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entitled 'Indian Health Service: Increased Oversight Needed to Ensure
Accuracy of Data Used for Estimating Contract Health Service Need'
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United States Government Accountability Office:
GAO:
Report to Congressional Addressees:
September 2011:
Indian Health Service:
Increased Oversight Needed to Ensure Accuracy of Data Used for
Estimating Contract Health Service Need:
GAO-11-767:
GAO Highlights:
Highlights of GAO-11-767, a report to congressional addressees.
Why GAO Did This Study:
The Indian Health Service (IHS), an agency in the Department of Health
and Human Services (HHS), provides health care to American Indians and
Alaska Natives. When care at an IHS-funded facility is unavailable,
IHS’s contract health services (CHS) program pays for care from
external providers if the patient meets certain requirements and
funding is available. The Patient Protection and Affordable Care Act
requires GAO to study the adequacy of federal funding for IHS’s CHS
program. To examine program funding needs, IHS collects data on
unfunded services—services for which funding was not available—from
the federal and tribal CHS programs. GAO examined (1) the extent to
which IHS ensures the data it collects on unfunded services are
accurate to determine a reliable estimate of CHS program need, (2) the
extent to which federal and tribal CHS programs report having funds
available to pay for contract health services, and (3) the experiences
of external providers in obtaining payment from the CHS program. GAO
surveyed 66 federal and 177 tribal CHS programs and spoke to IHS
officials and 23 providers.
What GAO Found:
Due to deficiencies in IHS’s oversight of data collection, the data on
unfunded services that IHS uses to estimate CHS program need were not
accurate. Specifically, the data that IHS collected from CHS programs
were incomplete and inconsistent. For example, 5 of the 66 federal and
30 of the 103 tribal CHS programs that responded to GAO’s survey
reported that they did not submit these data to IHS in fiscal year
2009. Also, the format of IHS’s annual request has not provided the
agency with complete information to determine which programs submitted
these data. In addition, individual CHS programs reported
inconsistencies in how they recorded information about a specific type
of unfunded service that IHS uses in its assessment of need. A
reliable estimate of need will require complete and consistent data
from each of the individual CHS programs. In November 2010, IHS
created a workgroup to examine weaknesses in its current data and
explore other sources of data to estimate need. IHS officials expect
the workgroup to make a recommendation to the IHS Director by the end
of calendar year 2011 that IHS adopt a new method of estimating need.
As of September 2011, IHS was continuing to develop this new method
and officials indicated that deferral and denial data would continue
to be collected until it makes further decisions about its needs
assessment methodology.
Sixty of the 66 federal and 73 of the 103 tribal CHS programs that
responded to GAO’s survey reported that in fiscal year 2009 they did
not have CHS funds available to pay for all services for which
patients otherwise met requirements. Some federal CHS programs
reported continuing to approve services for patients when sufficient
funds were not available; IHS officials told us they were unaware this
practice was occurring. In contrast, other federal CHS programs
reported using a variety of strategies to help patients receive
services outside of the CHS program in order to maximize the care that
they could purchase. For example, some federal CHS programs reported
helping patients locate free or low-cost health care. Tribal CHS
programs reported using a variety of strategies not available to
federal CHS programs. For example, 46 of 103 tribal CHS programs that
responded to GAO’s survey reported supplementing their CHS programs’
funding with tribal funds, which are earned from tribal businesses or
enterprises.
Most external providers that GAO interviewed described challenges in
the CHS program payment process. For example, when patients presented
for emergency services, 13 of 23 providers reported challenges
determining which services would be approved for payment because,
unlike other payers, they cannot check a patient’s eligibility
electronically. Eighteen providers noted challenges receiving
communications from IHS about CHS policies and procedures related to
payment, including having had few, if any, formal meetings with
program staff and a lack of training and guidance. IHS officials
acknowledged that the complexity of the CHS program makes provider
education important. Most providers said that these challenges
contributed to patient and provider burden. For example, providers
said they generally billed the patient when CHS programs denied
payment for services, although they rarely collected payment on care
billed to CHS patients. Some providers said that this uncompensated
care had not significantly affected them financially, but others
stated that care uncompensated by the CHS program had affected them
financially by, for example, limiting their ability to purchase new
equipment.
What GAO Recommends:
GAO recommends that HHS direct IHS to ensure unfunded services data
are accurately recorded, CHS program funds management is improved, and
provider communication is enhanced. HHS noted how IHS would address
the recommendations; describing the proposed new method to estimate
need. IHS’s steps will address some recommendations, but immediate
steps are needed to improve the collection of unfunded services data
to determine program need.
View [hyperlink, http://www.gao.gov/products/GAO-11-767]. For more
information, contact Kathleen M. King at (202) 512-7114 or
kingk@gao.gov.
[End of section]
Contents:
Letter:
Background:
IHS's Oversight of Data Collection Does Not Ensure the Accuracy of the
Data Used for Estimating CHS Program Need:
Most Federal and Tribal CHS Programs Reported They Did Not Have CHS
Funds Available to Pay for All Services:
Most External Providers Reported Challenges with the CHS Program
Payment Process That May Burden Both Patients and Providers:
Conclusions:
Recommendations for Executive Action:
Agency and Tribal Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Catastrophic Health Emergency Fund:
Appendix III: Comments from the Department of Health and Human
Services:
Appendix IV: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Requirements for Approving Care for CHS Funding:
Table 2: Categorization of Area Offices by Selection Criteria:
Figures:
Figure 1: Counties in the 12 IHS Areas:
Figure 2: Two Paths for Patient Care to Be Funded by a Federal CHS
Program:
Figure 3: IHS Process for Collecting Unfunded Services Data and
Estimating the CHS Program's Unmet Need:
Figure 4: Priority Levels for Which Federal CHS Programs Had Funds
Available to Pay for Services in Fiscal Year 2009:
Abbreviations:
CHEF: Catastrophic Health Emergency Fund:
CHS: contract health services:
EMTALA: Emergency Medical Treatment and Active Labor Act:
FDI: Federal Disparity Index:
FEHBP: Federal Employees Health Benefits Program:
HHS: Department of Health and Human Services:
IHS: Indian Health Service:
OIG: Office of Inspector General:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
September 23, 2011:
Congressional Addressees:
Access to health care services for American Indians and Alaska Natives
has been a long-standing concern.[Footnote 1] The Indian Health
Service (IHS), an agency within the Department of Health and Human
Services (HHS), is charged with providing health care to the
approximately 1.9 million American Indians and Alaska Natives who are
members or descendants of federally recognized tribes.[Footnote 2]
These services are provided at federally or tribally operated health
care facilities,[Footnote 3] which receive IHS funding and are located
in 12 geographic regions overseen by IHS area offices.[Footnote 4]
These IHS-funded facilities vary in the services that they provide.
For example, some facilities offer comprehensive hospital services,
while others offer only primary care services. When services are not
available at these facilities, the agency's contract health services
(CHS) program may pay for services from external health care
providers, including hospital-and office-based providers. The CHS
program is administered at the local level by individual CHS programs
generally affiliated with IHS-funded facilities in each area. These
individual CHS programs may be federally or tribally operated.
These federal and tribal CHS programs determine whether or not to pay
for the referral of a patient to an external provider or pay an
external provider for a service already provided. IHS requires that
patients meet certain eligibility and administrative requirements to
have the services paid by the CHS program. In addition, the CHS
program, which is funded through the annual appropriations process,
must operate within the limits of its appropriations. Therefore,
committees associated with each CHS program meet at least weekly to
review cases and approve payment based on the relative medical need of
each case. When the requirements have not been met or funds are not
available, CHS programs defer or deny requests to pay for services.
Services for which patients otherwise meet necessary requirements, but
for which CHS program funds are not available for payment, are known
as unfunded services.
Limits on available resources have affected the specific types of
services available to American Indians and Alaska Natives through the
CHS program. For example, in a 2005 report examining 13 IHS-funded
health care facilities, we reported that primary care services were
generally offered at the facilities, but certain specialty and other
services were not always directly available to American Indians and
Alaska Natives.[Footnote 5] These facilities also generally lacked
funds to pay for all of these services through their CHS programs. We
also noted that, in some cases, gaps in services resulted in diagnosis
or treatment delays that exacerbated the severity of a patient's
condition and required more intensive treatment.
Funding for the CHS program has increased significantly, from $498
million in fiscal year 2005 to $779 million in fiscal year 2010.
Despite the funding increases over this period, IHS reported an
increase in the number of services denied by CHS programs due to a
lack of funding. IHS uses the number of services that were deferred or
denied due to a lack of funds by the CHS programs to develop an
estimate of the additional funds needed for the CHS program. However,
IHS and other stakeholders have questioned whether these data on
unfunded services represent the extent of need. For example, IHS has
acknowledged that little is known about the extent of unfunded
services for tribal CHS programs. Just for federal CHS programs, IHS
has estimated that $360 million in services were unfunded in fiscal
year 2008.[Footnote 6]
The Patient Protection and Affordable Care Act requires GAO to study
the adequacy of federal funding for the CHS program.[Footnote 7] IHS
does not maintain comprehensive data and information about the program
that would be relevant to assessing the adequacy of federal funding.
As discussed with the committees of jurisdiction, we examine (1) the
extent to which IHS ensures the data it collects on unfunded services
are accurate to determine a reliable estimate of CHS program need, (2)
the extent to which federal and tribal CHS programs report having
funds available to pay for contract health services, and (3) the
experiences of external providers in obtaining payment from the CHS
program.
To examine the extent to which IHS ensures the data it collects on
unfunded services are accurate to determine a reliable estimate of CHS
program need and the extent to which federal and tribal CHS programs
report having funds available to pay for contract health services, we
administered a Web-based survey to the 66 federal CHS programs
identified by the area offices. We administered the survey between
October 2010 and January 2011 and received completed survey responses
from all 66 federal CHS programs. We also administered a mixed-mode
survey--both Web-based and by mail--to the 177 tribal CHS programs
identified by the area offices. We administered the survey between
September 2010 and January 2011 and received completed survey
responses from 103 of the tribal CHS programs, for a response rate of
58 percent. Because we did not receive responses from all tribal CHS
programs and because there is variability among programs due to the
flexibility tribes and tribal organizations have in administering
their programs, the results from our survey of tribal CHS programs are
not generalizable to all tribal CHS programs. In addition, we
conducted two site visits to IHS's Oklahoma City and Portland area
offices, interviewed officials from IHS and each of IHS's 12 area
offices to discuss oversight of the CHS program, and spoke with tribal
health advocacy groups. We also examined IHS oversight--such as the
provision of policy and guidance--conducted to ensure that CHS
programs consistently and completely record and report unfunded
services data. We compared these oversight activities to the standards
described in the Standards for Internal Control in the Federal
Government and the Internal Control Management and Evaluation Tool.
[Footnote 8] We also reviewed our cost estimating guide to assess
procedures for determining a reliable estimate for budgetary purposes.
[Footnote 9]
To examine the experiences of external providers in obtaining payment
from the CHS program, we interviewed representatives from hospitals
and office-based health care providers in selected IHS areas. We
selected four areas based on their per capita CHS funding for fiscal
year 2009 and dependency on CHS funds for hospital services.[Footnote
10] The four areas we selected were Bemidji, Billings, Phoenix, and
Oklahoma City,[Footnote 11] which represent areas that were above or
below average for each of our selection criteria. Within these four
areas, we selected 16 hospitals and 7 office-based providers from a
list of providers that were identified by federal CHS programs in our
survey and by other experts as interacting frequently with IHS's CHS
program. Given the small number of providers in our sample and our
process for selecting them, the results from these interviews are not
generalizable to all providers interacting with the CHS program. We
asked providers about their experiences obtaining effective and timely
communication related to the payment process, such as training or
guidance on determining patient eligibility for CHS program payment of
services, and determining the status of claims or receiving payment,
and compared their experiences with the standards described in the
Standards for Internal Control in the Federal Government and the
Internal Control Management and Evaluation Tool.[Footnote 12] We asked
providers a standard set of open-ended questions and we did not
independently validate their reported experiences, but we did discuss
many of the issues they raised with IHS officials. (See appendix I for
more details on our scope and methodology.)
We conducted this performance audit from January 2010 to September
2011 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit
to obtain sufficient, appropriate evidence to provide a reasonable
basis for our findings and conclusions based on our audit objectives.
We believe that the evidence obtained provides a reasonable basis for
our findings and conclusions based on our audit objectives.
Background:
IHS oversees the CHS program through 12 area offices. Federal and
tribal CHS programs in each of these areas pay for services from
external providers if services are not available directly through IHS-
funded facilities, if patients meet certain requirements, and if funds
are available. IHS conducts an annual assessment to estimate CHS
program need. To perform its needs assessment, IHS requests data from
area offices and individual CHS programs on health care services they
were unable to fund.
CHS Program Organization:
IHS manages the CHS program through a decentralized system of 12 area
offices, which oversee individual CHS programs in 35 states where many
American Indian and Alaska Native communities are located. (See figure
1 for a map of the counties included in the 12 areas. Residence in
these counties is generally a requirement for obtaining contract
health services.)
Figure 1: Counties in the 12 IHS Areas:
[Refer to PDF for image: illustrated U.S. map]
Nashville;
Billings;
Phoenix;
Counties in both California and Phoenix;
Counties in both Phoenix and Tucson;
Counties in both Phoenix and Navajo;
Counties in both Navajo and Albuquerque;
Bemidji;
Portland;
California;
Alaska;
Oklahoma City;
Aberdeen;
Albuquerque;
Navajo;
Tucson;
Source: GAO analysis of IHS information, as of July 2011.
[End of figure]
IHS headquarters is responsible for overseeing the CHS program. Among
other things, it sets program policy and distributes CHS program funds
to the 12 area offices. The 12 area offices then distribute funds to
CHS programs within their respective areas, monitor the CHS programs,
establish procedures within the policies set by IHS, and provide
programs with guidance and technical assistance. About 46 percent of
CHS funds are distributed to federal CHS programs and the other 54
percent to tribal CHS programs.[Footnote 13] Tribal CHS programs must
meet the same statutory and regulatory requirements as federal CHS
programs, but they are not generally subject to the same policies,
procedures, and reporting requirements established for federal CHS
programs.[Footnote 14]
Federal and tribal CHS programs pay for services from external
providers if the services are not available at IHS-funded facilities.
The services purchased include hospital, specialty physician,
outpatient, laboratory, dental, radiology, pharmacy, and
transportation services. While programs may have agreements or
contracts with providers, they are not required for a provider to be
paid. For example, a CHS program may have a contract with a nearby
hospital or specialty providers, such as an orthopedic practice, to
provide services to American Indians and Alaska Natives served by the
CHS program. However, in the event of an emergency, patients have the
option of visiting the nearest available provider, regardless of
whether that provider has any prior relationship with the CHS program.
Patients must meet certain eligibility, administrative, and medical
priority requirements to have their services paid for by the CHS
program. (See table 1.) To be eligible to receive services through the
CHS program, patients must be members of federally recognized tribes
and live in specific areas. In addition, patients must meet specific
administrative requirements. For example, if there are other health
care resources available to a patient, such as Medicaid and Medicare,
[Footnote 15] these resources must pay for services before the CHS
program because the CHS program is generally the payer of last resort.
[Footnote 16] If a patient has met these requirements, a program
committee (often including medical staff) that is part of the local
CHS program evaluates the medical necessity of the service. IHS has
established four broad medical priority levels of health care services
eligible for payment and a fifth for excluded services that cannot be
paid for with CHS program funds. Each area office is required to
establish priorities that are consistent with these medical priority
levels and are adapted to the specific needs of the CHS programs in
their area. Federal CHS programs must assign a priority level to
services based on the priority system established by their area
office. Funds permitting, federal CHS programs first pay for the
highest priority services (priority level I: emergent/acutely urgent
care), and then for all or only some of the lower priority services
they fund. Tribal CHS programs must use medical priorities when making
funding decisions, but unlike federal CHS programs, they may develop a
system that differs from the set of priorities established by IHS.
Table 1: Requirements for Approving Care for CHS Funding:
Category: Eligibility;
Requirement[A,B]:
* Individual is a member or descendant of a federally recognized tribe
or maintains close social and economic ties with the tribe;
* Individual lives on a federally recognized Indian reservation or
within the designated service delivery area for the CHS program.
Category: Administrative;
Requirement[A,B]:
* Any available alternate source of payment for care, such as
Medicare, Medicaid, or private insurance, for which an individual is
eligible, must be used before the CHS program will pay;
* IHS-funded facility is not reasonably available and accessible to
provide the care;
* Prior approval is obtained for non-emergency services;
* For emergency services, the CHS program is notified within 72 hours
of the care being provided or within 30 days for elderly and disabled
persons.
Category: Medical Priority;
Requirement[A,B]: Each area office is required to establish priorities
that are consistent with IHS's medical priority levels and that are
adapted to the specific needs of the CHS programs in their area. In
contrast, tribes have flexibility to create their own priorities,
which can differ from IHS's. Below are the medical priority levels
established by IHS[C];
* Priority level I, includes emergent/acutely urgent care services,
such as trauma care, acute/chronic renal replacement therapy,
obstetrical delivery and neonatal care;
* Priority level II, includes preventive care services, such as
preventive ambulatory care, routine prenatal care, and screening
mammograms;
* Priority level III, includes primary and secondary care services,
such as scheduled ambulatory services for nonemergent conditions,
elective surgeries, and specialty consultations;
* Priority level IV, includes chronic tertiary and extended care
services, such as rehabilitation care, skilled nursing facility care,
and organ transplants;
* Priority level V, includes excluded services, such as cosmetic
plastic surgery and experimental procedures, that programs may not pay
for with CHS program funds.
Source: GAO analysis of IHS's Indian Health Manual and regulations,
which can be found at 42 C.F.R. §§ 136.23, 136.61 (2010).
[A] If eligibility, administrative, and medical priority requirements
have been met, but funds are not available, care is to be deferred or
denied.
[B] There are also certain exceptions to these requirements.
[C] Funds permitting, federal CHS programs first pay for all of the
highest priority services, and then all or some of the lower priority
services, but CHS program funds may not be used to pay for priority
level V services.
[End of table]
There are two primary paths through which patients may have their care
paid for by a federal CHS program. The subsequent sections generally
describe these two paths, which IHS officials told us federal CHS
programs are expected to follow. First, a patient may obtain a
referral from a provider at an IHS-funded health care facility to
receive services from an external provider, such as a hospital or
office-based physician. That referral is submitted to the CHS program
for review. If the patient meets the requirements and the CHS program
has funding available, the services in the referral are approved by
the CHS program and a purchase order is issued to the external
provider and sent to IHS's fiscal intermediary.[Footnote 17] Once the
patient receives the services from the external provider, that
provider obtains payment for the services in the approved referral by
sending a claim to IHS's fiscal intermediary. Second, in the case of
an emergency, the patient may seek care from an external provider
without first obtaining a referral. Once that care is provided, the
external provider must send the patient's medical records and a claim
for payment to the CHS program.[Footnote 18] At that time, the CHS
program will determine if the patient meets the necessary program
requirements and CHS funding is available for a purchase order to be
issued and sent to the fiscal intermediary. As in the earlier
instance, the provider obtains payment by submitting a claim to IHS's
fiscal intermediary. Patients seeking to have their care paid for by
tribal CHS programs follow similar pathways, but these programs have
certain flexibilities. For example, while some tribal CHS programs
also contract with IHS's fiscal intermediary to pay claims, they may
also utilize other arrangements. (See figure 2 for an overview of
these two paths for a patient to access the CHS program.)
Figure 2: Two Paths for Patient Care to Be Funded by a Federal CHS
Program:
[Refer to PDF for image: illustration]
Payment process with referral:
* Patient goes to an IHS-funded facility for treatment[A];
* Provider gives patient a referral to an external provider if
treatment is not available[A];
* CHS program reviews referral with the input of its CHS committee[A];
* Eligibility requirement is reviewed[A];
* Administrative requirement is reviewed[A];
* Medical priority requirement is reviewed[A];
* CHS program approves claim and issues purchase order if requirements
are met and funding is available. CHS program approval takes place at
this step[A].
* External provider delivers services;
* External provider submits claim to the CHS program fiscal
intermediary for payment;
* Fiscal intermediary validates and pays claim[A].
Payment process without referral (emergency situations):
* Patient goes directly to an external provider for treatment;
* External provider delivers services;
* External provider submits patient medical records and claim to CHS
program;
* CHS program reviews patient medical records and claim with the input
of its CHS committee[A];
* Eligibility requirement is reviewed[A];
* Administrative requirement is reviewed[A];
* Medical priority requirement is reviewed[A];
* CHS program approves claim and issues purchase order if requirements
are met and funding is available. CHS program approval takes place at
this step.
* External provider delivers services;
* External provider submits claim to the CHS program fiscal
intermediary for payment;
* Fiscal intermediary validates and pays claim[A].
[A] CHS program plays role in decision-making during these steps.
Source: GAO interviews with IHS officials and analysis of IHS
documents.
[End of figure]
Within either of these pathways, if the CHS program determines that
the patient's service does not meet the necessary requirements or
funding is not available, it denies CHS funding. It may also defer
funding a service. The CHS program may issue a deferral when CHS funds
are not available for a service but the patient has otherwise met the
eligibility and administrative requirements.[Footnote 19]
Needs Assessment for the CHS Program:
IHS conducts an annual assessment to estimate the CHS program's unmet
need, which helps inform its budget request for the CHS program. To
gather information for its needs assessment, IHS headquarters sends an
annual request for information to each of the 12 area offices asking
them to report information from the federal and tribal CHS programs in
their respective areas. The annual request contains a template that
asks each area office to provide, among other things, summary counts
of deferrals and denials that were recorded by the CHS programs in
their areas. For example, each area office is asked to provide
areawide totals of the number of new deferrals that remained unfunded
at the end of the fiscal year. They are also to provide summary counts
of denials that have been issued for each of eight categories of
denial reasons, regardless of the type of service denied. The eight
categories generally correspond to the CHS program's eligibility,
administrative, and medical priority requirements.[Footnote 20]
Although funding for a service may be denied for multiple reasons,
programs are required to categorize each denial by a single primary
reason.
IHS uses the data recorded by the individual CHS programs and
collected by the area offices to develop an estimate of the CHS
program's unmet need. (See figure 3.) To develop its estimate, IHS
headquarters adds the total number of reported deferrals and the total
number of denials reported in one of eight IHS-defined denial
categories: "care not within medical priority." According to IHS, CHS
programs are only to record a denial as "care not within medical
priority" to indicate that the patient met eligibility and
administrative requirements, but the care requested was not within one
of the medical priority levels for which funding was available. For
example, a program that determines it only has funding available to
pay for care designated as priority level I may deny a request to pay
for care designated as priority level II because the care requested
was not within the medical priority for which funding was available.
Although IHS requests that the area offices report data from both
federal and tribal CHS programs, it cannot require tribal CHS programs
to report these data. Therefore, IHS officials told us they make an
assumption in their assessment of program need that most tribal CHS
programs do not report deferral and denial counts to the area offices.
Because tribal programs receive about half of IHS's CHS funding, and
because IHS believes that tribal CHS programs' experiences are similar
to federal programs, IHS takes the data reported by area offices and
multiplies them by two to calculate an estimate of the total number of
deferrals and denials for the entire CHS program. IHS then multiplies
this count of deferrals and denials by an estimated average cost per
claim (calculated using a weighted average of the costs for inpatient
and outpatient paid CHS claims) to develop an estimate of the funds
needed for the CHS program. To this estimate, IHS adds data from the
CHS program's Catastrophic Health Emergency Fund (CHEF), a fund that
IHS headquarters administers to reimburse CHS programs for their
expenses from high-cost medical cases.[Footnote 21] Specifically, IHS
adds the total billed charges from services for which CHS programs
sought reimbursement from IHS headquarters through CHEF, but that CHEF
was unable to fund. (See appendix II for further discussion of CHEF.)
Figure 3: IHS Process for Collecting Unfunded Services Data and
Estimating the CHS Program's Unmet Need:
[Refer to PDF for image: illustration]
Data collection:
Federal and tribal CHS programs:
Each program is requested to submit unfunded services data to its area
office:
* Counts of deferrals;
* Counts of denials (counts in 8 categories)[A];
Area office:
Each office compiles area-wide summary totals based on the unfunded
services data submitted by CHS programs in response to the annual
request.
IHS headquarters:
IHS headquarters begins its estimate calculation.
Estimate calculation:
Count of total deferrals;
multiplied by:
Count of total denials for care not within medical priority;
equals:
Count of unfunded services.
Count of unfunded services multiplied by 2 (multiplied by two based on
IHS assumption that few tribal CHS programs submit data) equals:
Subtotal for count of unfunded services;
multiplied by:
Estimated average cost of paid claims[B];
equals:
Estimated cost of unfunded services;
plus:
CHEF unfunded charges[C];
equals:
Estimated CHS program unmet need.
Source: GAO interviews with IHS officials and analysis of IHS
documents.
[A] The eight categories of denial are: (1) eligible but care not
within medical priority, (2) eligible but alternate resource
available, (3) patient ineligible for CHS, (4) emergency notification
not within 72 hours, (5) non-emergency prior approval not authorized,
(6) patient resides outside CHS delivery area, (7) IHS facility
available and accessible, and (8) all other denials.
[B] IHS estimates an average cost per claim by calculating a weighted
average of the costs for inpatient and outpatient paid CHS claims. IHS
then multiplies this estimate by the count of deferrals and denials.
[C] The Catastrophic Health Emergency Fund (CHEF) is administered by
IHS headquarters to reimburse CHS programs for their expenses from
high cost medical cases. IHS adds the total billed charges from
services for which CHS programs sought reimbursement from IHS
headquarters through CHEF, but that CHEF was unable to fund.
[End of figure]
IHS's Oversight of Data Collection Does Not Ensure the Accuracy of the
Data Used for Estimating CHS Program Need:
Due to deficiencies in IHS's oversight of data collection, the
unfunded services data on deferrals and denials that IHS used to
estimate program need are incomplete and inconsistent. IHS does not
have complete deferral and denial data from all federal and tribal CHS
programs to estimate CHS program need. While IHS headquarters told us
that area offices submit a report on unfunded services from their
federal and tribal CHS programs in response to the annual request,
[Footnote 22] these reports did not include data from all federal or
tribal CHS programs. Of the 66 federal CHS programs that responded to
our survey, 5 reported that they did not submit any deferral or denial
data to their area offices in response to IHS's annual request in
fiscal year 2009. IHS officials acknowledged that they did not follow
up with federal CHS programs to ensure they submitted data. Although
not required, tribal programs may choose to submit deferral and denial
data to IHS and the agency asks the area offices to include tribal
data in their annual reports. Of the 103 tribal CHS programs that
responded to our survey, 30 indicated that they collected data on
unfunded services and submitted these data to their area offices in
response to IHS's annual request in fiscal year 2009.[Footnote 23] IHS
officials acknowledged that the agency needed to provide more outreach
and technical assistance to tribal programs to submit data in response
to IHS's annual request. For example, they told us that an area office
used such efforts during one fiscal year and was successful at
eliciting data submissions from more tribes. By not encouraging the
reporting of unfunded services data from all programs, IHS's data
collection activities are not consistent with the Standards for
Internal Control in the Federal Government, which state that an
organization's management should provide reasonable assurance of the
reliability of its reporting data for the agency to achieve its goals-
-in this instance, IHS's goal to appropriately determine CHS program
need. As we have also previously reported, the ability to generate
reliable estimates is a critical function for agency management;
having accurate data contributes to the reliability of the estimate.
[Footnote 24]
Second, IHS's report template was not designed to allow the agency to
collect complete information for estimating need because it did not
distinguish between the federal and tribal CHS programs that did
report data. Because IHS headquarters only requested areawide totals
in its report template, IHS officials were unable to determine which
CHS programs reported data from the area reports that were submitted.
IHS officials told us they did not know how many federal or tribal CHS
programs reported data, although they estimated that most of the data
were from federal programs and only a small percentage were from
tribal programs. To account for the lack of complete data from tribal
programs, when conducting its needs assessment, IHS doubled the count
of unfunded services it received from the area offices. However, this
means that any data received from tribal programs were being doubled
along with the federal data, contributing to an unreliable estimate of
need. For example, in fiscal year 2009, one area office reported a
total of 4,858 denials for "care not within medical priority," which
IHS doubled to account for the lack of complete data from tribal
programs. However, we determined that 2,901 of the 4,858 denials were
reported by tribal CHS programs.[Footnote 25] IHS officials told us
that they do not distinguish federal and tribal CHS program data in
their annual data reporting template because they believe the data
they receive from tribal CHS programs are so limited that they would
not significantly affect their estimate of need.
Additionally, CHS programs inconsistently categorized a specific type
of denial reason that is reported to IHS headquarters and used in its
estimate of CHS program need because IHS has not provided guidance on
this issue. CHS programs can deny care for multiple reasons, but IHS
requires CHS programs to select a primary reason for denial.
Specifically, IHS officials told us that IHS only counted those
denials with a primary reason identified as "care not within medical
priority" in its needs assessment because these services were denied
solely if funds were not available.[Footnote 26] However, neither IHS
headquarters nor the area offices had provided guidance to federal CHS
programs on how to select this primary reason for denial.
Consequently, we found some area office and CHS program officials
defined this type of denial reason in different ways. Officials from
four area offices told us that they defined denials for "care not
within medical priority" as also including services denied for
administrative reasons or services that are excluded even if CHS funds
are available such as cosmetic or experimental procedures. In our
survey of the 66 federal CHS programs, 51 reported that they would
apply this denial category if the care requested was an excluded
service. One CHS program reported not knowing that a primary reason
for denial existed. Because this category of denial was the only
denial reason IHS used in its estimate, inconsistencies in how this
denial reason was categorized by CHS programs have directly affected
IHS's estimate of need.
Some CHS programs also inconsistently recorded deferrals because IHS
has not provided guidance about how it uses deferral data in its needs
assessment. IHS officials told us that both deferral and denial data
were used in IHS's needs assessment. However, officials from one area
office reported that their understanding was that only denials were
counted in IHS's needs assessment. In our survey of the 66 federal CHS
programs, we found that 15 reported recording a decision to defer a
service as both a deferral and a denial (making the count of denials
inaccurate). Because IHS uses both deferrals and denials to estimate
need, the inconsistent recording of deferrals would directly affect
IHS's estimate of need. IHS did not have a written policy documenting
how the deferral and denial data it requests annually from the CHS
programs would be used in its needs assessment and IHS officials told
us they had not provided training to area offices or CHS programs on
how to complete the annual request.[Footnote 27] However, this lack of
guidance is inconsistent with the Standards for Internal Control in
the Federal Government, which notes that formally documented policies
and procedures provide guidance that, among other things, helps to
ensure that staff perform activities consistently across an agency.
[Footnote 28]
IHS officials have also identified weaknesses in the deferral and
denial data that they used to estimate CHS program need. For example,
they told us the data did not capture complete information on needed
services that were not requested of the CHS programs because patients
may have been discouraged from presenting for care or providers may
have chosen not to write referrals if they believed funds were not
available to pay for services.[Footnote 29] IHS officials also told us
that these data did not capture data on the extent to which tribes
supplemented their CHS funds with tribal funds to avoid deferring or
denying health care services.[Footnote 30]
IHS has initiated steps to examine these weaknesses in its current
data and explore other sources of data to estimate CHS program need.
In November 2010, IHS convened an Unmet Needs Data Subcommittee as
part of its Director's Workgroup on Improving the CHS Program.
[Footnote 31] The subcommittee was comprised of representatives from
federal and tribal CHS programs. In a January 2011 report, the
subcommittee noted that IHS's deferral and denial data had
inaccuracies. While the report noted that reliably captured deferral
and denial data on all patients would present the strongest evidence
of need, it acknowledged that these data were incompletely and
inconsistently reported by CHS programs, and recognized that this
undermined the reliability of the estimated need IHS reports to the
Committees on Appropriations annually in its budget justification. In
February 2011, the subcommittee presented options for improving IHS's
assessment of CHS program need to the Director's Workgroup.
Based on these options, the Director's Workgroup agreed that the
subcommittee should explore a new methodology for estimating CHS
program funding needs that relies on different sources of data. Rather
than relying on deferral and denial data, the new method would use
IHS's existing Federal Disparity Index (FDI). IHS calculates the FDI
to estimate the disparity between its overall health care funding and
the amount of funding needed to provide care to American Indians and
Alaska Natives at a level comparable to the care provided by the
Federal Employees Health Benefits Program (FEHBP), which is a
nationwide health insurance program available to federal employees.
[Footnote 32] With this new method, IHS would adapt the FDI to
calculate an estimate of need for each CHS program. Specifically, each
IHS-funded facility would use a standardized tool to (1) calculate
what proportion of services is paid for by its CHS program because
these services are not available on-site at an IHS-funded facility,
(2) estimate the level of CHS funding that would be needed to provide
comparable services to those covered by FEHBP, and (3) compare that
estimated level of funding to the program's actual level of funding.
As a first step, each IHS area was to pilot the methodology on-site at
two of its IHS-funded facilities. Once the pilots were completed, IHS
officials told us the Workgroup planned to review the results of these
pilots and issue a final report that contains a recommendation for the
Director of IHS to consider for approval. As of September 2011, IHS
officials said that they had finished the on-site pilots, but they
were still making decisions about how to best adapt the FDI method to
estimate CHS program need and they did not have a formal agency
approved plan for implementing it. Officials indicated that they
expected the Workgroup to issue a final report to the Director for
approval by the end of calendar year 2011.
In addition to the proposed new method for estimating need, the
Director's Workgroup agreed that actions be taken to improve the
agency's collection of deferral and denial data that is currently used
for that purpose. However, as of September 2011, IHS officials told us
that the agency had not determined whether it would make improvements
to the collection of deferral and denial data because it had not
determined how such data would be used if the FDI method is adopted.
But, officials said that they still see merit in using deferral and
denial data to estimate CHS program need and, therefore, IHS may
supplement the estimates from the FDI method with deferral and denial
data from CHS programs that agency officials believe collect accurate
data. IHS officials indicated that, until this decision is made, the
agency will continue to collect deferral and denial data from the area
offices through its annual request.
Most Federal and Tribal CHS Programs Reported They Did Not Have CHS
Funds Available to Pay for All Services:
Most federal and tribal CHS programs reported that they did not have
CHS funds available to pay for all services for patients who otherwise
met eligibility and administrative requirements in fiscal year 2009.
In addition, some federal CHS programs reported using problematic
funds management practices.
Most Federal CHS Programs Reported That They Did Not Have CHS Funds
Available to Pay for All Services, and Some Reported Using Problematic
Funds Management Practices:
Of the 66 federal CHS programs that responded to our survey, 60
reported that they did not have CHS funds available to pay for all
services for patients who otherwise met eligibility and administrative
requirements in fiscal year 2009.[Footnote 33] IHS officials told us
that most CHS programs establish budgets as a way to help ensure that
funds are available throughout the year.[Footnote 34] However, even
with this budgeting, 11 of these 60 CHS programs reported that they
depleted their funds before the end of the fiscal year. Officials from
three CHS programs we spoke with said their programs experienced
multiple high-cost cases in the fourth quarter that depleted their
funds. An official from another CHS program noted that the program is
located in a rural area and the closest specialty care providers are 3
hours away by car. Therefore, if emergency care is required, the
patient must be transported by air, which the CHS official said is
expensive. In our survey, each federal CHS program identified the
three most common categories of services it deferred or denied in
fiscal year 2009. The most commonly cited categories of services were
dental services, orthopedic services, vision services, and diagnostic
and imaging services.[Footnote 35]
The 60 federal CHS programs that reported not having CHS funds
available to pay for all services in fiscal year 2009 varied in the
extent to which they had funds available to pay for services in each
of the priority levels. Some programs described the circumstances that
influenced the extent to which they had funds available to pay for
services in fiscal year 2009. (See figure 4.)
* Thirty-nine of these programs reported having funds available to pay
for all priority level I services (emergent/acutely urgent care) and
some services in lower priority levels. Some of these CHS programs
said that after purchasing all of their priority level I services,
they had funds remaining at the end of the fiscal year and were able
to use these funds to pay for lower priority services for patients
whose services they had originally deferred or denied. For example,
officials from one CHS program reported that in fiscal year 2009, they
were able to use funds at the end of the fiscal year to provide
eyeglasses to children and the elderly; a lower priority service that
normally would not have been funded.
* Ten of these programs reported having funds available to pay for all
priority level I services, but no services in lower priority levels.
Some of these CHS programs reported that they never fund services
beyond priority level I because their funds are so limited. An
official from one of these programs noted that if a patient's case was
originally deferred or denied because it was not a priority level I
service but the patient's condition became more severe, the case may
later be reclassified as a priority level I and the services purchased.
* Six of these programs reported having funds available to pay for
some of their priority level I services and some services in lower
priority levels. An official from one of these CHS programs told us
that they strictly adhere to a weekly budget. For example, if they
approved three high-cost cancer treatment cases one week, they may
deny other priority level I cases because they do not have funds
remaining to pay for these services. But, if funds in another week are
sufficient to pay for all priority level I cases, they may also have
funds available to pay for some lower priority services. An official
from another of these CHS programs told us that staffing shortages
over 2 years resulted in the program paying for services as the
requests were received rather than funding them in order of medical
priority. The official told us that, as a result, the CHS program paid
for some priority level IV services, like durable medical equipment,
even though they did not have funds available to pay for all of their
priority level I services for the year.
* Five of these programs reported depleting their CHS funds before the
end of the fiscal year and reported that they did not have funds
available to pay for all priority level I services. One of these
programs reported depleting its funds for the fiscal year in the
second quarter of fiscal year 2009, two programs reported depleting
their funds in the third quarter, and two programs reported depleting
their funds in the fourth quarter.
