New Claim Forms and Changes in Administrative Procedures May Increase Improper CHAMPUS Payments

HRD-81-75: Published: Apr 15, 1981. Publicly Released: Apr 15, 1981.

Additional Materials:

Contact:

Office of Public Affairs
(202) 512-4800
youngc1@gao.gov

Unlike Medicare and health plans of the Federal Employees Health Benefits Program, the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) has no central files of beneficiaries that may be checked to determine each claimant's eligibility. Instead, fiscal intermediaries determine eligibility from data provided on the claim form. Since this system relies on data provided by the claimant, it provides little control over payments to ineligible persons.

GAO believes that certain program changes recently implemented or planned by the Office of the Civilian Health and Medical Program of the Uniformed Services (OCHAMPUS) will result in weakening program controls, increasing improper benefit payments, and providing slower service to beneficiaries due to claim processing delays. GAO is concerned that: (1) new claim forms do not provide adequate beneficiary eligibility data and will result in delays in processing in order to obtain necessary information; (2) beneficiaries residing within 40 miles of a uniformed services medical facility will no longer be required to submit, with their CHAMPUS claims, statements that nonemergency inpatient care is unavailable at those facilities; and (3) fiscal intermediaries no longer are required to obtain certification as to the continued eligibility of dependent children over age 21.

Recommendations for Executive Action

  1. Status: Closed

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

    Recommendation: The Assistant Secretary of Defense (Health Affairs) should require OCHAMPUS to reinstate the requirement that fiscal intermediaries obtain certification from sponsors or parents as the continued eligibility of overage dependents.

    Agency Affected: Department of Defense

  2. Status: Closed

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

    Recommendation: The Assistant Secretary of Defense (Health Affairs) should require OCHAMPUS to retain the requirement that nonavailability statements be submitted with claims for nonemergency inpatient care.

    Agency Affected: Department of Defense

  3. Status: Closed

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

    Recommendation: The Assistant Secretary of Defense (Health Affairs) should require OCHAMPUS to assure that claim forms now in use and new forms to be introduced provide complete beneficiary information, including dates of eligibility.

    Agency Affected: Department of Defense

 

Explore the full database of GAO's Open Recommendations »

Sep 15, 2016

Sep 14, 2016

Sep 12, 2016

Sep 9, 2016

Sep 6, 2016

Aug 31, 2016

Looking for more? Browse all our products here