Military Treatment Facilities: Eligibility Follow-up at Wilford  
Hall Air Force Medical Center (04-APR-03, GAO-03-402R). 	 
                                                                 
In October 2002, we reported the results of our audit of selected
internal control activities at three military treatment 	 
facilities: Eisenhower Army Medical Center, Augusta, Georgia;	 
Naval Medical Center-Portsmouth, Portsmouth, Virginia; and	 
Wilford Hall Air Force Medical Center, San Antonio, Texas. As	 
part of our work for that report, we requested data files of all 
patients who had been admitted, treated as outpatients, or	 
received pharmaceutical benefits during fiscal year 2001. Despite
considerable effort by the three facilities, only Wilford Hall	 
Air Force Medical Center was able to provide a file of		 
beneficiaries who received pharmaceuticals during the year. We	 
compared this file to data in the Social Security		 
Administration's (SSA) Death Master File as a technique to	 
identify instances of potential fraud or abuse. For Wilford Hall,
we identified 41 cases in which a prescription was ordered for an
individual after the date of his or her death as recorded in the 
SSA Death Master File. Congress requested  that we determine	 
whether individuals fraudulently obtained pharmaceuticals or	 
other health benefits by assuming the identity of a dead person, 
and, if so, to identify the specific breakdowns in internal	 
controls that allowed such fraud to occur. We confined our	 
investigation to the 41 cases described above.			 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-03-402R					        
    ACCNO:   A06596						        
  TITLE:     Military Treatment Facilities: Eligibility Follow-up at  
Wilford Hall Air Force Medical Center				 
     DATE:   04/04/2003 
  SUBJECT:   Fraud						 
	     Health care services				 
	     Internal controls					 
	     Medical records					 
	     Military facilities				 
	     Defense Enrollment Eligibility Reporting		 
	     System						 
                                                                 
	     SSA Death Master File				 
	     DOD Composite Health Care System			 

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GAO-03-402R

GAO- 03- 402R MTF Eligibility Follow- up United States General Accounting
Office Washington, DC 20548

April 4, 2003 The Honorable Dennis J. Kucinich Ranking Minority Member
Subcommittee on National Security, Emerging Threats and International
Relations Committee on Government Reform House of Representatives

The Honorable Edolphus Towns Ranking Minority Member Subcommittee on
Government Efficiency and Financial Management Committee on Government
Reform House of Representatives

The Honorable Janice D. Schakowsky House of Representatives

Subject: Military Treatment Facilities: Eligibility Follow- up at Wilford
Hall Air Force Medical Center

In October 2002, we reported to you on the results of our audit of
selected internal control activities at three military treatment
facilities: Eisenhower Army Medical Center, Augusta, Georgia; Naval
Medical Center- Portsmouth, Portsmouth, Virginia; and Wilford Hall Air
Force Medical Center, San Antonio, Texas. 1 As part of our work for that
report, we requested data files of all patients who had been admitted,
treated as outpatients, or received pharmaceutical benefits during fiscal
year 2001. Despite considerable effort by the three facilities, only
Wilford Hall Air Force Medical Center was able to provide a file of
beneficiaries who received pharmaceuticals during the year. We compared
this file to data in the Social Security Administration*s (SSA) Death
Master File as a technique to identify instances of potential fraud or
abuse. 2 For Wilford Hall, we identified 41 cases in which a prescription
was ordered for an individual

after the date of his or her death as recorded in the SSA Death Master
File. You requested that we determine whether individuals fraudulently
obtained pharmaceuticals or other health benefits by assuming the identity
of a dead person, and, if so, to identify the specific breakdowns in
internal controls that allowed such fraud to occur. As agreed to with your
staffs, we confined our investigation to the 41 cases described above.