Figure 4: Priority Levels for Which Federal CHS Programs Had Funds
Available to Pay for Services in Fiscal Year 2009:
[Refer to PDF for image: illustration]
All federal CHS programs (66):
* Programs that reported having CHS funds available to pay for all
services in fiscal year 2009 (6);
* Programs that reported not having CHS funds available to pay for all
services in fiscal year 2009 (60):
- Programs that reported having funds available to pay for all
priority level I services and some services in lower priority levels
(39);
- Programs that reported having funds available to pay for all
priority level I services but no services in lower priority levels
(10);
- Programs that reported having funds available to pay for some
priority level I services and some services in lower priority levels
(6);
- Programs that reported having funds available to pay for some
priority level I services but no services in lower priority levels (5).
Source: GAO survey of federal CHS programs.
[End of figure]
Federal CHS programs we spoke with reported using a variety of
strategies to help patients receive services outside of the CHS
program in order to maximize the care that they could purchase. For
example, strategies noted by some CHS programs included helping
patients locate free or low-cost health care or negotiating reduced
rates with providers on the patient's behalf. Although CHS programs
are required to identify alternate resources before approving a
referral, some officials we spoke with said they have implemented
additional measures to help enroll patients in alternate coverage,
such as Medicare and Medicaid. For example, one CHS program reported
hiring a benefits coordinator who is responsible for helping enroll
people in alternate coverage.
IHS's CHS programs are not able to pay for services for all patients
who meet program requirements because they must operate within the
limited funding available. Whenever a program incurs costs for
services, the program incurs legal obligations to make payments. IHS
does not authorize programs to incur obligations in excess of their
"allowances," which are distributions of funds that IHS makes to
programs from appropriations for contract health services.[Footnote
36],[Footnote 37] According to IHS officials, programs are expected to
actively manage their funds in order to maximize the care that can be
purchased, and defer or deny care when sufficient funds are not
available. Officials from five federal CHS programs told us, however,
that they approved services when funds were depleted for a fiscal year
with the understanding that providers would not be paid until the next
fiscal year. For example, one of these officials reported that at the
beginning of fiscal year 2009, the program owed $2 million to
providers for care provided in fiscal year 2008 for which funds had
not been available. At least one of these officials believed that she
was not authorized to deny care due to lack of funds.
The reports from these officials suggest significant weaknesses in
funds management and violations of IHS policy creating the potential
for violations of the Antideficiency Act.[Footnote 38] They also
suggest significant inconsistencies in the administration of federal
CHS programs. When asked about this issue, IHS officials told us that
they were not aware that CHS programs had approved services without
available funds, but acknowledged that there had been some confusion
in the past regarding programs' authority to deny care when funds were
not available. They also noted that the agency guidance on funds
management that is provided to CHS program staff is vague and needs to
be updated and clarified. The officials told us that the agency plans
to update and revise relevant IHS guidance, but had not developed a
timeline for these revisions. The officials said that they have
delegated responsibility to the area offices for issuing specific
guidance to CHS programs, as well as conducting oversight regarding
funds management and other issues. The officials, however,
acknowledged that additional guidance and training from IHS
headquarters for the CHS programs on funds management would be helpful.
Most Tribal CHS Programs Reported That They Did Not Have CHS Funds
Available to Pay for All Services but Many Used Other Strategies to
Expand Access to Care:
Of the 103 tribal CHS programs that responded to our survey, most
reported they did not have CHS funds available to pay for all services
for patients who otherwise met eligibility and administrative
requirements, with 73 reporting that they depleted their CHS funds at
some point during fiscal year 2009.[Footnote 39] In our survey, each
tribal CHS program identified the three most common categories of
services that were requested but not funded in fiscal year 2009. The
most commonly cited categories of services that were requested but not
funded were dental services, orthopedic services, prescription drugs,
diagnostic and imaging services, and hospital services.[Footnote 40]
Tribal CHS programs reported using a variety of strategies not
available to federal CHS programs to expand access to care. Forty-six
of the 103 tribal CHS programs that responded to our survey reported
supplementing their CHS programs' funding with tribal funds--funds
earned from tribal businesses or enterprises.[Footnote 41] For
example, one tribal CHS program we spoke with used the profits from
its tribally funded medical and dental clinics, which served non-IHS
patients on a fee-for-service basis, to supplement its CHS funding. Of
the 46 programs that reported finding it necessary to supplement their
CHS programs with tribal funds, 28 reported contributing as much as
was needed each year, while the other 18 reported that their tribal
contributions were limited by the availability of funds from year to
year. In our survey, tribal CHS programs identified the three most
common categories of services paid for with tribal funds in fiscal
year 2009. The most commonly cited categories of services were
prescription drugs, dental services, hospital services, and orthopedic
services. Five tribal CHS programs we spoke with reported using tribal
funds to expand access to contract health services to individuals
living outside the designated CHS delivery area, or to pay for
services CHS funding would not usually cover.
Tribal CHS programs also reported supplementing their CHS funding by
using reimbursements from third party payers to pay for CHS services,
a strategy not available to federal CHS programs. Thirty-four of the
103 tribal CHS programs that responded to our survey reported using
reimbursements for services provided at their IHS-funded facilities
from third party payers such as Medicare, Medicaid, or private
insurance to pay for additional services through their CHS programs.
One tribal CHS program we spoke with reported that more than half of
its budget relied on funds from third party reimbursements, although
officials noted that even with this supplemental funding, they were
still limited to funding priority level I services only.
In addition, five tribal CHS programs we spoke with reported using
strategies to expand access to care that reduced their reliance on CHS
funds. For example, two programs we spoke with were able to directly
enroll patients in a state-based insurance program for low-income
individuals who did not qualify for Medicaid, and to pay the premiums
using tribal funds. For uninsured CHS-eligible patients who are
ineligible for government programs, one program reported using its IHS-
allocated CHS funds to purchase private insurance coverage under a
waiver from IHS.[Footnote 42] Enrolling eligible patients in alternate
coverage reduced the reliance on CHS funds because the CHS program
would only have to pay for services to the extent they are not covered
by the alternate resources. Another program was able to achieve cost
savings by contracting with a third party administrator to process its
CHS claims, which allowed it to access a preferred provider network
that provided care at discounted rates. Officials from another program
reported bringing specialty providers, such as cardiologists and ear,
nose, and throat specialists on-site at their facility to save money,
compared to what it would cost to pay providers in the community for
individual services.
Most External Providers Reported Challenges with the CHS Program
Payment Process That May Burden Both Patients and Providers:
Most of the external providers who we interviewed reported challenges
in determining patient eligibility for CHS payment of services, in
obtaining CHS payment, and in receiving communications on CHS policies
and procedures from IHS related to payment. Providers stated that
these challenges contributed to patient and provider burdens.
Most Providers Reported Challenges Determining Patient Eligibility, in
Obtaining Payment, and in Receiving Communications on CHS Policies and
Procedures Related to Payment:
Thirteen of the 23 providers who we interviewed reported challenges in
determining whether patients presenting for care without a CHS
referral were eligible to have services paid by the CHS program.
Fourteen providers also reported challenges obtaining timely payment
from CHS programs. Lastly, 18 providers noted challenges receiving
communications from IHS about CHS policies and procedures related to
payment, including having had few, if any, formal meetings with CHS
staff and a lack of training and guidance.
Determining Patient Eligibility for CHS Program Payment of Services:
Thirteen providers who we interviewed reported challenges determining
whether patient services would be approved by the CHS program for
payment. Providers interact with American Indian and Alaska Native
patients if these patients bring a referral from an IHS-funded health
care facility. In the case of an emergency, a patient may seek care
without obtaining a prior referral. Thirteen providers said it was
especially challenging to determine patient eligibility when patients
presented for care without a CHS program referral. Six providers noted
that for other payers with which they interact, they are able to
electronically check a patient's eligibility or covered services.
However, IHS officials indicated that it is not possible for providers
to check electronically whether the CHS program will pay for a
service. Five providers indicated that, when possible, they attempted
to contact the CHS programs in order to obtain information about a
patient's eligibility. However, those providers said they were
generally not able to get in contact with CHS program staff. Moreover,
even if a provider determined that a patient met some CHS program
eligibility requirements, such as tribal membership, payment was still
conditional on whether the CHS program reviewed the patient's medical
record and later determined that the emergency service met medical
priority requirements and funds were available. Therefore, providers
may not know if they will receive payment for services delivered to
the patient until the claim they have submitted to the CHS program is
reviewed. In the absence of a process to determine patient eligibility
for the CHS program, 12 providers said they submit claims for payment
to CHS programs for all patients who self-identified as being American
Indian or Alaska Native or eligible for the CHS program.
Fourteen providers said that when a patient presented for care with a
CHS program referral, the likelihood that they would receive payment
for the services delivered to the patient increased. For example, one
provider stated that for the care delivered to American Indian and
Alaska Native patients without a CHS program referral, about 80
percent of claims were denied; in comparison, about 20 percent of
claims were denied when patients had a CHS referral. IHS officials
said that denials may occur for a patient who has a referral if the
patient presented for care at the external provider before the
referral was approved by the CHS program committee.[Footnote 43]
However, they also noted that there were situations in which a
referral that had been approved by a CHS program committee could still
be denied. For example, if a patient did not apply for alternate
resources, such as Medicare and Medicaid, for which the patient was
eligible or the provider did not bill other payers for which the
patient was eligible, the claim may be denied for CHS
payment.[Footnote 44] Additionally, although CHS programs are required
to consider the availability of alternate resources when deciding
whether to approve a referral, IHS officials acknowledged that
programs may not always take this into consideration when making their
decision.
Providers reported a number of reasons for which they received denials
for payment from CHS programs. While providers said that some of the
denials they received were related to patient eligibility, such as a
patient living outside of the CHS delivery area, which was noted by
four providers, most of the denials they received were related to
administrative requirements. Twelve providers indicated that one of
the most common reasons for denial was that an alternate resource was
available to the patient. Other common administrative denial reasons
included the availability and accessibility of IHS facilities to
deliver services, noted by seven providers, and failure to provide
notification within 72 hours of the patient receiving emergency
services, noted by six providers. Seven providers also stated that
they received denials because the CHS program determined that the care
was non-emergent or not within medical priority for which funding was
available. In addition, eight providers stated that some denials may
have occurred because CHS patients may not have had a clear
understanding of CHS policies and procedures related to payment. Eight
providers stated that CHS patients could benefit from education on CHS
procedures, including the need to obtain a CHS program referral prior
to receiving care and the understanding that a CHS program referral
does not guarantee payment.
Obtaining Payments from CHS Programs:
Fourteen providers who we interviewed reported challenges obtaining
timely payment from CHS programs. Seven of these providers stated that
these delays occurred in obtaining a purchase order. However, six
providers stated that after they obtained a purchase order from the
CHS program, they received payment from IHS's fiscal intermediary in a
timely manner. In fiscal year 2010, IHS reported that the average
number of days between receiving a provider claim and issuing a
purchase order was 82 days, 4 days more than the agency's target of 78
days for that fiscal year.[Footnote 45] Of the providers who we
interviewed, 12 providers stated that it has taken several months, or
in some cases years, to receive payment for CHS program claims. Seven
providers said that these delays tended to occur when the CHS
program's funding for the fiscal year had been depleted. According to
IHS officials, delays in issuing purchase orders can be attributed to
several factors, including a shortage of the CHS program staff who
process purchase orders and the lengthy amount of time it takes
providers to send patient medical records needed to make a
determination for CHS payment.
Fourteen providers stated that the CHS program's paper-based claims
process required a lot of paperwork to be submitted, such as a
patient's medical records, or was otherwise time consuming. Twelve
providers also stated that for some payers with which they interacted,
including Medicare and Medicaid, they were able to process claims
electronically, which in some cases also allowed them to
electronically track a claim's status. In contrast, to obtain payment
for emergency care through the CHS program, providers have had to send
paper copies of patient medical records and a paper claim to the CHS
program to be reviewed. Seven providers stated that this process had
led to delays because CHS staff may lose paperwork and then ask the
provider to resubmit the information. However, seven other providers
noted that they were electronically submitting claims for payment to
IHS's fiscal intermediary, or working with CHS programs to begin this
process, which should reduce the amount of required paperwork.
[Footnote 46]
Some providers also stated that it was difficult to determine the
status of claims while waiting for approval to be paid. Four providers
said that when they contacted CHS program staff to determine the
status of claims, the staff were not always able to provide the
information. Of these providers, two said that CHS programs did not
communicate the status of submitted claims. Additionally, one provider
told us that one federal CHS program with which they interacted did
not communicate to them when a claim had been denied.[Footnote 47]
Instead, the CHS program provided no response to the provider's claim
for payment.[Footnote 48] IHS officials acknowledged that additional
agency efforts toward improving customer service are needed to ensure
that CHS program staff communicate more promptly with providers.
