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Testifying before Congress in 2002, military beneficiary groups and civilian managed care support contractors described problems with the processing of TRICARE claims for civilian-provided care. These problems included slow payments and procedures that made claims processing inefficient. The Bob Stump National Defense Authorization Act of 2003 required GAO to review improvements to TRICARE claims processing and continuing impediments to claims processing efficiency. Specifically, GAO describes (1) efforts to improve claims processing and changes in processing timeliness and (2) Department of Defense (DOD) procedures and data that continue to affect claims processing efficiency. To identify improvements to claims processing and impediments to processing efficiency, GAO analyzed 1999 and 2002 claims data for changes in processing timeliness. GAO also interviewed and analyzed claims processing documentation from DOD officials, managed care support contractors, and claims processors. In an effort to improve TRICARE claims processing, DOD and its managed care support (MCS) contractors have made changes that are designed to make it more efficient. First, they have jointly identified--and then eliminated or changed--certain DOD requirements they deemed inefficient and nonessential to accurate claims processing. For example, contractors are no longer required to hold claims with incomplete information and request the missing information from the provider or beneficiary. Instead, contractors may now return some claims with missing information. In another change, DOD eliminated preauthorization requirements for certain procedures and gave the MCS contractors more latitude for determining when preauthorizations are appropriate. To encourage providers to submit their claims electronically, DOD gave MCS contractors the authority to decide whether to adjudicate electronically submitted claims sooner than those submitted on paper. Further, MCS contractors have worked with their claims processors to implement new technologies for data input, claims routing, customer service, and claims submission. Finally, MCS contractors and their claims processors have improved the timeliness with which they process claims. In fiscal year 2002, claims processors processed over 97 percent of claims in 30 days or less--an improvement over fiscal year 1999, when 91 percent of claims were processed in 30 days or less. Although DOD and its MCS contractors have made changes to improve claims processing, some DOD procedures and inaccuracies in its data continue to create inefficiencies in TRICARE claims processing. Some DOD procedures may create inefficiencies by inadvertently increasing the demand for customer service, which claims processors are required to provide. Additionally, inaccuracies in DOD eligibility data--data that are needed to process TRICARE claims--can contribute to claims processing delays or rework if, for example, claims must be reprocessed when errors are identified. Finally, some DOD procedures lead to rework for claims processors, either in the form of reprocessing claims or reprogramming processing software. For example, when DOD makes program changes to TRICARE to alter or create a health benefit, it does not adhere to any schedule. In 2002, DOD made 123 program changes on 19 different dates throughout the year. Given the fact that implementing these changes often involves reprogramming and testing processing software, this approach can create rework for claims processors when DOD issues similar or related changes on separate occasions. [ABSTRACT FROM AUTHOR]