1 U. S. General Accounting Office, Military Treatment Facilities: Internal
Control Activities Need Improvement, GAO- 03- 168 (Washington, D. C.: Oct.
25, 2002). 2 We used a database of pharmacy prescriptions recorded in
fiscal year 2001 provided to us by Wilford

Hall that included prescriptions recorded for about 100, 000 individuals
at Brooke Army Medical Center and Randolph Air Force Base Clinic, which
share health- care- related computer files with Wilford Hall. In this
report, we refer to them collectively as Wilford Hall.

GAO- 03- 402R MTF Eligibility Follow- up 2

Results in Brief

We did not find indications of individuals fraudulently obtaining health
care benefits in our examination of the 41 cases we identified of people
receiving treatment after they were listed in SSA*s Death Master File. In
40 of the 41 cases, data entry errors and/ or internal control weaknesses
at either SSA or at the military treatment facilities created the
impression that a deceased person had received prescriptions. Of the 40
cases, 10 were instances in which SSA*s Death Master File had incorrectly
listed as deceased

the individual to whom a prescription was dispensed and

30 resulted from Department of Defense (DOD) data entry errors. In the 10
cases involving inaccurate SSA death records, most of the individuals
concerned found out about the erroneous report of their deaths when they
were notified that their SSA benefits had ended. The individuals had their
benefits restored, and most did not experience significant problems as a
result of the errors; however, some had other problems, including
temporary suspension of their retired military payments and difficulty in
getting reimbursed for a prescription filled at a retail pharmacy.
Inaccurate information in the SSA database has caused DOD to expend
resources researching inaccurate death information for living individuals,
not only at Wilford Hall, but also for the eligibility system DOD- wide.

Thirty of the 40 cases were data entry errors that occurred during the
process of entering a prescription into DOD*s health care database. For 14
of these 30 cases, the pharmacy dispensed a prescription to the intended
eligible individual but inadvertently recorded the prescription under a
deceased person*s Social Security number (SSN). In 10 of these 14 cases,
the deceased person was either the spouse or another eligible relative of
the individual receiving the prescription. In 2 of the 30 cases, we could
not determine who received the prescriptions, but they totaled only 3
prescriptions of small value. In 14 of the 30 cases, the prescriptions
were not dispensed. Pharmacy records show that 8 were canceled before they
were filled and 6 were never picked up.

The 30 cases of data entry errors at DOD were the result of human error as
well as the result of DOD not having adequate controls over the data entry
process. Specifically, DOD does not have a preventive control in its data
entry process that prohibits entering new clinical data such as
prescriptions into a deceased person*s record in the DOD automated health
care database. When this happens, prescriptions are not entered into the
correct individual*s file and the potentially significant patient safety
issue of hazardous drug interactions may not be addressed. The remaining
case involved an elderly former spouse of a retired service member who

continued to receive prescriptions valued at about $350 after she became
ineligible when they divorced. We concluded that this situation existed
because the retired service member may not have reported the divorce as
required by DOD policy. Therefore, DOD*s eligibility system continued to
show the former spouse as eligible. The ineligible former spouse told us
she was not aware she was ineligible, and that she thought she could
continue to get prescriptions until her identification card expired, about
3 years after her divorce. Although this case resulted in inappropriately
provided health care benefits, i. e., improper payments, our investigation
did not conclude that the payments were fraudulently obtained. Rather,
they most likely resulted from a lack of information about eligibility
criteria.

This letter includes a recommendation to the Secretary of Defense to
develop and implement a preventive control for data entry errors involving
a deceased person*s clinical record. In a written response to a draft of
this report, SSA agreed that the Death Master File has some

GAO- 03- 402R MTF Eligibility Follow- up 3 problems with accuracy and
discussed the improvement efforts it has underway. In oral

comments, DOD agreed with our findings but disagreed with our
recommendation and said that our report overstates the extent of the
problem because of the small number of data entry errors. We disagree with
DOD. In our work, we focused only on the 41 cases and did not attempt to
determine the overall extent of the problem. We believe that a preventive
control can effectively avoid the data entry problems we identified and
thereby help ensue that patient safety issues are addressed.