Receiving Communications on CHS Policies and Procedures to Receive
Payment:
Eighteen providers noted challenges receiving communications from IHS
about CHS policies and procedures related to payment, including having
had few, if any, formal meetings with program staff and a lack of
training and guidance. For example, 10 providers stated that they had
never met CHS program staff or did not meet regularly with them,
although eight other providers said that they benefited from regular
communications with CHS program staff, such as establishing good
working relationships with CHS program staff and getting assistance in
clarifying CHS program policies and procedures to receive payments.
According to the Standards for Internal Control in the Federal
Government and the Internal Control Management and Evaluation Tool,
agency management should ensure that there are adequate means of
timely and effective communication with, and obtaining information
from, external stakeholders that have significant impact on the agency
achieving its goals and an agency should employ many and various means
of communications, such as policy and procedure manuals and Internet
web pages.[Footnote 49] By not ensuring that its CHS programs have
timely and effective communication with external providers about CHS
policies and procedures related to payment, IHS has no reasonable
assurance that the agency is achieving its objectives.
The providers who we interviewed generally indicated that their
understanding of the CHS program came from experience, rather than
communications, including formal training and guidance from IHS.
Twelve providers stated that they had at least a basic understanding
of CHS policies and procedures for obtaining CHS payments. The
providers we interviewed told us that the amount of training they
received from IHS varied. While 3 of 4 providers in one IHS area
stated that they received recent training from the staff of CHS
programs or their area office, 13 providers in other areas told us
that they had never received training from IHS staff or had not
received training in many years. Of those 13 providers, 6 mentioned
that they had not received educational materials, including guidance,
about the CHS program. Instead, 6 providers stated that their
knowledge of the CHS program had been self-taught or obtained from
working with CHS program staff. In contrast, 7 providers stated that
other payers with which they interacted provided regular on-site
training, guidance manuals, or online resources that allowed them to
learn about a payer's payment policies. IHS officials said that the
responsibility for educating providers is delegated to the area
offices. According to IHS officials, during past meetings with area
office staff, they have emphasized the importance of external provider
training and shared area office best practices for educating
providers. IHS headquarters officials also stated that, in 2009, they
developed a CHS program manual for external providers and sent it to
the area offices to be distributed to providers.[Footnote 50] However,
IHS officials acknowledged that, given the complexity of the CHS
program, additional agency efforts are needed to ensure that all IHS
areas are engaged in external provider education.[Footnote 51]
In the absence of training from IHS, one provider stated that it had
developed its own training on the CHS program. This provider used the
experience of one of its staff members who had previously worked for
the CHS program to provide training to multiple health care facilities
within its health system. However, that staff member had not received
any training from either individual CHS programs or the area office
since being hired by the provider 4 years ago and, therefore, would
not have been aware of any policy changes IHS made during that time.
Most Providers Generally Reported That CHS Program Challenges
Contributed to Patient and Provider Burden:
Most providers who we interviewed generally reported that challenges
with the CHS program, particularly denied payment for services, added
to the burden of both patients and providers. Twenty-two providers
stated that when care they provided was denied by the CHS program,
they billed the patient. Of these providers, 3 stated that, because of
the length of time that it took the CHS program to approve or deny a
service, they started billing the patient even if a denial had not yet
been received.[Footnote 52] For example, 1 provider stated that they
used to wait as long as 4 years for CHS programs to make claims
decisions, but they now bill the patient if they do not receive
communication from CHS programs within a timeframe typical to that of
other payers.[Footnote 53]
Twelve providers told us that, for the care denied by CHS programs
that was billed to patients, either they were not able to obtain
payment or patients did not apply for provider payment assistance
programs. Eleven providers stated that they were only able to collect
a small portion of the care billed to American Indian and Alaska
Native patients or patients for whom payment was denied. Of the 12
providers who discussed how uncompensated care is classified in their
financial records, all indicated that it was considered bad debt if
the patient was not able to pay for services or qualify for charity
care.[Footnote 54] One provider estimated that it had a collections
rate of about 1 percent for services billed to patients denied by the
CHS program. The provider noted that while CHS patients accounted for
about 30 percent of its patient population, they accounted for about
85 percent of the provider's bad debt. Ten providers stated that when
the patients' bill was not paid, they were turned over to collections.
[Footnote 55] In addition, 18 providers had a charity care program,
which offered reduced charges or free care to patients who met income
and other requirements and was available to patients whose care was
denied for payment by the CHS program. However, 8 of these providers
stated that patients for whom CHS program payment was denied generally
did not apply for charity care, and 8 of the other 10 providers did
not mention or did not have information on the number of patients
denied by the CHS program that applied for charity care.[Footnote 56]
Providers varied in whether they reported that this uncompensated care
affected their operations. Ten providers, including five of the eight
critical access hospitals that we interviewed,[Footnote 57] reported
that the amount of uncompensated care associated with the CHS program
affected them financially by, among other things, limiting their
ability to purchase new equipment or resulting in increased costs to
other patients. One critical access hospital stated that because of
the uncompensated care associated with the CHS program, it was seeking
new ownership. However, four providers who we interviewed told us that
the amount of uncompensated care had not significantly affected them
financially. Additionally, some providers sought payment from other
resources for services delivered to patients. For example, eight
providers, seven of which were larger than critical access hospitals,
stated that they hired a benefits coordinator or were able to get
their state health benefits agency to place a benefits coordinator at
their facility to assist patients in applying for alternate resources,
such as Medicaid.
The providers who we interviewed told us that these burdens had
varying effects on the delivery of care to patients. Nine of the 12
providers who discussed this issue with us stated that they provided
care to patients regardless of their ability to obtain payment from
the CHS program. In addition, the Emergency Medical Treatment and
Active Labor Act (EMTALA) requires most hospitals to provide an
examination and needed stabilizing treatment, without consideration of
insurance coverage or ability to pay, when a patient presents to an
emergency room for attention to an emergency medical condition.
[Footnote 58] However, 3 of the 7 office-based providers that we
interviewed said that when dealing with the CHS program, generally,
they only saw patients who had obtained a CHS program referral.
Conclusions:
IHS's CHS program serves as an important resource for American Indian
and Alaska Native individuals who need health care services not
available at IHS-funded federal and tribal facilities. Despite recent
funding increases, most federal and tribal CHS programs that responded
to our surveys reported that they did not have funds available to pay
for all requested health care services for patients who otherwise met
requirements, including emergent and acutely urgent care. However,
IHS's estimate of the extent to which unmet need exists in the CHS
program is not reliable because of deficiencies in the agency's
oversight of the collection of unfunded services data on which it
relies to develop this estimate. IHS's acknowledgment of these
limitations and the early efforts of its workgroup to explore
additional options for estimating need are positive steps. However,
IHS has not yet completed the development of its new method for
estimating CHS program need using the FDI or made a decision about how
it will use deferral and denial data to help estimate CHS program
need. Further, as its workgroup has noted, reliably captured deferral
and denial data on all patients would present the strongest evidence
of CHS program need. Therefore, it continues to be important that the
agency take steps to ensure that complete and consistent deferral and
denial data are collected. IHS has not provided adequate oversight to
ensure that the annual reports it receives from each area office and
uses to estimate unmet need include data from all of their federal CHS
programs. In addition, although the agency cannot require reporting by
tribal CHS programs, its efforts to provide outreach have not been
sufficient to encourage such reporting from all tribal programs.
Without complete reporting from federal and tribal programs, IHS does
not have complete data for its estimate of unmet need. In addition,
the agency's ability to determine the completeness of the data it
collects and take steps to improve reporting is limited because its
current template does not provide sufficient detail about which
federal and tribal programs are reporting deferral and denial counts.
As IHS responds to the future recommendations of its workgroup, the
agency should ensure that it expeditiously addresses the weaknesses we
identified in the deferral and denial data that provide the agency
with information about program need.
Given the decentralized nature of the CHS program, effective guidance,
training, and oversight by IHS can help ensure that policies and
procedures affecting its determination of need are consistently
applied across CHS programs. Our survey results suggest that current
agency practices have not ensured consistent recording of unfunded
services by CHS programs. Documenting how IHS uses unfunded services
data to assess CHS program need could help ensure that area offices
and CHS programs maintain data collection practices that contribute to
the reliability of IHS's estimate of need.
Given that CHS program funds may be depleted before the end of the
fiscal year, it is important that CHS programs take steps to maximize
the care that patients receive. However, they should not engage in
practices that risk incurring obligations in excess of the available
funding. IHS officials acknowledge that the guidance that IHS provides
to CHS program staff on funds management may not be sufficient to
ensure that CHS programs do not engage in problematic funds management
practices.
Effective communication with providers is an important element of
IHS's oversight to ensure proper CHS program management. The providers
we spoke with noted challenges related to their participation in the
CHS program that they said created a burden for themselves and their
patients. Among their concerns was a lack of timely and effective
communication with the individual CHS programs to determine whether or
when CHS programs would provide payment for services provided to
American Indian and Alaska Native patients. Timely and effective
communication between IHS and providers is especially important to
ensuring efficient program operations. As acknowledged by IHS
officials, the complexity of the CHS program makes this communication
particularly important. The challenges that providers described--
determining patient eligibility for payment, contacting CHS programs
with questions about claims, and ensuring the timely receipt of
payment--would be mitigated by improved CHS program processes and
communications, including training.
Recommendations for Executive Action:
To develop more accurate data for estimating the funds needed for the
CHS program and improving IHS oversight, we recommend that the
Secretary of Health and Human Services direct the Director of IHS to
take the following eight actions:
* ensure that area offices submit data on unfunded services from all
federal CHS programs;
* conduct outreach and technical assistance to tribal CHS programs to
encourage and support their efforts to voluntarily provide data that
can be used to better estimate the needs of tribal CHS programs;
* develop an annual data reporting template that requires area offices
to report available deferral and denial counts for each federal and
tribal CHS program;
* develop a plan and timeline for improving the agency's deferral and
denial data;
* develop written guidance, provide training, and conduct oversight
activities necessary to ensure unfunded services data are consistently
and completely recorded by federal CHS programs;
* develop a written policy documenting how IHS evaluates need for the
CHS program and disseminate it to area offices and CHS programs to
ensure they understand how unfunded services data are used to estimate
overall program needs;
* provide written guidance to CHS programs on a process to use when
funds are depleted and there is a continued need for services, and
monitor to ensure that appropriate actions are taken; and:
* develop ways to enhance CHS program communication with providers,
such as providing regular trainings on patient eligibility and claim
approval decisions to providers.
Agency and Tribal Comments and Our Evaluation:
We provided a draft of this report to HHS for review and comment and
subsequently met with HHS and IHS officials to obtain additional
information. In its written comments, HHS indicated steps that IHS
would take to implement some of our recommendations and discussed
steps the agency was taking to implement a new method for estimating
CHS program need. HHS and IHS officials subsequently provided us with
clarification about the status of IHS's plans for estimating program
need and HHS submitted revised written comments. HHS's letter and
revised general written comments are reprinted in appendix III. We
also provided tribal representatives with an opportunity to present
oral comments and the representatives we spoke with primarily
discussed the role of tribal programs in IHS's needs assessment
process. The comments from HHS and the tribal representatives are
summarized below.
In its original written comments, HHS commented that IHS is making
efforts to address the problems identified in our draft report and
provided additional information about the development of its new
methodology for estimating program need. With regard to our first five
recommendations to improve the collection of deferral and denial data
from individual CHS programs, HHS agreed that these data are
incomplete and inconsistent. HHS also agreed that such data could
provide a reliable estimate of need if they were universally and
uniformly collected. However, HHS indicated that IHS's proposed new
method for estimating CHS program need by adapting its existing FDI
would provide IHS with a sufficiently reliable estimate of CHS program
need without relying on deferral and denial data. In our draft report,
we acknowledged that IHS has taken positive steps to identify and
examine the weaknesses in its current data and explore other sources
of data to estimate CHS program need, such as exploring the use of the
FDI method. As HHS noted in its comments, the IHS Director's Workgroup
proposing this methodology has not yet issued a final recommendation
to the Director of IHS for approval.
Following the receipt of HHS's original written comments, we met with
HHS and IHS officials to obtain clarification about the status of
IHS's plans for assessing CHS program need. The officials confirmed
that the agency was continuing to develop the new method by adapting
the FDI methodology to measure CHS program need. They said that the
new method had not yet been formally recommended to the Director and
that IHS did not have a formal agency approved plan for implementing
it. IHS officials also indicated the agency had not yet determined the
extent to which deferral and denial data would continue to be used by
IHS headquarters to estimate program need if the FDI method is
adopted. However, they indicated that until this decision is made, the
agency will continue to collect deferral and denial data from the area
offices.
