Medicaid

Pursuant to a congressional request, GAO assessed the adequacy of the Health Care Financing Administration's (HCFA) and Illinois' oversight of the quality of care provided to Medicaid recipients by Chicago-area health maintenance organizations (HMO).

GAO found that: (1) Chicago's two largest HMO used incentive payments that could jeopardize the quality of care provided to Medicaid recipients; (2) stronger HMO management controls could help identify and prevent physician behavior that adversely affects quality of care; (3) unlike the Medicare program, Medicaid contractors do not have a minimum enrollment of Medicaid beneficiaries; (4) high turnover of Medicaid recipients enrolled in Chicago-area HMO could increase the incentives to inappropriately delay or deny care; (5) Chicago-area HMO made limited progress toward developing quality assurance programs; (6) HCFA, Illinois Department of Public Aid (IDPA), and Chicago-area HMO did not establish effective mechanisms to identify and correct potential underservicing and other quality-of-care problems; (7) Illinois did not take effective follow-up action after identifying potential quality-of-care problems during Medicaid compliance audits and other reviews; and (8) IDPA did not attempt to determine whether the problems previously identified through compliance reviews and peer reviews were caused by poor documentation or underservicing.

Recommendations

Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.

Director: Team: Phone: