Defense Health Care: Information on DOD's Processing of TRICARE Claims from Behavioral Health Providers
Fast Facts
The psychological effects of military service can be difficult on a personal level, but can also affect military readiness. To address this, the Department of Defense offers behavioral health care—such as treatment for depression or substance use—through its TRICARE health program.
Participants can seek this care from private providers, who then must submit claims to be paid for it. Our work included looking at how quickly DOD contractors processed claims from behavioral health providers for care delivered from 2018 through 2023.
These claims were generally processed as quickly as other types of claims, with almost 90% processed within 30 days.
Highlights
What GAO Found
The Department of Defense's (DOD) two managed care support contractors generally processed TRICARE claims for care provided between 2018 and 2023 within required timeliness standards. The claims process involves determining payment amounts to civilian health care providers, including behavioral health providers. DOD's timeliness standards require contractors to process 98 percent of TRICARE claims within 30 days, and 100 percent of claims within 90 days.
Although DOD does not apply these standards to specific provider types, GAO separately analyzed the nearly 28 million claims from behavioral health providers over the 6-year period. GAO found that almost 90 percent were processed in 30 days. In addition, the percentage of claims processed within 30 and 90 days generally increased each year (see figure for the 3 most recent years).
Time to Process TRICARE Claims Submitted by Behavioral Health Providers for Care Provided in Calendar Years 2021-2023, by Managed Care Support Contractor
To oversee TRICARE payment accuracy, DOD monitored internal and external audit reports of randomly sampled claims from all types of providers, including behavioral health providers. DOD assessed contractor performance on all audited claims against the payment accuracy standards—which require payment error rates to not exceed between 2 and 1.75 percent, depending on the year of the contract—and took action when necessary. Across the audit reports from 2018 through 2023, claims from behavioral health providers made up between 1 and 8 percent of audited claims.
DOD's oversight actions were consistent with its oversight goal for early identification and resolution of performance issues, and with a recommended practice from the Office of Management and Budget and prior GAO work that federal agencies use multiple sources of evidence to support decision-making.
Why GAO Did This Study
To support military deployments and provide health care, including behavioral health care, DOD operates a health system known as TRICARE. This system offers behavioral health and other services to over nine million eligible beneficiaries in military hospitals and clinics, or through authorized civilian providers in the private sector.
The Conference Report 118-301 accompanying the National Defense Authorization Act for Fiscal Year 2024 includes a provision for GAO to report on TRICARE's payments to civilian network behavioral health providers. This report examines (1) the timeliness of TRICARE claims processing and (2) DOD's oversight of payment accuracy to all civilian providers, including behavioral health providers.
GAO reviewed relevant documents, such as DOD and contractor reports for timeliness and accuracy, and DOD's oversight plans for the TRICARE contracts. GAO also analyzed time frames for processing claims from behavioral health providers from 2018 through 2023 and audit findings on payment accuracy. Finally, GAO interviewed DOD officials with oversight responsibilities of TRICARE's contractors, contractor staff, and four selected behavioral health provider groups who participate in TRICARE. GAO compared DOD's oversight activities to a DOD goal and a recommended practice.
For more information, contact Sharon Silas at [email protected].