World Trade Center Health Program: Administrator's Plans for Evaluating Clinics' Capabilities to Provide Required Data

This report discusses the briefing presented to congressional staff on June 30, 2011 regarding the James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act). The Zadroga Act requires GAO to report by July 1, 2011, on whether the Clinical Centers of Excellence (CCE) under contract with the World Trade Center Health Program (WTCHP) Administrator have financial systems that allow for the timely submission of health care claims data as envisioned by the act. Beginning on July 1, 2011, the WTCHP is to provide medical services to responders and survivors of the September 11, 2001, terrorist attacks through contracted medical facilities known as CCEs in the New York City/New Jersey metropolitan area and a nationwide network of providers. In addition to providing medical services, the WTCHP is required to collect, report, and analyze data, including health care claims data; perform research on World Trade Center-related health conditions; and establish an outreach program. The Secretary of Health and Human Services designated the Director of the National Institute for Occupational Safety and Health (NIOSH) as the WTCHP Administrator. The Administrator is responsible, as specified by the Zadroga Act, for all provisions of the act not related to payments for eligible health care claims. As discussed with the committees, our objective was to describe the WTCHP Administrator's plans and processes for determining whether the CCEs' financial systems can provide timely and accurate health care claims data as required by the Zadroga Act. Accordingly, the briefing focused on the (1) Centers for Disease Control and Prevention (CDC)/NIOSH schedule for awarding contracts to CCEs, (2) health care claims data requirements for the CCEs and planned procedures, and (3) Administrator's plans for evaluating each CCE system's health care claims data capabilities during and after the award of the contracts.

At the time of our review, CDC/NIOSH officials were pursuing a CCE contract awards schedule that was driven by the Zadroga Act's program implementation date of July 1, 2011. CDC/NIOSH officials anticipated awarding multiple cost-plus, fixed-fee contracts for the CCEs on June 30, 2011--the day before WTCHP implementation. The CCE request for proposals issued by NIOSH included requirements that were based on the health claims data requirements included in the Zadroga Act. According to NIOSH officials, as of June 21, 2011, all acquisition milestone dates had been met. Subsequent to our briefing, CDC awarded seven CCE contracts on July 1, 2011. If CDC/NIOSH had not met the planned CCE contract award date, CDC/NIOSH officials' contingency plan was to extend the cooperative agreements with the clinical centers under the current World Trade Center health programs administered by NIOSH to provide medical services to responders and survivors. The WTCHP Administrator plans to develop programwide procedures to be used by the CCEs for collecting and reporting of health care claims data after the program is implemented and CCEs begin submitting health care claims for payment. According to the request for proposals, the CCEs will be expected to use the Centers for Medicare and Medicaid Services (CMS) 1500 form or a similar form to collect the needed health claims data. CCEs will be expected to electronically submit, within specified time frames, all valid health care claims for payment. The request for proposals also required that each CCE implement a quality assurance program that includes a review of all health claims forms for completeness and accuracy before the claims are submitted. The Administrator planned to evaluate potential CCEs' capabilities for collecting and reporting health care claims data as part of the contract awards process. According to the request for proposals, members of a technical panel were to evaluate offerors' approach for accomplishing the contract requirements, including the collecting and reporting of health care claims data. The panel members also were to review offerors' narrative descriptions of their accounting systems' capabilities to assess whether each system is adequate for determining costs applicable to the CCE contract as required by the Federal Acquisition Regulation. NIOSH officials stated that the compressed CCE contract awards schedule could not accommodate site visits by its personnel or personnel from an outside entity, such as the Defense Contract Audit Agency (DCAA), to assess the offerors' financial systems' health care claims data capabilities. The officials also stated that they may consider having DCAA assess the CCEs' financial systems after the contracts are awarded. Further, the WTCHP Administrator plans to establish procedures to randomly monitor and/or periodically inspect a CCE's compliance with the timely submission of health care claims data as part of assessing a CCE's contract performance.