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HRD-85-48 1 (1985-03-08)

handle is hein.gao/gaobabeyk0001 and id is 1 raw text is: IT!ITX. - I11t li be roleoeed eutdo 0 t Aeeoea g Office exeett Ot th bad01 s pedidic apw,,,' by the Office of Cegroseenaj noinW.,., BY THE US. GENERAL ACCOUNTING OFFICE Report To The Honorable Lawrence J. Smith House Of Representatives Problems In Administering Medicare's Health Maintenance Organization Demonstration ProjectsWi Florida In February 1985, the Department of Health and Human Services initiated a program to expand the use of health maintenance organizations (HMOs) by Medicare beneficiaries. This new program was preceded by 26 demonstration projects throughout the country to test HMOs' effec- tiveness. Four of the demonstration projects, involving about half of lt Medicare beneficiaries in such projects, were started in south Florida,, Because of beneficiary complaints and concerns regarding those HMOs, GAO was asked to review them. GAO found the system for coordinating HMO and Medicare payments to_ physicians and hospitals susceptible to errors, such as Medicare paying for services that an HMO had already been paid for. Many errors GAO identified occurred becausebeneficiary HMO enrollment dates were not recorded until after the actions became effective. This led to'incorrect determinations as to who shouldyV medical expenses--the HMOor the regular Medicare program,-GAD recommends that HHS correct probleom resulting in erroneoUs paylvilitS because of the program's wcpansion nationwide. GAO also ide elatively small number of beneficiaries for whom reimbursemeal expenses was uncertain because they were transitioning' of HMOs. During such periods, i is not always clear who is t for paying medical expenses--this beneficiary, the HMO, or . GAO is continuing to assess the magnitude end specific causes ofthe transitioning problems. In a follow-on report, GAO. will address this andthe remaining questions it was asked to pursue. 01 z 0u m. GAO/ HRD-85-48 MARCH 8, 1985

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