Providing benefits to disabled individuals is one of the Social Security Administration's (SSA) most important service delivery obligations--touching the lives of about 10 million individuals. In recent years, however, providing this benefit in a timely and efficient manner has become an increasing challenge for the agency. This past January, in fact, GAO designated SSA's disability programs as highrisk. Following a prior unsuccessful attempt, the agency is now in the midst of a major initiative to automate its disability claims functions, taking advantage of technology to improve this service. Seeking immediate program improvements, SSA is using an accelerated approach--called AeDib--to develop an electronic disability claims processing system. At the request of the Subcommittee on Social Security, House Committee on Ways and Means, GAO is currently assessing the strategy that underlies SSA's latest initiative to develop the electronic disability system. For this testimony, GAO was asked to discuss its key observations to date regarding the AeDib initiative, including strategy, risks, and stakeholder involvement. GAO plans to discuss more fully the results of this continuing review in a subsequent reportSSA's goal to establish a more efficient, paperless disability claims processing system is important, and one that could benefit millions. To achieve this goal, SSA's immediate focus is on developing an electronic folder to store claimant information and large volumes of medical images, files, and other documents that are currently maintained in paper folders, and then make this information accessible to all entities involved in disability determinations. SSA's accelerated strategy calls for development of this capability by January 2004 rather than in 2005, as originally planned. Since accelerating this effort, SSA has performed important tasks toward establishing this initial electronic capability. Nonetheless, it has substantial work to accomplish in order to develop the technologically complex electronic folder and begin implementation by late next January. While responsive to the agency's need for an operational system as soon as possible, SSA's accelerated strategy involves risks. For example, pilot tests that are to provide important information about the electronic folder's performance are not expected until late December--just 1 month before its planned implementation. In addition, a strategy for end-to-end testing to demonstrate that the individual components will work together reliably has not been completed. Further increasing the system's vulnerability is that SSA has not yet comprehensively assessed project risks. Unless addressed, these factors could ultimately derail the initiative. While SSA has taken steps to involve key stakeholders in the systems development process, officials in state Disability Determination Services offices that we contacted expressed concerns that they had only limited involvement in the development effort. They stated that their concerns were not adequately heard and considered in the decision-making process. Unless SSA addresses these issues, it cannot be assured of stakeholder agreement with and full use of the system. [ABSTRACT FROM AUTHOR]

To help ensure the integrity of Medicare, the Health Care Financing Administration (HCFA) and its contractors need to develop reliable and sophisticated approaches to identify potentially fraudulent billing practices. It is especially important that they be able to match up third-party billers with the providers they represent so contractors can identify potentially questionable billing patterns and subject these claims to more scrutiny. Although HCFA has various efforts under way to better identify providers' questionable claims and their associated third-party billers, there continue to be gaps in its safeguards. HCFA needs to complete its provider recertification program as soon as possible so that it will have comprehensive information on all Medicare providers and their billers. GAO is also concerned about inherent problems with data reliability. [ABSTRACT FROM AUTHOR]

The article presents a U.S. Government Accountability Office (GAO) study of the health care costs of firearm injuries from 2016 to 2017 based on data collected by the Agency for Healthcare Research and Quality. Topics discussed include the estimated hospital costs of such injuries at more than one billion dollars annually, readmission rate for firearm injury survivors, and barriers to care facing survivors such as denial of care due to lack of insurance coverage.

Pursuant to a congressional request, GAO described how the Health Care Financing Administration (HCFA) and its contractors monitor third-party billing companies' involvement in the submission of claims to Medicare. GAO noted that: (1) providers are ultimately responsible for the claims that they submit or that are submitted on their behalf; (2) despite this, HCFA has an interest in tracking claims submitted by third-party billers as one way of targeting its program safeguard resources and determining the source of inappropriate or fraudulent claims; (3) GAO found that HCFA cannot identify when third-party billers were involved in the more than 700 million electronic claims in fiscal year 1998, because its systems identify only one of the many possible entities involved in preparing a claim; (4) further, paper claims--146 million in 1998--do not have any identifying information that would indicate whether third-party billers submitted them; (5) GAO also found weaknesses in HCFA's efforts to obtain information about third-party billers; (6) HCFA issued a new enrollment form for providers first enrolling in Medicare after May 1996; (7) this form obtains the identity of third-party billers that the enrolling providers use; (8) however, since 96 percent of Medicare's providers enrolled in Medicare before 1996, HCFA has no information on billing arrangements for most providers; (9) HCFA is proceeding with plans to develop a national system to capture this information on the enrollment form, even though the system would initially contain data for only a fraction of all Medicare providers; and (10) although HCFA's plans for implementing this system are not final, HCFA officials told GAO they plan to complete it after addressing computer systems work needed to prepare for year 2000. [ABSTRACT FROM AUTHOR]

The article offers information related to a report for health service from the U.S. Government Accountability Office. Topics discussed include medicaid programs provided by Patient Protection and Affordable Care Act (PPACA); expansion in services following increases in health insurance coverage and collections; and selection of facilities to include a mix of federally operated and tribally operated hospitals and health centers in the U.S.

