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120152 1 (1979-03-09)

handle is hein.gao/gaobacxvd0001 and id is 1 raw text is: * ~ LI j - UNITED STATES GENERAL ACCOUNTING OFFICE REGIONAL OFFICE 221 COURTLAND STRZET. N.E. ATLANTA, GEORGIA 30303 M A f? 1-1 ls. Virginia M. Smyth Regional Administrator Health Care Financing Administration Department of Health, Education, and Welfare 101 Marietta Tower Atlanta, Georgia 30303 pl Dear Ms. Smyth: We recently completed a survey of Medicare Clinics in Florida. As you know, the clinics have a high potential for over- 6tillzation by Medicare eligibles; and we wanted to -know whether controls are in place to monitor the situation and whether those controls are adequate. Our review indicated that, despite efforts to screen overuse, some beneficiary overutilization goes undetected. iV- - c~&26 >4~ t?/~f(7 Ceneraly. we found that HOFA Re --nT and the Florida carriers--GI, and, Blue Shield--are aware of the probled and-are 1ai2 action to control 1. For examle, in N ovember 1977 a Regional Intermediary Letter was issued to Region IV carriers alerting them to the oroblem with the clinics. Also, during our visits to GHI and Blue Shield, we noted that the carriers were subjecting physician billings from the clinics to special utiliza- tion review nrocedures. However, our work at GHI and Blue Shield did disclose a potential weakness in the carriers' utilization controls. Specifically, baiciary utilization sc ens for routine office visits may be set too high; consequently, certain beneficiary veratilization is possibly bein- overico -ed. The utilization screens for routine office visits at both G HI and Blue Shield are 24 visits per year; yet nationally, 7edicare eligi'oles !:ho visit doctors make an average of only 6.3 visits per year. Thus, the screens are set at about times the national average for such visits. In sampling a number of clinics in Florida, we found of abcat 20 visits per year. 3 times the national average less than the screens at G{I bene ficiaries who visited 11edicare that they w-ere cl aiming an average This utilization rate, w.ile about for su2h visits, is still considera'bly and Ble Shield. 120152 ) IV mDiO - 5

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