Defense Health Care: DOD Needs to Improve Its Monitoring of Claims
Processing Activities (Testimony, 03/10/99, GAO/T-HEHS-99-78).

Pursuant to a congressional request, GAO discussed the Department of
Defense's (DOD) monitoring of health care claims processing activities,
focusing on: (1) GAO's preliminary findings on claims processing
timeliness and accuracy; and (2) the effectiveness of a commercially
available software program to edit TRICARE claims.

GAO noted that: (1) GAO's work to date for the 1-year period included in
its review has shown that TRICARE's contractors in 8 of the 11 regions
processed 86 percent (or 16 million) of the claims on time overall,
exceeding DOD's timeliness standard of processing 75 percent of claims
within 21 days; (2) however, only 66 percent of hospital or
institutional claims were processed on time, while 97 percent of
pharmacy claims were processed on time, and 81 percent of professional
claims were processed on time; (3) the nearly 3 million claims that did
not meet the timeliness standards were mostly from physicians and other
providers; (4) moreover, DOD does not know whether contractors are
paying claims accurately because fewer than half of the claims are
subject to the audit, and the methodology used to calculate payment
error is statistically unsound; (5) according to contractors, the
principal reasons for claims processing problems are the complexity of
the TRICARE program and frequent program changes, requiring
modifications to claims processing software and procedures; (6)
specifically, at the time of GAO's review, DOD had instructed
contractors to implement about 650 changes, or about 130 changes on
average for each contract; (7) DOD's claims editing software, designed
to ensure that providers are accurately reimbursed for services,
affected 3.5 percent of claims and saved more than $53 million in fiscal
year 1998; (8) GAO found, however, that inappropriate denials were
sometimes made because DOD's software did not always comply with
industry standards; (9) this resulted from DOD's poor communication and
slowness to make program changes that affected editing outcomes; (10) in
addition, providers were frustrated because they mistakenly believed
that they had no recourse for claims denied by the editing software; and
(11) if not resolved, these kinds of problems as well as the volume of
claims processed late, despite meeting the timeliness standard overall,
could cause problems in attracting the number of civilian providers
necessary to ensure that beneficiaries have adequate access to health
care.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  T-HEHS-99-78
     TITLE:  Defense Health Care: DOD Needs to Improve Its Monitoring of 
             Claims Processing Activities
      DATE:  03/10/99
   SUBJECT:  Contract oversight
             Managed health care
             Department of Defense contractors
             Health care programs
             Claims settlement
             Claims processing
             Computer software
IDENTIFIER:  DOD TRICARE Program
             
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HE99078T.book GAO United States General Accounting Office

Testimony Before the Subcommittee on Military Personnel, Committee
on Armed Services, House of Representatives

For Release on Delivery Expected at 1: 00 p. m. Wednesday, March
10, 1999 DEFENSE HEALTH CARE

DOD Needs to Improve Its Monitoring of Claims Processing
Activities

Statement of Stephen P. Backhus, Director Veterans' Affairs and
Military Health Care Issues Health, Education, and Human Services
Division




GAO/T-HEHS-99-78

  GAO/T-HEHS-99-78

Page 1 GAO/T-HEHS-99-78 Defense Health Care: DOD Needs to Improve
Its Monitoring of Claims Processing Activities

Mr. Chairman and Members of the Subcommittee: We are pleased to be
here today to discuss issues and problems we have identified
relating to our ongoing assessment of health care claims
processing for the Department of Defense's (DOD) TRICARE program.
TRICARE is a nationwide managed health care program and represents
a

redesign of DOD's $15. 6 billion per year health care system. 1
DOD has contracted with private sector health care companies, who
are referred to as managed care support contractors, to administer
the program on a

regional basis. Contractors' responsibilities include developing
networks of civilian providers, arranging care for beneficiaries,
providing customer service, and processing claims. During 1998,
contractors processed about 28 million health care claims,
including those submitted under DOD's former fee- for- service
program. Last year, we reported on providers' concerns about
TRICARE reimbursement rates and slow and cumbersome claims
payment. 2 Contractors acknowledged that during the start- up
phase of health care delivery they experienced some problems
processing claims in a timely manner, primarily because claims
volume was higher than expected.

However, even when contractors became more timely, providers
continued to complain about slow payment and expressed confusion
about claims adjudication. In response to this Subcommittee's
concerns about these complaints, we are evaluating the performance
of DOD's contractors in processing TRICARE claims.

My statement today will highlight our preliminary findings on
claims processing timeliness and accuracy as well as the
effectiveness of a commercially available software program to edit
TRICARE claims. The information we present is based on an ongoing
evaluation of the claims processing performance of TRICARE regions
that were in operation for at

least 1 year as of July 1998. (See appendix I.) During the course
of our work, we met with officials of DOD and its contractors and
toured their claims processing facilities. We also spoke with
representatives of physicians' groups and with officials of the
company responsible for developing and distributing the claims
editing software that DOD uses. In 1 DOD previously provided
health care under the Civilian Health and Medical Program of the
Uniformed

Services, a fee- for- service program 2 Defense Health Care:
Reimbursement Rates Appropriately Set; Other Problems Concern
Physicians (GAO/HEHS-98-80, Feb. 26, 1998).

Defense Health Care: DOD Needs to Improve Its Monitoring of Claims
Processing Activities

Page 2 GAO/T-HEHS-99-78 addition, we obtained and analyzed nearly
20 million completed claims to determine whether they were
processed in a timely manner. We reviewed DOD's efforts to assess
accuracy but did not independently audit claims for

accuracy. We expect to issue a report in the near future. In
summary, our work to date for the 1- year period included in our
review has shown that TRICARE's contractors in 8 of the 11 regions
processed 86 percent (or 16 million) of the claims on time
overall, exceeding DOD's timeliness standard of processing 75
percent of claims within 21 days.

However, only 66 percent of hospital or institutional claims were
processed on time, while 97 percent of pharmacy claims were
processed on time, and 81 percent of professional claims were
processed on time. The nearly 3 million claims that did not meet
the timeliness standards were mostly from physicians and other
providers. Moreover, DOD does not know

whether contractors are paying claims accurately because fewer
than half of the claims are subject to the audit, and the
methodology used to calculate payment error is statistically
unsound. According to contractors, the principal reasons for
claims processing problems are the complexity of the TRICARE
program and frequent program changes, requiring modifications to
claims processing software and procedures. Specifically, at the
time of our review, DOD had instructed contractors to implement
about 650 changes, or about 130 changes on average for each
contract. DOD's claims editing software, designed to ensure that
providers are accurately reimbursed for services, affected 3.5
percent of claims and saved more than $53 million in fiscal year
1998. We found, however, that inappropriate denials were sometimes
made because DOD's software did not always comply with industry
standards. This resulted from DOD's poor communication and
slowness to make program changes that affected editing outcomes.
In addition, providers were frustrated because they mistakenly
believed that they had no recourse for claims denied by the

editing software. If not resolved, these kinds of problems as well
as the volume of claims processed late, despite meeting the
timeliness standard overall, could cause problems in attracting
the number of civilian providers necessary to ensure that
beneficiaries have adequate access to health care.

Background DOD's primary medical mission is to maintain the health
of 1.6 million active duty service personnel and to provide health
care for them during

military operations. DOD additionally offers health care to 6. 6
million nonactive duty beneficiaries, including dependents of
active duty personnel, military retirees, and dependents of
retirees. Most health care is

Defense Health Care: DOD Needs to Improve Its Monitoring of Claims
Processing Activities

Page 3 GAO/T-HEHS-99-78 provided in military- operated hospitals
and clinics worldwide and is supplemented by care provided by
civilian providers under TRICARE. TRICARE is a triple- option
benefit program designed to give beneficiaries a

choice among a health maintenance organization, a preferred
provider organization, and a fee- for- service benefit. The health
maintenance organization option, called TRICARE Prime, is the only
option for which beneficiaries must enroll. TRICARE Extra is the
preferred provider organization option, and TRICARE Standard is
the fee- for- service option.

TRICARE is geographically organized into 11 health care regions
that are administered by five contractors. Among the contractors'
many responsibilities are claims processing, for which all have
subcontracted with one of two companies. DOD requires contractors
to meet specific timeliness and accuracy standards when processing
claims. The tasks

required to process claims include claims receipt, data entry,
claims adjudication, and claims payment or denial. Contractors
must process 75 percent of claims within 21 days to meet DOD's
timeliness standard. This standard applies to all claims, even
those that need additional information to be processed. By way of
comparison, Medicare requires

that 95 percent of complete electronic claims be paid in 14 days
and that 95 percent of complete paper claims be paid in 30 days.
DOD also requires contractors to maintain a 98- percent payment
accuracy rate. Medicare has a goal of 90- percent accuracy for the
next 5 years. The timeliness and accuracy standards of private
plans vary.

DOD verifies timeliness standards but relies upon external audits
for accuracy verification. DOD uses information from its
electronic health care service record (HCSR) database to verify
timeliness. Contractors prepare and submit to DOD a HCSR for every
claim processed to completion. To verify whether contractors'
accuracy standards are being met, DOD monitors a sample of
processed claims through a quarterly external audit with two
components payment accuracy and data input accuracy.

DOD requires contractors to use ClaimCheck, a commercial off- the-
shelf software program that performs a prepayment review of claims
and helps prevent overpayments by analyzing the appropriateness of
billing on professional claims. The basic ClaimCheck software
package contains approximately five million edits. However,
companies that purchase ClaimCheck may customize the edits to
reflect their plans' benefit structure. DOD purchased ClaimCheck
software in March 1994 and had it

Defense Health Care: DOD Needs to Improve Its Monitoring of Claims
Processing Activities

Page 4 GAO/T-HEHS-99-78 customized for TRICARE. DOD refers to its
customized version as TRICARE ClaimCheck.

Concerns Exist About Claims Processing Timeliness Our analysis to
date has shown that TRICARE's contractors met DOD's

timeliness standards by paying more than 16 million claims within
21 days. 3 Even so, nearly three million claims were paid late. We
found differences in timeliness by category, which includes
pharmacy, hospital or institutional, and professional claims. For
example, contractors did not meet the standard for hospital or
institutional claims. Nonetheless, they were still able to meet
DOD's standard overall, primarily because pharmacy claims were
paid faster. DOD has proposed several initiatives to improve

claims processing timeliness, including the adoption of some
Medicare standards.

Timeliness Standards Were Met Overall, but Some Impediments Exist

As table 1 shows, the three contractors responsible for 8 of the
11 TRICARE regions met DOD's contractual timeliness standards of
processing 75 percent of claims within 21 days. In fact, between
July 1997 and June 1998, these contractors exceeded the standard
by processing 86 percent of claims on time. However, nearly three
million claims did not meet the timeliness standard, and of these
claims, more than 80 percent were from physicians and other
professional providers. Furthermore, only

66 percent of claims from hospitals and other institutions were
processed within 21 days. Hospital claims take longer to process
for many reasons such as their higher cost, numerous line items,
and the need for review by a medical professional. In contrast, 97
percent of pharmacy claims met the standard. Pharmacy claims were
processed more quickly because they are

usually simple claims and 90 percent are submitted electronically,
which is faster. 3 Includes claims from Foundation Health Federal
Services, Inc.; Humana Military Healthcare Services, Inc.; and
TriWest Healthcare Alliance, Inc.; but not from Anthem Alliance
for Health, Inc., or Sierra Military Health Services.

Defense Health Care: DOD Needs to Improve Its Monitoring of Claims
Processing Activities

Page 5 GAO/T-HEHS-99-78 Table 1: Processing Time for Claims
Processed Between July 1, 1997, and June 30, 1998

Planned Efforts to Improve Timeliness

Through discussions with contractors, DOD has identified changes
that could improve claims processing timeliness as well as other
aspects of the program. One of these proposed changes will
eliminate unnecessarily prescriptive requirements for assessing
the medical necessity of care that has been provided and will
allow contractors to select and use a nationally accepted
criterion for assessing necessity. The current adjudication

process is slowed because contractors must review and follow
extensive criteria to determine whether payment should be allowed.
A second change will adopt Medicare's timeliness standards, which
differentiate

between paper and electronic claims and require contractors to pay
interest on late claims. Medicare requires that 95 percent of
complete electronic claims be paid in 14 days and that 95 percent
of complete paper claims be paid in 30 days. Another change will
adopt Medicare's practice of returning incomplete claims. By
adopting Medicare's standards and

practices, DOD will be mirroring a program that is more familiar
to providers. These initiatives should help improve the
completeness of claims initially received as well as provide
incentives for contractors to

process claims in a timely way. In addition, they should increase
the submission of electronic claims, which are paid faster and are
cheaper to process.

Another impending change that should increase electronic claims
submissions is the administrative simplification requirement of
the Health Insurance Portability and Accountability Act of 1996
(P. L. 104- 191). The act requires the industrywide adoption of
uniform standards for electronic transactions, including filing
claims. The timetable to adopt standards has slipped because of
the large number of comments received in response to

Claims processed 0 21 days More than 21 days Category of claims
Number Percent Number Percent All claims

Pharmacy 6,506,867 97 215, 252 3 6, 722, 119 Hospital or
institutional 473, 964 66 243, 382 34 717, 346

Professional 9,480,983 81 2, 265, 093 19 11, 746, 076 All claims
16, 461, 814 86 2,723, 727 14 19,185, 541

Defense Health Care: DOD Needs to Improve Its Monitoring of Claims
Processing Activities

Page 6 GAO/T-HEHS-99-78 the proposed regulations implementing the
act and industry preoccupation with identifying and resolving year
2000 computer issues. However, this effort should be under way in
middle to late 1999.

Claims Processing Accuracy Is Unknown; Program Complexity Affects
Processing Accuracy

DOD does not know whether contractors are meeting contractual
requirements for claims processing payment accuracy because its
primary assessment tool uses a statistically unsound methodology.
Furthermore,

several factors, including TRICARE's complex program structure and
continual program changes, add to the difficulty of accurately
processing claims.

Audit Methodology Does Not Adequately Measure Payment Accuracy

DOD uses external audits to assess the contractors' compliance
with payment accuracy standards by sampling processed claims and
calculating the percentage of dollars paid in error. However, the
method for these audits is statistically unsound because it does
not accurately represent the amount of overpayment and
underpayment for two reasons. First, the sample excludes all
claims under $100; consequently, only about 40 percent of
processed claims are subject to the audit for payment accuracy.
Second,

the magnitude of inaccurate payment is calculated in such a way
that the computed error rate is not representative of all claims
subject to audit in a given period. Therefore, the calculated
error rate is not an accurate indicator of the overall payment
processing accuracy. We applied appropriate statistical methods to
the same data DOD used in its quarterly audit reports and
recomputed error rates. Rates were generally higher, in one
instance increasing from 5.5 percent to 10. 5 percent.

In addition, DOD's method for calculating payment accuracy does
not give a complete picture of payment accuracy. For example,
another useful measure would be to calculate the number of claims
processed accurately as a percentage of the total number of claims
processed. When accuracy is calculated using this method, error
rates for some of the contract periods we examined were as high as
25 percent.

TRICARE's Complexity and Frequent Changes Add to the Difficulty of
Accurately Processing Claims

Contractors told us that, of the many programs they administer
including Medicare and other private plans TRICARE is the most
complicated and unique, contributing to claims processing
difficulties. The following features contribute to TRICARE's
complexity.

