Medicare HMO Institutional Payments: Improved HCFA Oversight, More Recent Cost211 Data Could Reduce Overpayments

摘要

Concerned about the potential incentive for some health maintenance organizations211u001e(HMOs) to inappropriately classify beneficiaries as instutionalized and the 211u001epossibility that flaws in the methodology for calculating the institutional rate 211u001eare generating excessive payments, you asked us to examine (1) the criteria the 211u001eHealth Care Financing Administration (HCFA) uses to determine a beneficiary's 211u001einstitutional status, (2) the methods HCFA employs to ensure that HMOs properly 211u001eclassify beneficiaries as institutionalized, and (3) whether the higher 211u001ecapitation rate for beneficiaries who live in institutions is justified by higher 211u001ehealth care costs. To do this work, we visited selected facilities classified by 211u001eHMOs as institutions; reviewed HCFA's relevant policy and procedure manuals at 211u001eHCFA headquarters and the agency's reporting and verification procedures at two 211u001eregional offices (San Francisco and Seattle) that cover high managed care 211u001epenetration areas; and interviewed HCFA officials, industry groups, and Medicare 211u001eHMO representatives.