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102509 1 (1977-03-16)

handle is hein.gao/gaobacxom0001 and id is 1 raw text is: *o a 1 0 Mr. Don I. N Acting Admin Health Care Adminfstra Department c and elfar Dear Mr. Nor This is zation revie services unc sicians, den - - - - - - - -- - RELEASE UNITED STATES GENERAL ACCOUNTING OFFICE WASMNGTON D.C. 205s ct nke availab1 to pmbae redag 6, 1 LMJO2509 ortmar . C.... istrator Financing tion f Health, Education. ('0 tman: to advise you that we have completed a survey of States' utili.Z .w (also called utilization control) progras for non-institutional r Medicaid. Such progress focus on services provided by phy- ists, pharmacies, and other ractitioners and are intended to assure that medical serv ces Prov e un eredicuid are necessary and appro- priate as well as to control Medicaid costs by minimizing, and denying pay- sent 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 deterrine 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. RELEASED .O 6 . ...... 4

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