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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... paid before medical necessity is verified . This is true of even the 74 most costly Medicare services which were the subject of the General Accounting Office's investigation . Paying claims without first verifying medical necessity is ...
... paid before medical necessity is verified . This is true of even the 74 most costly Medicare services which were the subject of the General Accounting Office's investigation . Paying claims without first verifying medical necessity is ...
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... paid by seniors with Medicare . When medically unnecessary claims are paid , both the Federal deficit and Medicare premiums keep soaring . Paying medically unnecessary claims can be hard on senior citi- zens in two additional ways ...
... paid by seniors with Medicare . When medically unnecessary claims are paid , both the Federal deficit and Medicare premiums keep soaring . Paying medically unnecessary claims can be hard on senior citi- zens in two additional ways ...
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... paid , Medicare pays claims that ought to be denied , and does not have a systematic approach to knowing the difference . It doesn't take much imagination to see what will happen in 5 years if private insurers get more money to ...
... paid , Medicare pays claims that ought to be denied , and does not have a systematic approach to knowing the difference . It doesn't take much imagination to see what will happen in 5 years if private insurers get more money to ...
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... paid . The Chair wants to thank our witnesses and , in particular , to ex- press the subcommittee's appreciation to the General Accounting Office for the exceptional service that they have provided in prepar- ing this testimony ...
... paid . The Chair wants to thank our witnesses and , in particular , to ex- press the subcommittee's appreciation to the General Accounting Office for the exceptional service that they have provided in prepar- ing this testimony ...
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... paid , Medicare pays claims that ought to be denied , and does not have a systematic approach to knowing the difference . It doesn't take much imagination to see what will happen in 5 years if private insurers get more money to ...
... paid , Medicare pays claims that ought to be denied , and does not have a systematic approach to knowing the difference . It doesn't take much imagination to see what will happen in 5 years if private insurers get more money to ...
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Expressions et termes fréquents
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 coverage policies develop diagnostic screen doctors DOWDAL durable medical equipment echocardiography Emergency department established patient example Financing Administration fiscal intermediaries HCFA's Health Care Financing HEDRICK high denial rates highest denial rates HMO's home health identify Illinois incomplete claims issue look low denial rates mammography MBDF medical necessity denial medical policies medical practice medical services medically unnecessary Medicare beneficiaries Medicare carriers Medicare claims Medicare HMO Medicare patients Medicare pays Medicare program medigap national coverage standards noncovered North Carolina Northern number of services nursing facility outpatient visit physician prepayment screens problem procedures Rates for Medical RON WYDEN seniors services denied Sharma six carriers Southern California Subcommittee on Regulation support the need Total Transamerica variation in carrier variation in denial VLADECK Wisconsin
Fréquemment cités
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.
Page 51 - Mr. Chairman and Members of the Subcommittee: It is a pleasure to be here to share with you the results of our ongoing work on the Medicare Part B claims processing system.