Defense Health Care: DOD Needs to Improve Its Monitoring of Claims
Processing Activities

Page 7 GAO/T-HEHS-99-78  Each of TRICARE's three options has a
different array of benefits, copayments, and deductibles. Claims
require different adjudication procedures, depending on which
option is involved, and, even within

each option, different claims processing rules apply.  For the
Prime and Extra options, provider reimbursement information is
difficult to keep accurate because payment agreements are
complicated

and individual providers may belong to multiple practices with
different agreements.  Claims submitted under the Standard option
are also confusing to

process because providers under this option can either accept
TRICARE payment in full or charge up to an additional 15 percent
on a claim- byclaim basis.  TRICARE is always the final payer when
other health insurance is involved. Thus, contractors must
understand the requirements of many other programs' benefit
structures and obtain reimbursement information before a claim can
be processed to completion.

 For each claim, contractors must connect with and rely on
selected DOD databases to determine eligibility, deductibles, and
enrollment. Contractors stated that this requirement complicates
claims processing and increases the opportunity for errors. In
contrast, most insurers maintain these data internally.

Further compounding claims processing complexity are TRICARE's
frequent program changes, which usually require contract
modifications. At the time of our review, DOD had instructed the
contractors we reviewed to implement about 650 contract
modifications an average of about 130 per contract since the
beginning of the program. According to the contractors, their
ability to process claims accurately is impeded because some
changes require system reprogramming and testing as well as staff

retraining. In the future, DOD hopes to resolve some of these
problems by consolidating changes and providing longer
notification periods.

Providers and beneficiaries also contribute to problems with
claims processing accuracy because they sometimes submit claims
with inaccurate information. Subsequently, when the errors are
identified, the claim must be resubmitted and reprocessed. The
contractors told us that because TRICARE is usually a small
percentage of most providers' practices, they have little
incentive to educate themselves on the complex

and frequently changing requirements.

Defense Health Care: DOD Needs to Improve Its Monitoring of Claims
Processing Activities

Page 8 GAO/T-HEHS-99-78 DOD Management Problems Impede the

Effectiveness of ClaimCheck

DOD's commercial claims editing software, ClaimCheck, is designed
to ensure that providers are accurately reimbursed for the
services they provide. During fiscal year 1998, ClaimCheck saved
more than $53 million and affected 3.5 percent of claims.
ClaimCheck is a key player in the claims editing software
industry, with more than 200 customers nationwide, including more
than 60 percent of Blue Cross Blue Shield carriers and the

Department of Veterans' Affairs. In October 1998, the Health Care
Financing Administration started using ClaimCheck to prevent
overpayments in the Medicare program. However, despite its general
acceptance in the insurance industry, providers have expressed
concerns about the accuracy of some ClaimCheck decisions because
some information is not shared with them. Some of these concerns
seem

appropriate because of DOD delays in initiating policy changes
that affect the software. For example, providers expressed
concerns about ClaimCheck because its edits are not published and
available to them. Therefore, they cannot be assured that it
follows the American Medical Association's (AMA) medical procedure
coding guidance, the industry standard. According to DOD
officials, TRICARE claims will be paid appropriately if providers
follow

AMA's guidelines because ClaimCheck's edits are based upon
industry standards. However, we identified a few instances in
which DOD's version of ClaimCheck did not comply with industry
standards because DOD was slow to implement policy changes that
affected the software's outcomes. The denial of surgical pathology
payments to dermatologists provides an

excellent example. 4 In April 1996 early into the implementation
of ClaimCheck DOD officials realized that the software did not
recognize physicians by specialty. As a result, it was not able to
identify dermatologists who, unlike other physicians, should be
paid for surgical pathology procedures. While this is a limitation
of ClaimCheck, it could

have been readily resolved through a modification of the
contractors' claims processing systems. However, DOD waited almost
2 years before providing contractors with the contract
modification directing them to make this change. One contractor
stated that it lost dermatologists from its network solely because
DOD did not react quickly to this needed modification. 4 Surgical
pathology is the microscopic examination of sampled tissue.

