Military Treatment Facilities
Eligibility Follow-up at Wilford Hall Air Force Medical Center Gao ID: GAO-03-402R April 4, 2003In October 2002, we reported the results of our audit of selected internal control activities at three military treatment facilities: Eisenhower Army Medical Center, Augusta, Georgia; Naval Medical Center-Portsmouth, Portsmouth, Virginia; and Wilford Hall Air Force Medical Center, San Antonio, Texas. As part of our work for that report, we requested data files of all patients who had been admitted, treated as outpatients, or received pharmaceutical benefits during fiscal year 2001. Despite considerable effort by the three facilities, only Wilford Hall Air Force Medical Center was able to provide a file of beneficiaries who received pharmaceuticals during the year. We compared this file to data in the Social Security Administration's (SSA) Death Master File as a technique to identify instances of potential fraud or abuse. For Wilford Hall, we identified 41 cases in which a prescription was ordered for an individual after the date of his or her death as recorded in the SSA Death Master File. Congress requested that we determine whether individuals fraudulently obtained pharmaceuticals or other health benefits by assuming the identity of a dead person, and, if so, to identify the specific breakdowns in internal controls that allowed such fraud to occur. We confined our investigation to the 41 cases described above.
We did not find indications of individuals fraudulently obtaining health care benefits in our examination of the 41 cases we identified of people receiving treatment after they were listed in SSA's Death Master File. In 40 of the 41 cases, data entry errors and/or internal control weaknesses at either SSA or at the military treatment facilities created the impression that a deceased person had received prescriptions. Of the 40 cases, 10 were instances in which SSA's Death Master File had incorrectly listed as deceased the individual on whom a prescription was dispensed and 30 resulted from Department of Defense (DOD) data entry errors.
RecommendationsOur 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.
Director: Team: Phone:GAO-03-402R, Military Treatment Facilities: Eligibility Follow-up at Wilford Hall Air Force Medical Center
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April 4, 2003:
The Honorable Dennis J. Kucinich:
Ranking Minority Member:
Subcommittee on National Security, Emerging Threats:
and International Relations:
Committee on Government Reform:
House of Representatives:
The Honorable Edolphus Towns:
Ranking Minority Member:
Subcommittee on Government Efficiency and Financial Management:
Committee on Government Reform:
House of Representatives:
The Honorable Janice D. Schakowsky:
House of Representatives:
Subject: Military Treatment Facilities: Eligibility Follow-up at
Wilford Hall Air Force Medical Center:
In October 2002, we reported to you on the results of our audit of
selected internal control activities at three military treatment
facilities: Eisenhower Army Medical Center, Augusta, Georgia; Naval
Medical Center-Portsmouth, Portsmouth, Virginia; and Wilford Hall Air
Force Medical Center, San Antonio, Texas.[Footnote 1] As part of our
work for that report, we requested data files of all patients who had
been admitted, treated as outpatients, or received pharmaceutical
benefits during fiscal year 2001. Despite considerable effort by the
three facilities, only Wilford Hall Air Force Medical Center was able
to provide a file of beneficiaries who received pharmaceuticals during
the year. We compared this file to data in the Social Security
Administration‘s (SSA) Death Master File as a technique to identify
instances of potential fraud or abuse.[Footnote 2]
For Wilford Hall, we identified 41 cases in which a prescription was
ordered for an individual after the date of his or her death as
recorded in the SSA Death Master File. You requested that we determine
whether individuals fraudulently obtained pharmaceuticals or other
health benefits by assuming the identity of a dead person, and, if so,
to identify the specific breakdowns in internal controls that allowed
such fraud to occur. As agreed to with your staffs, we confined our
investigation to the 41 cases described above.
Results in Brief:
We did not find indications of individuals fraudulently obtaining
health care benefits in our examination of the 41 cases we identified
of people receiving treatment after they were listed in SSA‘s Death
Master File. In 40 of the 41 cases, data entry errors and/or internal
control weaknesses at either SSA or at the military treatment
facilities created the impression that a deceased person had received
prescriptions. Of the 40 cases,
* 10 were instances in which SSA‘s Death Master File had incorrectly
listed as deceased the individual to whom a prescription was dispensed
and:
* 30 resulted from Department of Defense (DOD) data entry errors.
