United States Government Publishing Office publisher pbl distributor dst United States Government Accountability Office Health, Education, and Human Services Division author aut Government Organization text government publication eng GAOREPORTS Legislative Agency Publications gao legislative 2010-08-12 U.S. Government Printing Office 1998-02-26 monographic deposited born digital 29 p. GA 1.13:HEHS-98-80 https://www.govinfo.gov/app/details/GAOREPORTS-HEHS-98-80 P0b002ee18037614c f:he98080 DGPO 2010-08-12 2011-03-23 GAOREPORTS-HEHS-98-80 machine generated eng fdlp REPORT GAOREPORTS-HEHS-98-80 HEHS-98-80 Managed health care Medical fees Health care cost control Military personnel Physicians Health care services Medical services rates Civilian Health and Medical Program of the Uniformed Services Medicare Program DOD TRICARE Program CHAMPUS Letter Report HEHS Pursuant to a legislative requirement, GAO examined: (1) whether the Department of Defense's (DOD) methodology for setting the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) maximum allowable charge (CMAC) rates complies with statutory requirements and how current CMAC rates compare with Medicare rates for similar services; (2) the basis for physicians' concerns about CMAC rates and how these concerns affect physicians' willingness to treat military beneficiaries; (3) the basis for other concerns physicians have about TRICARE that could also affect their willingness to treat military beneficiaries; and (4) how balance billing limits are being enforced.<p/>GAO noted that: (1) the methodology used by DOD to transition CMAC rates to the Medicare level of payment complies with statutory requirements and generally conforms with accepted actuarial practice; (2) these adjustments will result in DOD saving about three-quarters of a billion dollars in fiscal year 1998 in health care expenditures; (3) as of the most recent available CMAC rate adjustment in March 1997, 80 percent of CMAC rates nationwide were at the same level as Medicare, with about 20 percent higher and less than 1 percent below the Medicare level of payment; (4) the CMAC rates at each of the four locations GAO selected were generally consistent with Medicare rates; (5) while physicians' initial concerns about low obstetric and pediatric rates have been addressed by DOD, current physician complaints about reimbursement levels are focused on the discounted CMAC rates paid to network physicians under DOD's TRICARE program; (6) because most CMAC rates are now equivalent to Medicare rates, the discounted CMAC rates that TRICARE network physicians agree to accept are typically below the Medicare level of payment; (7) some physicians told GAO that they considered the discounts unacceptable, and as a result, they would not join the TRICARE network but would continue to treat military beneficiaries as nonnetwork physicians; (8) the discount rates physicians were willing to accept in each of the four locations were largely dependent on local health care market factors such as the degree of health maintenance organization penetration and the dependence of local physicians on the military beneficiary population; (9) physicians GAO met with also expressed concerns about administrative hassles, which contributed to their frustration with the TRICARE program; (10) in many cases, physicians said that while they would be willing to accept discounted CMAC rates, the administrative impediments provided significant disincentives to joining the TRICARE network; (11) DOD and managed care support contractors (MCSC) officials acknowledged these complaints and are making efforts to address them and alleviate physicians' concerns; (12) DOD and MCSC officials told GAO that they were aware of only a very small number of balance billing infractions--all of which had been easily resolved; (13) while the MCSC's attempt to educate beneficiaries about balance billing limits, the explanation of benefits statement does not include information on the balance billing limits; and (14) Medicare, which has the same balance billing limit, sends notice of balance billing limitations on the statements it provides to https://www.govinfo.gov/content/pkg/GAOREPORTS-HEHS-98-80/html/GAOREPORTS-HEHS-98-80.htm https://www.govinfo.gov/content/pkg/GAOREPORTS-HEHS-98-80/pdf/GAOREPORTS-HEHS-98-80.pdf GAO/HEHS-98-80 https://www.govinfo.gov/app/details/GAOREPORTS-HEHS-98-80 Letter Report GAO/HEHS-98-80; Defense Health Care: Reimbursement Rates Appropriately Set; Other Problems Concern Physicians; Managed health care Medical fees Health care cost control Military personnel Physicians Health care services Medical services rates Civilian Health and Medical Program of the Uniformed Services Medicare Program DOD TRICARE Program CHAMPUS Public Law 101-511 Public Law 102-396 Public Law 103-160 Public Law 105-85