Defense Health Care: Actions Needed to Improve Billing and Collection of Debt for Civilian Emergency Care
Fast Facts
DOD medical facilities primarily provide care to servicemembers, their dependents, and retirees. In 2010, DOD was authorized to provide emergency care to civilians, too.
DOD states that treating civilians benefits its medical staff by giving them more experience. But DOD hasn't assessed the extent to which this experience supports medical staff's readiness.
DOD facilities bill civilians and refer delinquent debts to Treasury. But they don't always update billing records to reflect payments that Treasury collects. So, DOD doesn't know exactly how much money is collected for providing this care. Our recommendations address these issues and more.
At Madigan Army Medical Center, civilian emergency patients were evaluated and treated for injuries sustained during a train derailment in 2017.
Highlights
What GAO Found
Department of Defense (DOD) documentation and officials have identified several benefits to providing care to civilian emergency patients at DOD medical treatment facilities (MTFs). For example, providing such care can promote the readiness of military health care providers because it increases the volume of patients they treat and allows them to treat a broader range of cases, including complex cases. However, DOD has not assessed and monitored the extent to which providing emergency medical care to civilians offers the relevant mix and volume of cases needed to maintain readiness. Doing so would better position DOD to determine if continuing or expanding this care maintains readiness.
DOD has limited oversight of billing and collection of debt for civilian emergency care patients. GAO found that MTFs do not always update DOD's billing system to reflect payments collected while debt was with the Department of the Treasury (see figure) because DOD has not issued guidance that clarifies the extent to which MTFs should do so. Without guidance to ensure accurate accounting of billing and collection efforts, DOD leaders risk being unable to account for potentially millions of dollars collected each year. DOD also risks making decisions about civilian care using incomplete information.
Extent to Which Medical Treatment Facilities Updated Department of Defense Billing System to Reflect Payments Collected While Debt Was with the Department of the Treasury
DOD does not consistently use or communicate options for financial relief for civilian emergency patients, according to GAO's analysis of DOD and Treasury data. Specifically, DOD
rarely uses certain financial relief options—including waiving or settling medical debt for less than the full amount owed. For example, only the Navy confirmed approving waivers from fiscal years 2016 through 2021, and
does not consistently inform civilian emergency patients about options to request financial relief, to include waivers or settling of medical debt.
By systematically tracking and monitoring the use of waivers, DOD may better understand the number of waiver requests it receives, the amount of debt it waives, and the circumstances under which it approves them to ensure timeliness and consistency. Additionally, by clearly communicating financial relief options, DOD could help civilian emergency patients better understand those options and pursue them in a timely manner.
Why GAO Did This Study
DOD primarily provides medical care to servicemembers, their dependents, and retirees. In 2010, DOD became authorized to provide emergency care to civilians at MTFs. DOD is generally required to bill civilians for care provided at MTFs, but the cost of such care may create financial hardships for these civilian patients. When the debt becomes delinquent, DOD turns it over to Treasury for collection.
The National Defense Authorization Act for Fiscal Year 2021 contained a provision for GAO to assess DOD's efforts to bill and collect debts for civilian emergency care at MTFs, among other things. This report assesses the extent to which DOD (1) has identified benefits of providing emergency care to civilians, (2) oversees billing and debt collection for emergency care provided to civilians, and (3) uses and communicates options for financial relief to lessen the effect of the cost of care on civilian emergency patients.
GAO analyzed DOD and Treasury billing data for services provided from fiscal years 2016 through 2021; reviewed information related to benefits of providing care to civilians; and interviewed DOD and Treasury officials.
Recommendations
GAO is recommending that DOD assess and monitor how providing civilian emergency care maintains medical readiness, issue guidance to update systems with complete collection information, track and monitor waiver requests, and communicate financial relief options. DOD did not provide comments on a draft of this report.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Defense | The Secretary of Defense should ensure that the Director of the Defense Health Agency assesses and monitors the extent to which medical care provided to civilian emergency patients offers the relevant mix and volume of medical casework required to maintain medical readiness skills and competencies. (Recommendation 1) |
DOD concurred with this recommendation, but has not yet implemented this recommendation. In a November 2023 status update, DOD stated that it plans to conduct an assessment of medical care provided to civilian emergency patients (including trauma) to evaluate volume and case mix, followed by ongoing monitoring. DOD estimates this recommendation will be fully implemented by October 2024. We will continue to monitor DOD's actions to implement this recommendation.
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| Department of Defense | The Secretary of Defense should ensure that the Director of the Defense Health Agency issues and implements guidance for MTFs to update their billing systems to ensure the systems contain complete and accurate billing and collection information. (Recommendation 2) |
DOD concurred with this recommendation, but has not yet implemented this recommendation. In a March 2023 status update, DOD stated that DHA developed the Debt Adjudication Management Program (DAMP) as a standardized debt adjudication process to consistently manage non-DoD beneficiary delinquent patient medical debt within the Military Health System. To ensure the billing system contains complete and accurate billing and collection information as the information allows, DOD has updated its DAMP Policy Guide to include billing system documentation guidance. DHA implemented the first set of MTFs into DAMP in July 2022. In a November 2023 update, DOD noted it plans to complete its implementation of MTFs into DAMP by January 2024. DOD estimates this recommendation will be fully implemented by March 2024. We will continue to monitor DOD's actions to implement this recommendation.
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| Department of Defense | The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness, in coordination with the Director of the Defense Health Agency and the Secretaries of the military departments, issues and implements guidance to systematically track and monitor waiver requests from and waivers for civilian emergency patients. (Recommendation 3) |
DOD concurred with this recommendation, but has not yet implemented this recommendation. In a November 2023 status update, DOD stated that it plans to issue and implement guidance on systematically tracking and monitoring waiver requests from and waivers for civilian emergency patients. DOD estimates this recommendation will be fully implemented by March 2024. We will continue to monitor DOD's actions to implement this recommendation.
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| Department of Defense | The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness and the Director of the Defense Health Agency issue and implement guidance for MTFs that clarifies what financial relief options are available to civilian emergency patients and how such information should be communicated to them, such as by including information in patient invoices about how to request applicable forms of financial relief. (Recommendation 4) |
DOD concurred with this recommendation, but has not yet implemented this recommendation. In a March 2023 status update, DOD stated that it plans to issue and implement guidance for medical treatment facilities that clarifies what financial relief options are available to civilian emergency patients and how information should be communicated to patients regarding the process for requesting financial relief. In a November 2023 status update, DOD estimates this recommendation will be fully implemented by March 2024. We will continue to monitor DOD's actions to implement this recommendation.
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