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 4
United States. Congress. House. Committee on Small Business. Subcommittee on Regulation, Business Opportunities, and Technology
U.S. Government Printing Office, 1995 - 147 pages
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Accounting Office additional allowed analysis APPENDIX appropriate approved believe beneficiaries billing Calif carrier denial rates carriers Chairman WYDEN changed chest X-ray claims codes consistency consultation correct covered criteria denial rates denied determine develop diagnostic screen doctors DOWDAL effective established examination example factors Financing Administration finding given going HCFA Health Care Financing HEDRICK hospital identify Illinois improve issue kind look medical necessity medical policies medical practice medical review medically unnecessary Medicare Medicare carriers necessary noncovered North Carolina northern paid particular patient patterns payment percent performed physician problem procedures providers question reason received responsible result screens seniors serve Sharma Southern California specific subcommittee submitted Table Total treatment types utilization variation in denial varied VLADECK Wisconsin
Page 101 - 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 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 53 - 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 65 - ... 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 100 - ... 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 91 - An x-ray demonstrating the spinal problem must be available, signs and symptoms must be stated, and the precise level of subluxation must be reported. The six carriers had all incorporated these criteria into their medical policies for chiropractic spinal manipulation. 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...
Page 128 - ... 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.
Page 55 - ... medical technologies, see US General Accounting Office, Technology Assessment and Medical Coverage Decisions, GAO/HEHS-94-195FS (Washington, DC: July 1994). B-257799 appears to be reasonable and necessary and therefore covered by Medicare."7 HCFA has given carriers broad latitude in this area — that is, it has given them primary responsibility for defining the criteria that are used to assess the medical necessity of services. Such local medical policies allow carriers to target specific services...
Page 130 - For example, code 71020 refers to a chest x-ray. It is important to note that a Medicare claim can contain submitted charges for more than one service. A claim for a physician's office visit, for example, may also include the charges for laboratory tests performed during the visit The denial rates presented in this report are based on specific services, not on claims.