Medicare

Health Hippo: Medicare

US CODE || CFR || CASES || REPORTS || CONGRESSIONAL RECORD || BILLS || FEDERAL REGISTER

Sleep and watchfulness, both of them, when immoderate, constitute disease.

The Medicare program was signed into law on July 30, 1965 by President Lyndon B. Johnson to provide health insurance for the elderly and disabled. Medicare’s early days were within the Social Security Administration, until it was combined with Medicaid into one agency under the Department of Health and Human Services in 1977. Medicare spending currently accounts for more than 15% of the federal budget, but is expected to exceed 1 trillion dollars and 20% of the budget in the next decade.

The Medicare Modernization Act (MMA), was signed into law on December 8, 2003. The MMA added prescription drug benefits to Medicare, revamped the managed care program, added important rural health protections and strengthened the program through cost containment and fraud and abuse provisions. The program is currently divided into four parts: Part A (hospital insurance), Part B (outpatient services and medical supplies/equipment), Part C (managed care), and Part D (prescription drugs).

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U.S. Code

• Protecting Access to Medicare Act of 2014 The 2014 “doc fix”. Includes another short-term fix to the SGR, as well as provisions with significant impact on providers and suppliers, including: clinical laboratories, skilled nursing facilities, hospitals, community mental health centers and dialysis providers. The law extends the current moratorium on RAC audits of hospital inpatient stays through March 31, 2015.

• Medicare IVIG Access and Strengthening Medicare and Repaying Taxpayers Act of 2012
  (coverage for in-home administration of intravenous immune globulin
  (IVIG) and amends the Social Security Act with respect to the application of Medicare secondary
  payer rules).
  • Sec. 101 Medicare Patient IVIG Access
    Demonstration Project.
  • Sec. 201 Determination of Reimbursement Amount Through CMS
    Website to Improve Program Efficiency.
  • Sec. 202 Fiscal Efficiency and Revenue
    Neutrality.
  • Sec. 203 Reporting Requirement.
  • Sec.
    204 Use of Social Security Numbers and Other Identifying Information in Reporting.
  • Sec. 205 Statute of Limitations.

• Health Care and Education Reconciliation Act: Medicare
  • Sec. 1101. Closing the medicare prescription drug donut hole.
  • Sec. 1102. Medicare Advantage payments.
  • Sec. 1103. Savings from limits on MA plan administrative costs.
  • Sec. 1302. Medicare prepayment medical review limitations.
  • Sec. 1402. Unearned income Medicare contribution.
  • Sec. 1407. Delay of elimination of deduction for expenses allocable to medicare part D subsidy.

• Affordable Care Act: Medicare Provisions.
  • Sec. 3401. Revision of certain market basket updates and incorporation of productivity improvements into market basket updates that do not already incorporate such improvements.
  • Sec. 3402. Temporary adjustment to the calculation of part B premiums.
  • Sec. 3403. Independent Medicare Advisory Board.
  • Sec. 4104. Removal of barriers to preventive services in Medicare.
  • Sec. 4103. Medicare coverage of annual wellness visit providing a personalized prevention plan.
  • Sec. 4105. Evidence-based coverage of preventive services in Medicare.
  • Sec. 10307. Improvements to the Medicare shared savings program.
  • Sec. 10320. Expansion of the scope of, and additional improvements to, the Independent Medicare Advisory Board.
  • Sec. 10323. Medicare coverage for individuals exposed to environmental health hazards.
  • Sec. 10330. Modernizing computer and data systems of the Centers for Medicare & Medicaid services to support improvements in care delivery.
  • Sec. 10402. Amendments to subtitle B.
    • Preventive physical examination

• Balanced Budget
  Act
  • Sec. 4103 Prostate cancer screening tests.
  • Sec. 4104 Coverage of colorectal screening.
  • Sec. 4105 Diabetes self-management benefits.
  • Sec. 4106 Standardization of medicare coverage of bone mass measurements.
  • Sec. 4108 Study on preventive and enhanced benefits.
  • Sec. 4631 Permanent extension and revision of certain secondary payer
    provisions.

  • Sec. 4632 Clarification of time and filing limitations.
  • Sec. 4633 Permitting recovery against third party administrators.
  • Sec. 4641 Placement of advance directive in medical record.
  • Sec. 4642 Increased certification period for certain organ procurement
    organizations.

  • Sec. 4643 Office of the Chief Actuary in the Health Care Financing
    Administration.

  • Sec. 4644 Conforming amendments to comply with congressional review of
    agency rulemaking.

• 42 USC CHAPTER 7
  SOCIAL SECURITY BENEFITS
  • Subchapter II FEDERAL OLD-AGE, SURVIVORS, AND DISABILITY INSURANCE BENEFITS
    • 42 USC Sec. 405. Evidence, procedure, and certification for payments.
    • 42 USC Sec. 426. Entitlement to hospital insurance benefits.
    • 42 USC Sec. 426a. Transitional provision of eligibility of uninsured individuals for hospital insurance benefits.
  • Subchapter XVIII HEALTH INSURANCE FOR AGED AND DISABLED
    • Part A Hospital Insurance Benefits for Aged and Disabled (1395c–1395i5)
    • Part B Supplementary Medical Insurance Benefits for Aged and Disabled (1395j–1395w5)
    • Part C Medicare Choice Program (1395w21–1395w29)
    • Part D Voluntary Prescription Drug Benefit Program (1395w101–1395w154)
    • Part E Miscellaneous Provisions (1395x–1395kkk1)
    • Sec. 1395 Prohibition against any Federal interference
    • Sec. 1395a Free choice by patient guaranteed
    • Sec. 1395b Option to individuals to obtain other health insurance protection
    • Sec. 1395b-1 Incentives for economy while maintaining or improving quality in provision of health services
    • Sec. 1395b-2 Notice of medicare benefits; medicare and medigap information
    • Sec. 1395b-3 Health insurance advisory service for medicare beneficiaries
    • Sec. 1395b-4 Health insurance information, counseling, and assistance grants
    • Sec. 1395b-5 Beneficiary incentive programs
    • Sec. 1395b-6 Medicare Payment Advisory Commission
    • Sec. 1395b-7 Explanation of medicare benefits
    • Sec. 1395b-8 Chronic care improvement
    • Sec. 1395b-9 Provisions relating to administration
    • Sec. 1395b-10 Addressing health care disparities

