Medicaid's Quality Control System is Not Realizing Its Full Potential: Report to the Congress |
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Page i
... claims paid for these cases are analyzed to determine if ( 1 ) the individual ( s ) in each sampled case were eligible for Medicaid , ( 2 ) the amount paid for each claim was correct , and ( 3 ) any other liable parties ( Medicare ...
... claims paid for these cases are analyzed to determine if ( 1 ) the individual ( s ) in each sampled case were eligible for Medicaid , ( 2 ) the amount paid for each claim was correct , and ( 3 ) any other liable parties ( Medicare ...
Page iii
... claims processing errors , and failure to use liable third parties . ( See pp . 18 to 21 ) . In addition , GAO also identified three weaknesses which raise questions about the accuracy of other quality control ... claims paid for the.
... claims processing errors , and failure to use liable third parties . ( See pp . 18 to 21 ) . In addition , GAO also identified three weaknesses which raise questions about the accuracy of other quality control ... claims paid for the.
Page iv
... claims paid for the cases selected for eligibil- ity review does not assure that a representative sample of all types of claims are reviewed . If claims for payment review were selected from the universe of paid claims , quality control ...
... claims paid for the cases selected for eligibil- ity review does not assure that a representative sample of all types of claims are reviewed . If claims for payment review were selected from the universe of paid claims , quality control ...
Page vi
... paid claims for claims APPENDIX I processing reviews Need for more timely data to correct problems Need for accurate reporting of program losses due to ineligibility Need for review criteria that identify all program weaknesses Need to ...
... paid claims for claims APPENDIX I processing reviews Need for more timely data to correct problems Need for accurate reporting of program losses due to ineligibility Need for review criteria that identify all program weaknesses Need to ...
Page 2
... claims are paid only for covered Medicaid services to eligible providers in the correct amount ; and that third parties ( Medicare , workmen's compensation , insurance companies , etc. ) are fully utilized , making Medicaid the payer of ...
... claims are paid only for covered Medicaid services to eligible providers in the correct amount ; and that third parties ( Medicare , workmen's compensation , insurance companies , etc. ) are fully utilized , making Medicaid the payer of ...
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Common terms and phrases
accuracy administrative costs AFDC Alabama APPENDIX II APPENDIX base period believe claims paid claims processing errors claims processing review claims processing sample corrective action activities corrective action plans corrective action program disallowance dollar effective eligibility determinations eligibility review eligible for Medicaid erroneous Medicaid payments erroneous payments examined example Federal Medicaid regulations Federal regulations Federal sharing fiscal penalties fiscal sanctions funds GAO Recommendation HCFA MQC reviewers HCFA regional offices HCFA reviewers HCFA subsample HCFA's identified implementation improve incentives independent ineligible Louisiana manual Medicaid eligibility Medicaid program Medicaid Quality Control misspent MQC corrective action MQC data MQC file MQC program MQC system MQC unit MQC's Office of Quality Oklahoma paid claims percent problems processing and third-party program weaknesses quality control program re-review recipients recovery efforts review criteria review month Secretary of HHS State's Medicaid statistical sample stratum target error rate third-party liability reviews verification Washington
Popular passages
Page 2 - Association, the national professional association of registered nurses. The American Nurses' Association is the professional organization of over 200,000 registered nurses in 50 States, the District of Columbia, Guam, Puerto Rico, the Virgin Islands, and the Canal Zone. I have with me two members of the staff, Mr. Zembower and Mr. Craig who are members of the staff of the American Nurses' Association to answer any questions you might have.
Page 1 - Medicaid— authorized by title XIX of the Social Security Act, as amended (42 USC 1396...
Page 2 - AFDC family (adjusted for family size) and 133y3 percent of the payment to such AFDC family. All of these variations — in benefits offered, in groups covered, in income standards, and in levels of reimbursement for providers — mean that Medicaid programs differ greatly from state to state. All states require Medicaid patients in longterm care institutions to contribute their excess income (generally all income over the $25 they require for personal needs) to help pay for the cost of their care....
Page 1 - Medicare, this is the Health Care Financing Administration (HCFA), Department of Health and Human Services (HHS).
Page ii - ... of which would reduce erroneous payments. Because the error rates are tied to the penalties, HCFA has placed its emphasis on developing quality control processes and policies which will provide statistically defensible error rates which can withstand challenge if penalties are assessed.
Page 2 - MQC findings), approximately $461 million was paid for health services to ineligible beneficiaries, $74 million was lost in unrecovered third-party liability, and $100 million was wasted through claims processing errors.
Page 11 - Unfortunately, this emphasis on corrective action plans apparently was an effort not so much to improve Medicaid management as to avoid imposing the fiscal penalties.
Page 7 - Because corrective action is the ultimate purpose of MQC, the threat of penalties has partially negated its expected benefits...
Page ii - This could be accomplished by — reducing the magnitude of the penalties for poor performance and — providing rewards of similar magnitude for good performance...
Page 43 - Medicaid's Quality Control System Is Not Realizing Its Full Potential.