Federal Employees Health Benefits Program: Additional Actions Needed to Address Significant Risks in Verifying Provider Eligibility
Fast Facts
The Federal Employees Health Benefits program is the largest employer-sponsored health insurance program in the United States. The Office of Personnel Management is responsible for managing fraud risks in the program.
But OPM's process for verifying whether health care providers were eligible to provide care under the program isn't always working. For example, our data analyses identified claims from providers who were deceased or excluded from other federal programs for certain violations.
Our recommendations would improve OPM's process for verifying health care provider eligibility and reduce risks to the program.
A person wearing scrubs holding a magnifying glass that says fraud and improper payments.
Highlights
What GAO Found
Limitations in control activities allowed potentially ineligible providers to participate in the Federal Employees Health Benefits (FEHB) program. The Office of Personnel Management (OPM) and its Office of the Inspector General (OIG) have a variety of control activities for identifying ineligible providers. However, GAO found limitations in these control activities. GAO’s data analyses identified FEHB claims from approximately 400 providers who were deceased and over 2,000 additional claims from providers who were excluded from federal programs. While such claims are a small proportion of annual FEHB claims, they represent a risk the agency could mitigate. Taking additional steps to identify providers who are deceased or excluded from other federal programs would help OPM and OPM OIG prevent fraud and improper payments in the FEHB program. For example, comparing death data with FEHB claims could help prevent improper payments or fraud in FEHB claims payments.
Selected FEHB carriers do not always comply with requirements for identifying and excluding suspended or debarred providers. GAO found that selected FEHB carriers—which operate health benefit plans—do not always notify patients that their providers are suspended or debarred, as required. Carriers also did not notify OPM OIG when providers may warrant suspension or debarment, as required by OPM OIG policy. Clarifying requirements would help OPM and OPM OIG ensure that patients are not exposed to risks related to suspended or debarred providers.
Why GAO Did This Study
The FEHB program is the largest employer-sponsored health insurance program in the United Sates. OPM is responsible for managing fraud and improper payment risks in the FEHB program, including risks associated with ineligible health care providers. Ineligible providers can increase costs and may pose safety risks to patients.
GAO was asked to review OPM’s efforts to manage provider-related fraud risks in the FEHB program. This report examines the extent to which (1) program control activities allow potentially ineligible providers to participate in the FEHB program; and (2) selected FEHB carriers comply with requirements for identifying and excluding suspended or debarred providers, among other objectives.
GAO performed analyses comparing FEHB claims data with various data sets indicating that providers may be ineligible, such as data on deceased providers or providers excluded from other federal programs. GAO also reviewed documents and interviewed officials from OPM, OPM OIG, and FEHB carriers. GAO compared this information with applicable regulations, guidelines, and federal standards for internal control.
Recommendations
GAO is making 15 recommendations to OPM and OPM OIG, including that OPM improve control activities for identifying deceased providers and clarify requirements for notifying patients who have seen a suspended or debarred provider. OPM and OPM OIG concurred with all our recommendations.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Office of Personnel Management | The Director of OPM should improve its control activities for identifying deceased or incarcerated providers. At a minimum, this should include OPM directing FEHB carriers to regularly obtain and use death information to identify deceased providers, prevent payments to deceased providers, and engage in related recovery efforts. This might also include OPM OIG comparing death and incarceration data from DNP with the claims data they receive, as we did. (Recommendation 1) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
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| Office of the Inspector General | The OPM Inspector General should develop a monitoring mechanism to identify providers on LEIE with roles they do not consider for debarment that are submitting claims to FEHB carriers and suspend or debar them, as appropriate. (Recommendation 2) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
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| Office of the Inspector General | The OPM Inspector General should review the exclusions we identified on LEIE that are missing from its suspension and debarment list and (1) determine if the excluded providers should be included on its list; (2) investigate why they were not added from the LEIE files; and (3) update its suspension and debarment list with providers on LEIE in a timely manner, as appropriate. (Recommendation 3) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
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| Office of the Inspector General | The OPM Inspector General should update its guidance documentation about which roles from the Department of Health and Human Services OIG List of Excluded Individuals and Entities (LEIE) that OPM OIG considers for debarment to include all possible roles that appear on LEIE. (Recommendation 4) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
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| Office of the Inspector General | The OPM Inspector General should update its guidance documentation and its written procedures to clarify when OPM OIG must conduct additional research on providers on LEIE to determine if the provider meets the criteria for debarment. (Recommendation 5) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
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| Office of Personnel Management | The Director of OPM should obtain additional identifying information for providers, including providers' Tax Identification Number and National Provider Identifier. To the extent appropriate, the Director of OPM should coordinate this effort with the OPM Inspector General. (Recommendation 6) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
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| Office of the Inspector General | The OPM Inspector General should review providers on its suspension and debarment list that we could not readily identify on the SAM exclusions list and (1) determine if the excluded providers should be included on the SAM exclusions list; (2) investigate why they were not added to the SAM exclusions list; and (3) update SAM with information on suspended and debarred providers in a timely manner, as appropriate. (Recommendation 7) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
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| Office of the Inspector General | The OPM Inspector General should review providers on the SAM exclusions list with OPM as the excluding agency that we could not readily identify on OPM OIG's suspension and debarment list and (1) determine if the excluded providers should be removed from the SAM exclusions list, (2) investigate why they were not removed from the SAM exclusions list, and (3) remove providers from the SAM exclusions list after OPM OIG reinstates them in a timely manner. (Recommendation 8) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
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| Office of Personnel Management | The Director of OPM, in coordination with the OPM Inspector General, should clarify to carriers when they must notify patients whose claims from suspended or debarred providers are denied, such as through FEHB Program Carrier Letters, OPM contracts, and OPM OIG's suspension and debarment guidelines. (Recommendation 9) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
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| Office of Personnel Management | The Director of OPM, in consultation with the OPM Inspector General, should take action to ensure that carriers' claims systems are designed and operating effectively to notify patients that a provider is suspended or debarred, when a claim is denied. (Recommendation 10) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
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| Office of Personnel Management | The Director of OPM, in coordination with the OPM Inspector General, should clarify to FEHB carriers – such as through FEHB Program Carrier Letters, OPM contracts, and OPM OIG's suspension and debarment guidelines – that carriers are permitted to search other sources, such as LEIE and the SAM exclusions list, for providers who may warrant suspension or debarment, and that carriers must notify OPM OIG when they identify such providers. (Recommendation 11) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
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| Office of Personnel Management | The Director of OPM, in coordination with the OPM Inspector General, should clarify to FEHB carriers – such as through FEHB Program Carrier Letters, OPM contracts, and OPM OIG's suspension and debarment guidelines – that only the OPM OIG Debarring Official is authorized to exclude providers from receiving FEHB payments. (Recommendation 12) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
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| Office of Personnel Management | The Director of OPM, in coordination with the OPM Inspector General, should ensure that FEHB carrier processes comply with requirements to consult with OPM OIG about provider matches from the OPM OIG suspension and debarment list before manually overriding controls to change a provider's suspension or debarment status. (Recommendation 13) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
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| Office of Personnel Management | The Director of OPM, in coordination with the OPM Inspector General, should improve methods of communication to ensure that information about suspended and debarred providers is more readily available to new and unknowing patients, such as by flagging suspended or debarred providers on carriers' public websites. (Recommendation 14) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
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| Office of Personnel Management | The Director of OPM, in consultation with the OPM Inspector General, should coordinate with FEHB carriers to develop and implement controls that reduce the amount of time that suspended and debarred providers can wait to submit claims and receive FEHB payments, while taking carrier filing policies into consideration. (Recommendation 15) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
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