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Code of Federal
Regulations

• 42 CFR CHAPTER IV, SUBCHAPTER B MEDICARE PROGRAM
  • PART 405 FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED (405.201 – 405.2472)
    • SUBPART A [Reserved]
    • SUBPART B Medical Services Coverage Decisions
      That Relate to Health Care Technology (405.201 – 405.215)
      • Sec. 405.201 Scope of subpart and
        definitions.
      • Sec. 405.203 FDA categorization of
        investigational devices.
      • Sec. 405.205 Coverage of
        a non-experimental/investigational (Category B) device.
      • Sec. 405.207 Services related to a noncovered device.
      • Sec. 405.209 Payment for a
        non-experimental/investigational (Category B) device.
      • Sec. 405.211 Procedures for Medicare contractors in
        making coverage decisions for a non-experimental/investigational (Category B) device.
      • Sec. 405.213 Re-evaluation of a device categorization.
      • Sec. 405.215 Confidential commercial and trade
        secret information.
    • SUBPART C
      Suspension of Payment, Recovery of Overpayments, and Repayment of Scholarships and Loans (405.301 – 405.380)
    • SUBPART D Private Contracts (405.400 –
      405.455)
    • SUBPART E Criteria for Determining Reasonable Charges (405.500 – 405.535)
    • SUBPART F-G [Reserved]
    • SUBPART H Appeals Under the Medicare Part B
      Program (405.800 – 405.818)
    • SUBPART I
      Determinations, Redeterminations, Reconsiderations, and Appeals Under Original Medicare (Part A and Part B) (405.900 – 405.1140)
      • Sec. 405.900 Basis and scope.
      • Sec. 405.902 Definitions.
      • Sec. 405.904 Medicare initial determinations,
        redeterminations and appeals: General description.
      • Sec. 405.906 Parties to the initial determinations,
        redeterminations, reconsiderations, hearings and reviews.
      • Sec. 405.908 Medicaid State agencies.
      • Sec. 405.910 Appointed representatives.
      • Sec. 405.912 Assignment of appeal rights.
      • Sec. 405.920 Initial determinations.
      • Sec. 405.921 Notice of initial determination.
      • Sec. 405.922 Time frame for processing initial determinations.
      • Sec. 405.924 Actions that are initial determinations.
      • Sec. 405.925 Decisions of utilization review committees.
      • Sec. 405.926 Actions that are not initial determinations.
      • Sec. 405.927 Initial determinations subject to the reopenings process.
      • Sec. 405.928 Effect of the initial determination.
      • Sec. 405.940 Redeterminations.
      • Sec. 405.942 Time frame for filing a request for a
        redetermination.
      • Sec. 405.944 Place and method of filing a request for a redetermination.
      • Sec. 405.946 Evidence to be submitted with the redetermination request.
      • Sec. 405.948 Conduct of a redetermination.
      • Sec. 405.950 Time frame for making a redetermination.
      • Sec. 405.952 Withdrawal or dismissal of a request
        for a redetermination.
      • Sec. 405.954 Redetermination.
      • Sec. 405.956 Notice of a redetermination.
      • Sec. 405.958 Effect of a
        redetermination.
      • Sec. 405.960 Reconsiderations.
      • Sec. 405.962 Timeframe for filing a request for a reconsideration.
      • Sec. 405.964 Place and method of filing a request for a
        reconsideration.
      • Sec. 405.966 Evidence to be submitted with the reconsideration request.
      • Sec. 405.968 Conduct of a reconsideration.
      • Sec. 405.970 Timeframe for making a reconsideration.
      • Sec. 405.972 Withdrawal or dismissal of a request for a
        reconsideration.
      • Sec. 405.974 Reconsideration.
      • Sec. 405.976 Notice of a reconsideration.
      • Sec. 405.978 Effect of a reconsideration.
      • Sec. 405.980 Reopenings.
      • Sec. 405.982 Notice of a revised determination or
        decision.
      • Sec. 405.984 Effect of a revised
        determination or decision.
      • Sec. 405.986 Good
        cause for reopening.
      • Sec. 405.990 Expedited access to judicial review.
      • Sec. 405.1000 Hearings before an ALJ.
      • Sec. 405.1002 Right to an ALJ hearing.
      • Sec. 405.1004 Right to ALJ review of QIC notice of dismissal.
      • Sec. 405.1006 Amount in controversy required to request an ALJ hearing and judicial review.
      • Sec. 405.1008 Parties to an ALJ hearing.
      • Sec. 405.1010 When CMS or its contractors may
        participate in an ALJ hearing.
      • Sec. 405.1012 When CMS or its contractors may be a party to a hearing.
      • Sec. 405.1014 Request for an ALJ hearing.
      • Sec. 405.1016 Time frames for deciding an appeal before
        an ALJ.
      • Sec. 405.1018 Submitting evidence before the ALJ hearing.
      • Sec. 405.1020 Time and place for a hearing before an ALJ.
      • Sec. 405.1022 Notice of a hearing before an ALJ.
      • Sec. 405.1024 Objections to the issues.
      • Sec. 405.1026 Disqualification of the ALJ.
      • Sec. 405.1028 Prehearing case review of evidence submitted to the ALJ.
      • Sec. 405.1030 ALJ hearing procedures.
      • Sec. 405.1032 Issues before an ALJ.
      • Sec. 405.1034 When an ALJ may remand a case to the QIC.
      • Sec. 405.1036 Description of an ALJ hearing
        process.
      • Sec. 405.1037 Discovery.
      • Sec. 405.1038 Deciding a case without a hearing before
        an ALJ.
      • Sec. 405.1040 Prehearing and posthearing
        conferences.
      • Sec. 405.1042 The administrative
        record.
      • Sec. 405.1044 Consolidated hearing
        before an ALJ.
      • Sec. 405.1046 Notice of an ALJ
        decision.
      • Sec. 405.1048 The effect of an ALJ’s
        decision.
      • Sec. 405.1050 Removal of a hearing
        request from an ALJ to the MAC.
      • Sec. 405.1052 Dismissal of a request for a hearing before an ALJ.
      • Sec. 405.1054 Effect of dismissal of a request for a
        hearing before an ALJ.
      • Sec. 405.1060 Applicability of national coverage
        determinations (NCDs).
      • Sec. 405.1062 Applicability of local coverage determinations and other policies not binding on the ALJ and MAC.
      • Sec. 405.1063 Applicability of laws, regulations and
        CMS Rulings.
      • Sec. 405.1064 ALJ decisions
        involving statistical samples.
      • Sec. 405.1100 Medicare Appeals Council review.
      • Sec. 405.1102 Request for MAC review when ALJ
        issues decision or dismissal.
      • Sec. 405.1104
        Request for MAC review when an ALJ does not issue a decision timely.
      • Sec. 405.1106 Where a request for review or escalation
        may be filed.
      • Sec. 405.1108 MAC actions when
        request for review or escalation is filed.
      • Sec.
        405.1110 MAC reviews on its own motion.
      • Sec.
        405.1112 Content of request for review.
      • Sec.
        405.1114 Dismissal of request for review.
      • Sec.
        405.1116 Effect of dismissal of request for MAC review or request for hearing.
      • Sec. 405.1118 Obtaining evidence from the MAC.
      • Sec. 405.1120 Filing briefs with the MAC.
      • Sec. 405.1122 What evidence may be submitted to the
        MAC.
      • Sec. 405.1124 Oral argument.
      • Sec. 405.1126 Case remanded by the MAC.
      • Sec. 405.1128 Action of the MAC.
      • Sec. 405.1130 Effect of the MAC’s decision.
      • Sec. 405.1132 Request for escalation to Federal court.
      • Sec. 405.1134 Extension of time to file action
        in Federal district court.
      • Sec. 405.1136
        Judicial review.
      • Sec. 405.1138 Case remanded by
        a Federal district court.
      • Sec. 405.1140 MAC
        review of ALJ decision in a case remanded by a Federal district court.
    • SUBPART J Expedited Determinations and
      Reconsiderations of Provider Service Terminations, and Procedures for Inpatient Hospital Discharges (405.1200 –
      405.1208)
      • Sec. 405.1200 Notifying beneficiaries of
        provider service terminations.
      • Sec. 405.1202
        Expedited determination procedures.
      • Sec. 405.1204
        Expedited reconsiderations.
      • Sec. 405.1205
        Notifying beneficiaries of hospital discharge appeal rights.
      • Sec. 405.1206 Expedited determination procedures for
        inpatient hospital care.
      • Sec. 405.1208 Hospital
        requests expedited QIO review.
    • SUBPART K-Q [Reserved]
    • SUBPART R Provider Reimbursement
      Determinations and Appeals (405.1801 – 405.1889)
    • SUBPART S-T [Reserved]
    • SUBPART U Conditions for Coverage of
      Suppliers of End-Stage Renal Disease (ESRD) Services (405.2100-405.2101 – 405.2131-405.2184)
    • SUBPART V-W [Reserved]
    • SUBPART
      X Rural Health Clinic and Federally Qualified Health Center Services (405.2400 – 405.2472)