In the 10 cases involving inaccurate SSA death records, most of the
individuals concerned found out about the erroneous report of their
deaths when they were notified that their SSA benefits had ended. The
individuals had their benefits restored, and most did not experience
significant problems as a result of the errors; however, some had other
problems, including temporary suspension of their retired military
payments and difficulty in getting reimbursed for a prescription filled
at a retail pharmacy. Inaccurate information in the SSA database has
caused DOD to expend resources researching inaccurate death information
for living individuals, not only at Wilford Hall, but also for the
eligibility system DOD-wide.
Thirty of the 40 cases were data entry errors that occurred during the
process of entering a prescription into DOD‘s health care database. For
14 of these 30 cases, the pharmacy dispensed a prescription to the
intended eligible individual but inadvertently recorded the
prescription under a deceased person‘s Social Security number (SSN). In
10 of these 14 cases, the deceased person was either the spouse or
another eligible relative of the individual receiving the prescription.
In 2 of the 30 cases, we could not determine who received the
prescriptions, but they totaled only 3 prescriptions of small value. In
14 of the 30 cases, the prescriptions were not dispensed. Pharmacy
records show that 8 were canceled before they were filled and 6 were
never picked up.
The 30 cases of data entry errors at DOD were the result of human error
as well as the result of DOD not having adequate controls over the data
entry process. Specifically, DOD does not have a preventive control in
its data entry process that prohibits entering new clinical data such
as prescriptions into a deceased person‘s record in the DOD automated
health care database. When this happens, prescriptions are not entered
into the correct individual‘s file and the potentially significant
patient safety issue of hazardous drug interactions may not be
addressed.
The remaining case involved an elderly former spouse of a retired
service member who continued to receive prescriptions valued at about
$350 after she became ineligible when they divorced. We concluded that
this situation existed because the retired service member may not have
reported the divorce as required by DOD policy. Therefore, DOD‘s
eligibility system continued to show the former spouse as eligible. The
ineligible former spouse told us she was not aware she was ineligible,
and that she thought she could continue to get prescriptions until her
identification card expired, about 3 years after her divorce. Although
this case resulted in inappropriately provided health care benefits,
i.e., improper payments, our investigation did not conclude that the
payments were fraudulently obtained. Rather, they most likely resulted
from a lack of information about eligibility criteria.
This letter includes a recommendation to the Secretary of Defense to
develop and implement a preventive control for data entry errors
involving a deceased person‘s clinical record. In a written response to
a draft of this report, SSA agreed that the Death Master File has some
problems with accuracy and discussed the improvement efforts it has
underway. In oral comments, DOD agreed with our findings but disagreed
with our recommendation and said that our report overstates the extent
of the problem because of the small number of data entry errors. We
disagree with DOD. In our work, we focused only on the 41 cases and did
not attempt to determine the overall extent of the problem. We believe
that a preventive control can effectively avoid the data entry problems
we identified and thereby help ensue that patient safety issues are
addressed.
Background:
Wilford Hall is the Air Force‘s largest medical facility. It provides a
wide range of medical services, including pharmacy-dispensed
prescription drugs to active and retired military personnel and their
dependents. Wilford Hall reports that it fills approximately 2.6
million prescriptions annually for about 100,000 people.
Wilford Hall‘s clinical records are contained in DOD‘s Composite Health
Care System (CHCS). CHCS is DOD‘s primary medical information system,
which medical treatment facilities use to support their various
activities, including registering patients, documenting inpatient
activity, and tracking pharmacy prescriptions. Since 1997, DOD has had
a project underway to replace CHCS with a new system, CHCS II, that DOD
envisions as a state-of-the-art automated medical information system.
Part of DOD‘s goal for CHCS II is to assist clinicians in making health
care decisions.[Footnote 3]
In our October 2002 report based on work at three military treatment
facilities,[Footnote 4] we reported that erroneous eligibility
information contained in DOD information systems, including CHCS,
precluded the military treatment facilities from providing reasonable
assurance that medical care was provided only to eligible persons. We
found that unreliable and inaccurate data, system inadequacies,
complicated processes, and a lack of adherence to policies and
procedures contributed to internal control weaknesses.