As we noted in our draft, the FDI method would be adapted to provide
IHS with an estimate of funding needed to provide care to American
Indians and Alaska Natives through the CHS program at a level
comparable to the care available through the health insurance program
available to federal employees. IHS's Director's Workgroup previously
indicated that reliably captured deferral and denial data on all
patients would present the strongest evidence of CHS program need.
Given that the proposed FDI methodology is still in early development
and IHS plans to continue collecting deferral and denial data, we
believe that expeditious implementation of our first five
recommendations is vital to ensure the data IHS uses to calculate
program need are accurate. With regard to our other three
recommendations, HHS described in its comments the steps that IHS
would take to develop a written policy on how IHS evaluates CHS
program need and provide training to CHS program officials on the
process to use when funds are depleted. HHS also indicated that the
IHS Director's Workgroup would be providing recommendations for
enhancing communication with providers. HHS also provided us with
technical comments, which we incorporated as appropriate.
Subsequent to our conversation with HHS and IHS officials, HHS
submitted revised comments to our report. In the revisions, HHS
clarified that the FDI method represents one of multiple options for
estimating unmet need that IHS's Director's Workgroup is considering
and clarified that the development of this new methodology is still
ongoing. The revisions HHS made to its written comments do not
substantively change our response.
We also provided tribal representatives, including the 177 tribal CHS
programs we surveyed and the three tribal advocacy groups we
interviewed, the opportunity to provide oral comments on a draft of
this report. Representatives from 11 tribal CHS programs and two
tribal advocacy groups provided comments. The most frequent comment
related to our recommendation that IHS provide outreach and technical
assistance to tribal CHS programs to encourage them to submit data
that can be used to assess CHS program need. Specifically,
representatives from 2 tribal CHS programs stated that more technical
assistance from IHS would be helpful, because it is important that the
needs of the tribal programs be captured in IHS's needs assessment. A
tribal advocacy group representative noted that some tribes have
chosen not to collect deferral and denial data because of its cost
burden. A representative from a tribal CHS program noted the added
cost of tracking these data was justified by the benefit they provide
to IHS's budget process. In addition, a tribal representative
expressed concern that our finding on the accuracy of IHS's estimate
of need could be interpreted to suggest that the actual level of need
is lower than what IHS is estimating. In our report, we did not
examine whether or not IHS's estimate of need over-or under-estimates
the actual level of unfunded need, but rather found that the estimate
is not reliable because of deficiencies in the agency's oversight of
the collection of unfunded services data.
We are sending copies of this report to the Secretary of Health and
Human Services and other interested parties. In addition, the report
is available at no charge on the GAO web site at [hyperlink,
http://www.gao.gov].
If you or your staffs have any questions about this report, please
contact me at (202) 512-7114 or kingk@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff who made major contributions
to this report are listed in appendix IV.
Signed by:
Kathleen M. King:
Director, Health Care:
List of Addressees:
The Honorable Daniel Akaka:
Chairman:
The Honorable John Barrasso:
Ranking Member:
Committee on Indian Affairs:
United States Senate:
The Honorable Don Young:
Chairman:
The Honorable Dan Boren:
Ranking Member:
Subcommittee on Indian and Alaska Native Affairs:
Committee on Natural Resources:
House of Representatives:
Jeff Bingaman:
Tim Johnson:
Lisa Murkowski:
John Thune:
United States Senate:
[End of section]
Appendix I: Scope and Methodology:
In this report, we examined (1) the extent to which the Indian Health
Service (IHS) ensures the data it collects on unfunded services are
accurate to determine a reliable estimate of contract health services
(CHS) program need, (2) the extent to which federal and tribal CHS
programs report having funds available to pay for contract health
services, and (3) the experiences of external providers in obtaining
payment from the CHS program.
To address part of our work for our first two objectives, we
administered two surveys--one each to federal and tribal CHS programs.
From March 2010 through August 2010, we obtained lists of federal and
tribal CHS programs from each area office, from which we identified 66
federal CHS programs and 177 tribal CHS programs. We administered a
web-based survey to all of the federal CHS programs from October 2010
through January 2011. In addition, from September 2010 through January
2011, we administered a mixed-mode survey--both web-based and by mail-
-to all of the tribal CHS programs; this survey was blinded to
maintain the anonymity of respondents. To ensure the clarity and
precision of our survey questions, we pretested our federal CHS
program survey with officials from IHS and our tribal CHS program
survey with officials from three tribal health advocacy groups and a
tribal health official. We analyzed complete survey data from all 66
federal CHS programs, for a response rate of 100 percent, and 103 of
177 tribal CHS programs, for a response rate of 58 percent.[Footnote
59] The results from our survey of tribal CHS programs are not
generalizable to all tribal CHS programs because we did not receive
responses from all tribal CHS programs and tribal programs vary due to
the flexibility tribes have in administering their programs. We relied
on the data as reported by the CHS program officials who were
identified as the primary contacts for the CHS program and did not
independently verify these data or ask IHS to verify them. However, we
reviewed all responses for reasonableness and internal consistency.
For our survey of federal CHS programs, when necessary, we followed up
with the program officials who completed our survey for clarification.
Based on these activities, we determined these data were sufficiently
reliable for the purpose of our report.
We also conducted site visits to IHS area offices based in Oklahoma
City, Oklahoma and Portland, Oregon in March and April, 2010. During
these site visits, we interviewed area office officials and
representatives from a total of four federal and eight tribal CHS
programs located in those areas. In addition, we interviewed officials
from IHS headquarters and each of IHS's 12 area offices to discuss
oversight of the CHS program, and spoke with three tribal health
advocacy groups. We also examined IHS oversight, such as the provision
of policy and guidance, conducted to ensure that CHS programs
consistently and completely record and report unfunded services data.
We compared these oversight activities to the standards described in
the Standards for Internal Control in the Federal Government and the
Internal Control Management and Evaluation Tool.[Footnote 60] We also
reviewed our cost estimating guide to assess procedures for
determining a reliable estimate for budgetary purposes.[Footnote 61]
To examine the experiences of external providers in obtaining payment
from the CHS program, we interviewed representatives from hospitals
and office-based health care providers from selected IHS areas. We
selected four areas from which to identify providers based on their
fiscal year 2009 per capita CHS program funding and dependency on CHS
funds for hospital services. We estimated per capita funding using the
agency's fiscal year 2009 user population estimates and allocation of
CHS program funds.[Footnote 62] To estimate dependency, we used an IHS
measure of dependency it uses to allocate certain funds to the area
offices. It measures whether patients in an area have practical access
to IHS-funded federally and tribally operated hospitals.[Footnote 63]
If the patients do not have access to such facilities, then they are
considered to be more dependent on the CHS program for hospital
services and therefore, the area receives additional funding. The four
areas we selected were Bemidji, Billings, Phoenix, and Oklahoma City,
[Footnote 64] which represent areas that were above or below average
for each of our selection criteria. (See table 3.) In fiscal year
2009, the four areas represented 43 percent of the IHS user population
and received 37 percent of CHS funding.
Table 2: Categorization of Area Offices by Selection Criteria:
Category: Above average funding, above average CHS dependency:
Area office: Bemidji;
Per capita CHS program funding in fiscal year 2009: $407.35;
Percent of CHS-dependent operating units in fiscal year 2009[A]: 94.1%.
Area office: Nashville;
Per capita CHS program funding in fiscal year 2009: $470.84;
Percent of CHS-dependent operating units in fiscal year 2009[A]: 92.0%.
Area office: Portland;
Per capita CHS program funding in fiscal year 2009: $664.30;
Percent of CHS-dependent operating units in fiscal year 2009[A]:
100.0%.
Area office: California;
Per capita CHS program funding in fiscal year 2009: $399.34;
Percent of CHS-dependent operating units in fiscal year 2009[A]:
100.0%.
Category: Above average funding, below average CHS dependency:
Area office: Billings;
Per capita CHS program funding in fiscal year 2009: $694.50;
Percent of CHS-dependent operating units in fiscal year 2009[A]: 62.5%.
Area office: Tucson;
Per capita CHS program funding in fiscal year 2009: $579.21;
Percent of CHS-dependent operating units in fiscal year 2009[A]: 50.0%.
Area office: Aberdeen;
Per capita CHS program funding in fiscal year 2009: $557.27;
Percent of CHS-dependent operating units in fiscal year 2009[A]: 59.1%.
Area office: Alaska;
Per capita CHS program funding in fiscal year 2009: $456.01;
Percent of CHS-dependent operating units in fiscal year 2009[A]: 15.8%.
Category: Below average funding, above average CHS dependency:
Area office: Phoenix;
Per capita CHS program funding in fiscal year 2009: $323.90;
Percent of CHS-dependent operating units in fiscal year 2009[A]: 72.7%.
Category: Below average funding, below average CHS dependency:
Area office: Oklahoma City;
Per capita CHS program funding in fiscal year 2009: $237.61;
Percent of CHS-dependent operating units in fiscal year 2009[A]: 32.0%.
Area office: Navajo;
Per capita CHS program funding in fiscal year 2009: $286.54;
Percent of CHS-dependent operating units in fiscal year 2009[A]: 16.7%.
Area office: Albuquerque;
Per capita CHS program funding in fiscal year 2009: $347.09;
Percent of CHS-dependent operating units in fiscal year 2009[A]: 50.0%.
Category: Average;
Per capita CHS program funding in fiscal year 2009: $392.19;
Percent of CHS-dependent operating units in fiscal year 2009[A]: 71.9%.
Source: GAO analysis of IHS documents.
[A] Operating units are the entities at the local level that have
financial responsibility for CHS-eligible persons.
[End of table]
Within these four areas, we selected 23 providers--16 hospitals and 7
office-based providers--to interview. Most of these providers were
identified through our survey of federal CHS programs as providers who
provided the highest volume of care to CHS program users in fiscal
year 2009. In addition, we also identified providers who interact
frequently with CHS programs through our discussions with state
hospital associations and a tribal health advocacy group. Given the
small number of providers in our sample and our process for selecting
them, the results from these interviews are not generalizable to all
providers interacting with the CHS program. We asked providers about
their experiences obtaining effective and timely communication related
to the payment process, such as training or guidance on determining
patient eligibility for CHS program payment of services and
determining the status of claims, and compared their experiences with
the standards described in the Standards for Internal Control in the
Federal Government and the Internal Control Management and Evaluation
Tool.[Footnote 65] We asked providers a standard set of open-ended
questions and we did not independently validate their reported
experiences, but we did discuss many of their comments with IHS
officials.
We conducted this performance audit from January 2010 to September
2011 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit
to obtain sufficient, appropriate evidence to provide a reasonable
basis for our findings and conclusions based on our audit objectives.
We believe that the evidence obtained provides a reasonable basis for
our findings and conclusions based on our audit objectives.
[End of section]
Appendix II: Catastrophic Health Emergency Fund:
The Indian Health Care Amendments of 1988 established the Catastrophic
Health Emergency Fund (CHEF) to meet the medical costs associated with
treating catastrophic illnesses or victims of disasters.[Footnote 66]
CHEF is administered centrally within the Indian Health Service (IHS)
and reimburses federal and tribal contract health services (CHS)
programs on a first-come first-served basis for CHS program cases with
costs exceeding the threshold set annually within the range
established by law.[Footnote 67] Specifically, CHS programs pay for
the services and then request reimbursement from IHS for expenses over
the threshold, which was $25,000 in fiscal year 2009.[Footnote 68] In
fiscal year 2009, IHS reimbursed 1,223 cases at a total cost of $31
million; in fiscal year 2010, IHS reimbursed 1,747 cases at a total
cost of $48 million. The top three diagnostic categories funded in
fiscal year 2010 were injuries, cancer, and heart disease.
When CHEF funds are depleted, requests for reimbursement are denied by
IHS. As part of IHS's needs assessment for the CHS program, the agency
determines the number of CHEF requests for reimbursement that were
denied and then uses the actual billed charges that were submitted by
CHS programs to determine the cost of these services. In fiscal year
2009, IHS denied 1,065 cases totaling $24 million; in fiscal year
2010, it denied 865 cases totaling $14 million. However, IHS
speculated that this may underestimate the need for CHEF reimbursement
because additional cases may have qualified for CHEF reimbursement,
but CHS programs may not have submitted a request for reimbursement
due to the depletion of CHEF before the end of the fiscal year.