  • PART 406 HOSPITAL INSURANCE ELIGIBILITY AND
    ENTITLEMENT (406.1 – 406.52)
    • SUBPART A General Provisions (406.1 – 406.7)
      • Sec. 406.1 Statutory basis.
      • Sec. 406.2 Scope.
      • Sec. 406.3 Definitions.
      • Sec. 406.5 Basis of eligibility and entitlement.
      • Sec. 406.6 Application or enrollment for hospital insurance.
      • Sec. 406.7 Forms to apply for entitlement under Medicare Part A.
    • SUBPART B Hospital Insurance Without Monthly Premiums (406.10 – 406.15)
      • Sec. 406.10 Individual age 65 or over who is entitled to social security or railroad retirement benefits, or who is eligible for social security benefits.
      • Sec. 406.11 Individual age 65 or over who is not eligible as a social security or railroad retirement benefits beneficiary, or on the basis of government employment.
      • Sec. 406.12 Individual under age 65 who is entitled to social security or railroad retirement disability benefits.
      • Sec. 406.13 Individual who has end-stage renal disease.
      • Sec. 406.15 Special provisions applicable to Medicare qualified government employment.
    • SUBPART C Premium Hospital Insurance (406.20 – 406.38)
      • Sec. 406.20 Basic requirements.
      • Sec. 406.21 Individual enrollment.
      • Sec. 406.22 Effect of month of enrollment on entitlement.
      • Sec. 406.24 Special enrollment period related to coverage under group health plans.
      • Sec. 406.25 Special enrollment period for volunteers outside the United States.
      • Sec. 406.26 Enrollment under State buy-in.
      • Sec. 406.28 End of entitlement.
      • Sec. 406.32 Monthly premiums.
      • Sec. 406.33 Determination of months to be counted for premium increase: Enrollment.
      • Sec. 406.34 Determination of months to be counted for premium increase: Reenrollment.
      • Sec. 406.38 Prejudice to enrollment rights because of Federal Government error.
    • SUBPART D Special Circumstances That Affect Entitlement to Hospital Insurance (406.50 – 406.52)
      • Sec. 406.50 Nonpayment of benefits on behalf of certain aliens.
      • Sec. 406.52 Conviction of certain offenses.
  • PART 407
    SUPPLEMENTARY MEDICAL INSURANCE (SMI) ENROLLMENT AND ENTITLEMENT (407.1 – 407.50)
  • PART 408 PREMIUMS FOR SUPPLEMENTARY MEDICAL INSURANCE
    (408.1 – 408.210)
  • PART 409 HOSPITAL INSURANCE
    BENEFITS (409.1 – 409.102)
    • SUBPART A Hospital Insurance
      Benefits: General Provisions (409.1 – 409.5)
    • SUBPART B Inpatient Hospital Services and
      Inpatient Critical Access Hospital Services (409.10 – 409.18)
    • SUBPART C Posthospital SNF Care (409.20 –
      409.27)
    • SUBPART D Requirements for
      Coverage of Posthospital SNF Care (409.30 – 409.36)
      • Sec. 409.30 Basic requirements.
      • Sec. 409.31 Level of care requirement.
      • Sec. 409.32 Criteria for skilled services and the need
        for skilled services.
      • Sec. 409.33 Examples of
        skilled nursing and rehabilitation services.
      • Sec.
        409.34 Criteria for daily basis.
      • Sec. 409.35
        Criteria for practical matter.
      • Sec. 409.36 Effect
        of discharge from posthospital SNF care.
    • SUBPART E Home Health Services Under
      Hospital Insurance (409.40 – 409.50)
      • Sec. 409.40 Basis, purpose, and scope.
      • Sec. 409.41 Requirement for payment.
      • Sec. 409.42 Beneficiary qualifications for coverage of
        services.
      • Sec. 409.43 Plan of care requirements.
      • Sec. 409.44 Skilled services requirements.
      • Sec. 409.45 Dependent services requirements.
      • Sec. 409.46 Allowable administrative costs.
      • Sec. 409.47 Place of service requirements.
      • Sec. 409.48 Visits.
      • Sec. 409.49 Excluded services.
      • Sec. 409.50 Coinsurance for durable medical equipment
        (DME) furnished as a home health service.
    • SUBPART F Scope of Hospital Insurance
      Benefits (409.60 – 409.68)
    • SUBPART G
      Hospital Insurance Deductibles and Coinsurance (409.80 – 409.89)
    • SUBPART H Payment of Hospital Insurance
      Benefits (409.100 – 409.102)
  • PART 410 SUPPLEMENTARY MEDICAL INSURANCE (SMI)
    BENEFITS (410.1 – 410.175)
  • PART 411 EXCLUSIONS
    FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT (411.1 – 411.408)
    • SUBPART A General Exclusions and
      Exclusion of Particular Services (411.1 – 411.15)
      • Sec. 411.15 Particular services excluded from coverage.
  • PART 412 PROSPECTIVE PAYMENT SYSTEMS FOR
    INPATIENT HOSPITAL SERVICES (412.1 – 412.632)
  • PART
    413 PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; OPTIONAL
    PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES (413.1 – 413.355)
  • PART 414 PAYMENT FOR PART B MEDICAL AND OTHER HEALTH
    SERVICES (414.1 – 414.1105)
    • SUBPART A General Provisions
      (414.1 – 414.4)
    • SUBPART B Physicians
      and Other Practitioners (414.20 – 414.92)
    • SUBPART C Fee Schedules for Parenteral and
      Enteral Nutrition (PEN) Nutrients, Equipment and Supplies (414.100 – 414.104)
    • SUBPART D Payment for Durable Medical
      Equipment and Prosthetic and Orthotic Devices (414.200 – 414.232)
    • SUBPART E Determination of Reasonable Charges
      Under the ESRD Program (414.300 – 414.335)
    • SUBPART F Competitive Bidding for Certain
      Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) (414.400 – 414.426)
    • SUBPART G Payment for New Clinical Diagnostic
      Laboratory Tests (414.500 – 414.510)
    • SUBPART H Fee Schedule for Ambulance Services
      (414.601 – 414.625)
    • SUBPART I Payment
      for Drugs and Biologicals (414.701 – 414.707)
    • SUBPART J Submission of Manufacturer’s
      Average Sales Price Data (414.800 – 414.806)
    • SUBPART K Payment for Drugs and Biologicals
      Under Part B (414.900 – 414.930)
    • SUBPART
      L Supplying and Dispensing Fees (414.1000 – 414.1001)
    • SUBPART M Payment for Comprehensive
      Outpatient Rehabilitation Facility (CORF) Services (414.1100 – 414.1105)
  • PART 415 SERVICES FURNISHED BY PHYSICIANS IN
    PROVIDERS, SUPERVISING PHYSICIANS IN TEACHING SETTINGS, AND RESIDENTS IN CERTAIN SETTINGS (415.1 – 415.208)
  • PART 416 AMBULATORY SURGICAL SERVICES (416.1 – 416.200)
  • PART 417 HEALTH MAINTENANCE ORGANIZATIONS,
    COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS (417.1 – 417.940)
  • PART 418 HOSPICE CARE (418.1 – 418.405)
    • SUBPART A General Provision and
      Definitions (418.1 – 418.3)
    • SUBPART B
      Eligibility, Election and Duration of Benefits (418.20 – 418.30)
    • SUBPART C Conditions of Participation:
      Patient Care (418.52 – 418.78)
    • SUBPART
      D Conditions of participation: Organizational Environment (418.100 – 418.116)
    • SUBPART E
      [Reserved]
    • SUBPART F Covered Services
      (418.200 – 418.205)
    • SUBPART G Payment
      for Hospice Care (418.301 – 418.311)
    • SUBPART H Coinsurance (418.400 –
      418.405)
  • PART 419 PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL
    OUTPATIENT DEPARTMENT SERVICES (419.1 – 419.70)
  • PART
    420 PROGRAM INTEGRITY: MEDICARE (420.1 – 420.410)
    • SUBPART A General Provisions
      (420.1 – 420.3)
    • SUBPART B [Reserved]
    • SUBPART C Disclosure of Ownership and Control
      Information (420.200 – 420.206)
    • SUBPART
      D Access to Books, Documents, and Records of Subcontractors (420.300 – 420.304)
    • SUBPART E Rewards for Information Relating to
      Medicare Fraud and Abuse, and Establishment of a Program to Collect Suggestions for Improving Medicare Program
      Efficiency and to Reward Suggesters for Monetary Savings (420.400 – 420.410)
  • PART 421 MEDICARE CONTRACTING (421.1 – 421.505)
  • PART 422 MEDICARE ADVANTAGE PROGRAM (422.1 –
    422.2276)
    • SUBPART A General Provisions
      (422.1 – 422.6)
    • SUBPART B Eligibility,
      Election, and Enrollment (422.50 – 422.74)
    • SUBPART C Benefits and Beneficiary
      Protections (422.100 – 422.133)
    • SUBPART
      D Quality Improvement (422.152 – 422.158)
    • SUBPART E Relationships With Providers
      (422.200 – 422.220)
    • SUBPART F
      Submission of Bids, Premiums, and Related Information and Plan Approval (422.250 – 422.270)
    • SUBPART G Payments to Medicare Advantage
      Organizations (422.300 – 422.324)
    • SUBPART
      H Provider-Sponsored Organizations (422.350 – 422.390)
    • SUBPART I Organization Compliance With State
      Law and Preemption by Federal Law (422.400 – 422.404)
    • SUBPART J Special Rules for MA Regional Plans
      (422.451 – 422.458)
    • SUBPART K
      Application Procedures and Contracts for Medicare Advantage Organizations (422.500 – 422.527)
    • SUBPART L Effect of Change of Ownership or
      Leasing of Facilities During Term of Contract (422.550 – 422.553)
    • SUBPART M Grievances, Organization
      Determinations and Appeals (422.560 – 422.626)
    • SUBPART N Medicare Contract Determinations
      and Appeals (422.641 – 422.696)
    • SUBPART
      O Intermediate Sanctions (422.750 – 422.764)
    • SUBPART P [Reserved]
    • SUBPART T Appeal procedures for Civil Money
      Penalties (422.1000 – 422.1094)
    • SUBPART
      V Medicare Advantage Marketing Requirements (422.2260 – 422.2276)
  • PART 423 VOLUNTARY MEDICARE PRESCRIPTION DRUG
    BENEFIT (423.1 – 423.2345)
    • SUBPART A General Provisions
      (423.1 – 423.6)
    • SUBPART B Eligibility
      and Enrollment (423.30 – 423.56)
    • SUBPART
      C Benefits and Beneficiary Protections (423.100 – 423.136)
    • SUBPART D Cost Control and Quality
      Improvement Requirements (423.150 – 423.171)
    • SUBPART E [Reserved]
    • SUBPART F Submission of Bids and Monthly
      Beneficiary Premiums; Plan Approval (423.251 – 423.293)
    • SUBPART G Payments to Part D Plan Sponsors
      For Qualified Prescription Drug Coverage (423.301 – 423.350)
    • SUBPART H [Reserved]
    • SUBPART I Organization Compliance with State
      Law and Preemption by Federal Law (423.401 – 423.440)
    • SUBPART J Coordination of Part D Plans With
      Other Prescription Drug Coverage (423.452 – 423.466)
    • SUBPART K Application Procedures and
      Contracts with Part D plan sponsors (423.500 – 423.520)
    • SUBPART L Effect of Change of Ownership or
      Leasing of Facilities During Term of Contract (423.551 – 423.553)
    • SUBPART M Grievances, Coverage
      Determinations, Redeterminations, and Reconsiderations (423.558 – 423.638)
    • SUBPART N Medicare Contract Determinations
      and Appeals (423.641 – 423.668)
    • SUBPART
      O Intermediate Sanctions (423.750 – 423.764)
    • SUBPART P Premiums and Cost-Sharing Subsidies
      for Low-Income Individuals (423.771 – 423.800)
    • SUBPART Q Guaranteeing Access to a Choice of
      Coverage (Fallback Prescription Drug Plans) (423.851 – 423.875)
    • SUBPART R Payments to Sponsors of Retiree
      Prescription Drug Plans (423.880 – 423.894)
    • SUBPART S Special Rules for
      States-Eligibility Determinations for Subsidies and General Payment Provisions (423.900 – 423.910)
    • SUBPART T Appeal Procedures for Civil Money
      Penalties (423.1000 – 423.1094)
    • SUBPART
      U Reopening, ALJ Hearings, MAC review, and Judicial Review (423.1968 – 423.2140)
    • SUBPART V Part D Marketing Requirements
      (423.2260 – 423.2276)
    • SUBPART W
      Medicare Coverage Gap Discount Program (423.2300 – 423.2345)
  • PART 424 CONDITIONS FOR MEDICARE PAYMENT (424.1
    – 424.570)
  • PART 425 MEDICARE SHARED SAVINGS
    PROGRAM (425.10 – 425.810)
  • PART 426 REVIEW OF
    NATIONAL COVERAGE DETERMINATIONS AND LOCAL COVERAGE DETERMINATIONS (426.100 – 426.587)

