Summary

Unlike Medicare and health plans of the Federal Employees Health Benefits Program, the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) has no central files of beneficiaries that may be checked to determine each claimant's eligibility. Instead, fiscal intermediaries determine eligibility from data provided on the claim form. Since this system relies on data provided by the claimant, it provides little control over payments to ineligible persons.

GAO believes that certain program changes recently implemented or planned by the Office of the Civilian Health and Medical Program of the Uniformed Services (OCHAMPUS) will result in weakening program controls, increasing improper benefit payments, and providing slower service to beneficiaries due to claim processing delays. GAO is concerned that: (1) new claim forms do not provide adequate beneficiary eligibility data and will result in delays in processing in order to obtain necessary information; (2) beneficiaries residing within 40 miles of a uniformed services medical facility will no longer be required to submit, with their CHAMPUS claims, statements that nonemergency inpatient care is unavailable at those facilities; and (3) fiscal intermediaries no longer are required to obtain certification as to the continued eligibility of dependent children over age 21.