Defense Health Care

Reimbursement of Hospitals Not Meeting CHAMPUS Copayment Requirements Gao ID: HRD-88-102 June 1, 1988

Pursuant to a legislative requirement, GAO reviewed Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) payment procedures for hospitals that failed to require patients to pay for their medical services.

GAO compared CHAMPUS practices to other insurance plans and programs, and found that: (1) the 13 private and federally funded health benefits plans it reviewed denied payments to hospitals that did not require patients to pay for medical services; (2) only CHAMPUS and Medicare dealt with hospitals that did not bill patients for copayments; (3) CHAMPUS denied reimbursement to hospitals that failed to bill their patients for copayments, while Medicare reimbursed such hospitals; (4) hospitals that waived patients' copayments often increased the amount they charged to the insurance companies to recoup lost revenues; (5) CHAMPUS reimbursement to hospitals that do not bill patients for copayments could financially benefit; and (6) CHAMPUS reimbursement would relieve hospitals of the burden of funding the total care of beneficiaries. GAO identified four options that Congress may wish to consider in dealing with this issue, and recommended the one it believes to be most appropriate.

Recommendations

Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.

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