Background

Wilford Hall is the Air Force*s largest medical facility. It provides a
wide range of medical services, including pharmacy- dispensed prescription
drugs to active and retired military personnel and their dependents.
Wilford Hall reports that it fills approximately 2.6 million prescriptions
annually for about 100,000 people. Wilford Hall*s clinical records are
contained in DOD*s Composite Health Care System (CHCS). CHCS is DOD*s
primary medical information system, which medical treatment

facilities use to support their various activities, including registering
patients, documenting inpatient activity, and tracking pharmacy
prescriptions. Since 1997, DOD has had a project underway to replace CHCS
with a new system, CHCS II, that DOD envisions as a state- of- theart
automated medical information system. Part of DOD*s goal for CHCS II is to
assist clinicians in making health care decisions. 3 In our October 2002
report based on work at three military treatment facilities, 4 we reported

that erroneous eligibility information contained in DOD information
systems, including CHCS, precluded the military treatment facilities from
providing reasonable assurance that medical care was provided only to
eligible persons. We found that unreliable and inaccurate data, system
inadequacies, complicated processes, and a lack of adherence to policies
and procedures contributed to internal control weaknesses.

Military treatment facilities such as Wilford Hall are required to verify
a person*s eligibility for DOD health care benefits before providing
treatment, except in emergencies. The facilities use a two- step process
to verify eligibility. One step is for a staff person to physically review
the person*s military identification card, which includes a picture of the
person, and visually verify the identity of the person requesting health
care. The military identification card is issued at over 900 DOD locations
and is used DOD- wide to access a variety of DOD services in addition to
health care. Sponsors* the military active duty persons or retirees upon
whom their dependents* eligibility is based* are responsible for reporting
any changes in status for themselves and their dependents.

The other step is for the facility*s staff to access the person*s clinical
record in CHCS, which verifies the person*s eligibility status by
interfacing with the Defense Enrollment Eligibility Reporting System
(DEERS). DEERS is a DOD- wide system that contains eligibility information
on active, reserve, and retired military and their dependents. It is used
by DOD facilities such as commissaries and base exchanges as well as
military treatment facilities to determine eligibility for various types
of DOD benefits. DEERS regularly receives updated data from SSA regarding
deaths reported to it. 3 U. S. General Accounting Office, Information
Technology: Greater Use of Best Practices Can Reduce

Risks in Acquiring Defense Health Care System, GAO- 02- 345 (Washington,
D. C.: Sept. 26, 2002). 4 GAO- 03- 168.

GAO- 03- 402R MTF Eligibility Follow- up 4 SSA*s Death Master File is the
agency*s repository of death information and is available for

use by both public and private sector organizations. The Death Master File
is a national file listing the SSNs of individuals whose deaths have been
reported to SSA. Data sources include friends and relatives of deceased
individuals, funeral directors, financial institutions, postal
authorities, and other federal and state agencies.

Scope and Methodology

To determine if any ineligible persons were using the identity of a
deceased person to obtain health care benefits, we compared a data file
from Wilford Hall Medical Center of patients who had received a
prescription to data from SSA*s Death Master File. The patient data file
was extracted by Wilford Hall staff from CHCS and identified about 100,000
individuals in Wilford Hall*s database who had a pharmacy prescription
during fiscal year 2001. These files included prescriptions recorded at
Brooke Army Medical Center and Randolph Air Force Base Clinic as well as
Wilford Hall because the facilities share computer services for health
care matters. As of April 2002, the Death Master File contained about 70
million records of persons with SSNs who, according to SSA, have been
reported as deceased.

We first matched only on SSN and identified 266 matches. However, most
matched only on SSN but not on other critical data such as name and date
of birth. Because the military treatment facilities* eligibility
verification process is to match both the sponsor*s SSN and the patient*s
name, we selected for further analysis and investigation only the 41 cases
in which the SSN matched in both files and other identifying information,
such as the same name and date of birth, raised questions about how the
deceased person in the SSA database could have received care after his or
her reported death.

