Defense Health Care: Claims Processing Improvements Are Underway but Further Enhancements Are Needed
HEHS-99-128
Published: Aug 23, 1999. Publicly Released: Aug 23, 1999.
Skip to Highlights
Highlights
Pursuant to a congressional request, GAO reviewed the timeliness and accuracy of the Department of Defense's (DOD) health care claims processing procedures.
Recommendations
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Defense | In order to better measure and improve claims processing accuracy, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to restructure the methodology used for claims processing accuracy audits so that performance measures more accurately and completely reflect managed care support contractors' (MCSC) performance and are more comparable to those generally used in the industry. This restructuring should include: (1) ensuring that claims of all dollar amounts are subject to the payment accuracy audit; (2) ensuring that error rate computations are statistically accurate and meaningful; and (3) adding additional measures of program performance, such as the percentage of claims processed with errors. |
Closed – Implemented
GAO recommended that DOD restructure the methodology used for claims processing accuracy audits so that the performance measures more accurately and completely reflect contractors' performance and are more comparable to those generally used in industry. DOD agreed with the recommendation and conducted four separate payment audits of 903 claims that included claims with billed amounts under $100. While DOD was responsive to the recommendation, its analysis showed that the average error amount per audited claim equaled about $.83. Thus, DOD concluded this audit would not recoup enough to cover the costs of auditing these claims.
|
| Department of Defense | To ensure that needed program changes are made in a timely manner, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to expedite the process used to direct the MCSCs to implement program changes. |
Closed – Implemented
The program change process and change management board action identified for implementation in January 2000 has occurred. The change management board meets quarterly to approve proposed changes to benefits and/or contract modifications for the Tricare managed care support contracts.
|
| Department of Defense | To help eliminate confusion resulting from frequent program changes, the Secretary of Defense should consolidate contract modifications and direct MCSCs to implement them on a quarterly basis. |
Closed – Implemented
The Department continues to support consolidating changes, and is in the process of determining the most advantageous interval for issuing such changes. The Department will be considering the impact consolidation will cause on DOD's beneficiaries, and the implication associated with directing the implementation of multiple changes concurrently.
|
| Department of Defense | In order to better measure and improve claims processing accuracy, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to grant MCSCs a longer transition period--9 to 12 months--between contract award and the start of health care delivery. |
Closed – Implemented
The Department has recognized for some time that the "transition" period available to start-up new MCSCs should be longer. Throughout GAO's planning process for the procurement of the next generation of MCSCs, the transition period will allow new MCSCs to successfully implement the purchased care segment of the TRICARE program. This transition period has been incorporated into DOD's long term acquisition schedule and corresponds with the GAO recommendation.
|
Full Report
Office of Public Affairs
Topics
Claims processingContractor paymentsDepartment of Defense contractorsHealth insuranceInternal controlsLate paymentsManaged health careMedical expense claimsMilitary benefits claimsPerformance measures