GAO raps Blue Cross Medicare procedure

February 12, 1991|By Stacey Evers | Stacey Evers,States News Service

WASHINGTON -- Blue Cross and Blue Shield of Maryland has paid at least $8.8 million in Medicare claims even though other insurers are responsible for the bills, according to a recent government report.

The General Accounting Office claims that the insurance company, which is the federal Medicare claims-processing contractor for the state, has done "little" to pursue recovery of the payments, which were made between 1983 and 1989.

But Blue Cross and Blue Shield officials said the problem is budgetary: The federal government hasn't given them enough money or staffing to go after the primary insurers. The GAO drew the same conclusion.

The contractor repeatedly has told the Health Care Financing Administration, which oversees the giant health-insurance program for the elderly, that additional staffing is needed to recover the costs, said Bettye Newton, the contractor's Medicare division director.

"With the resources we had, we've done a heck of a job," said Blue Cross and Blue Shield spokeswoman Liz Ziemski.

In 1990, the contractor recovered $45 million from primary insurers, she said.

Medicare contractors sometimes mistakenly make payments when patients eligible for Medicare benefits also have other health insurance but don't realize that the private insurer has the responsibility to pay claims first.

For instance, a working person who is 65 or older -- meaning they are eligible for Medicare benefits -- may not know that his employer's group health insurance is primarily responsible for his medical bills. The same is true for his spouse, provided she also is 65 or older.

The process can be as confusing for the patient to follow as tracking down mispaid claims can be for the contractor, Ziemski said.

In the Medicare division of Blue Cross and Blue Shield of Maryland, only 1.5 full-time positions are devoted to recovering payments -- half of the staffing level three years ago, Newton said. Budget cutbacks in 1989 forced the contractor to reduce staff, she said.

Since then, the caseworkers have tried to recoup funds from top-dollar cases first, Newton said. Using this system, about $2.7 million of the $8.8 million has been recovered since June, she said.

The General Accounting Office, which used the contractor's handwritten ledgers to create a computerized listing of the 3,059 mistakenly paid claims, found that 13 insurers are responsible for more than $100,000 each of those payments.

But, because the ledgers included only a partial listing of cases in the inventory of potential recoveries, the total backlog could be more than 7,000 cases, the report said.

Topping the list is Blue Cross and Blue Shield of Maryland, which may have primary responsibility for $4.1 million -- almost half -- of the identified payments.

The insurance agency's Medicare division operates solely on federal funds, receiving $21.05 million in fiscal 1991, Ziemski said. About $1.17 million will be devoted to recovering mistakenly paid payments, she said.

The GAO recommended that the Health Care Financing Administration give Blue Cross and Blue Shield more workers to eliminate the backlog, which could be done in a year for about $200,000, Newton estimated.

Officials for the financing administration had not seen the report and would not comment on the recommendations.

But Newton and Ziemski said they are resigned to letting some payments go because they would lose money pursuing them.

"If we could, we would get every penny," Ziemski said. "But, when your primary responsibility is to pay claims and you have limited resources, you've got to allocate them the best you can."

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