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Cases

Entitlement

• NCD 140.3: Transsexual Surgery (2014)(National Coverage Determination (NCD) denying Medicare coverage of all transsexual surgery as a treatment for transsexualism is not valid under the “reasonableness standard”)
• In the Case of Y.H.
  (February 22, 2010) (the purported statements of an employee in the administrative office of a U.S. Post Office are
  insufficient, standing alone, to warrant equitable relief from a Part B premium surcharge for late enrollment in
  the Medicare Supplementary Medicare Insurance program).
• In the Case of F.C. (October 21,
  2009) (current employment, for the purpose of enrolling in Medicare Part B during a special enrollment period, is
  when an individual is actively working as an employee or has a business relationship with an employer).
• In the Case of J.B.K. (November
  18, 2009) (equitable relief from a premium penalty for delayed enrollment is not available due to non-action by a
  non-federal entity).
• In the
  Case of J.J.K. (October 9, 2009) (the beneficiary is not entitled to withdrawal from Medicare Part A hospital
  insurance and be paid only monthly retirement benefits).
• In the Case of D.B. (December
  15, 2009) (the beneficiary is not entitled to equitable relief as the evidence indicates the beneficiary chose not
  to enroll in Medicare Part B due to incorrect information she provided about her spouse’s group health insurance
  plan, not due to misrepresentation from the Social Security Administration).

