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HRD-81-75 1 (1981-04-15)

handle is hein.gao/gaobabbup0001 and id is 1 raw text is: II 9957 RUNITED STATES GENERAL ACCOUNTING OFFICE WASHINGTON, D.C. 20548 HUMAN RKSOuRCE$ DIVISION April 15, 1981 The Honorable John H. Moxley III Assistant Secretary of Defense U U I H I I 114957 Dear Mr. Moxley: Subject: Cew Claim Forms and Changes in Administrative Procedures May Increase Improper CHAMPUS Payments(HRD-81-75) In a March 16, 1979, letter to the Secretary of Defense (HRD-79-58), we reported that internal control procedures in the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) were inadequate to prevent ineligible persons from ob- taining program benefits. We estimated that $780,000 in benefits were improperly paid over a 26-month period for just one category of ineligible persons--dependents of former active-duty members who had separated from the service. In a February 2, 1981, report to the Congress (HRD-81-38), we reported that CHAMPUS fiscal inter- mediaries frequently paid claims erroneously because proper eligi- bility information was not obtained. Among the errors noted were (1) claims paid for services provided children age 21 and over without documentation supporting student or incapacity status and (2) claims paid with dates of care that were either before or after eligibility dates shown. Unlike Medicare and health plans of the Federal Employees Health Benefits Program, CHAMPUS has no central files of benefi- ciaries that may be checked to determine each claimant's eligi- bility. Instead, fiscal intermediaries determine eligibility from data provided on the claim form. Since this system relies on data provided by the claimant, it provides little control over payments to ineligible persons. DOD is developing a centralized enrollment system that should help prevent payments for ineligible persons. However, the system-- the Defense Enrollment Eligibility System (DEERS)--is not expected to be fully operational for several years. Until DEERS is opera- tional, fiscal intermediaries must continue to rely on the claim form to provide sufficient information to determine eligibility for CHAMPUS benefits. (101036) ,&j /,$: Sf'5

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