Military treatment facilities such as Wilford Hall are required to
verify a person‘s eligibility for DOD health care benefits before
providing treatment, except in emergencies. The facilities use a two-
step process to verify eligibility. One step is for a staff person to
physically review the person‘s military identification card, which
includes a picture of the person, and visually verify the identity of
the person requesting health care. The military identification card is
issued at over 900 DOD locations and is used DOD-wide to access a
variety of DOD services in addition to health care. Sponsors--the
military active duty persons or retirees upon whom their dependents‘
eligibility is based--are responsible for reporting any changes in
status for themselves and their dependents.
The other step is for the facility‘s staff to access the person‘s
clinical record in CHCS, which verifies the person‘s eligibility status
by interfacing with the Defense Enrollment Eligibility Reporting System
(DEERS). DEERS is a DOD-wide system that contains eligibility
information on active, reserve, and retired military and their
dependents. It is used by DOD facilities such as commissaries and base
exchanges as well as military treatment facilities to determine
eligibility for various types of DOD benefits. DEERS regularly receives
updated data from SSA regarding deaths reported to it.
SSA‘s Death Master File is the agency‘s repository of death information
and is available for use by both public and private sector
organizations. The Death Master File is a national file listing the
SSNs of individuals whose deaths have been reported to SSA. Data
sources include friends and relatives of deceased individuals, funeral
directors, financial institutions, postal authorities, and other
federal and state agencies.
Scope and Methodology:
To determine if any ineligible persons were using the identity of a
deceased person to obtain health care benefits, we compared a data file
from Wilford Hall Medical Center of patients who had received a
prescription to data from SSA‘s Death Master File. The patient data
file was extracted by Wilford Hall staff from CHCS and identified about
100,000 individuals in Wilford Hall‘s database who had a pharmacy
prescription during fiscal year 2001. These files included
prescriptions recorded at Brooke Army Medical Center and Randolph Air
Force Base Clinic as well as Wilford Hall because the facilities share
computer services for health care matters. As of April 2002, the Death
Master File contained about 70 million records of persons with SSNs
who, according to SSA, have been reported as deceased.
We first matched only on SSN and identified 266 matches. However, most
matched only on SSN but not on other critical data such as name and
date of birth. Because the military treatment facilities‘ eligibility
verification process is to match both the sponsor‘s SSN and the
patient‘s name, we selected for further analysis and investigation only
the 41 cases in which the SSN matched in both files and other
identifying information, such as the same name and date of birth,
raised questions about how the deceased person in the SSA database
could have received care after his or her reported death.
For all 41 people, we also obtained from Wilford Hall a list of
prescriptions ordered after the date of death recorded in the SSA Death
Master File. We also obtained eligibility information from DOD‘s
automated eligibility systems.
To obtain an explanation of the facts of each case and to identify
indications of fraud, our investigators reviewed other records such as
death certificates and divorce decrees as needed. For the 10 cases of
inaccurate reports of death, our investigators interviewed patients,
family members, and others, as needed.
We conducted our work from November 2002 though January 2003 in
accordance with U.S. generally accepted government auditing standards,
and we performed our investigative work in accordance with standards
prescribed by the President‘s Council on Integrity and Efficiency, as
adapted for GAO‘s work. We provided a draft of this letter to DOD and
SSA for comment. DOD provided oral comments, which are discussed in the
’Agency Comments and Our Evaluation“ section, and SSA provided written
comments, which are reprinted as an enclosure.
Benefits Provided to Eligible Individuals but Data Entry Errors Raise
Concerns:
In 40 of the 41 cases we investigated, a data entry error and/or
internal control weaknesses either at SSA or at the military treatment
facility caused these cases to appear to have had a prescription
ordered for a deceased person. We did not find indications of potential
fraud in any of these 40 cases. A data entry error at SSA caused 10 of
the errors. The remaining 30 cases stemmed from data entry errors made
at Wilford Hall. They occurred in part because DOD has not built a
control into CHCS‘ data entry process to prevent entering new clinical
data into a deceased person‘s record rather than the correct record.