Secondary Payer

• In the Case of E.M.P. (June
  28, 2011) (the Council orders three charges removed from the Medicare lien assessed against the appellant, noting
  that the ICD identifies a condition while the HCPCS identifies a treatment for that condition).
• In the Case of F.G.
  (October 20, 2010) (A settling party must consider Medicare’s right of recovery when negotiating a settlement
  amount).
• In the Case of
  M.B.C. (March 19, 2010) (the beneficiary is not liable for Medicare payments for treatment associated with a
  lower back injury under the Medicare Secondary Payer Act as the evidence of record shows these treatments are
  unrelated to the cervical spine injuries that resulted in a workers’ compensation settlement).
• In the Case of W.G. (November
  10, 2009) (the beneficiary is required to repay the conditional payments made on her behalf for medical treatment
  following an automobile accident as all medical expenses are presumptively included in a settlement amount).
• In the Case of A.H. (November 6,
  2009) (Medicare is entitled to recover from settlement proceeds without regard to how the settlement agreement
  stipulates disbursement should be made, even if the parties agreed that a portion of the settlement proceeds are
  unrelated to the accident or injury).

Overpayment

• In the Case of Discount
  Diabetic (June 29, 2012) (The Council determined that pursuant to section 1870(b) of the Act, the appellant is
  waived from recovery of the overpayment).
• In the Case of Steven Kalter,
  M.D. (August 11, 2011) (a contractor only needs to account for underpayments that have been uncovered as the
  result of an audit when calculating an overpayment, it need not actively pursue underpayments).
• In the Case of
  Charles Stockwell, O.D. (February 14, 2011) (Prior to applying the waiver provisions of sections 1879 and 1870,
  the ALJ should have first determined whether services provided to the beneficiaries in each case met the coverage
  provisions of the Act).
• In the Case of
  The Endocrine Clinic, P.C. (November 10, 2010) (While the appellant contends that the Medicare contractor erred
  in recalculating Medicare’s overpayment following the ALJ’s decision, the regulations contemplate that an ALJ’s
  decision is not final for the purposes of determining the amount of payment due).
• In the Case of
  Excel Diagnostics, Ltd. (October 14, 2010) (Medicare payment is appropriate for diagnostic doses of Indium-111
  administered to beneficiaries during a clinical trial but payment is denied for additional therapeutic doses).
• In the Case of
  Home Care 4 U, Inc. (May 25, 2010) (overpayment cannot be sustained as a matter of due process when the PSC has
  failed to provide evidence in the record to support its finding that the treating physician did not sign the plans
  of care at issue).
• In the Case of
  American Health Network of Indiana, LLC, and Adam D. Perler, D.P.M. (February 25, 2010) (the ALJ erred in
  addressing the issues of coverage and liability when the Council had addressed these issues prior to remanding the
  case back to the ALJ to address the sole issue of whether the appellant was “without fault” under the provisions of
  section 1870(b) of the Act).
• In the Case of KGV
  Easy Leasing Corporation (February 22, 2010) (beneficiary information submitted that does not indicate that the
  referring physician was the treating physician, that the treating physician used results from diagnostic tests in
  managing the patient, or present a complete clinical picture of the medical conditions that presumptively warranted
  the testing fails to demonstrate that the claims were medically reasonable and necessary for the purposes of
  Medicare coverage).
• In the Case
  of Mid South Psychiatric Associates (December 23, 2009) (the fact that the appellant filed individual requests
  for ALJ hearing, rather than discussing the basis for re-adjudicating sampled claims in one submission, does not
  require that the appellant seek aggregation of those claims in order to exercise appeal rights of an extrapolated
  overpayment).
• In the Case of
  Lakeside Foot Clinic (October 15, 2009) (in a case arising from an overpayment based on statistical sampling,
  an appellant must be given an opportunity to challenge both the findings on the individual services reviewed in the
  sample and the sampling methodology and extrapolation).
• In the Case of Transyd
  Enterprises, LLC (September 15, 2009) (the burden is on the appellant to prove the statistical sampling
  methodology was invalid and not on the contractor to establish that it chose the most precise methodology).
• In the Case of Whidbey
  General Hospital (December 3, 2007) (the appellant had sufficient notice at the time the provider billed and
  received payment for the supplied drugs to identify the overpayments received and the recovery of the overpayment
  is not waived under section 1870(b) of the Social Security Act).
• In the Case of
  Quality Home Health Services, Inc. (September 14, 2009) (the appellant does not challenge the validity of the
  statistical sample or the extrapolation methodology but instead focuses the appellate arguments on the individual
  claims for home health services).
• In the Case of Lance E.
  Daniel, O.D. (December 3, 2009) (if, as in this case, some of the individual sample claims were wrongly denied,
  the overpayment is re-extrapolated based on the remaining denied claims in the sample).
• In the Case of
  Comprehensive Decubitus Therapy (March 13, 2009) (the supplier was without fault in creating an overpayment for
  surgical dressing based on its efforts to verify the beneficiary’s coverage status in advance of providing the
  items).

Statistical Sampling

• In the Case of Robert D.
  Lesser, M.D. & Associates (Dec. 7, 2011) (The ALJ erred by invalidating the statistical sample in this case and
  by waiving the appellant’s liability for all overpayments during the applicable time period).
• In the Case of Meridian
  Laboratory Corporation (June 24, 2011) (the appellant is obligated to provide supporting documentation to
  establish the medical necessity of the sampled claims).
• In the Case of John Sanders,
  M.D. (May 12, 2011) (the Council determines that the sampling was sufficiently flawed to preclude calculation
  of an overpayment by extrapolation and the appellant is financially liable only for the overpayments on the
  individual claims in the sample).
• In the Case of Michael King,
  M.D. and Kinston Medical Specialists, P.A. (May 10, 2011) (the Council need not find that CMS or its contractor
  undertook statistical sampling and extrapolation based on the most precise methodology that might be devised in
  order to uphold an overpayment extrapolation but instead the test is whether the methodology is statistically
  valid).
• In
  the Case of Global Home Care, Inc. (January 11, 2011) (When the record does not contain complete documentation
  to recreate the sampling frame, a provider does not have the information and data necessary to mount a due process
  challenge to the statistical validity of the sample).
• In the Case of
  Podiatric Medical Associates (June 22, 2010) (appellant was deprived of its ability to review the extrapolation
  in question when PSC failed to provide pertinent audit-related information).
• In the Case of Maxxim
  Care, EMS (February 25, 2010) (CMS or its contractor must use a statistically valid methodology for sampling
  and extrapolation, not necessarily the most precise methodology that might be devised).
• In the Case of Idaho
  Falls Chiropractic Clinic, P.L.L.C. (February 22, 2010) (in a probe review, contractors collect overpayments
  only on claims that are actually reviewed and may not extrapolate the overpayment to a universe of claims pursuant
  to the MPIM).

