Federal Health Care

H.R. 4401 would establish a Health Care Infrastructure Commission within the Department of Health and Human Services (HHS) to design, construct, and implement an immediate claim, administration, payment resolution, and data collection system that would initially be used by the Medicare part B program. However, most Medicare claims could be paid more quickly using current processes by simply eliminating the mandatory delay in paying claims. One drawback to eliminating this delay is that the Supplementary Medical Insurance Trust Fund, which funds part B, would lose some of the interest it earns on its balance. A drop in interest earnings could require additional appropriations or an increase in beneficiaries' premiums. Because a real-time claims processing system could open the process to a possible risk of improper payments, appropriate internal controls are needed. Current program safeguards, such as the edit process, must not be compromised. Because a real-time claims processing system is vulnerable to code manipulation, problem providers should be excluded from participating, and adequate documentation controls must ensure that the electronic trail is not lost or tampered with. The project's return on investment, links to a strategic plan, and evidence of compliance with the organization's overall systems architecture must also be considered as well as the possibility of computer viruses and computer attacks. Further, developing a single real-time claims processing system for both Medicare part B and the Federal Employees Health Benefits program would be challenging because the systems are so different.

GAO noted that: (1) H.R. 4401 would establish an Infrastructure Commission within the Department of Health and Human Services to design, construct, and implement an immediate claim, administration, payment resolution, and data collection system that would initially be used by the Medicare part B program; (2) this system would: (a) immediately notify each provider and supplier of coverage determination; (b) immediately notify each provider and supplier of any incomplete or invalid claims, including the identification of missing data and coding errors; (c) immediately process clean claims so that a provider or supplier may provide a written explanation of medical benefits, including costs and coverage to any beneficiary at the point of care; and (d) allow electronic payment of claims for which payment is not made on a periodic payment basis; (3) one outcome of developing an immediate claim, administration, payment resolution, and data collection system would be faster Medicare part B claims payments; (4) while the development of an immediate claim, administration, payment, resolution, and data collection system to be used by the Medicare part B program might be feasible, it would significantly change the government's current processes because it would require the real-time processing of certain elements of the claims process that are performed in batch mode or manually; (5) H.R. 4401 would also affect FEHBP, which is run by the Office of Personnel Management (OPM); (6) H.R. 4401 requires that: (a) OPM adapt the immediate claim, administration, payment resolution, and data collection system for use by the FEHBP; and (b) carriers participating in FEHBP use the system to satisfy certain minimum requirements for claim submission, processing, and payment; (7) because Medicare part B and FEHBP are substantially different programs, it would be difficult to design and implement a single system to process claims under both programs, as called for by H.R. 4401; (8) although all health plans offer inpatient hospital and outpatient medical coverage as well as certain OPM-required services, specific benefits vary; (9) these differences would make it challenging and costly to design and implement a real-time claims processing system for both programs; and (10) if a real-time claims processing system is to be developed, consideration should be given to including key Health Care Financing Administration (HCFA) and carrier officials with health care claims processing, program integrity, and financial management expertise on the Infrastructure Commission, as well as OPM and providers, since the system would affect HCFA, OPM, and the providers.