For all 41 people, we also obtained from Wilford Hall a list of
prescriptions ordered after the date of death recorded in the SSA Death
Master File. We also obtained eligibility information from DOD*s automated
eligibility systems.

To obtain an explanation of the facts of each case and to identify
indications of fraud, our investigators reviewed other records such as
death certificates and divorce decrees as needed. For the 10 cases of
inaccurate reports of death, our investigators interviewed patients,
family members, and others, as needed. We conducted our work from November
2002 though January 2003 in accordance with U. S.

generally accepted government auditing standards, and we performed our
investigative work in accordance with standards prescribed by the
President*s Council on Integrity and Efficiency, as adapted for GAO*s
work. We provided a draft of this letter to DOD and SSA for

comment. DOD provided oral comments, which are discussed in the *Agency
Comments and Our Evaluation* section, and SSA provided written comments,
which are reprinted as an enclosure. Benefits Provided to Eligible
Individuals

but Data Entry Errors Raise Concerns

In 40 of the 41 cases we investigated, a data entry error and/ or internal
control weaknesses either at SSA or at the military treatment facility
caused these cases to appear to have had a prescription ordered for a
deceased person. We did not find indications of potential fraud in any of
these 40 cases. A data entry error at SSA caused 10 of the errors. The
remaining 30 cases stemmed from data entry errors made at Wilford Hall.
They occurred in part because DOD has not built a control into CHCS* data
entry process to prevent entering new clinical

GAO- 03- 402R MTF Eligibility Follow- up 5 data into a deceased person*s
record rather than the correct record. Table 1 summarizes our

analysis. The remaining case is discussed in the next section of this
letter. Table 1: Results of Analysis of 40 People for Whom a Prescription
Was Ordered after Their Reported Date of Death Description of case Totals
Subtotals

Individuals incorrectly recorded as deceased by SSA 10

DOD data entry errors 30

o Prescription dispensed to an eligible individual but recorded under a
deceased person*s SSN 14

Dispensed under deceased spouse*s SSN 5 Dispensed under other related
person*s SSN 5 Dispensed under nonrelated person*s SSN 4

o Prescription dispensed to an unknown individual and recorded under a
deceased person*s SSN 2

o Prescription not dispensed 14 Physician or pharmacy staff canceled
prescription prior to dispensing 8 Patient did not pick up prescription 6
Source: DOD and SSA data. Note: GAO analysis of DOD and SSA data.

Individuals Incorrectly Listed as Deceased by SSA Ten of the 40 cases
involved individuals who were incorrectly listed as deceased in SSA*s
Death Master File. These individuals were not only alive, but they were
also eligible for health care benefits. Our interviews with the
individuals or their family members disclosed that the erroneous entry
typically occurred when the individual reported the death of a spouse. The
SSA official receiving the report of death appears to have recorded not
only the death of the actual deceased person but also the individual
reporting the death. In each case, the individual who was incorrectly
recorded as deceased told us that he or she notified SSA

of its error and benefits were restored. However, these individuals
continued to be listed in the SSA Death Master File. These inaccuracies in
SSA*s database had generally persisted for years. For example, 5 of the 10
had been listed as deceased for over 10 years.

Incorrect recordings of death are not isolated incidents. SSA*s Inspector
General has reported that erroneous dates of death continue to exist in
the Death Master File database. 5 These erroneous dates stayed in the
database because SSA*s payments and Death Master File

systems were not fully integrated. Although SSA restarted payments,
changes in the payment system database to restart the payments did not
trigger subsequent changes in the Death Master File. According to the
Inspector General report, these erroneous dates of death have caused other
agencies to expend resources researching death information for living
individuals. In our work, a DOD official told us that DEERS officials have
to reverify that individuals were alive and eligible for health care not
only at Wilford Hall but also throughout the DOD- wide eligibility system.
In a January 2003 report on SSA*s efforts to improve its Death Master
File, the SSA Inspector General reported that as of September 2002, SSA
had

5 Social Security Administration, Office of the Inspector General, The
Social Security Administration*s Procedures to Identify Representative
Payees Who Are Deceased, A- 01- 98- 61009 (Baltimore, Md.: September 1999)
and Disclosure of Personal Beneficiary Information to the Public, A- 01-
01- 01018 (Baltimore, Md.: December 2001).

GAO- 03- 402R MTF Eligibility Follow- up 6 implemented an automated
process to (1) identify inaccurate death data and (2) generate a

quarterly report that lists names and SSNs requiring investigation. 6 In
addition to causing agencies additional work, erroneous reports of death
in the Death Master File can result in living individuals* SSN and other
personal information becoming public information because SSA makes the
Death Master File information available to the public upon request. The
SSA Inspector General reported that as a result, at least some erroneously
reported deceased individuals had experienced various continuing
difficulties, such as obtaining credit. 7 In one case we investigated, for
example, the individual, whose SSN had been listed in the

Death Master File since 1991, reported experiencing periodic problems ever
since her reported death. She told us she had been denied a cell phone and
had difficulty getting reimbursement for a prescription filled at a retail
pharmacy. In two other cases, the

individuals said that their retired military and/ or Social Security
payments were temporarily suspended when the problem first occurred in the
1990s, but their benefits were restored within a couple of months. They
said they had not experienced additional problems caused by the inaccurate
death file.

In the remaining cases we investigated, the individuals reported that they
had not experienced significant problems because of these errors. They had
found out about the erroneous reports of their deaths when they received a
notification that their Social Security or other government benefits had
ended. However, they reported the error to SSA and had not experienced
subsequent difficulties, although the Death Master File continued to show
them as deceased.

Prescriptions Dispensed to an Eligible Individual but Recorded under a
Deceased Person*s SSN For 14 of the cases, prescription drugs were
dispensed to an eligible individual but were recorded under a deceased
person*s SSN. We concluded that these situations were data entry errors
made by physician or pharmacy staff when they entered a prescription into
the CHCS database. Usually, only one or two prescriptions were dispensed
under the incorrect SSN for the 14 cases, and the errors were one- time
events limited to a single day.

To record a prescription in the patient*s CHCS clinical record, physician
or pharmacy staff must access the patient*s record in the CHCS database,
which also includes records of deceased patients. The staff is to use the
first letter of the last name and the last four digits of the SSN of the
individual*s sponsor to search for and select the appropriate record. In
these 14 cases, the person who entered the prescription into the CHCS
database selected the wrong individual*s record. In 5 of the 14 cases,
they chose the patients* deceased sponsor*s record. In 5 other cases, they
chose another related individual* s record. In the remaining 4 cases, they
appear to have chosen the record of an individual unrelated to the
patient.

We identified the likely recipients of the prescriptions by examining
relevant data such as the prescription history and physician appointments
of the deceased person*s family members and others with similar names. For
example, one case involved a deceased sponsor whose widow*s first name was
very similar to his. The widow had a history of taking the pain 6 Social
Security Administration, Office of the Inspector General, The Social
Security Administration*s

Efforts to Process Death Reports and Improve its Death Master File, A- 09-
03- 23067 (Baltimore, Md.: January 2003). 7 SSA, Office of the Inspector
General, A- 01- 01- 01018.

GAO- 03- 402R MTF Eligibility Follow- up 7 medication that showed up in
her deceased sponsor*s CHCS record, and she also had a

doctor*s visit on the same day that the prescription was entered into her
sponsor*s CHCS record. In another example, an individual with a similar
last name and the same last four digits of the SSN as our case had a
history of using the same ophthalmic medication that showed up in our
case*s CHCS record.

Even though our work indicated that the intended individuals received the
prescriptions, we believe these cases raise a clinical issue because the
prescriptions were not entered into the correct individuals* records,
leaving those records incomplete. When they are incomplete, patient safety
issues such as potentially dangerous drug interactions for those
individuals may not surface and be addressed. Prescription Dispensed to
Unknown Individual and Recorded under a Deceased Person*s SSN For two
cases, a prescription was dispensed and recorded under a deceased
individual*s SSN,

but we could not determine who received the prescription. A total of three
prescriptions were dispensed. In one case, a single prescription was
dispensed for the generic equivalent of the sleeping aid Ambien. The other
case was for two prescriptions for four pills each of the inexpensive
antibiotic Amoxicillin. Although we were not able to determine who
received these prescriptions, the limited number and small value of the
prescriptions dispensed led us to conclude that these two cases were
probably not indications of fraudulent or abusive activity. Rather, we
concluded that these cases were caused by the same type data entry errors
as just discussed.

Prescriptions Not Dispensed For 14 cases, Wilford Hall*s records show that
the prescriptions did not leave the pharmacy and were canceled. We
concluded that these cases involved data entry errors similar to the ones
discussed in the previous two sections except that in these cases the
prescriptions were not dispensed, according to the clinical records. For 8
of these 14 cases, the physician or pharmacy staff identified the data
entry errors and canceled the prescriptions in the CHCS database before
they were filled. In most of these cases, they caught and corrected their
own error within minutes. In the remaining 6 cases, the prescription was
filled but was not picked up. At Wilford Hall, the pharmacy*s practice is
to return medications to inventory if they have not been picked up after 7
days. A prescription is canceled in the individual*s CHCS record when the
medication is returned to inventory.

CHCS Missing Important Data Entry Control Thirty of these errors were
caused by Wilford Hall staff accessing the wrong person*s CHCS record to
enter a prescription. DOD*s process for entering clinical data into an
individual*s CHCS record does not include a preventive edit or control to
prohibit entering new data into a deceased person*s record. While such
data entry errors would not necessarily be unexpected given the workload,
they should be anticipated and mitigated. These types of data entry errors
can create a risk that a prescription does not get into the correct
person*s clinical record, which can result in a potential patient safety
issue not being addressed since the clinical record is incomplete.

Neither CHCS nor its planned successor system, CHCS II, have edits or
controls built into them to prevent new data from being entered into a
deceased person*s clinical record, according to DOD officials responsible
for the successor system. Both CHCS and CHCS II have an alert/ reminder
feature that can notify clinicians of potentially dangerous drug

GAO- 03- 402R MTF Eligibility Follow- up 8 interactions based on comparing
the prescriptions a patient is currently taking to a new one

that is prescribed. However, this alert feature cannot work effectively
when prescription information is entered into the wrong individual*s
record.

Various edits and controls to help ensure the integrity of data entered
into clinical records are possible, such as making the records of deceased
persons *read- only* so that new data cannot be entered. Another
possibility includes programming CHCS so that when a deceased individual*s
clinical record is accessed, a warning message appears saying that the
individual

is deceased and asking if new data should be entered.

Prescriptions Dispensed to an Ineligible Individual

The last of the 41 cases involved prescriptions dispensed to an ineligible
individual. However, based on our investigation and analysis of the
circumstances of this case, we did not identify health care benefits that
we could conclude were fraudulently obtained. In this case, an elderly
retired military member*s second wife was listed under her name as
eligible in DOD*s DEERS eligibility system but was incorrectly assigned
the member*s deceased first wife*s SSN. Therefore, when we compared the
SSNs in the Wilford Hall file to the SSNs in the Death Master File, she
was identified as having prescriptions ordered after the date of her
death. According to Wilford Hall records, the divorced second wife
received 39 original prescriptions and refills that Wilford Hall valued at
less than $500 from 1997 through 2001. However, she became ineligible for
DOD health care benefits upon her divorce from the retired service member
in March 1998. We determined that 31 of these prescriptions, valued in
Wilford Hall*s records at about $350, were for prescriptions after she
became ineligible.

DOD*s policy is that sponsors are to report any change in dependent
status, which enables DOD facilities to determine when a divorced spouse
or other dependents are no longer eligible for benefits. In this case, we
were unable to determine if the sponsor had reported his divorce to DOD
because the sponsor*s very poor health at the time of our investigation
precluded our contacting him on this matter.

The second wife explained that when her husband established her
eligibility, he used his deceased first wife*s SSN. The second wife said
she did not correct the error because she was provided benefits under her
sponsor husband*s SSN, which the military treatment facility uses to
access the clinical care records. She was issued an identification card
before she was divorced from the sponsor that was valid until September
2001, 3 years after her divorce. Absent a record of the divorce, DEERS*
DOD*s eligibility system* showed her eligible for benefits. As of January
2003, the last recorded prescription in Wilford Hall*s database for the
patient was in August 2001, the month before the expiration date on her
identification card. According to this individual, no one told her that
she became ineligible when she was divorced. She said she stopped using
the military treatment facility when her identification card expired. We
have provided our documentation on this case to DOD to correct its
eligibility records.

Cases similar to this one do not appear to be unusual, and may, in fact,
be quite commonplace. In a January 2000 report on DEERS, 8 the DOD
Inspector General reported that in 30 of the 81 cases it analyzed in which
individuals were ineligible for benefits, the sponsor had not reported a
divorce to DEERS, as required by DOD policy. Fifteen of the divorces had
been final for at least a year, and of those, 9 had been final from 4 to
26 years.

8 Department of Defense, Office of the Inspector General, Evaluation of
The Criminal Investigative Environment In Which The Defense Enrollment
Eligibility Reporting System Operates,

CIPO2000S001 (Washington, D. C.: Jan. 7, 2000).

GAO- 03- 402R MTF Eligibility Follow- up 9 In these 9 cases, the
identification cards had been renewed at least one time after the

divorces became final. Some cards were renewed with the sponsor*s
signature on the application and some with the sponsor*s divorced spouse*s
signature. In the latter cases, the former spouses used their expiring
identification cards as the basis for obtaining new cards. Based on the
Inspector General*s recommendations, DOD established a 30- day time limit
for sponsors to report a change in their dependents* eligibility status.

Conclusion We did not find evidence of fraudulently obtained health
benefits in the 41 cases we investigated. However, our follow- up work
suggests that the process for entering data into patients* clinical
records at DOD*s military treatment facilities has a key flaw. While the
10 cases related to errors in the SSA Death Master File are beyond DOD*s
control, the other 30 are not. They are the result of human data entry
errors that, while not unexpected in a busy environment such as the one at
Wilford Hall, can result in incomplete medical records and significant
patient safety issues such as potentially hazardous drug interactions not
being identified. These errors could reasonably be addressed by adding
preventive data entry controls.

Recommendation for Executive Action

To strengthen controls over data entry into the DOD clinical records
database and to help ensure that patient safety issues are identified, we
recommend that the Secretary of Defense direct the Assistant Secretary of
Defense for Health Affairs, in conjunction with the military services*
Surgeons General, to institute a standardized preventive control procedure
or procedures to prevent inadvertent entry of new clinical data into a
deceased person*s record clinical record in CHCS and CHCS II.

Agency Comments and Our Evaluation We provided a draft of this report to
both SSA and DOD for their review. SSA, in its written comments reprinted
as an enclosure, agreed that some issues of accuracy exist about
information contained in the Death Master File. SSA explained why these
inaccuracies exist and the efforts it has underway to improve file
accuracy.

In DOD*s oral comments, the Assistant Secretary of Defense for Health
Affairs concurred with the findings of the report but did not concur with
the recommendation. DOD*s position is that the report overstated the
extent of the problem and that the small number of data entry errors
compared to the number of prescriptions written annually does not warrant
a global change to its processes for entering data into its clinical
database. DOD said that its current data entry procedures and oversight
controls are adequate to prevent errors in medical care or the delivery of
significant levels of inappropriate health care, and it believed a
continuing emphasis on ongoing pharmacy training programs to ensure
correct data entry

was a more feasible approach. DOD also said that the results of our work
verify that DOD*s health care eligibility system works extremely well.

With regard to DOD*s health care eligibility system, we do not agree with
DOD. Our work was narrowly focused on investigating the 41 cases for
potential fraud. In our work, we did not attempt to measure the full
extent of the problem of data entry errors, and we neither evaluated nor
do we comment on the effectiveness of controls over DOD*s health care
eligibility system. In the course of investigating the 41 cases, instead
of identifying fraud, we determined that DOD clerical errors in 30 of the
41cases had created the appearance that individuals had received a
prescription drug after their death.

GAO- 03- 402R MTF Eligibility Follow- up 10 With regard to the best
approach to avoiding clerical data entry errors, we continue to believe
that the practical solution to these clerical errors is for DOD to
implement our

recommendation to develop a preventive control over the process for
entering data into the clinical database. The problems we discuss in the
report are a matter of entering prescription information into the wrong
individual*s medical file, which can raise patient safety concerns. When a
prescription is not entered into the file for the individual who is to
receive the prescription, CHCS* ability to compare the prescription to
others the individual may be taking and identify potentially hazardous
drug interactions is jeopardized.

The problems we identified were caused by human error in the data entry
process. While we understand that human errors will always occur to some
extent and that training is very valuable, we do not believe that
additional training alone is the best approach to preventing these types
of errors. We believe they can be even more effectively avoided by adding
a systemic preventive control to the data entry process. For example, CHCS
II could be programmed to present a *flag* to the data entry person when a
deceased person*s record is

accessed that presents a message such as the following on the screen.
*This person is deceased. Are you sure you want to enter new clinical
data?* The system could also be programmed to not allow further data entry
until the question is answered.

When patient safety is at stake, we believe that DOD should take all
reasonable safeguard measures, particularly during the development stage
of a new system when changes are comparatively less costly. We believe DOD
will miss a significant opportunity to improve its control over data entry
and help ensure the safety of its patients if it does not address this
weakness in the data entry process, especially during the development of
the CHCS II pharmacy module.

- - - - - - - - - - - - - - - - - - - - - - Unless you publicly announce
its contents earlier, we will not distribute this letter until 15 days
from its date. At that time, we will send copies of this report to the
Chairmen of the Subcommittee on National Security, Emerging Threats and
International Relations and the Subcommittee on Government Efficiency and
Financial Management of the House Committee on Government Reform as well
as other congressional committees. We are also sending copies to the
Secretary of Defense; the Assistant Secretary of Defense for Health
Affairs; the Surgeons General of the military services; the Secretary of
the Air Force; and the Commanders of Brooke Army Medical Center, Randolph
Air Force Base Clinic, and Wilford Hall Medical Center. Copies will be
made available to others upon request. In addition, the letter will also
be available at no charge on the GAO Web site at http:// www. gao. gov.

GAO- 03- 402R MTF Eligibility Follow- up 11 Please contact Greg Kutz at
(202) 512- 9095 or by e- mail at kutzg@ gao. gov or Linda Garrison,

Assistant Director at (404) 679- 1902 or by e- mail at garrisonl@ gao. gov
if you or your staffs have any questions concerning this report. Major
contributors to this correspondence were Mario Artesiano, Ray Bush, Carl
Higginbotham, Ken Hill, Sue Piyapongroj, John Ryan, and Lisa Warde.
Gregory D. Kutz

Director, Financial Management and Assurance Robert J. Cramer Managing
Director Office of Special Investigations

Enclosure

GAO- 03- 402R MTF Eligibility Follow- up 12 Enclosure

Comments from The Social Security Administration

GAO- 03- 402R MTF Eligibility Follow- up 13 (192081)
*** End of document. ***