Civil Service Needs To Improve Claims Review Process Under the Federal Employee Health Benefits Program

HRD-78-68: Published: Mar 14, 1978. Publicly Released: Mar 14, 1978.

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In a review of the Civil Service Commission's (CSC) administration of the claims review process under the Federal Employees Health Benefits (FEHB) Program, an examination was made of: (1) a random sample of 62 closed disputed claim files from a March and April 1977 listing and an additional 42 files from cases closed during 4 days in October 1977; (2) all disputed claim files closed during December 1975 to April 1977 with required reports and records and, additionally, all disputed claim files from January to April 1977 with or without reports and records; and (3) all disputed claim files closed for December 1975 to May 1977 for the comprehensive plans (Aetna and Blue Cross and Blue Shield). In addition, a medical advisor reviewed 120 disputed claims files and the medical records for 55 of those cases.

CSC needs to increase the timeliness of its responses to enrollees who dispute claim denials under the FEHB program. None of the CSC divisions complied fully with the established 30-day timeliness criterion for resolving disputed claims and responding to enrollees. The Division of Government-wide Plans frequently did not review medical records as the regulations require; it often relied on summary medical reports furnished by the Federal Employee Program (FEP) office to arrive at conclusions. In view of the CSC position that each of the five medical records advisors should be able to review an average of five cases each per day, all disputed claims of the Division of Government-wide Plans could have been reviewed.

Recommendation for Executive Action

  1. Status: Closed

    Comments: Please call 202/512-6100 for additional information.

    Recommendation: The Division of Government-wide Plans should be directed to: (1) require health plans to comply with the regulation that an enrollee be provided a detailed explanation of why the claim was denied; (2) rely on the plans' detailed explanations of reasons for denials in lieu of FEP office reports; (3) request FEP office to provide records to CSC within 5 days of receipt from the local plans; and (4) establish a standard which would require medical records advisors to review an average of at least five records every day.

    Agency Affected:

 

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