Hearings and Appeals Procedures

• In the Case of King’s Daughter
  Medical Center (June 26, 2012) (The Council found that the regulation on which CMS relied in its referral
  memorandum does not apply in this case and that the ALJ did not err in affording greater weight to the admitting
  physician’s decision for inpatient admission).
• In the Case of Spokane
  Washington Hospital Company (June 19, 2012) (The Council declined to review the ALJ’s decision because,
  contrary to CMS’s assertion, there were no errors of law material to the outcome of the case).
• In the Case of Nizhoni Health
  Systems (June 1, 2012) (The Council remanded because the ALJ failed to notify the provider of the home health
  services at issue of the proceedings at the ALJ level and provide it with an opportunity to participate).
• In the Case of Eagle Air
  Medical Corporation (April 12, 2012) (remanding where the beneficiary did not receive notice of the appeals
  proceeding that took place after the QIC’s review).
• In the Case of Cashflow
  Solutions, Inc. (April 6, 2012) (adding claims at the ALJ level that have not been adjudicated at lower appeals
  levels is prohibited).
• In the Case of American Home
  Podiatry (May 20, 2011) (an appellant may not seek a subpoena in order to shift the burden of proof to the
  contractor).
• In the
  Case of A.L. (January 21, 2011) (The beneficiary died after filing a request for hearing before an ALJ. The
  appellant has not demonstrated that she is authorized to act on behalf of a proper party, or otherwise has any
  interest as a substitute party).
• In the case of C.C. (July
  2, 2010) (the unrepresented beneficiary filed a single request for hearing before the ALJ listing five dates of
  services originally at issue and the record demonstrates it was reasonable for the beneficiary to believe the all
  the dates of service at issue would be treated as one aggregated appeal).
• In the Case of
  International Rehab. Sciences (April 8, 2009) (if a request for claims to be aggregated for an ALJ hearing is
  based on common issues of law and fact, the claims must arise from similar, but not necessarily identical, fact
  patterns).
• In the
  Case of Philip B. Khourty, M.D. (October 2, 2009) (the appellant submitted evidence of a serious illness in his immediate family as good cause for the untimely filing of his request for hearing before an ALJ).
• In the Case of
  Health & Oncology, Inc. (September 21, 2009) (the appellant had good cause for submitting new evidence after
  the reconsideration by the qualified independent contractor (QIC) as the QIC’s decision identified a new issue for
  the basis of the denial).
• In the Case of Robert
  Markman, M.D. (October 21, 2009) (the ALJ did not abuse his discretion in denying the appellant’s request for
  subpoenas).
• In the Case of
  Breton L. Morgan, M.D. (November 5, 2009) (an ALJ must identify in a meaningful way the documentation which
  will be excluded from the record).
• In the Case of John
  Handron, Ph.D. (May 22, 2008) (while section 504 of the Equal Access to Justice Act allows for fees and
  expenses for administrative proceedings conducted before an ALJ in connection with adversarial Medicare
  proceedings, the position of the United States must be represented at the ALJ hearing by counsel or otherwise to
  qualify for payment of attorney fees).
• In the Case of General
  Medicine, P.C. (September 6, 2007) (if an ALJ fails to adjudicate claims for which perfected requests for
  hearing were filed within the 90-day deadline, an appellant may request the claim be escalated to the Council;
  after receiving the request for escalation, the ALJ has five days to adjudicate the claims, if the ALJ is unable to
  adjudicate the claims, the appellant must then file a request for escalation with the Council to review the
  reconsideration decision(s); an appellant has no right to request escalation to the Council when it waived, in
  writing, the ALJ’s adjudication deadline).

IRMAA (Medicare Part B Premium)

• In the Case of R.F. (October 8,
  2009) (gambling winnings are included in the calculation of a modified adjusted gross income but gambling losses
  are not subtracted).

