Status of Implementation of Medicaid Utilization Control Requirements

Published by the Government Accountability Office on 1977-03-01.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

STATUS OF IMPLEMENTATION OF MEDICAID                                                                    F .
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INSTITUTIONAL UTILIZATION CONTROL                                                                     3mz7.
REQuIR~ENTS~,fr~,i.'/::,'   . i ; I,,* ': :,.-y," .; ; , [ : ,i ,i ,‘.                             /j HRD-77-56
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       Pursuant            to a request            from Chairman,               Subcommittee               on Oversight                      : I1

and Investigation.s,       House Committee on Interstate     and Foreign Commerce,
      --y$& f ; ,I\ I_'.! /(_jl , $&,:.?, .j : +;,   ; :,'<." .,-
we reviewed,'HEW and States compliance with section 1903(g) of the Social

Security          Act.
                                                        - .
        Section           1903(g)(l)           requires   each State                to submit a quarterly

showing          (certification)               that     it has an effective                  program of utilization
control          over     long-term           institution           care.       HEW must validate                   States'

certifications              by at least               conducting         on-site      sample surveys                    at medical

facilities       with Medicaid recipients.
              +-7 Q6: t&d
          Wey;lave-=d,e~~rm~nned.that:                                                       .

          -All          States     except Delaware               have submitted              all     required            certifications

             of compliance              for      the quarters            starting       April         1 and July             1, 1976.

             As a result,              Delaware's           grant     award for         long-term               care in mental

             hospitals           were reduced            for     the quarter          starting             April        1, 1976.

          -HEW has sent disallowance                           letters         to three          States         indicating          a total

             amount of $122,371                   to be reduced              from the States'                   grant      awards

             for        not submitting             the required             certifications                for    the fiscal
             year 1975 validation                      survey.

          -HEW should              request        more information                 from States as evidence                         of

             having         an effective              program of utilization                     control.

          -The          HEW validation             survey      for    fiscal        year     1975 was very                 limited

             in scope.


            .       .’      -

                                We recommended that                 Congress     should   amend the law to improve             a

                         specific          timeframe       within    which the Secretary           must conduct   validation

                     surveys.               We also reported          that    Congress    should     amend the provision           in

                         1903(g)(l)          to set an adherence             level   of less than 100 percent.           We

                     made recommendations                     to the Secretary of HEW with respect to including
.                                                                        .
                     visits           to    institutions        on a sample basis as required  by law and revise