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At least 1,495 records · Page 83Linked to original sources
PubMed1992

Medicare program; carrier jurisdiction for claims for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) and other issues involving suppliers, and criteria and standards for evaluating regional DMEPOS carriers--HCFA. Final rule with comment period.

This final rule Modifies regulations to provide that claims for durable medical equipment, prosthetics, orthotics and certain other items covered under part B of Medicare be processed by designated carriers. Specifies the jurisdictions each designated carrier will serve. Changes the method by which claims for these items are allocated among the carriers from "point of sale" to "beneficiary residence." Establishes certain minimum standards for suppliers for purposes of submitting the above claims. Incorporates in regulations certain supplier disclosure requirements imposed under section 4164 of the Omnibus Budget Reconciliation Act of 1990, as part of the process for issuing and renewing a supplier's billing number. Describes the criteria and standards to be used beginning October 1, 1993 for evaluating the performance of designated carriers processing claims for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) in the administration of the Medicare program. Section 1842(b)(2) of the Social Security Act requires us to publish criteria and standards against which we evaluate Medicare carriers for public comment in the Federal Register. We expect the above changes to lead to more efficient and economical administration of the Medicare program.

Durable Medical Equipment↗
PubMed1998

Medicare program; Medicare integrity program, intermediary and carrier functions, and conflict of interest requirements--HCFA. Proposed rule.

This proposed rule would implement section 1893 of the Social Security Act (the Act) by establishing the Medicare integrity program (MIP) to carry out Medicare program integrity activities that are funded from the Medicare Trust Funds. Section 1893 expands our contracting authority to allow us to contract with "eligible entities" to perform Medicare program integrity activities. These activities include review of provider and supplier activities, including medical, fraud, and utilization review: cost report audits; Medicare secondary payer determinations; education of providers, suppliers, beneficiaries, and other persons regarding payment integrity and benefit quality assurance issues; and developing and updating a list of durable medical equipment items that are subject to prior authorization. This proposed rule would set forth the definition of eligible entities, services to be procured, competitive requirements based on Federal acquisition regulations and exceptions (guidelines for automatic renewal), procedures for identification, evaluation, and resolution of conflicts of interest, and limitations on contractor liability. In addition, this proposed rule would bring certain sections of the Medicare regulations concerning fiscal intermediaries and carriers into conformity with the Act. The rule would distinguish between those functions that the statute requires be included in agreements with intermediaries and those that may be included in the agreements. It would also provide that some or all of the listed functions may be included in carrier contracts. Currently all these functions are mandatory for carrier contracts. These changes would give us the flexibility to transfer functions from one intermediary or carrier to another or to otherwise limit the functions an intermediary or carrier performs if we determine that to do so would result in more effective and efficient program administration.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1988

Formation and operation of a captive insurance company for malpractice coverage.

With the onset of the "malpractice crisis" of spiralling insurance costs in the 1970s, many medical groups began viewing self-insurance as a viable alternative to conventional carriers. Captive insurance companies are not without their risks, but continue to hold promise for controlling escalating insurance costs and providing a positive cash flow for the parent company.

Group Practice↗
PubMed1993

Medicare program; carrier jurisdiction for claims for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)--HCFA. Final rule.

This final rule would address the provisions of section 1834(a)(12) of the Social Security Act that authorizes us to designate one carrier for one or more regions to process all claims within that region. It incorporates in regulations the four designated carriers that will process claims for durable medical equipment, prosthetics, orthotics, supplies and certain other items covered under Part B of Medicare. We expect the above changes to lead to more efficient and economical administration of the Medicare program.

Durable Medical Equipment↗
PubMed1994

Medicare program; Medicare secondary payment--HCFA. General notice.

This notice provides guidelines for complying with 42 CFR 411.25, which provides that certain third party payers for health services furnished to Medicare beneficiaries must furnish certain information to Medicare intermediaries and carriers when they learn that Medicare made primary payment for services for which the third party payer has made or should have made primary payment. The notice also informs third party payers that they should contact HCFA if they wish to discuss arrangements for exchanging, on a voluntary basis, data about beneficiaries for whom the third party payer has a primary payment obligation under the Medicare Secondary Payer (MSP) provisions of the Medicare law. The third party payers affected by this notice are workers' compensation plans and insurers; all liability and no-fault insurers, including automobile insurers; and group health plans under certain circumstances, including plans which are self-insured and/or self-administered. If the group health plan, or workers' compensation plan is self-insured and self-administered, the employer must provide the notice; otherwise the insurer, underwriter or third party administrator must give the notice. This description of information third party payers must furnish is intended to help ensure that, in accordance with the Medicare law, Medicare pays only secondary to primary coverage of third party payers.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1998

Medicare program; criteria and standards for evaluating intermediary and carrier performance: millennium compliance--HCFA. General notice with comment period.

This notice revises the criteria and standards to be used for evaluating the performance of fiscal intermediaries and carriers in the administration of the Medicare program. This revision establishes a performance standard requiring these contractors to meet requirements for millennium compliance. We require contractors to certify that they have made all necessary system(s) changes and have tested those systems in accordance with HCFA guidelines.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1994

How will we use clinical guidelines? The experience of Medicare carriers.

While support for the development of clinical guidelines is widespread, there is little agreement about how they should be used. Because cost control is the force behind the medical effectiveness movement, the payers' preference, to link clinical guidelines to reimbursement, will likely prevail. We examine the utilization review programs of Medicare Part B carriers and the carriers' attempts to use clinical guidelines to determine medical necessity for the purpose of payment. We find that because the utilization review programs are driven by concerns about cost control, the carriers' actual review process relies on aggregate utilization and spending targets that have little to do with clinical guidelines. The carriers' medical review rhetoric--using the terms medically unnecessary and fraud and abuse as synonyms--also highlights their focus on cost control and the lack of concern about why services are used inappropriately.

Attitude of Health Personnel↗
PubMed1995

The effectiveness of Medicare Part B medical review: issues and alternatives.

The part B medical review methods currently used by Medicare carriers to control resource use suffer from a series of problems including failure to reward deterrence of unnecessary claims, failure to detect substitution of nonreviewed claims, reliance on average rather than marginal measures of performance, excessive focusing of reviews, and the inability to measure effectiveness separately from the intervention. This article describes these problems and proposes a series of alternative strategies for review that may improve these problems.

Cost-Benefit Analysis↗
PubMed1993

Unhealthy money: the growth in health PACs' congressional campaign contributions.

The health and insurance industries have launched a massive lobbying and public relations effort to undermine popular support in the United States for a national health care system. As part of their campaign, these industries have increased dramatically their PAC contributions to members of Congress. This article provides a detailed account of these PAC contributions to congressional incumbents and candidates, and discusses additional information on the health insurance industry's advertising campaigns.

American Medical Association↗
PubMed1990

Universal health insurance: lessons of the 1970s, prospects for the 1990s.

In the 1970s, proposals for universal health insurance were not successful. Health care providers, insurers, and others negotiating in the political process foresaw a better future without such legislation. Today, the growth of health insurance coverage has unmistakably reversed. Moral discomfort and self-interest shape the new politics of universal health insurance for the 1990s. Hospitals, physicians, insurers, employers, and tens of millions of individuals would benefit from a universal health insurance plan that was mindful of their concerns and interests. Proposals that require employers to provide insurance for full-time employees and expand public programs to cover to cover other uninsured persons now have the greatest chances for enactment. As leaders, health services and health insurance executives should be in the vanguard of efforts to enact universal health insurance.

Employment↗