Defense Health Care: DOD Needs to Improve Its Monitoring of Claims
Processing Activities

Page 9 GAO/T-HEHS-99-78 In another instance, providers were upset
because they mistakenly believed that they could not obtain
explanations for edits that affected their claims. In order to
maintain its competitive edge over other vendors,

ClaimCheck's programming is not shared with the public or even its
purchasers. But the distributors of ClaimCheck stated that their
product is not a mysterious black box because they provide
narrative explanations to purchasers on how every edit works. DOD
officials acknowledged that they were aware of contractors'
misconception that the edits are proprietary and cannot be shared
and added that providers can request and receive information on
specific edits. Finally, providers' frustrations are compounded by
poor communication by DOD and its contractors regarding their
available recourse over ClaimCheck determinations. DOD told
contractors that ClaimCheck

determinations could not be appealed but did not sufficiently
communicate to them that an allowable charge review process could
be used for reviewing ClaimCheck determinations. As a result,
contractors improperly informed providers and beneficiaries that
they had no recourse when ClaimCheck denied or modified a claim.
After beneficiaries and providers complained that DOD and its
contractors did not make a review process

available to them, the Congress mandated that DOD establish an
appeals process for ClaimCheck denials in the Defense
Authorization Act for Fiscal Year 1999 (P. L. 105- 261).

Conclusions In conclusion, we found that DOD's contractors have
met DOD's standard by paying at least 75 percent of claims on
time. Even so, providers are

concerned because millions of claims are not being paid in a
timely way. Moreover, the overall timeliness of contractors'
performance masks weaker performance in processing certain
specific claims, including those submitted by hospitals. It
appears that the majority of claims processing issues currently
being faced by the TRICARE system are rooted in weaknesses in
DOD's approach to monitoring and communicating with its
contractors. Furthermore, DOD's methodology for its payment
accuracy

audits is statistically unsound and does not provide an accurate
measurement of payment errors. Although the extent of error is
unknown, contractors told us that TRICARE's inherent complexity
also impedes claims processing accuracy. In addition, we found
that inappropriate denials were sometimes made because of DOD's
poor communication and

slowness to make program changes that affect ClaimCheck outcomes.
Providers were further frustrated because they mistakenly believed
that they had no recourse for ClaimCheck denials.

Defense Health Care: DOD Needs to Improve Its Monitoring of Claims
Processing Activities

Page 10 GAO/T-HEHS-99-78 Claims processing problems are causing
providers to become disillusioned with the TRICARE program.
Although DOD and contractors are taking steps to address these
problems, if they are not resolved, DOD could face

increasing problems attracting the number of civilian providers
necessary to ensure that beneficiaries have adequate access to
health care. Later this year, we will be issuing a report with
recommendations, which, if implemented, should help address DOD's
claims processing problems. Mr. Chairman, this concludes my
prepared statement. I will be glad to respond to any questions you
or other Subcommittee members may have. We look forward to
continuing to work with the Subcommittee as it exercises its
oversight of the TRICARE program.

Page 11 GAO/T-HEHS-99-78

Appendix I

Appendi x I

a We did not include these regions because they did not have at
least 1 year of claims processing experience as of July 1998.

TRICARE contractor TRICARE subcontractor Regions included in our
review

Northwest Foundation Health Federal Services, Inc. Wisconsin
Physicians Service Southwest Foundation Health Federal Services,
Inc. Wisconsin Physicians Service Southern California, Golden
Gate, and Hawaii- Pacific Foundation Health Federal Services, Inc.
Palmetto Government Benefits Administrators Central TriWest
Healthcare Alliance, Inc. Palmetto Government Benefits
Administrators Southeast and Gulf South Humana Military Healthcare
Services Palmetto Government Benefits Administrators

Regions not included in our review a

Northeast Sierra Military Health Services Palmetto Government
Benefits Administrators Mid- Atlantic and Heartland Anthem
Alliance for Health,

Inc. Palmetto Government Benefits Administrators

(101614) Let t er

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