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089062 1 (1977-03-16)

handle is hein.gao/gaobacvbp0001 and id is 1 raw text is: UNITED STATES GENERAL ACCOUNTING OFFICE WASHINGTON, D.C. 20548 IN REPLY REFER TO: HUMAN RESOURCES DIVISION March 16, 1977 Mr. Don I. Wortman Acting Administrator Health Care Financing LM089062 Administration Department of Health, Education, P and Welfare Dear Mr. Wortman: This is to advise you that we have completed a survey of States' utili- zation review (also called utilization control) programs for non-institutional services under Medicaid. Such programs focus on services provided by phy- sicians, dentists, pharmacies, and other practitioners and are intended to assure that medical services prcvided under Medicaid are necessary and appro- priate as well as to control 0'edicaid costs by minimizing, and denying pay- ment for, unnecessary and inappropriate services. We surveyed through a questionnaire the procedures used by States to control the utilization of noninstitutional services including: --edits and checks in the States' claims processing systems, including exception criteria used to identify possibly unnecessary services; --practices used to deternine if claims identified as being possibly unnecessary were in fact unnecessary; --the types of services subjected to review for appropriateness of care and the methods used to check for appropriateness; --the number of personnel assigned to determine necessity of care and the number assigned to check appropriateness of care (also called quality of care reviews); --the types of information the States' claims processing system is capable of producing, and does produce, to assist the utilization control program; and --the results of the utilization control program. 10 f? i l ? III, .o,6

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