Table 1 summarizes our analysis. The remaining case is discussed in the
next section of this letter.
Table 1: Results of Analysis of 40 People for Whom a Prescription Was
Ordered after Their Reported Date of Death:
[See PDF for image]
Source: DOD and SSA data.
Note: GAO analysis of DOD and SSA data.
[End of table]
Individuals Incorrectly Listed as Deceased by SSA:
Ten of the 40 cases involved individuals who were incorrectly listed as
deceased in SSA‘s Death Master File. These individuals were not only
alive, but they were also eligible for health care benefits. Our
interviews with the individuals or their family members disclosed that
the erroneous entry typically occurred when the individual reported the
death of a spouse. The SSA official receiving the report of death
appears to have recorded not only the death of the actual deceased
person but also the individual reporting the death. In each case, the
individual who was incorrectly recorded as deceased told us that he or
she notified SSA of its error and benefits were restored. However,
these individuals continued to be listed in the SSA Death Master File.
These inaccuracies in SSA‘s database had generally persisted for years.
For example, 5 of the 10 had been listed as deceased for over 10 years.
Incorrect recordings of death are not isolated incidents. SSA‘s
Inspector General has reported that erroneous dates of death continue
to exist in the Death Master File database.[Footnote 5] These erroneous
dates stayed in the database because SSA‘s payments and Death Master
File systems were not fully integrated. Although SSA restarted
payments, changes in the payment system database to restart the
payments did not trigger subsequent changes in the Death Master File.
According to the Inspector General report, these erroneous dates of
death have caused other agencies to expend resources researching death
information for living individuals. In our work, a DOD official told us
that DEERS officials have to reverify that individuals were alive and
eligible for health care not only at Wilford Hall but also throughout
the DOD-wide eligibility system. In a January 2003 report on SSA‘s
efforts to improve its Death Master File, the SSA Inspector General
reported that as of September 2002, SSA had implemented an automated
process to (1) identify inaccurate death data and (2) generate a
quarterly report that lists names and SSNs requiring
investigation.[Footnote 6]
In addition to causing agencies additional work, erroneous reports of
death in the Death Master File can result in living individuals‘ SSN
and other personal information becoming public information because SSA
makes the Death Master File information available to the public upon
request. The SSA Inspector General reported that as a result, at least
some erroneously reported deceased individuals had experienced various
continuing difficulties, such as obtaining credit.[Footnote 7]
In one case we investigated, for example, the individual, whose SSN had
been listed in the Death Master File since 1991, reported experiencing
periodic problems ever since her reported death. She told us she had
been denied a cell phone and had difficulty getting reimbursement for a
prescription filled at a retail pharmacy. In two other cases, the
individuals said that their retired military and/or Social Security
payments were temporarily suspended when the problem first occurred in
the 1990s, but their benefits were restored within a couple of months.
They said they had not experienced additional problems caused by the
inaccurate death file.
In the remaining cases we investigated, the individuals reported that
they had not experienced significant problems because of these errors.
They had found out about the erroneous reports of their deaths when
they received a notification that their Social Security or other
government benefits had ended. However, they reported the error to SSA
and had not experienced subsequent difficulties, although the Death
Master File continued to show them as deceased.
Prescriptions Dispensed to an Eligible Individual
but Recorded under a Deceased Person‘s SSN:
For 14 of the cases, prescription drugs were dispensed to an eligible
individual but were recorded under a deceased person‘s SSN. We
concluded that these situations were data entry errors made by
physician or pharmacy staff when they entered a prescription into the
CHCS database. Usually, only one or two prescriptions were dispensed
under the incorrect SSN for the 14 cases, and the errors were one-time
events limited to a single day.
