coverage GAO/PEMD-95-10 Medicare Part B determinations: It is not, as HCFA has observed, "an all-inclusive list of specific items, services, treatments, procedures or technologies covered by Medicare."3 Recognizing that the law could not anticipate all possible coverage issues, the Congress provided the following guidance to HCFA for making decisions: "Notwithstanding any other provisions of...