Review of Fee-for-Service Payments for Selected Medicare Beneficiaries Enrolled in Managed Care Risk Plans

This final report points out that Medicare fiscal intermediaries improperly paid Part A providers under Medicare's fee-for-service system for services provided to beneficiaries enrolled in health maintenance organizations (HMO) in Colorado, Florida, Missouri, and Pennsylvania $2.3 million for Calendar Years 1995 through 1997. This may be a national problem since the Health Care Financing Administration (HCFA) has not implemented procedures to detect and prevent such duplicate payments. Moreover, the amount of improper duplicate payments may be significant considering the remaining States and the Medicare Part B program. We are recommending that HCFA strengthen procedures to prevent and detect duplicate payments where the HMO has payment responsibility, and identify and recoup all duplicate fee-for-service payments made under Medicare Parts A and B for HMO enrollees, including the $2.3 million identified in this report.