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Reports

• Statistical Sampling in OIG Reviews (OIG 2015) Statistical sampling gives OIG the ability to cover thousands or even millions of claims in a fair and objective fashion.
• The CMS Blog The official blog for the Centers for Medicare & Medicaid Services (CMS) responsible for Medicare, Medicaid and CHIP.
• MedPAC Report to the Congress: Medicare and the Health Care Delivery System (2014) Discussing synchronizing Medicare policy across payment models; improving risk adjustment in the Medicare program; reevaluating current approaches to measuring the quality of care in Medicare, with a discussion of an alternative approach; aligning financial assistance policies for low-income beneficiaries; paying for primary care using a per beneficiary payment; addressing Medicare payment differences across post-acute settings; and measuring the effects of medication adherence on medical spending for the Medicare population.
• MedPAC Data Book (2014) The MedPAC Data Book provides information on national health care and Medicare spending as well as Medicare beneficiary demographics, dual-eligible beneficiaries, quality of care in the Medicare program, and Medicare beneficiary and other payer liability.
• MedPac: Medicare Payment Policy (2014) Health care has accounted for a large and growing share of economic activity in the United States, nearly doubling as a share of gross domestic product (GDP) in the period between 1980 and 2012, from 8.9 percent to 17.2 percent. Social Security, Medicare, Medicaid, other health insurance programs, and net interest will account for about 14 percent of GDP in 10 years, whereas total federal revenues have averaged a little over 17 percent of GDP over the past 40 years.
• Vulnerabilities in the HHS Small Business Innovation Research Program (OIG 2014) Unlike most other SBIR awarding agencies, HHS does not have a single office responsible for overseeing its SBIR program. In 1999, the Office of Inspector General reported that HHS had not evaluated the success of the program.
• Over Four Million Medicare Summary Notices Mailed to Beneficiaries Were Not Delivered in 2012 (OIG 2014) MSNs are paper forms that summarize processed claims. Claims processors are responsible for providing MSNs to beneficiaries. If MSNs go undelivered, beneficiaries do not have the opportunity to review the services or items billed to Medicare.
• Medicare Claims Administration Contractors’ Error Rate Reduction Plans (OIG 2014) According to the Centers for Medicare & Medicaid Services’ (CMS) Comprehensive Error Rate Testing (CERT) program, Medicare claims administration contractors improperly paid an estimated $29.6 billion during the Federal fiscal year 2012 reporting period.
• Medicare Administrative Contractors’ Performance (OIG 2014) MACs did not meet one-quarter of the standards reviewed, and MACs had not resolved issues with 27 percent of these unmet standards as of June 2012. MAC standards have stringent performance requirements; a number of standards require 100-percent performance compliance. CMS did not require action plans for 12 percent of unmet standards, and unmet standards without action plans were almost four times more likely to have issues go unresolved.
• MedPAC Data Book: Beneficiaries Dually Eligible for Medicare and Medicaid (2013) Presents information on the demographic and other personal characteristics, expenditures, and health care utilization of individuals who are dually eligible for Medicare and Medicaid coverage. Dual-eligible beneficiaries receive both Medicare and Medicaid benefits by virtue of their age or disability and low incomes.
• Medicare Recovery Audit Contractors and CMS’s Actions To Address Improper Payments, Referrals of Potential Fraud, and Performance (OIG 2013) RACs identified half of all claims they reviewed as having resulted in improper payments totaling $1.3 billion. CMS’s performance evaluations did not include metrics to evaluate RACs’ performance on all contract requirements.
• MedPac: Reforming Medicare Benefit Design (2013) Individuals who receive cash benefits from Social Security on the basis of age or disability are automatically entitled to Part A benefits, including hospital inpatient care, short-term care in skilled nursing facilities, post-institutional home care, and hospice services. Part B enrollment is voluntary, although the vast majority of beneficiaries choose to enroll and pay a monthly premium.
• The First Level of the Medicare Appeals Process, 2008-2012: Volume, Outcomes, and Timeliness (OIG 2013) In 2012, contractors processed 2.9 million redeterminations, which involved 3.7 million claims, an increase of 33 percent since 2008. Although 80 percent of all redeterminations in 2012 involved Part B services, redeterminations involving Part A services have risen more rapidly. By 2012, appeals involving recovery audit contractors accounted for 39 percent of all appealed Part A claims. Contractors decided in favor of Part A appellants at a lower rate than that for Part B appellants.
• Improvements Are Needed at the Administrative Law Judge Level of Medicare Appeals (OIG 2012) For 56 percent of appeals, ALJs reversed QIC decisions and decided in favor of appellants; this rate varied substantially across Medicare program areas. Differences between ALJ and QIC decisions were due to different interpretations of Medicare policies and other factors.
• Status of 244 Provider Audits Identified Using Review Medicaid Integrity Contractor Analysis (OIG 2012) This memorandum report is intended as an addendum to our February 2012 report, Early Assessment of Review Medicaid Integrity Contractors (OEI-05-1 0-00200), in which we identified concerns with the quality of Review Medicaid Integrity Contractor (MIC) analysis.
• Early Assessment of Audit Medicaid Integrity Contractors (OIG 2012) This study presents an early assessment of the efforts of Audit Medicaid Integrity Contractors (Audit MIC) to identify overpayments in Medicaid. Eighty-one percent of audits either did not or are unlikely to identify overpayments.
• Conflicts and Financial Relationships Among Potential Zone Program Integrity Contractors (OIG 2012) Conflicts of interest among ZPICs could compromise CMS’s efforts to protect the program. CMS requires companies that submit proposals for ZPIC contracts (offerors) and their subcontractors to (1) disclose information about any business or contractual relationships that may present conflicts and (2) provide a strategy to mitigate all conflicts of interest that may compromise the ZPICs’ impartiality in conducting their work.
• Addressing Vulnerabilities Reported by Medicare Benefit Integrity Contractors (OIG 2011) Of the 62 vulnerabilities reported by contractors in 2009, 48 (77 percent) had not been resolved as of January 2011, nor had CMS taken significant action to resolve them. CMS indicated that of these 48 reported vulnerabilities, 20 were “currently under review” and 3 required additional analysis to determine whether they were actual vulnerabilities.
• Zone Program Integrity Contractors’ Data Issues Hinder Effective Oversight (OIG 2011) The inaccuracies and lack of uniformity we identified in ZPICs’ data prevented us from making a conclusive assessment of their program integrity activities; however, the issues we identified present a serious obstacle to CMS in effectively overseeing ZPIC operations.
• Beneficiary Appeals in Medicare Advantage (OIG 2009) We found that MAOs make the vast majority of organization determinations in favor of beneficiaries, and deny very few. Of these denials, called adverse determinations, very few were appealed, and upon appeal, MAOs overturned more than half of their own denials. We also found that MAOs decided 23 percent of adverse expedited determinations, and 18 percent of appeals, late. At the second level of appeal, the Independent Review Entity (IRE) overturned about one in five adverse MAO reconsiderations.
• Medicare Administrative Law Judge Hearings: Update, 2007-2008 (OIG 2009) OMHA improved the timeliness of its decisions from its first to thrd year of operation. For the cases that had a 90-day decision requirement, OMRA decided 94 percent on time in its third year, compared to 85 percent inits first year of operation.
• Medicare Administrative Law Judge Hearings: Early Implementation, 2005-2006 (OIG 2008) Beginning in July 2005, the responsibility for conducting ALJ hearings was transferred from the Social Security Administration (SSA) to OMHA in the Department of Health and Human Services. The SSA hearings were held primarily in person at the 141 Social Security offices throughout the country. Under SSA, there was no timeliness requirement for appeal decisions. In contrast, OMHA, with four field offices, planned to use primarily telephone and video teleconference to conduct ALJ hearings. Further, OMHA faced a new statutory requirement that certain cases be decided within 90 days.
• Early Implementation Review of Qualified Independent Contractor Processing of Medicare Appeal Reconsiderations (OIG 2008) During our review, the Part A QICs had been processing reconsiderations for 15 months and the Part B QICs for 7 months. We found that, during this timeframe, QICs had challenges meeting timeliness, correspondence, and data entry requirements. CMS made several changes to improve the reconsiderations process, including facilitating some improvements in the appeals system, restructuring the Part B workload into three jurisdictions, and recompeting the contracts among all QICs.
• Carrier Medical Review Progressive Corrective Action (OIG 2005) Carriers are required to have a tracking system and document the following five items: all educational contacts made as a result of actions to correct identified problems; the results of quarterly reassessments for all providers; the date a provider is put on a provider-specific edit; the date edits are turned off; and the results of appealed medical review decisions.
• Medicare Administrative Appeals: The Potential Impact of BIPA (OIG 2002) An administrative appeals system within the Department of Health and Human Services may be structured in a variety of ways. Regardless of structure, however, consideration should be given to factors such as the number of levels of appeal, formats, timeliness standards, and qualifications of reviewers.
• Duplicate Medicare Payments by Individual Carriers (OIG 2001) Questionable allowances for the 15 codes totaled an estimated $2.25 million. Individual carriers made an estimated $2.2 million in potential duplicate payments for an additional 55 evaluation and management codes that should never or rarely be billed more than once per day. We also estimated that Medicare made $89 million in potential duplicate payments for 2,000 other procedure codes.
• Medicare Payments for the Same Service by More Than One Carrier (OIG 2001) After furnishing a physician service, providers submit a claim for reimbursement to the carrier with jurisdiction over this service. Under the Common Working File system, the carrier then sends the claims information to one of nine host sites for approval. At the host site, the claim is screened for consistency, entitlement, and duplication of previously processed claims.
• Inconsistent Medicare Data Concerning Carrier Payment Dates (OIG 2000) If there is no correlation between the claim payment date variable and the carriers’ actual date of payment, we recommend that HCFA (1) define for carriers what data should be entered into this field and how it should be calculated, and/or (2) revise the current variable definition to clarify for National Claims History data users that the scheduled date of payment is not an accurate reflection of the actual claim payment date.
• Medicare Administrative Appeals (OIG 1999) A number of elements contribute to inconsistencies in the appeals process. The elements include; lack of consistent criteria for contractors and Administrative Law Judges, lack of communication by parties in the appeals system, and lack of precedence of Administrative Law Judge cases.
• Medicare: Private Payer Strategies Suggest Options to Reduce Rapid Spending Growth (GAO 1996) GAO discussed strategies to curb Medicare spending, which has grown by over 10 percent a year since 1989, twice the rate of the national economy.
• Medicare: HCFA
  Faces Multiple Challenges to Prepare for the 21st Century. (GAO 1998) Discusses the Health Care Financing Administration’s (HCFA) ability to meet growing program management challenges, focusing on: (1) HCFA’s new authorities under recent Medicare legislation; (2) HCFA managers’ views on the agency’s capacity to carry out various Medicare-related functions; and (3) the actions HCFA needs to take to accomplish its objectives over the next several years.