To record a prescription in the patient‘s CHCS clinical record,
physician or pharmacy staff must access the patient‘s record in the
CHCS database, which also includes records of deceased patients. The
staff is to use the first letter of the last name and the last four
digits of the SSN of the individual‘s sponsor to search for and select
the appropriate record. In these 14 cases, the person who entered the
prescription into the CHCS database selected the wrong individual‘s
record. In 5 of the 14 cases, they chose the patients‘ deceased
sponsor‘s record. In 5 other cases, they chose another related
individual‘ s record. In the remaining 4 cases, they appear to have
chosen the record of an individual unrelated to the patient.
We identified the likely recipients of the prescriptions by examining
relevant data such as the prescription history and physician
appointments of the deceased person‘s family members and others with
similar names. For example, one case involved a deceased sponsor whose
widow‘s first name was very similar to his. The widow had a history of
taking the pain medication that showed up in her deceased sponsor‘s
CHCS record, and she also had a doctor‘s visit on the same day that the
prescription was entered into her sponsor‘s CHCS record. In another
example, an individual with a similar last name and the same last four
digits of the SSN as our case had a history of using the same
ophthalmic medication that showed up in our case‘s CHCS record.
Even though our work indicated that the intended individuals received
the prescriptions, we believe these cases raise a clinical issue
because the prescriptions were not entered into the correct
individuals‘ records, leaving those records incomplete. When they are
incomplete, patient safety issues such as potentially dangerous drug
interactions for those individuals may not surface and be addressed.
Prescription Dispensed to Unknown Individual
and Recorded under a Deceased Person‘s SSN:
For two cases, a prescription was dispensed and recorded under a
deceased individual‘s SSN, but we could not determine who received the
prescription. A total of three prescriptions were dispensed. In one
case, a single prescription was dispensed for the generic equivalent of
the sleeping aid Ambien. The other case was for two prescriptions for
four pills each of the inexpensive antibiotic Amoxicillin. Although we
were not able to determine who received these prescriptions, the
limited number and small value of the prescriptions dispensed led us to
conclude that these two cases were probably not indications of
fraudulent or abusive activity. Rather, we concluded that these cases
were caused by the same type data entry errors as just discussed.
Prescriptions Not Dispensed:
For 14 cases, Wilford Hall‘s records show that the prescriptions did
not leave the pharmacy and were canceled. We concluded that these cases
involved data entry errors similar to the ones discussed in the
previous two sections except that in these cases the prescriptions were
not dispensed, according to the clinical records. For 8 of these 14
cases, the physician or pharmacy staff identified the data entry errors
and canceled the prescriptions in the CHCS database before they were
filled. In most of these cases, they caught and corrected their own
error within minutes. In the remaining 6 cases, the prescription was
filled but was not picked up. At Wilford Hall, the pharmacy‘s practice
is to return medications to inventory if they have not been picked up
after 7 days. A prescription is canceled in the individual‘s CHCS
record when the medication is returned to inventory.
CHCS Missing Important Data Entry Control:
Thirty of these errors were caused by Wilford Hall staff accessing the
wrong person‘s CHCS record to enter a prescription. DOD‘s process for
entering clinical data into an individual‘s CHCS record does not
include a preventive edit or control to prohibit entering new data into
a deceased person‘s record. While such data entry errors would not
necessarily be unexpected given the workload, they should be
anticipated and mitigated. These types of data entry errors can create
a risk that a prescription does not get into the correct person‘s
clinical record, which can result in a potential patient safety issue
not being addressed since the clinical record is incomplete.
Neither CHCS nor its planned successor system, CHCS II, have edits or
controls built into them to prevent new data from being entered into a
deceased person‘s clinical record, according to DOD officials
responsible for the successor system. Both CHCS and CHCS II have an
alert/reminder feature that can notify clinicians of potentially
dangerous drug interactions based on comparing the prescriptions a
patient is currently taking to a new one that is prescribed. However,
this alert feature cannot work effectively when prescription
information is entered into the wrong individual‘s record.
Various edits and controls to help ensure the integrity of data entered
into clinical records are possible, such as making the records of
deceased persons ’read-only“ so that new data cannot be entered.
Another possibility includes programming CHCS so that when a deceased
individual‘s clinical record is accessed, a warning message appears
saying that the individual is deceased and asking if new data should be
entered.