The article presents U.S. Government Accountability Office report regarding states' use and distribution of supplemental payments to hospitals with reference to Medicaid. Topics include Medicaid disproportionate share hospital (DSH) payments, one type of supplemental payment, gap between a state's Medicaid payment rates and hospitals' costs, and reports of hospital-level uncompensated care costs.

The article focuses on a report by the U.S. Government Accountability Office, which shows that actions are needed to strengthen oversight and coordination of health care for American Indian and Alaska Native veterans. Topics include American Indians and Alaska Natives (AI/AN) have served in the military at a higher rate than members of other racial groups, yet AI/AN veterans are more likely than other veterans to lack health insurance or have a service-connected disability.

The article highlights the U.S, Government Accountability Office (GAO's) Medicare and Medicaid health care programs that provides health insurance coverage through different mechanisms, including fee-for-service. Topics discusses include Medicare and Medicaid documentation requirements based on statutes, regulations, and other national and state coverage policies; and information on Medicare referring physicians to support the medical necessity like home health, and laboratory services.

The article offers information on several aspects associated with the U.S. based Medicaid abortion coverage and payment. The topics addressed include details on the variation in Medicaid abortion coverage and payment requirements which could complicate access for program beneficiaries and factors challenges the women to access to abortions.

The article investigates the outreach and enrollment for the health insurance exchanges in the U.S. Information about the enrollment outcomes and factors affecting open enrollment performance of the U.S. government agency Department of Health and Human Services, is highlighted. An overview on the perspectives from navigator organizations, issuers and insurance departments in the country, is also emphasized.

The article presents a report by the U.S. Government Accountability Office (GAO) focusing on the prescription of opioids in Medicare and Medicaid services in the U.S. Topics discussed include the oversight of Medicare beneficiaries by the Centers for Medicare & Medicaid Services (CMS); CMS's strategy to prevent opioid abuse; and the role of insurance plans and sponsors in the U.S.

The article focuses on the study from the U.S. Government Accountability Office (GAO) concerning need for the U.S. Centers for Medicare & Medicaid Services (CMS) to take actions to continue prior authorization efforts to reduce spending. It mentions that CMS monitors prior authorization through various Medicare Administrative Contractors (MAC) reports. It also mentions that CMS risks missed opportunities for achieving its stated goals of reducing costs.

The article focuses on a report from the U.S. Government Accountability Office about millions of individuals enrolled in the federal health insurance exchange in 37 states. The report highlights the need for the Centers for Medicare and Medicaid Services to ensure complete and accurate information about the terminations of coverage for nonpayment of premiums.

The article presents a report on the U.S. defense health care from the Government Accountability Office, which found TRICARE surveys indicating improvement of nonenrolled beneficiaries' access to healthcare. Topics mentioned include more number of nonenrolled TRICARE beneficiaries obtaining care when desired, the increase in nonenrolled beneficiaries' positive ratings of TRICARE over time which vary compared to other federal health plans, and civilian providers' reported awareness of TRICARE.

The article focuses on the U.S. Government Accountability Office' report on an "Analysis of Plan Year 2015 Application, Enrollment, and Eligibility-Verification Process" for federal health insurance. Topics discussed includes termination of coverage and subsidies for non-payment of premium after an applicant's death, case with unresolved Social Security Number inconsistencies for 2015, and feasibility of approaches to identify the deaths of enrollees.

The article presents the U.S Government Accountability Office (GAO) report assessing Patient Protection and Affordable Care Act's (PPACA) stipulated provision that led to Internal Revenue Service (IRS) tax excision on high-cost health plan. It states that PPACA's age and gender adjustment adjustments for Federal Employees Health Benefits Program's (FEHBP) Blue Cross and Blue Shield (BCBS) Standard plan cost. GAO's recommendation to IRS are discussed.

