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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.
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Highlights

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.

Recommendations

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Defense 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.
Closed
Please call 202/512-6100 for additional information.
Department of Defense 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.
Closed
Please call 202/512-6100 for additional information.
Department of Defense 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.
Closed
Please call 202/512-6100 for additional information.

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Topics

Health Care
BeneficiariesClaims processingFederal formsHealth care programsMedical expense claimsMilitary compensationMilitary personnelHospitalsVeterans hospitalsHealth care