Prescriptions Dispensed to an Ineligible Individual:
The last of the 41 cases involved prescriptions dispensed to an
ineligible individual. However, based on our investigation and analysis
of the circumstances of this case, we did not identify health care
benefits that we could conclude were fraudulently obtained. In this
case, an elderly retired military member‘s second wife was listed under
her name as eligible in DOD‘s DEERS eligibility system but was
incorrectly assigned the member‘s deceased first wife‘s SSN. Therefore,
when we compared the SSNs in the Wilford Hall file to the SSNs in the
Death Master File, she was identified as having prescriptions ordered
after the date of her death. According to Wilford Hall records, the
divorced second wife received 39 original prescriptions and refills
that Wilford Hall valued at less than $500 from 1997 through 2001.
However, she became ineligible for DOD health care benefits upon her
divorce from the retired service member in March 1998. We determined
that 31 of these prescriptions, valued in Wilford Hall‘s records at
about $350, were for prescriptions after she became ineligible.
DOD‘s policy is that sponsors are to report any change in dependent
status, which enables DOD facilities to determine when a divorced
spouse or other dependents are no longer eligible for benefits. In this
case, we were unable to determine if the sponsor had reported his
divorce to DOD because the sponsor‘s very poor health at the time of
our investigation precluded our contacting him on this matter.
The second wife explained that when her husband established her
eligibility, he used his deceased first wife‘s SSN. The second wife
said she did not correct the error because she was provided benefits
under her sponsor husband‘s SSN, which the military treatment facility
uses to access the clinical care records. She was issued an
identification card before she was divorced from the sponsor that was
valid until September 2001, 3 years after her divorce. Absent a record
of the divorce, DEERS--DOD‘s eligibility system--showed her eligible
for benefits. As of January 2003, the last recorded prescription in
Wilford Hall‘s database for the patient was in August 2001, the month
before the expiration date on her identification card. According to
this individual, no one told her that she became ineligible when she
was divorced. She said she stopped using the military treatment
facility when her identification card expired. We have provided our
documentation on this case to DOD to correct its eligibility records.
Cases similar to this one do not appear to be unusual, and may, in
fact, be quite commonplace. In a January 2000 report on DEERS,[Footnote
8] the DOD Inspector General reported that in 30 of the 81 cases it
analyzed in which individuals were ineligible for benefits, the sponsor
had not reported a divorce to DEERS, as required by DOD policy. Fifteen
of the divorces had been final for at least a year, and of those, 9 had
been final from 4 to 26 years. In these 9 cases, the identification
cards had been renewed at least one time after the divorces became
final. Some cards were renewed with the sponsor‘s signature on the
application and some with the sponsor‘s divorced spouse‘s signature. In
the latter cases, the former spouses used their expiring identification
cards as the basis for obtaining new cards. Based on the Inspector
General‘s recommendations, DOD established a 30-day time limit for
sponsors to report a change in their dependents‘ eligibility status.
Conclusion:
We did not find evidence of fraudulently obtained health benefits in
the 41 cases we investigated. However, our follow-up work suggests that
the process for entering data into patients‘ clinical records at DOD‘s
military treatment facilities has a key flaw. While the 10 cases
related to errors in the SSA Death Master File are beyond DOD‘s
control, the other 30 are not. They are the result of human data entry
errors that, while not unexpected in a busy environment such as the one
at Wilford Hall, can result in incomplete medical records and
significant patient safety issues such as potentially hazardous drug
interactions not being identified. These errors could reasonably be
addressed by adding preventive data entry controls.
Recommendation for Executive Action:
To strengthen controls over data entry into the DOD clinical records
database and to help ensure that patient safety issues are identified,
we recommend that the Secretary of Defense direct the Assistant
Secretary of Defense for Health Affairs, in conjunction with the
military services‘ Surgeons General, to institute a standardized
preventive control procedure or procedures to prevent inadvertent entry
of new clinical data into a deceased person‘s record clinical record in
CHCS and CHCS II.
