NCJ Number
81594
Date Published
1981
Length
20 pages
Annotation
Findings are presented from a review of the District of Columbia Department of Human Services' (DHS) surveillance and use review (SUR) procedures in identifying and controlling misuse and abuse of the medicaid program.
Abstract
DHS has not established and implemented effective methods and procedures to identify and safeguard against recipient misuse and abuse of medical services. Consequently, the department could not determine the extent of recipient misuse or abuse. Also, since audits are not made of all providers' records, some unidentified overpayments could exist. The review indicated a need for (1) a better system to identify potential misuse and abuse cases for review; (2) more effective procedures for counseling, monitoring, and controlling persons misusing or abusing medical services; (3) more effective controls for processing cases and an improved reporting system to facilitate management reviews; and (4) improved procedures for recovering improperly billed medicaid payments. A new medicaid management information system, expected to be operational in mid-1981, will correct some of the deficiencies noted in the review; however, to realize full benefits of the system, other operational improvements should be made. An adequate followup and enforcement mechanism should also be established to ensure that misuse and abuse of the medicaid program are minimized. The Office of Health Care Financing Chief and top SUR officials generally agreed with the recommendations and indicated corrective action would be taken. Their comments are included. (Author summary modified)