Accession Number : ADA187585

Title :   Medicare: Better Controls Needed for Peer Review Organizations' Evaluations.

Corporate Author : GENERAL ACCOUNTING OFFICE WASHINGTON DC HUMAN RESOURCES DIV

PDF Url : ADA187585

Report Date : Oct 1987

Pagination or Media Count : 56

Abstract : This report, issued at the Subcommittee's request, discusses the Health Care Financing Administration's (HCFA'S) evaluation of Peer Review Organizations' performance during the 1984-86 contract period. It also discusses HCFA'S process for determining program funding for the 1986-88 contract period. The report contains recommendations to the Secretary of Health and Human Services. Professional Review Organizations (PROS) contract with the Medicare program to review the necessity, appropriateness, and quality of inpatient hospital services received by the program's beneficiaries. From February through July 1986, the Department of Health and Human Services' (HHS'S) Health Care Financing Administration (HCFA) evaluated the PROS' performance under their contracts to determine whether the contracts, awarded for a 2-year period, should be renewed on a noncompetitive basis or whether a competition should be renewed on a noncompetitive basis or whether a competition should be held. As a result of the evaluations, HCFA was requiring competition for about half of the PRO contracts. Based on a concern that the high nonrenewal rate indicated problems either with some PROS or with HCFA'S management of the program, the Chairman and Ranking Minority Member of the Subcommittee on Health, Senate Committee on Finance, requested that GAO assess (1) HCFA'S PRO evaluation methodology and (2) the adequacy of HCFA'S routine monitoring of the PROS for identifying performance problems. In addition, GAO was asked to determine how HCFA decided on the funding level for the new contracts.

Descriptors :   *INSURANCE, *MEDICAL SERVICES, *CONTRACT ADMINISTRATION, HEALTH, HOSPITALS, HUMANS, MANAGEMENT, MEDICAL SERVICES, MINORITIES, MONITORING, PATIENTS, PLANNING PROGRAMMING BUDGETING, CONTRACT PROPOSALS, MANAGEMENT PLANNING AND CONTROL, CONTRACTS, JOB ANALYSIS, COST ANALYSIS

Subject Categories : Medicine and Medical Research
      Economics and Cost Analysis
      Administration and Management

Distribution Statement : APPROVED FOR PUBLIC RELEASE