• Department of
  Health and Human Services: Strategic Planning and Accountability Challenges (GAO 1998) Discusses the challenges the Department of Health and Human Services (HHS) faces in carrying out its mission effectively and cost-efficiently and in improving its accountability for the results of its efforts and its stewardship of taxpayer dollars.

• Medicare: HCFA Can Improve Methods for Revising Physician Practice Expense Payments (GAO 1998) GAO reviewed the Health Care Financing Administration’s (HCFA) proposed practice expense revisions and its ongoing efforts to
  refine its data and methodologies.

• Medicare
  Transaction System: Success Depends Upon Correcting Critical Managerial and Technical Weaknesses (GAO 1997) Pursuant to a congressional request, GAO reviewed the Health Care Financing Administration’s (HCFA) acquisition of its Medicare Transaction System.

• Medicare and
  Medicaid: Meeting Needs of Dual Eligibles Raises Difficult Cost and Care Issues (GAO 1997) Pursuant to a congressional request, GAO discussed several issues that arise in financing health care for people known as dual eligibles, Medicare beneficiaries who are also eligible for some form of Medicaid support.

• Medicare: Most
  Beneficiaries With Diabetes Do Not Receive Recommended Monitoring Services (GAO 1997) Pursuant to a congressional request, GAO reviewed how well the health care system provides preventive services to Medicare beneficiaries with diabetes.

• Medicare: Inherent Program Risks and Management Challenges Require Continued Federal Attention (GAO 1997) GAO discussed efforts to fight fraud and abuse in the Medicare program.
• Medicare:
  Private-Sector and Federal Efforts to Assess Health Care Quality (GAO 1996) GAO discussed the Health Care Financing Administration’s (HCFA) efforts to provide health care quality information to Medicare beneficiaries joining health maintenance organizations.

• Medicare: Private Payer Strategies Suggest Options to Reduce Rapid Spending Growth (GAO 1996) GAO discussed strategies to curb Medicare spending, which has grown by over 10 percent a year since 1989, twice the rate of the national economy.
• Medicare: Federal Efforts to Enhance Patient Quality of Care (GAO 1996) Pursuant to a congressional request, GAO reviewed the Health Care Financing Administration’s (HCFA) efforts to enhance the quality of care for Medicare beneficiaries.
• Medicare: Millions Can Be Saved by Screening Claims for Overused Services (GAO 1996) GAO provided information on Medicare payments for unnecessary medical services.
• Medicare:
  Enrollment Growth and Payment Practices for Kidney Dialysis Services (GAO 1995) Pursuant to a congressional request, GAO reviewed Medicare’s End Stage Renal Disease (ESRD) Program.

• Medicare Transaction System: Strengthened Management and Sound Development Approach Critical to Success (GAO 1995) GAO discussed the Health Care Financing Administration’s (HCFA) approach to managing the Medicare Transaction System (MTS).
• Medicare Spending: Modern Management Strategies Needed to Curb Billions in Unnecessary Payments (GAO 1995) Pursuant to a congressional request, GAO examined Medicare’s vulnerability to provider exploitation and ways to remedy Medicare fraud and abuse.
• Medicare: Increased
  HMO Oversight Could Improve Quality and Access to Care (GAO 1995) The Congress is considering ways to attract Medicare beneficiaries to health maintenance organizations (HMO) and other forms of managed care in hopes of containing cost growth while preserving or improving quality and access to care.

• Medicare Secondary Payer Program: Actions Needed to Realize Savings (GAO 1995) The Medicare secondary payer program ensures that other health and accident insurers pay medical costs for covered beneficiaries before Medicare kicks in.
• Medicare: New Claims Processing System Benefits and Acquisition Risks (GAO 1994) A new system for processing Medicare claims offers considerable opportunities to improve Medicare operations and safeguard program dollars.
• Medicare: Greater
  Investment in Claims Review Would Save Millions (GAO 1994) Given soaring U.S. health care costs and shrinking budgets for many government programs, Congress is concerned that Medicare pay only for appropriate medical services without compromising the quality of care provided to beneficiaries.

• Medicare: Inadequate Review of Claims Payments Limits Ability to Control Spending (GAO 1994) Medicare overpayments of millions of dollars are being made because of inadequate safeguards by contractors who process Medicare claims and inattention by the federal Health Care Financing Administration
• Medicare and
  Medicaid: Many Eligible People Not Enrolled in Qualified Medicare Beneficiary Program (GAO 1994). The Qualified Medicare Beneficiary Program pays many out-of-pocket expenses for Medicare recipients whose incomes are not quite low enough to qualify them for regular Medicare benefits.

• Medicare: Impact of
  OBRA-90’s Dialysis Provisions on Providers and Beneficiaries (GAO 1994). To control soaring Medicare costs, Congress has required that, in some cases, employer-sponsored group health plans covering Medicare beneficiaries pay medical claims before Medicare begins to foot the bill.

• Medicare: Shared
  System Conversion Led to Disruptions in Processing Maryland Claims (GAO 1994) Since 1989, the Health Care Financing Administration (HCFA) has tried to reduce administrative costs by urging Medicare contractors to share claims processing system software and hardware with other contractors.

• Medicare/Medicaid:
  Data Bank Unlikely to Increase Collections From Other Insurers (GAO 1994). The Department of Health and Human Services has been directed to establish a data bank, beginning in February 1995, that would contain information on all workers, spouses, and dependents who are covered by employer-provided health insurance.

• Medicare: HCFA’s
  Contracting Authority for Processing Medicare Claims (GAO 1994) Since 1966, the Health Care Financing Administration (HCFA) has awarded most contracts to process claims under Medicare parts A and B without competition, has renewed them annually, and has compensated contractors on a cost-reimbursement basis.

• Medicare: Technology Assessment and Medical Coverage Decisions (GAO 1994) Thousands of medical procedures, devices, and drugs are available for patient care in this country. Each year, public and private health care insurers make coverage decisions for these medical technologies.
• Using Social Security Records to Detect Inappropriate Medicare Payments for Work-Related Disability Expenses (OIG 1994) HCFA A could detect more beneficiaries with WC involvement by using SSA records. HCFA was unaware of the WC involvement of 45 percent of the SSA disabilty beneficiares in our sample.
• Medicare: Millions of Dollars in Mistaken Payments Not Recovered (GAO 1991) Reviewed Medicare contractors’ claims-processing activities, to identify: (1) Medicare payments mistakenly made to hospitals for inpatient services that resulted in credit balances due Medicare; (2) the reasons for such payments; (3) hospital efforts to refund credit balances; and (4) Medicare contractor actions to recover amounts owed to the program.
• Carrier Shopping (OIG 1991) Through repeated contacts with the Medicare carriers, suppliers learn which carriers pay the most for a medical supply item. They also learn just how much of a particular medical supply each carrier wil allow before stopping or cutting back on payments.
• Medicare Prepayment Review: MSP Procedures at Carriers (OIG 1991) Representatives from five of seven carriers in this review told the review team that they are conducting no MSP recovery activities. Representatives from the two remaining sample carriers indicated that they are recovering overpayments on a selective basis. These carriers recover those casesthat have greatest potential for savings and only do so within their current operating budget.
• Medicare Carrier Assessment of New Technologies (OIG 1990) We examined how the carriers identify new technologies,and how they make decisions about coverage and pricing for new devices, diagnostic tests, procedures, and treatment modalities. Also, we addressed how the carriers perceive their overall performance in carrying out technology assessment activities.

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