Medicare Part B: Inconsistent Denial Rates for Medical Necessity Across Six Carriers : Statement of Eleanor Chelimsky, Assistant Comptroller General, Program Evaluation and Methodology Division, Before the Subcommittee on Regulation, Business Opportunities, and Technology, Committee on Small Business, House of RepresentativesThe Office, 1994 - 20 pages |
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Accounting Office additional visits allowed charges APPENDIX I APPENDIX Arthroplasty beneficiaries and providers billed service billing practices California North Carolina California Southern California Carolina South Carolina carriers processed chiropractic claims denied claims processed Colonoscopy Common Working File Denied for Medical differences in denial differences in medical Echocardiography Emergency department visit established patient figure Filename fiscal year 1993 HCFA heart catheterization high utilization rates Initial inpatient consultation line item medical necessity denial medical policy medically necessary Medicare claims million claims Necessity Per 1000 North Carolina South Northern California Southern number of claims Number of Services outpatient visit percent sample procedure code rates among carriers Rates based Rates for Medical sample of 1992 screen in place screened for medical service codes Services Denied Services Screened six carriers Social Security Act South Carolina Illinois Southern California North spinal manipulation splenic flexure subluxation Subsequent hospital top 71 services transluminal coronary angioplasty Variation in Denial
Fréquemment cités
Page 16 - ... claims review activities to better assure that beneficiaries and providers are equitably treated. Mr. Chairman, this concludes my remarks. I would be happy to answer any questions that you or members of the Committee may have.
Page 17 - File contains information on many claimsrelated variables, including the type of billed service and the action that was taken as a result of the claim review process. Medicare claims can contain submitted charges for more than one service; a claim for a simple medical checkup, for example, may include both the doctor's fee as well as the charge for lab tests performed during the visit. On the Medicare claim form, each billed service, or line item, appears as a separate charge with a corresponding...
Page 16 - ... 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 1 - 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. Section 1842 of the Social Security Act...
Page 1 - The Medicare program consists of two distinct insurance programs. Part A (Hospital Insurance Benefits for the Aged and Disabled) covers services furnished by hospitals, home health agencies, hospices, and skilled nursing facilities. Part B (Supplementary Medical Insurance for the Aged and Disabled) covers a wide range of medical services and supplies — including physician services, outpatient hospital services, and home health services not covered under Part A, as well as diagnostic laboratory...
Page 1 - 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.
Page 1 - Medicare program and establishes the regulations and policies under which the program operates. The Medicare program consists of two distinct Insurance programs. Part A (Hospital Insurance Benefits for the Aged and Disabled) covers services furnished by hospitals, home health agencies, hospices, and skilled nursing facilities. Part...
Page 16 - In selecting carriers, we considered two factors: geographic location and the number of claims processed.1 Table II lists the carriers we visited and the number of claims they processed in fiscal year 1992. Table II: Selected Medicare Part B Carriers (Data for 1992) Taken together, these six carriers processed about 19 percent of all Part B claims in fiscal year 1992; however, because of our judgmental selection process, we cannot generalize our findings to the universe of carriers. Source of Data...
Page 1 - A payments and accounted for about $50 billion of the Medicare expenditures in fiscal year 1992. Part B coverage requires beneficiaries to pay monthly premiums, meet a $100 deductible, and pay 20 percent of coinsurance. There is no cap on out-of-pocket expenses for beneficiaries under Part B. In accordance with title XVIII of the Social Security Act, as amended, HCFA contracts with 34 private insurance carriers to process and issue benefit payment on claims submitted under Part B coverage. Carriers...
Page 2 - Determining the medical necessity of a service, on the other hand, requires that carriers develop a medical policy that reflects local standards of medical practice and apply that policy in making determinations as to whether the billed service was performed in accordance with those standards. Carriers have been given broad latitude in this respect — that is, they have been given primary responsibility for defining the criteria that are used to assess the medical necessity of the services on a...