Defense Health Care: Reimbursement Rates Appropriately Set; Other Problems Concern Physicians
HEHS-98-80
Published: Feb 26, 1998. Publicly Released: Feb 26, 1998.
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Highlights
Pursuant to a legislative requirement, GAO examined: (1) whether the Department of Defense's (DOD) methodology for setting the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) maximum allowable charge (CMAC) rates complies with statutory requirements and how current CMAC rates compare with Medicare rates for similar services; (2) the basis for physicians' concerns about CMAC rates and how these concerns affect physicians' willingness to treat military beneficiaries; (3) the basis for other concerns physicians have about TRICARE that could also affect their willingness to treat military beneficiaries; and (4) how balance billing limits are being enforced.
Recommendations
Recommendations for Executive Action
Agency Affected | Recommendation | Status |
---|---|---|
Department of Defense | To improve the administration of the TRICARE program, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to require MCSCs to provide to physicians written or published locality-specific fee schedules after each yearly CMAC update to help eliminate confusion about CMAC reimbursement rate amounts. |
Closed – Implemented
Actions have been taken by DOD and the Congress which complete the action intended by the recommendation. First, DOD provides CHAMPUS maximum allowable charges on the Internet. With the growth and widespread use of the Internet as a business communications medium, this information source helps eliminate the necessity of distributing paper fee schedules. Second, and more importantly, GAO has worked with congressional staff to draft legislative language to replace the term "CHAMPUS maximum allowable charges" with the more-familiar term "Medicare rates," which, when implemented, will eliminate confusion about reimbursement rates. In the near future, when CMAC rates are equivalent to Medicare rates, there will be no need for a TRICARE fee schedule.
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Department of Defense | To improve the administration of the TRICARE program, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to require MCSCs to notify beneficiaries and physicians of balance billing limits on the explanation of benefits statements for all TRICARE Standard claims submitted by nonparticipating physicians. |
Closed – Implemented
DOD stated that the requirement for managed care support contractors to provide balance-billing information on nonparticipating claims has been funded. The managed care support contractors will compose their own messages explaining balance billing limits for the explanation of benefit statements, which explain claim adjudication.
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Health care cost controlHealth care servicesManaged health careMedical feesMedical services ratesMedicareMilitary personnelPhysiciansMilitary health servicesQuestionable billing