Publicly Released: August 18, 2022
The objective of this audit was to determine whether the Department of Defense (DoD) paid providers for ambulance transport claims in accordance with TRICARE reimbursement requirements.
TRICARE is the DoD’s worldwide health care program available to beneficiaries in the Army, Navy, Air Force, Marine Corps, and Coast Guard. TRICARE-eligible beneficiaries may include active duty Service members and their families, retired Service members and their families, National Guard and Reserve members and their families, survivors, and others.
The Defense Health Agency (DHA) issued multiple contracts to provide Managed Care Support to the TRICARE program for the East Region, West Region, and Overseas Program. The DHA also provides coverage worldwide for TRICARE-eligible beneficiaries who have both Medicare Part A and B, called TRICARE for Life.
According to the Code of Federal Regulations (CFR), TRICARE covers civilian ambulance service when medically necessary in connection with otherwise‑covered services and supplies and a covered medical condition. Furthermore, the CFR states that, before payment of benefits, an appropriate claim must be submitted that includes sufficient information as to beneficiary identification, the medical services and supplies provided, and double coverage information. Providers must also document that the care or service shown on the claim was rendered.
Between October 1, 2015, and September 30, 2020, the DHA, through its contractors, paid 1,304,761 claim line items, valued at $358,127,551, for ground ambulance transport claims (including mileage claims) with paid amounts of more than $50. From the universe of 1,304,761 ambulance claim lines, we developed and reviewed a stratified, statistically representative sample of 182 claim line items, valued at $70,635.77.
The DHA, through its contractors, made improper payments for ground ambulance transportation services. We found that the DHA improperly paid $28,516.97 on 85 of the 182 claims in our statistical sample. These improper payments occurred because DHA personnel, and their contractors, did not:
• provide documentation, or sufficient documentation, for 74 claims, valued at $24,126.76, to support whether the payments for ground ambulance transports were paid in accordance with TRICARE reimbursement requirements; or
• have adequate controls in place for 11 claims, valued at $4,390.21, to prevent overpayments on improperly billed claims; prevent payments on claims that did not meet TRICARE and Medicare definitions of medical necessity; or prevent payment on claims that did not meet TRICARE reimbursement requirements for ambulance transport point-of-pickup ZIP codes.
In addition, the Military Health System Data Repository (MDR) contained inaccurate and incomplete transport and payment information. These issues occurred because DHA personnel did not:
• have adequate controls in place to ensure accurate and complete submissions of claim data in the MDR; or
• require the TRICARE Overseas contractor to obtain and record all transport data elements for ambulance services received overseas.
As a result, without sufficient medical documentation and adequate controls, the DHA will continue to incur millions of dollars in improper payments on ground ambulance transports, while also missing the opportunity to potentially recover at least an estimated $118.85 million paid to ambulance transport providers for ground ambulance transports. Based on the statistical sample of 182 claims, valued at $70,635.77, and the improper payments identified on 85 claims, valued at $28,516.97, we statistically projected that the DHA, through its contractors, improperly paid at least $118.85 million of the $358.1 million paid to ambulance transport providers for ground ambulance transportation services performed between October 1, 2015, and September 30, 2020. In addition, improper payment estimations and reporting will be understated; inaccurate and incomplete data will affect the DHA’s ability to review and report on data for ground ambulance transports; and overseas transport claims will not have accurate baseline costs for future comparison. Finally, without adequate controls to prevent overpaying for services not provided, the DHA will continue to waste funds that could otherwise enhance the quality of health care for beneficiaries.
Among other recommendations, we recommend that the DHA Director:
• reinforce contractor requirements to obtain documentation necessary to support medical necessity of ambulance transports;
• review the 74 unsupported claims and 11 improperly paid claims and recoup any overpayments made to providers, while also using payment recapture audits, as defined in OMB guidance, to identify and recover other overpayments to ambulance providers outside of our sample;
• review TRICARE policy to determine whether recoveries are allowed from TRICARE contractors based on statistical projections of improper payments for ambulance claims outside our sample, and based on the outcome of this review, determine the best course of action for recovering projected improper payments;
• review the 74 unsupported claims and 11 improperly paid claims to determine whether there are patterns of abuse among the providers and, if so, refer these providers to the DHA Program Integrity Office;
• ensure samples for quarterly, annual, and external claim audits include ground ambulance transport claims; and
• implement data quality reviews of TRICARE overseas ambulance transport data to identify instances where the coding is incomplete or inaccurate.
Management Comments and Our Response
The Acting Assistant Secretary of Defense for Health Affairs (ASD(HA)), responding for the DHA Director, agreed with all 12 recommendations. The Acting ASD(HA)’s comments and action taken was sufficient to close one recommendation. In addition, the Acting ASD(HA)’s comments addressed the specifics for nine other recommendations; therefore, those recommendations are resolved but open.
Although the Acting ASD(HA) agreed with the recommendations to reinforce requirements to obtain documentation to support medical necessity of ambulance transports and ensure samples for audits include ground ambulance transport claims, the actions planned did not meet the intent of the recommendations. Therefore, the two recommendations are unresolved. We request that the DHA Director provide additional comments for those two recommendations on the final report, along with commenting on the projected potential monetary benefits of $118.85 million.
This report is a result of Project No. D2021-D000AX-0073.000.