Armed Forces News

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The Defense Health Agency (DHA) failed to sufficiently document contractors’ claims for ambulance services between October 2015 and September 2020, according to an audit by the Pentagon’s inspector general. In a sample of 182 claims during that time frame, the IG also determined that DHA improperly paid $28,500 in 85 of them.

“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 recover at least an estimated $118.85 million paid to ambulance transport providers for ground ambulance transports,” the audit stated.

As such, the IG also concluded that lack of control by DHA and Tricare – the Defense Department’s managed health-care arm – resulted in overpayments, improperly billed claims, other claims that failed to meet Tricare and Medicare definitions of medical necessity, and those that failed to meet agency criteria for point-of-pickup zip codes.

The IG audit also determined that the Military Health System Data Repository “contained inaccurate and incomplete transport and payment information.”

The agency also did not require Tricare’s overseas contractor to gather and record ambulance transport data.

Slipshod reviews and reports of ambulance-services data by DHA “will affect 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,” the IG report stated.

The auditors put forth several recommendations for DHA, to include:

• Reinforcing requirements that contractors get and hold onto documentation of necessary ambulance trips.

• Review 74 unreported and 11 improperly paid claims and recoup overpayments made to providers, and use payment recapture audits to determine and recover any other overpayments to ambulance providers. These claims also should be reviewed, to determine if they indicate patterns of abuse among providers. If such patterns are discovered, providers should be referred to the DHA Program Integrity Office.

• Review Tricare’s policy to determine whether the agency can recover improper payments from contractors in cases that were not specifically addressed in the IG’s audit, and determine the best plan for recovering such projected improper payments.

• Make sure than any external claim audits include ground ambulance transport claims regardless of how often such audits occur.

• Implement data quality reviews of Tricare’s overseas ambulance data, with an eye on identifying incomplete or inaccurate coding.

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