Agency Comments and Our Evaluation:
We provided a draft of this report to both SSA and DOD for their
review. SSA, in its written comments reprinted as an enclosure, agreed
that some issues of accuracy exist about information contained in the
Death Master File. SSA explained why these inaccuracies exist and the
efforts it has underway to improve file accuracy.
In DOD‘s oral comments, the Assistant Secretary of Defense for Health
Affairs concurred with the findings of the report but did not concur
with the recommendation. DOD‘s position is that the report overstated
the extent of the problem and that the small number of data entry
errors compared to the number of prescriptions written annually does
not warrant a global change to its processes for entering data into its
clinical database. DOD said that its current data entry procedures and
oversight controls are adequate to prevent errors in medical care or
the delivery of significant levels of inappropriate health care, and it
believed a continuing emphasis on ongoing pharmacy training programs to
ensure correct data entry was a more feasible approach. DOD also said
that the results of our work verify that DOD‘s health care eligibility
system works extremely well.
With regard to DOD‘s health care eligibility system, we do not agree
with DOD. Our work was narrowly focused on investigating the 41 cases
for potential fraud. In our work, we did not attempt to measure the
full extent of the problem of data entry errors, and we neither
evaluated nor do we comment on the effectiveness of controls over DOD‘s
health care
eligibility system. In the course of investigating the 41 cases,
instead of identifying fraud, we determined that DOD clerical errors in
30 of the 41cases had created the appearance that individuals had
received a prescription drug after their death.
:
With regard to the best approach to avoiding clerical data entry
errors, we continue to believe that the practical solution to these
clerical errors is for DOD to implement our recommendation to develop a
preventive control over the process for entering data into the clinical
database. The problems we discuss in the report are a matter of
entering prescription information into the wrong individual‘s medical
file, which can raise patient safety concerns. When a prescription is
not entered into the file for the individual who is to receive the
prescription, CHCS‘ ability to compare the prescription to others the
individual may be taking and identify potentially hazardous drug
interactions is jeopardized.
The problems we identified were caused by human error in the data entry
process. While we understand that human errors will always occur to
some extent and that training is very valuable, we do not believe that
additional training alone is the best approach to preventing these
types of errors. We believe they can be even more effectively avoided
by adding a systemic preventive control to the data entry process. For
example, CHCS II could be programmed to present a ’flag“ to the data
entry person when a deceased person‘s record is accessed that presents
a message such as the following on the screen. ’This person is
deceased. Are you sure you want to enter new clinical data?“ The system
could also be programmed to not allow further data entry until the
question is answered.
When patient safety is at stake, we believe that DOD should take all
reasonable safeguard measures, particularly during the development
stage of a new system when changes are comparatively less costly. We
believe DOD will miss a significant opportunity to improve its control
over data entry and help ensure the safety of its patients if it does
not address this weakness in the data entry process, especially during
the development of the CHCS II pharmacy module.
Unless you publicly announce its contents earlier, we will not
distribute this letter until 15 days from its date. At that time, we
will send copies of this report to the Chairmen of the Subcommittee on
National Security, Emerging Threats and International Relations and the
Subcommittee on Government Efficiency and Financial Management of the
House Committee on Government Reform as well as other congressional
committees. We are also sending copies to the Secretary of Defense; the
Assistant Secretary of Defense for Health Affairs; the Surgeons General
of the military services; the Secretary of the Air Force; and the
Commanders of Brooke Army Medical Center, Randolph Air Force Base
Clinic, and Wilford Hall Medical Center. Copies will be made available
to others upon request. In addition, the letter will also be available
at no charge on the GAO Web site at http://www.gao.gov.
Please contact Greg Kutz at (202) 512-9095 or by e-mail at
kutzg@gao.gov or Linda Garrison, Assistant Director at (404) 679-1902
or by e-mail at garrisonl@gao.gov if you or your staffs have any
questions concerning this report. Major contributors to this
correspondence were Mario Artesiano, Ray Bush, Carl Higginbotham, Ken
Hill, Sue Piyapongroj, John Ryan, and Lisa Warde.