A report from the U.S. Government Accountability Office on Medicaid's personal care services as of May 2017 is presented. It offers information on Medicaid which is a joint federal-state health care program for disabled and aged individuals in home and community settings. Topics include the requirements for protecting beneficiaries' safety and ensure financial assistance and the usefulness of the data collected by the Centers for Medicaid and Medicare Services for oversight.

The article presents the U.S. Government Accountability Office (GAO) report on how the program oversight has been hampered by data challenges. Topics include Centers for Medicare and Medicaid Services (CMS's) ability to oversee the Medicaid program, CMS's efforts to improve data, and recommendation for improving Medicaid data available for program oversight.

The article discusses the study conducted by the U.S. Government Accountability Office (GAO) on the impact of the Patient Protection and Affordable Care Act (PPACA) on private health insurance markets in 2015 and 2016. Health insurance markets was found to be concentrated among a small number of issuers and that PPACA exchange plans was more concentrated among few issuers. Individual market consumers were also found to have access to health plans in 2015 compared to 2014.

The article discusses how selected states in the U.S. ensure that beneficiaries receiving personal care services (PCS) are safe from harm and that billed services are provided, and efforts of the U.S. Centers for Medicare and Medicaid Services (CMS) to improve oversight of states' PCS programs and to harmonize requirements across the programs. Topics addressed include the significance of Medicaid PCS, and federal program requirements for maintaining beneficiary safety.

The article presents a study conducted by the U.S. Government Accountability Office (GAO) which examines the four levels of Medicare's appeals process, which consists of administrative levels of review with the Department of Health and Human Services (HHS), from fiscal years 2010 to 2014. GAO recommended actions for the HHS to take include improving the consistency and completeness of the data it used to monitor appeals and implementing a more efficient method of handling appeals.

The article offers information on a report by the U.S. Government Accountability Office on information security and privacy. Topics discussed include data hub security issues with the Centers for Medicare & Medicaid Services (CMS), m0onitoring of health insurance marketplace security controls, and mentions steps taken for privacy and security of data.

The article explores on the health-care coverage of the U.S. Obamacare Patient Protection and Affordable Care Act. It states major role of the Department of Health and Human Services' (HHS) Centers for Medicare & Medicaid Services (CMS) to expand enrollment controls and manage the risk of fraud. Also emphasized is the individual's citizenship and residence to become eligible and have access of private health-insurance plans.

The article discusses a report by the U.S. Government Accountability (GAO) on the U.S. Medicaid, as of November 2015. It discusses lack of transparency in Medicaid supplemental payments made in the U.S., and states that the U.S. Centers for Medicare & Medicaid Services (CMS) holds the responsibility to ensure that the U.S. state payments are consistent with Medicaid payment principles. It presents the suggestions made by GAO to the U.S. congress and CMS for enhancing transparency in Medicaid.

The article offers information on a report by the U.S. Government Accountability Office (GAO) on enrollment control for Medicaid. Topics discussed include subsidized healthplan coverage through Health Insurance Marketplace, duplicate enrollment of insurance, use of unissued security numbers according to the Social Security Administration (SSA).

The article offers information on a report conducted by the U.S. Government Accountability Office (GAO) on federal oversight of coordination between Medicaid and insurance exchanges. Topics discussed include health insurance to low income people of the U.S., establishment of health insurance exchanges under the Patient Protection and Affordable Care Act, and eligibility for enrolment of exchanges.

The article discusses a report from the U.S. Government Accountability Office (GAO) on private health insurance in the U.S. on premiums and plans available for individuals in 2014 and 2015. Topics discussed include provisions of the Patient Protection and Affordable Care Act (PPACA) in the establishing health insurance exchanges, PPACA's requirement to market health plans based on their metal tiers and GAO's examination of numbers of health plans and insurance premiums available to individuals.

