Defense Health Care: Oversight of the TRICARE Civilian Provider Network Should Be Improved
GAO-03-928
Published: Jul 31, 2003. Publicly Released: Jul 31, 2003.
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Highlights
Testifying before Congress in 2002, military beneficiary groups described problems accessing care from TRICARE's civilian medical providers. Providers also testified on their dissatisfaction with the TRICARE program, specifying low reimbursement rates and administrative burdens. The Bob Stump National Defense Authorization Act of 2003 required GAO to review the oversight of the TRICARE network of civilian providers. Specifically, GAO describes how the Department of Defense (DOD) oversees the adequacy of the civilian provider network, evaluates DOD's oversight of the civilian provider network, and describes the factors that have been reported to contribute to network inadequacy. GAO analyzed TRICARE Prime--the managed care component of TRICARE. To describe and evaluate DOD's oversight, GAO reviewed and analyzed information from reports on network adequacy and interviewed DOD and contractor officials in 5 of 11 TRICARE regions.
Recommendations
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Defense | To improve DOD's oversight of the civilian provider network, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to ensure that military treatment facility capabilities and all enrolled Prime beneficiaries in prime service areas are accounted for when assessing and documenting the adequacy of the civilian provider network. |
Since GAO made this recommendation, the Department of Defense (DOD) implemented new TRICARE contracts. Under these contracts, DOD uses a new method for ensuring network adequacy. Specifically, contractors are now required to ensure that no less than 96 percent of contractor referrals within a service are referred to an MTF or network provider with an appointment available with in the access standards. Contractors must also inform DOD within 24 hours of any instance of network inadequacy and must submit a corrective action plan with each notice of network inadequacy. Contractor fees are withheld when they fail to meet the standard.
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| Department of Defense | To improve DOD's oversight of the civilian provider network, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to ensure that the information reported on the required access standards is sufficient and reliable. |
Since GAO made this recommendation, the Department of Defense (DOD) implemented new TRICARE contracts. Under these contracts, DOD uses a new method for ensuring network adequacy. Specifically, contractors are now required to ensure that no less than 96 percent of contractor referrals within a service are are referred to an MTF or network provider with an appointment available with in the access standards. Contractors must also inform DOD within 24 hours of any instance of network inadequacy and must submit a corrective action plan with each notice of network inadequacy. Contractor fees are withheld when they fail to meet the standard.
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| Department of Defense | To improve DOD's oversight of the civilian provider network, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to explore ways to ensure that beneficiary complaints are systematically evaluated and used to oversee the civilian provider network. |
In March 2004, DOD began implementing a Centralized Assessment of Customer Feedback System to collect beneficiary feedback to customer service staff, monitor and analyze data, and explore new trends with program managers and beneficiaries.
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| Department of Defense | To improve DOD's oversight of the civilian provider network, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to explore options for improving the civilian provider surveys so that the results of the surveys could be useful to DOD and the contractors in identifying civilian provider concerns and developing actions that might mitigate concerns and help ensure the adequacy of the civilian provider network. |
In addition to our recommendation, the National Defense Authorization Act for FY2004 directed DOD to conduct a survey of U.S. civilian providers annually until all market areas in the United States have been surveyed. In response, DOD contracted for the first survey of civilian providers in August 2004.
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Civilian employeesHealth care facilitiesHealth care programsHealth care servicesManaged health careReporting requirementsPerformance measuresProgram beneficiariesParticipation ratesSurveys