CHEF Survey Data: Federal CHS Programs:
Of the 66 federal CHS programs we surveyed, 52 reported that they
submitted requests for CHEF reimbursement in fiscal year 2009. Of
these, 12 reported that they did not continue to submit requests for
CHEF reimbursement once the CHS program learned that CHEF funds were
depleted. Of the 66 federal CHS programs we surveyed, 14 reported that
they did not submit any requests for CHEF reimbursement in fiscal year
2009. The most common reasons they reported for not submitting
requests for CHEF reimbursement were that the CHS program did not
experience any cases costing over $25,000 (8 of 14 federal CHS
programs) and staffing shortages (5 of 14 federal CHS programs).
CHEF Survey Data: Tribal CHS Programs:
Of the 103 tribal CHS programs who responded to our survey, 46
submitted requests for CHEF reimbursement in fiscal year 2009. Fifty-
three of the tribal CHS programs reported that they did not submit
requests for CHEF reimbursement. The most common reasons they reported
for not submitting requests for CHEF reimbursement were that the CHS
program did not experience any cases costing over $25,000 (31 of 53
tribal CHS programs) and tribal programs were unable to pay for the
first $25,000 of expenses (13 of 53 tribal CHS programs).
[End of section]
Appendix III: Comments from the Department of Health and Human
Services:
Department Of Health & Human Services:
Office Of The Secretary:
Assistant Secretary for Legislation:
Washington, DC 20201:
September 19, 2011:
Kathleen M. King, Director:
Health Care:
U.S. Government Accountability Office:
441 G Street NW:
Washington, DC 20548:
Dear Ms. King:
Attached are comments on the U.S. Government Accountability Office's
(GAO) draft report entitled, "Indian Health Service: Increased
Oversight Needed to Ensure Accuracy of Data Used for Estimating
Contract Health Service Need" (GA0-11-767).
The Department appreciates the opportunity to review this report
before its publication.
Sincerely,
Signed by:
Jim R. Esquea:
Assistant Secretary for Legislation:
Attachment:
[End of letter]
General Comments Of The Department Of Health And Human Services (HHS)
On The Government Accountability Office's (GAO) Draft Report Entitled,
"Indian Health Service: Increased Oversight Needed To Ensure Accuracy
Of Data Used For Estimating Contract Health Service Need" (GAO-11-767):
The Department appreciates the opportunity to review and comment on
this draft report. The Indian Health Service (IHS) acknowledges that
oversight activities related to the identification of Contract Health
Service (CHS) unmet need estimates have not been carried out to the
extent described in the GAO's Standards for Internal Control in the
Federal Government.
Procedures described and reviewed during this engagement reflect IHS'
response to questions regarding the estimated additional dollar amount
needed to fund all Priority I cases (the unmet need). As cited in the
report, the IHS has established a workgroup to evaluate methods to
quantify the need due to increased interest in CHS program unmet need.
The IHS will establish appropriate management controls once the CHS
workgroup recommendation for the methodology for determining CHS unmet
need is finalized.
The report states that data that IHS collected from CHS programs were
incomplete and inconsistent. It concludes that "a reliable estimate of
need will require complete and consistent data from each of the
individual CHS programs." We agree that reporting has been incomplete
and inconsistent. We agree that additional funds needed for CHS could
be reliably calculated if all denied or deferred cases were
universally and uniformly reported. We believe that sufficiently
reliable estimates of CHS funding needs may also be calculated using
methods and data that are independent of denial and deferral counts
reported by individual CHS programs.
The CHS workgroup is reviewing several options for estimating the CHS
need. One option under discussion that can estimate the need with
reasonable, although not absolute assurance, is the Federal Disparity
Index (FDI) method which is used by the IHS already to estimate
resource needs for the IHS user population. The FDI based alternative
approach to calculating needs is referenced on page 21-23 of your
report. The FDI method can be adapted to calculate CHS resources as a
sub-set of total needed health care resources. Such estimates are
sufficiently reliable for annual CHS budget requests and other
purposes. Adapting the FDI method for this purpose will not impose
significant new data collection burdens.
GAO Recommendations:
To develop more accurate data for estimating the funds needed for the
CHS program and improving IHS oversight, we recommend that the
Secretary of Health and Human Services direct the Director of IHS to
take the following eight actions:
* ensure that area offices submit data on unfunded services from all
federal CHS programs;
* conduct outreach and technical assistance to tribal CHS programs to
encourage and support their efforts to voluntarily provide data that
can be used to better estimate the needs of tribal CHS programs;
* develop an annual data reporting template that requires area offices
to report available deferral and denial counts for each federal and
tribal CHS program;
* develop a plan and timeline for improving the agency's deferral and
denial data;
* develop written guidance, provide training, and conduct oversight
activities necessary to ensure unfunded services data are consistently
and completely recorded by federal CHS programs;
* develop a written policy documenting how IHS evaluates need for the
CHS program and disseminate it to area offices and CHS programs to
ensure they understand how unfunded services data are used to estimate
overall program needs;
* provide written guidance to CHS programs on a process to use when
funds are depleted and there is a continued need for services, and
monitor to ensure that appropriate actions are taken; and;
* develop ways to enhance CHS program communication with providers,
such as providing regular trainings on patient eligibility and claim
approval decision to providers.
Concerning the first five recommendations, the CHS workgroup is
discussing options for estimating unmet need and are conducting a
pilot study of one such option. The workgroup will review the pilot
study and make recommendations to the IHS Director.
In response to the last three recommendations, we offer the following
comments:
* The IHS will develop a written policy on how IHS evaluates CHS need
and disseminate it to Area offices to ensure they understand how
unfunded services data are used to estimate CHS need. This will be
accomplished after the Director has approved the method for estimating
CHS need.
* The IHS currently has a policy on the process to use when funds are
depleted and there is a continued need for services which will be
provided to all CHS program Officers. CHS program officers will
provide training on the Agency's policy regarding use of funds.
* The IHS has developed a provider training manual for use in
educating providers on CHS patient eligibility and claim approval
processes. The Directors Workgroup on Improving CHS will provide
recommendations for improving and enhancing CHS program communication
with providers.
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Kathleen M. King, Director, (202) 512-7114 or kingk@gao.gov:
Staff Acknowledgments:
In addition to the contact names above, Catina Bradley, Martha Kelly,
and Suzanne Worth, Assistant Directors; George Bogart; Zhi Boon;
William Hadley; Giselle Hicks; Darryl Joyce; Hannah Locke; Sarah-Lynn
McGrath; Jasleen Modi; Lisa Motley; Laurie Pachter; and Mario Ramsey
made key contributions to this report.
[End of section]
Footnotes:
[1] See, for example, GAO, Indian Health Service: Basic Services
Mostly Available; Substance Abuse Problems Need Attention, [hyperlink,
http://www.gao.gov/products/GAO/HRD-93-48] (Washington, D.C.: Apr. 9,
1993); and U.S. Commission on Civil Rights, Broken Promises:
Evaluating the Native American Health Care System (Washington, D.C.:
September 2004).
[2] IHS defines an Indian tribe as any Indian tribe, band, nation,
group, Pueblo, or community, including any Alaska Native village or
Native group, which is federally recognized as eligible for the
programs and services provided by the United States to Indians because
of their status as Indians.
[3] Under the Indian Self-Determination and Education Assistance Act,
as amended, federally recognized Indian tribes can enter into self-
determination contracts or self-governance compacts with the Secretary
of Health and Human Services to take over administration of IHS
programs for Indians previously administered by IHS on their behalf.
Self-governance compacts allow tribes to consolidate and assume
administration of all programs, services, activities, and competitive
grants administered throughout IHS, or portions thereof, that are
carried out for the benefit of Indians because of their status as
Indians. In contrast, self determination contracts allow tribes to
assume administration of a program, programs, or portions thereof. See
25 U.S.C. §§ 450f(a) (self determination contracts), 458aaa-4(b)(1)
(self-governance compacts).
[4] IHS's 12 area offices are: Aberdeen, Alaska, Albuquerque, Bemidji,
Billings, California, Nashville, Navajo, Oklahoma City, Phoenix,
Portland, and Tucson.
[5] GAO, Indian Health Service: Health Care Services Are Not Always
Available to Native Americans, [hyperlink,
http://www.gao.gov/products/GAO-05-789] (Washington, D.C.: Aug. 31,
2005).
[6] In fiscal year 2008, IHS received about $579 million for the CHS
program.
[7] This work originated as a request from the Senate Committee on
Indian Affairs and individual members prior to the enactment of the
Patient Protection and Affordable Care Act, which provided for the
enactment of the Indian Health Care Improvement Reauthorization and
Extension Act of 2009. The act also requires GAO to complete other
work on aspects of the CHS program, including funds distribution and
claims payment. See Pub. L. No. 111-148, § 10221, 124 Stat. 119, 935
(2010) (enacting S. 1790, as reported by the Committee on Indian
Affairs in the Senate in December 2009, into law with amendments); S.
1790, 111th Cong. §§ 137, 199 (2009).
[8] GAO, Standards for Internal Control in the Federal Government,
[hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1]
(Washington, D.C.: November 1999); and Internal Control Management and
Evaluation Tool, GAO-01-1008G (Washington, D.C.: August 2001).
Internal control is synonymous with management control and comprises
the plans, methods, and procedures used to meet missions, goals, and
objectives.
[9] GAO, GAO Cost Estimating and Assessment Guide: Best Practices for
Developing and Managing Capital Program Costs, [hyperlink,
http://www.gao.gov/products/GAO-09-3SP] (Washington, D.C.: March 2009).
[10] We measured dependency using an IHS measure of patient access to
an IHS-funded hospital. Patients in some areas do not have access to
an IHS-funded hospital. Therefore, IHS distributes additional CHS
funds to such areas, because patients in these locations are more
dependent on the CHS program to receive hospital-based services.
[11] The Bemidji area includes locations in Indiana, Minnesota,
Michigan, and Wisconsin; the Billings area includes locations in
Montana and Wyoming; the Phoenix area includes locations in Arizona,
California, Nevada, and Utah; and the Oklahoma City area includes
locations in Oklahoma, Kansas, and Texas.
[12] [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1] and
[hyperlink, http://www.gao.gov/products/GAO-01-1008G].
[13] Most CHS program funds are allocated according to historical
funding levels that are typically adjusted annually for inflation and
population growth.
[14] Tribal CHS programs are able to supplement their CHS program
funds received from IHS with reimbursements from Medicare, Medicaid,
and private insurance for services provided at their tribal health
care facilities. Tribal CHS programs are also able to supplement their
CHS funding with tribal funds earned from tribal business or
enterprises. See 25 U.S.C. § 1621f.
[15] Medicaid is a jointly funded federal-state health care program
that covers certain low-income individuals and families. Medicare is
the federal government's health care insurance program for individuals
aged 65 and older and for individuals with certain disabilities or end-
stage renal disease.
[16] See 25 U.S.C. §§ 1621e, 1623; 42 C.F.R. § 136.61 (2010). There
are certain exemptions to the CHS program's designation as a payer of
last resort. For example, certain tribally funded insurance plans are
not considered alternate resources and the CHS program must pay for
care before billing the tribally funded insurance plan. The CHS
program must also pay for care provided to eligible American Indians
and Alaska Natives before the crime victim compensation program, a
federal program that provides compensation to victims and survivors of
criminal violence.
[17] IHS contracts with BlueCross BlueShield of New Mexico to serve as
its fiscal intermediary to validate and pay all federal CHS program
claims.
[18] Before submitting a claim for payment to the CHS program, IHS
expects the external provider to seek reimbursement from any alternate
resources available to the patient.
[19] Deferrals may be authorized later if additional funds become
available. IHS policy requires that deferred services be for elective
care, rather than emergent or urgent care. Programs may not defer
payment for services already rendered, only for services that have not
been received.
[20] The eight categories of denial are: (1) eligible but care not
within medical priority, (2) eligible but alternate resource
available, (3) patient ineligible for CHS, (4) emergency notification
not within 72 hours, (5) non-emergency prior approval not authorized,
(6) patient resides outside CHS delivery area, (7) IHS facility
available and accessible, and (8) all other denials.
[21] CHEF was established by the Indian Health Care Amendments of 1988
to meet the medical costs associated with treating catastrophic
illnesses or victims of disasters. See 25 U.S.C. § 1621a.
[22] IHS headquarters officials told us they obtain these data through
the annual request because they do not have the capability to directly
access the CHS programs' data through the Resource and Patient
Management System, an information technology system that CHS programs
can use to record approved, deferred, and denied requests for contract
health services or claims for payment. In addition, the individual CHS
programs are not required to use the system to record data on unfunded
services and some programs reported to us that they did not use the
system to record either deferrals or denials.
[23] Overall, 49 of the 103 tribal CHS programs that responded to our
survey reported collecting data on unfunded services. Forty-four
tribal CHS programs did not collect data, with the two most common
reasons reported being staffing shortages (17) and technology
limitations (14). The remaining tribal CHS programs did not provide a
response or did not wish to share this information.
[24] [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1] and
[hyperlink, http://www.gao.gov/products/GAO-01-1008G].