The article discusses a report from U.S. Government Accountability Office aimed at improving eligibility verification of Medicare providers and suppliers. It mentions weaknesses in enrollment-screening procedures that implemented by the Centers for Medicare & Medicaid Services (CMS) to detect ineligible or fraudulent providers and suppliers from enrolling into Provider Enrollment, Chain and Ownership System (PECOS). It also discusses the Patient Protection & Affordable Care Act's provisions.

The article presents report of the U.S. Government Accountability Office (GAO) on what action will be needed to reduce financial incentives to prescribe 340B drugs at participating hospitals. Topics include comparing 340B hospitals with non-340B hospitals in terms of financial characteristics, comparing spending for Medicare Part B drugs at 340B hospitals for oncology drugs, and analysing data of Health Resources and Services Administration (HRSA) to compare Medicare Part B drug spending.

The article focuses on a report issued by the U.S. Government Accountability Office (GAO) regarding coverage of services and costs in the selected State Children's Health Insurance Program (CHIP) and private qualified health plans (QHP). It mentions that high enrollment was considered for selecting CHIP plan while QHP selection was based on low premiums. It informs that technical comments are provided on GAO's report by the U.S. Health and Human Services.

The article presents the review of the U.S. health insurance coverage done by the U.S. Government Accountability Office (GAO), after the mandation by the U.S. Patient Protection and Affordable Care Act (PPACA). It states that GAO examined the impact of the advance premium tax credit (APTC) on the U.S. health reforms and interviewed the members of the U.S. Department of Health and Human Services (HHS) and the U.S. Internal Revenue Service (IRS) regarding the same.

The article focuses on the use of several types of information technology (IT) systems to support efforts to prevent and detect the improper payments. Ten U.S. states had implemented a Medicaid Management Information System (MMIS) for processing claims to support their program integrity efforts, and 7 states had implemented additional types of systems for specific needs.

The article reports that the U.S. Government Accountability Office (GAO) examined improper payments in TRICARE health program of the U.S Department of Defense and Medicare. It is mentioned that improper payments result in excess medical care costs. GAO recommends that the U.S. Department of Defense needs to implement more effective TRICARE improper payment measurement methods which should include medical record reviews.

The article presents a study by the U.S. Government Accountability Office (GAO) which discusses considerations related to cost, coverage, and access in the U.S. Children's Health Insurance Program (CHIP) for extending federal funding for the program. The study mentions that CHIP plans did not require the payment of deductibles. Also the study finds that CHIP enrollees generally reported having access to health care at rates comparable to children with private insurance.

The article discusses U.S. Dept. of Health & Human Services' (HHS) approval for Arkansas's Medicaid expansion waiver as of August 2014. The topics discussed include testing and evaluation of new approaches for delivering and financing the Medicaid services, Arkansas' proposal to enable beneficiaries purchase private insurance through the state's health insurance exchange. Also discussed are HHS's approved spending limit for the proposal.

The article discusses the preliminary findings of the undercover testing by the U.S. Government Accountability Office (GAO) of enrollment controls for health care coverage and consumer subsidies provided by the U.S. Centers for Medicare and Medicaid Services (CMS) under the U.S. Patient Protection and Affordable Care Act. The undercover testing focused on identify- and income-verification of health insurance applicants. It says that GAO is expected to publish a final report of results in 2015.

A report to the U.S. Congressional Committees by the U.S. Government Accountability Office entitled "Comparisons of Selected Services under Fee-for Service, Managed Care, and Private Insurance" is presented. Topics discussed include a comparison between payments to physicians under Medicaid fee-for-service and private insurance due to the Health Care and Education Act of 2010, variation in relative payments across states, and a list of 26 selected evaluation and management services.

The article offers information on the evaluation of the U.S. Government Accountability Office (GAO) on the spina bifida health care benefit administration by the Department of Veterans Affairs' (VA) Veterans Health Administration (VHA). Topics discussed include the effort of VHA to inform key stakeholders about the available benefits, health care claims, and recommendations for action.