Gregory D. Kutz:
Director, Financial Management and Assurance:
Robert J. Cramer:
Managing Director:
Office of Special Investigations:
Signed by Gregory D. Kutz and Robert J. Cramer:
Enclosure:
Enclosure:
Comments from The Social Security Administration:
SOCIAL SECURITY ADMINISTRATION:
The Commissioner:
March 7, 2003:
Mr. Gregory D. Kutz:
Director, Financial Management and Assurance U.S. General Accounting
Office:
Washington, D.C. 20548:
Dear Mr. Kutz:
Thank you for the opportunity to review and comment on the draft report
’Military Treatment Facilities: Eligibility Follow-up at Wilford Hall
Air Force Medical Center“ (GAO-03-402R). We are pleased to know that
our Death Master File (DMF) assisted you in conducting this review.
Also, while some issues exist with respect to the accuracy of
information contained in the DMF, I want to take this opportunity to
note that prior audits of the DMF found that the file is over 95
percent accurate.
With respect to the 10 instances where SSA‘s DMF had the individual
incorrectly listed as deceased, I offer the following reasons why an
individual who is alive may be shown as deceased on the DMF.
* Erroneous Termination Cases - Prior to 2000, two actions in different
venues were required to return a person to payment status when
erroneously terminated: one to correct the payment record and one to
correct the Numident/DMF. A review of those processes found that often
times the DMF was not corrected. In November 2000, we modified our
Death Alert, Control and Update System to recognize reinstatement cases
and correct the DMF automatically.
* Returned Payment Policy - We also found that many erroneous death
terminations were due to returned payments marked ’deceased“ from the
postal authority and financial institutions. Under previous procedures,
these death notices were processed without further verification until
after the termination action occurred. However, in May 2002, we changed
our policy and now verify these payments for title 11 beneficiaries
marked deceased before terminating benefits, not after.
As demonstrated by the actions described above, we are committed to
working to improve the accuracy of the DMF. In 1999, we entered into
contracts with the National Association for Public Health Statistics
and Information Systems and with the individual States to fund the
Electronic Death Registration (EDR). EDR is a State system that
provides us with a verified death report and is reported within 5 days
of the person‘s death. When EDR is fully implemented, most of the death
data we process will be a State report with a verified SSN for
beneficiaries and for non-beneficiaries. We expect full implementation
of EDR will produce a nearly 100 percent accuracy rate for death
records reported via EDR.
If you have any questions, please have your staff contact Laura Bell at
(410) 965-2636.
Sincerely,
Jo Anne B. Barnhart:
Signed by Jo Anne B. Barnhart:
(192081):
FOOTNOTES
[1] U.S. General Accounting Office, Military Treatment Facilities:
Internal Control Activities Need Improvement, GAO-03-168 (Washington,
D.C.: Oct. 25, 2002).
[2] We used a database of pharmacy prescriptions recorded in fiscal
year 2001 provided to us by Wilford Hall that included prescriptions
recorded for about 100,000 individuals at Brooke Army Medical Center
and Randolph Air Force Base Clinic, which share health-care-related
computer files with Wilford Hall. In this report, we refer to them
collectively as Wilford Hall.
[3] U.S. General Accounting Office, Information Technology: Greater Use
of Best Practices Can Reduce Risks in Acquiring Defense Health Care
System, GAO-02-345 (Washington, D.C.: Sept. 26, 2002).
[4] GAO-03-168.
[5] Social Security Administration, Office of the Inspector General,
The Social Security Administration‘s Procedures to Identify
Representative Payees Who Are Deceased, A-01-98-61009 (Baltimore, Md.:
September 1999) and Disclosure of Personal Beneficiary Information to
the Public, A-01-01-01018 (Baltimore, Md.: December 2001).
[6] Social Security Administration, Office of the Inspector General,
The Social Security Administration‘s Efforts to Process Death Reports
and Improve its Death Master File, A-09-03-23067 (Baltimore, Md.:
January 2003).
[7] SSA, Office of the Inspector General, A-01-01-01018.
[8] Department of Defense, Office of the Inspector General, Evaluation
of The Criminal Investigative Environment In Which The Defense
Enrollment Eligibility Reporting System Operates, CIPO2000S001
(Washington, D.C.: Jan. 7, 2000).
