Medicare: Recent Legislation to Minimize Fraud and Abuse Requires Effective Implementation : Statement of William J. Scanlon, Director, Health Financing and Systems Issues, Health, Education, and Human Services Division, Before the Subcommittee on Health, Committee on Ways and Means, House of Representatives

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The Office, 1997 - Health insurance - 12 pages
 

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Page 3 - Medicare contractors, these companies use federal funds to pay health care providers and beneficiaries and are reimbursed for the administrative expenses incurred in performing the Medicare work. Over the years, HCFA has consolidated some of Medicare's operations, and the number of contractors has fallen from a peak of about 130 to about 65 in 1997. Generally, intermediaries are the contractors that handle claims submitted by "institutional providers...
Page 3 - risk" contract because regardless of what it spends for each enrollee's care, the HMO assumes the financial risk of providing health care in return for the payments received.
Page 6 - ... and hospital outpatient departments. Developing prospective payment systems, moreover, represents only a fraction of the design and implementation work that HIPAA and BBA require. Conducting demonstration projects and reporting to the Congress constitute another portion of work mandated by the legislation. MEDICARE'S NEW CHOICE PLANS PRESENT UNKNOWN CHALLENGES FOR PROGRAM MANAGERS Among the more challenging of BBA's provisions to implement are those establishing the Medicare+Choice program, which...
Page 3 - Managed Care Program Medicare's managed care program covers a growing number of beneficiaries — nearly 5 million at the end of 1996 — who have chosen to enroll in an HMO to receive their medical care rather than obtaining services from individual providers. The managed care program, which is funded from both the part A and part...
Page 3 - Medicare managed care program also includes cost contract HMOs and health care prepayment plans. Cost contract HMOs allow beneficiaries to choose health services from their HMO network or outside providers. Health care prepayment plans may cover only part B services. Together, both types of plans enroll fewer than 2 percent of the Medicare population. 4 "Administration's Proposed Budget Cuts Affecting the Medicare Program...
Page 3 - Medicare contractors, use federal funds to pay health care providers and beneficiaries and are reimbursed for their administrative expenses incurred in performing the work. Over the years, HCFA has consolidated some of Medicare's operations and the number of contractors has fallen from about 130 to about 80 today. Their duties encompass three major functions: claims processing, provider and beneficiary services, and payment control activities, called payment safeguards. In 1993 the contractor budget...
Page 3 - As Medicare contractors, these companies use federal funds to pay health care providers and beneficiaries and are reimbursed for their administrative expenses incurred in performing the work. Over the years, HCFA has consolidated some of Medicare's operations, and the number of contractors has fallen from about 130 to about 70 in 1996.
Page 2 - ... a fraction of all Medicare providers. Although HCFA's plans for implementing this system are not final, HCFA officials told us they plan to complete it after addressing computer systems work needed to prepare for year 2000. BACKGROUND Established under the Social Security Amendments of 1965, Medicare is a twopart program: (1) "hospital insurance, "or part A, which covers inpatient hospital, skilled nursing facility, hospice, and home health care services, and (2) "supplementary medical insurance...
Page 12 - July 19, 1995). Medicare: Commercial Technology Could Save Billions Lost to Billing Abuse (GAO/AIMD-95-135, May 5, 1995). Medicare: New Claims Processing System Benefits and Acquisition Risks (GAO/HEHS/AIMD-94-79, Jan.
Page 1 - ... and abuse. At your request, we have sent correspondence to the Subcommittee today that discusses the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (PL 104-191) and BBA that address anti-fraud-and-abuse recommendations that we and the Inspector General of the Department of Health and Human Services (HHS) have made.1 We also included in the correspondence our remaining open recommendations and those from the Inspector General. In noting the comprehensive...

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