The article presents a study conducted by the U.S. Government Accountability Office (GAO) on the effects of acquiring prior health insurance coverage on beneficiaries of Medicare. Several factors are evaluated which include program spending, health status of beneficiaries and Medicare's health services. A multivariate analysis was utilized through the data released by the Health and Retirement Study and Medicare.

The article provides information on the medicare expenditures for Part B drugs in the U.S. in 2010. It mentions that unlike Medicare Part D, Part B covers drugs that are commonly administered by a physician or under a physician's close supervision, such as chemotherapy drugs, and it may be expensive for the Medicare program. It provides information on five highest-expenditure medicare Part B Drugs in 2010.

The article presents a report issued by the U.S. Government Accountability Office (GAO) regarding the additional data of the enrollment and expenditure for the transitional medical assistance (TMA) program as of December 2012. It states that the TMA is a Medicaid program that offers up to 1 year of additional Medicaid health insurance benefits to certain low-income families. Two charts are also provided which show the program's enrollment and expenditures in every state from 2006 to 2011.

The article offers reasons why the Government Accountability Office (GAO) designated Medicaid and Medicare as high risk in the U.S. The agency rated Medicare as high-risk in 1990 due to its intricacy as well as its vulnerability to improper payments, thereby making it difficult to manage. Meanwhile, it also designated Medicaid as high-risk due to its size, diverse programs, growth and fiscal oversight adequacy.

The article discusses a report regarding Medicaid and the Children's Health Insurance Program (CHIP) in the U.S. It mentions that millions of children do not have health insurance coverage even though they are eligible for CHIP so the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) provide states with tools such as Express Lane Eligibility (ELE) which allows states to determine eligibility for children in Medicaid or CHIP. INSET: Louisiana's Express Lane Eligibility Implementation.

The article discusses a report related to the U.S. health insurance which has been prepared by the U.S. Government Accountability Office (GAO). It informs that annual audits and reports for disproportionate share hospital (DSH) payments can help the Centers for Medicare and Medicaid Services (CMS) in the estimation of Medicaid. It further states that the report has been presented to the U.S. Committee on Finance.

The article suggest the need to modify the models developed to test approaches for delivering or paying for grant of Medicare and Medicaid health insurance in the U.S. It mentions that the developed model requires co-ordination between the staff of the U.S. Centers for Medicare & Medicaid Services for effective implementation of the models. It mentions that the evaluation of the various health insurance scheme include assessment of cost of health insurance and quality of medical care.

The article offers information regarding amendments in rules for beneficiary eligibility verification by the U.S. Centers for Medicare and Medicaid Services. It presents four parts for Medicare which includes payment for inpatient hospital, durable medical equipment and private health plans. It discusses implementation of Health Insurance Portability and Accountability Act of 1996 (HIPAA) Eligibility Transaction System.

The article explores the use managed care in U.S. states. As a joint federal-state program that finances low-income individual's health insurance, the Medicaid program is an important source of healthcare coverage for its about 67 million beneficiaries. Colorado, Florida and Kansas are among those states that are using both the managed care organizations (MCO) and primary care case management (PCCM) programs. Southern U.S. was where Medicaid expansion index values were largely concentrated.

The article presents a report from the U.S. Government Accountability Office (GAO) that outlines the information about the variations of applicants' assets in Medicare long-term care. It notes that every state must balance the costs of eligibility determination efforts and to adhere to a risk-based approach. The importance of the electronic asset verification system (AVS) to help in identifying unreported or transferred assets is also emphasized.

The article offers information regarding the U.S. Government Accountability Office (GAO) report on Medicaid supplemental payments during fiscal year 2010. It discusses expenditure reports obtained from federal funds filed with the U.S Department of Health and Human Services (HHS) the U.S. Centers for Medicare and Medicaid Services (CMS). It states that the GAO designated Medicaid a high-risk program because of its inadequate fiscal oversight which cost dollar 383 billion in fiscal year2010.