[25] Further, we found that IHS's fiscal year 2009 estimate of need
included deferral and denial data from areas that only contained
tribal CHS programs (California and Alaska). Of the 32,309 denials for
"care not within medical priority" reported by the 12 area offices in
fiscal year 2009 that IHS used in its needs estimate, about 10 percent
were reported by the Alaska and California area offices.
[26] IHS distributed guidance that updated its definition for the
denial reason "care not within medical priority" while our federal
survey was being fielded. Specifically, the definition was changed
from "The medical care you received is not within the CHS medical
priorities. Medical priorities must be established when funding is
limited" to "CHS is limited to services that are medically indicated
and within the established IHS Medical Priorities. The medical
service(s) you were provided did not fall within these priorities
based on the medical information received and reviewed by the IHS
medical provider. Therefore, your request for payment of these
services is not approved." IHS indicated that this change did not
affect the way denials are categorized by CHS programs and it did not
affect how the agency uses these denials in its needs assessment.
[27] The annual request sent to the area offices asks for them to
report both deferral and denial data and indicates "the data and
information on Deferred Services, Denials, and CHS information from
these reports will be used to support unmet CHS financial needs and in
preparing budget justifications for the CHS program."
[28] [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1].
[29] According to our surveys, 16 of the 66 federal CHS programs and
21 of the 49 tribal CHS programs that reported collecting data on
unfunded services indicated that patients may be discouraged from
presenting for care if they believe funds are not available to pay for
services. In addition, 22 of the 66 federal CHS programs and 20 of the
49 tribal CHS programs reported that providers may choose not to write
referrals when they feel it is unlikely for CHS funds to pay for
services for a patient.
[30] IHS officials told us that tribal funds used to supplement CHS
funding should be a part of an estimate of CHS program unmet need
because tribes should not be expected to use their own funds to pay
for contract health services given the federal obligation to pay for
health care for eligible American Indians and Alaska Natives. In
addition, they noted that not all tribes have the means to contribute
financially to their CHS programs.
[31] IHS established the Director's Workgroup on Improving the CHS
Program in March 2010, and charged it with reviewing tribal input to
improve the CHS program, evaluating the existing formula for
distributing CHS funds, and recommending improvements in the way CHS
business operations are conducted within IHS and the Indian health
system. Following an October 2010 meeting, the Workgroup made several
recommendations to the Director, including the creation of a
subcommittee to examine need in the CHS program.
[32] The FDI was developed by a joint tribal-IHS workgroup that met to
determine the level of funding needed to provide all health care
services--direct care through IHS-funded federal and tribal facilities
and specialty health care through federally or tribally administered
CHS programs--to American Indians and Alaska Natives at a level that
is comparable to the nationwide FEHBP health insurance program
available to federal employees. IHS has used the FDI to distribute
health care funds received to carry out the Indian Health Care
Improvement Act to the area offices.
[33] The remaining six programs reported having CHS funds available to
pay for all services in fiscal year 2009. One of these CHS programs,
for example, reported that it was unique because it only served
students attending a boarding school. These six programs were located
in five different IHS areas, each of which also had federal CHS
programs that reported that they did not have funds available to pay
for all services in that year.
[34] For example, CHS programs may budget their funding on a weekly
basis.
[35] We grouped survey responses into categories of services. For
example, the category of dental services includes orthodontics and
prosthodontics; orthopedic services includes joint replacements and
other orthopedic surgeries; vision services includes ophthalmology and
optometry; and diagnostic and imaging services includes MRIs, CT
scans, and X-rays.
[36] Appropriations to IHS for contract health services are
apportioned by the Office of Management and Budget, allotted to area
office directors, and further distributed through allowances to
federal CHS programs or payments to tribal CHS programs.
[37] To help ensure compliance with the Antideficiency Act, which
generally prohibits federal officers and employees from incurring
obligations in excess of appropriations, apportionments, and certain
administrative subdivisions of funds, IHS has promulgated a funds
management policy. See 31 U.S.C. §§ 1341, 1514, 1517. The existing
policy provides that, even if there is no violation of the
Antideficiency Act, agency officials may be subject to administrative
discipline should they incur obligations in excess of the funds
distributed to them. See Indian Health Manual, Circular 95-19,
Administrative Control of Funds Policy; Indian Health Manual, Circular
91-7, Contract Health Service Funds Control. IHS officials told us
that the Indian Health Manual needs to be updated to reflect current
procedures for the administrative subdivision of funds, among other
things, but that the agency does not consider the over-obligation of
allowances to be a violation of the Antideficiency Act unless it
results in an over-obligation of the related allotment.
[38] An evaluation of individual programs' compliance with statutes
and policies regarding the obligation of funds and funds management
was outside the scope of our review. We have referred these matters to
the Department of Health and Human Services Office of Inspector
General (OIG) for a review and appropriate action. Given GAO's
responsibilities in this area, we will remain available to provide OIG
with technical assistance.
[39] Of these 73 tribal CHS programs, 47 reported depleting their CHS
funds before the end of the fiscal year and 26 reported they had CHS
funds available to pay for at least some care all year by budgeting
weekly, monthly, or quarterly.
[40] We grouped survey responses into categories of services. For
example, the category of dental services includes orthodontics and
prosthodontics; orthopedic services includes joint replacements and
other orthopedic surgeries; prescription drugs includes trial drugs
and pain medications; diagnostic and imaging services includes MRIs,
CT scans, and X-rays; and hospital services includes inpatient and
emergency room services.
[41] Unlike federal CHS programs, tribal CHS programs can use funds
from tribal enterprises and reimbursements from third party health
care payers such as Medicare or private insurance to supplement CHS
funds. Federal CHS programs are authorized to receive reimbursements
from third party health care payers, but these funds offset rather
than supplement IHS funding. See 25 U.S.C. § 1621f.
[42] Since the Patient Protection and Affordable Care Act provided for
the enactment of the Indian Health Care Improvement Reauthorization
and Extension Act of 2009, waivers are no longer needed and tribal CHS
programs are explicitly authorized to use CHS funds from IHS to
purchase private insurance. See 25 U.S.C. § 1642 (amended by Pub. L.
No. 111-148, § 10221, 124 Stat. 119, 935 (2010) (enacting S. 1790,
111th Cong. § 152 (2009))).
[43] When a physician at an IHS-funded facility gives a referral to a
patient, a copy of the referral is also sent to the CHS program
committee. While a referral must be reviewed and approved by the CHS
committee prior to payment, IHS officials stated that, in some
instances, a patient may present for care at an external provider
without first obtaining approval from the CHS program. Officials noted
that it is generally indicated on the referral if it has not yet been
approved.
[44] The CHS program requires that if there are other health care
resources available to a patient, such as Medicaid, these resources
must pay for services before the CHS program because the CHS program
is generally the payer of last resort. Three providers suggested that
the CHS program could play a greater role in ensuring that patients
are enrolled in any alternate resources prior to care being delivered.
IHS's Indian Health Manual states that both the CHS program and
providers have a responsibility to determine whether a patient would
be eligible for alternate resources. IHS officials noted that
provisions in the Patient Protection and Affordable Care Act could
expand the availability of alternate resources for patients whose
services would otherwise have been eligible for CHS program payment.
In IHS's fiscal year 2012 congressional budget justification, the
agency acknowledged the need to improve patients' understanding of
alternate resource enrollment and assist patients with enrollment in
state and federal programs and proposed new staff positions to
accomplish this. IHS anticipates that enrolling patients in alternate
resources will increase the availability of CHS program funds for
patients without alternate resources and improve customer satisfaction.
[45] After a purchase order is issued, the provider must submit a
claim to IHS's fiscal intermediary, which has a contract standard to
process payment to the provider within 21 calendar days of receiving a
claim.
[46] According to IHS, all providers have the option to electronically
submit claims to IHS's fiscal intermediary.
[47] CHS program guidelines state that if a service received by a
patient is denied CHS payment, both the patient and the provider must
be notified in writing of the denial with a statement containing all
the reasons for the denial.
[48] Under section 220 of the Indian Health Care Improvement Act, IHS
is required to respond to a notification of a claim by a provider with
either a purchase order or a denial within 5 working days after the
receipt of such notification. If IHS fails to do so, it must accept
the claim as valid. See 25 U.S.C. § 1621s. Examining compliance with
this requirement was beyond the scope of this review.
[49] [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1] and
[hyperlink, http://www.gao.gov/products/GAO-01-1008G].
[50] IHS headquarters officials said that the provider manual is not
available online and providers are only able to obtain a copy if it
was distributed to them through the area office.
[51] From 2006 through 2010, IHS annually conducted a national
training event for CHS program staff. Some of these events have
included training on customer service and educating providers. IHS's
Director's Workgroup on Improving the Contract Health Services Program
recently identified provider education as an important issue and
recommended that IHS make provider education a nationwide initiative
and develop national tools. However, IHS officials told us that the
agency has not yet developed a plan to implement this recommendation.
[52] In 2005, we found that 10 of the 15 external providers that we
interviewed reported that denials for or delays in payment resulted in
some of the providers terminating their relationship with IHS. We
noted that the termination of these relationships may affect a
patient's access to care.
[53] IHS officials told us that providers should not be billing
patients who are eligible for the CHS program. Under section 222 of
the Indian Health Care Improvement Act, as amended by the Indian
Health Care Improvement Reauthorization and Extension Act of 2009 on
March 23, 2010, IHS is required to formally notify providers not later
than 5 business days after receipt of notification of a claim that
patients who receive authorized contract health services are not
liable for any costs. See 25 U.S.C. § 1621u (amended by Pub. L. No.
111-148, § 10221, 124 Stat. 119, 935 (2010) (enacting S. 1790, 111th
Cong. § 135 (2009))). IHS officials told us that this requirement is
important because they heard from patients that they were being billed
for services while they were waiting for the CHS program to reimburse
the providers. Officials noted, however, that the requirement to send
out these notifications has created a burden for CHS program staff.
[54] Bad debt is generally defined as the uncollectible payment that
the patient is expected to, but does not, pay.
[55] Tribes and tribal organizations have testified before
congressional committees about some of the consequences of a patient
being billed for services denied by the CHS program, including
negative effects on the patient's credit history and providers
discontinuing services to patients because of nonpayment for services
delivered.
[56] Two of the external providers that we interviewed did not have an
application process associated with their charity care program.
[57] Critical access hospitals are limited to 25 beds and primarily
operate in rural areas.
[58] See generally 42 U.S.C. § 1395dd.
[59] In the case of one analysis of survey data, the federal and
tribal surveys asked the respective respondents to provide the three
most common health care services that were (1) deferred or denied by
federal CHS programs in fiscal year 2009, (2) requested but not funded
by tribal CHS programs in fiscal year 2009, and (3) purchased by
tribal CHS programs with tribal funds in fiscal year 2009. In our
analysis of these data, we grouped the specific reported health care
services into categories of health care services for the purposes of
reporting the data.
[60] [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1] and
[hyperlink, http://www.gao.gov/products/GAO-01-1008G]. Internal
control is synonymous with management control and comprises the plans,
methods, and procedures used to meet missions, goals, and objectives.
[61] [hyperlink, http://www.gao.gov/products/GAO-09-3SP].
[62] According to IHS officials, the agency does not have an estimate
of the number of individuals eligible to have their care paid by the
CHS program. Therefore, it utilizes a user population estimate that
generally represents the count of American Indian and Alaska Native
individuals who had at least one direct care or contract health
service inpatient stay, ambulatory care visit, or dental visit in the
last 3 years.
[63] According to IHS officials, the agency considers an area to have
practical access to a hospital if the hospital maintains a census of
more than five patients per day and is less than 90 minutes travel
time for most residents of the area.
[64] The Bemidji area includes locations in Indiana, Minnesota,
Michigan, and Wisconsin; the Billings area includes locations in
Montana and Wyoming; the Phoenix area includes locations in Arizona,
California, Nevada, and Utah; and the Oklahoma City area includes
locations in Oklahoma, Kansas, and Texas.
[65] [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1] and
[hyperlink, http://www.gao.gov/products/GAO-01-1008G].
[66] See 25 U.S.C. § 1621a.
[67] The Indian Health Care Improvement Reauthorization and Extension
Act of 2009, enacted by the Patient Protection and Affordable Care Act
in March 2010, provided for IHS to set the threshold at $19,000, to be
increased each year by a percentage established using a specific
formula. See S. 1790, § 122, 111th Cong. 2009 (enacted by Pub. L. No.
111-148, § 10221, 124 Stat. 119, 935 (2010)).
[68] In certain circumstances, CHS programs can submit medical bills
below the threshold to IHS and then be reimbursed on an ongoing basis
at 50 percent of expenses until the completion of the case.
[End of section]
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