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HRD-78-68 1 (1978-03-14)

handle is hein.gao/gaobaawsp0001 and id is 1 raw text is: DOCUIRNT lESUIN 05118 8 [07356591 *~~d Civil Sorvici Moods to Improve Clais Deview Process ander tk- Federal Employee Health Benefits Program. HRD-78-68; 8-164562. arch 10, 1976. 21 PP. Report to Rep. Gladys soon Spellman* Chairman, louse Comittee on Post Oftice and Civil Service: Compessation and 2mployoe Benefits Subcommittee; by Bluer S. ttaatso Cosptroller General. Issue Area: Health Programs (1200); Health Vrograms; Reinbursament Policies amd Utilization Co&trols (1206). Contact: Human Resources Div. Budget Function: Health: Naltl Care Services (551). Orqanization Concerned: Civil Service colissigon. Conqressionel Relevance: HousA Committee on Post Office and CiTil Service: Coapevuatiom and Employee Benefits Subcosaittee. Authorit; : !seral Employses Health Benefits Act of 1959 (5 U.S.C. 8901; P.L. 86-382). P.L. $J-246. Tn a review of the Civil Sarvic* Coamiasion's (CSCP8) administration of the claims review procesa under the Federal Eployees Health Benefits (P13S) Pryoram, an ezaaination was made of: (1) a random xample of 62 closed disputed claim files from a dai-ch and April 1977 listing and en additional 42 files from cases closed during 4 days in Octobor 1977; (2) all disputed claim files closed during Decembo 1975 to April 1977 with required reports and records and. additonallyg all disputed claim files from January to April 1977 with or without reports and records; arl (3) all disputed claim Uaes closed for December 1975 to May 1977 for the comprehensive plan a (Aetna and Blue Cross ad Blue Shield). In addition,, a medical advisor reviewad 120 dispated claims files and the medical records for 55 of those cases. FindingsaConclasions: The CSC needs to increase the tia±±-auess of its responses to earolleea who dispute claim denials under tfe FIBS program. None of the CSC divisions compliad fully with the established 30-day tinaliuess criterion for sesolving disputed claims and responding to enrollees. The Division of Government-wide Plans froguently dii not review medical :ecords as the zagulaticas require; it often relied on summary sedical reports furnished by the fedezal Employee Proqram JPEP) office to arrive at conclusions. In view of the CSCs position that each of tha five medical records advisors should be able to review an average of five cases each per day* aLl disputed caia q of the Divisioa of Governaeat-wide PlAns cou!4 have been reviewed. Iecommeadations the Divisicn of Governaent-wide Plans should be directed to: (1) require health plans to romply with the regulation tLat an enrollee be provided a detailed explanatioa of why the claim was denieft (2) rely on the plansg detailed explanations of reasons for d*Ialn in lieu of PEP office reports; (3) request the FIB office tU provide records to the CSC within 5 dais of receipt from the

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