Defense Health Care: DOD Expects New IT System Capabilities to Improve Other Health Insurance Processing

Through DOD’s TRICARE health plan, beneficiaries—including service members and dependents—may receive care from the direct care system of military hospitals or clinics, or from the private sector care system of civilian providers administered by contractors. When non-active duty beneficiaries have OHI, DOD is authorized to recover the cost of providing their health care.

Public Law 116-283 includes a provision for GAO to review DOD’s OHI billing practices for care received under the TRICARE program. This report describes challenges MTFs may face when processing OHI third-party claims for TRICARE beneficiaries; and examines OHI information contractors submit to DOD for beneficiaries who receive care from civilian providers.

GAO examined relevant documentation for the collection and billing of OHI claims and interviewed DHA officials, including those responsible for MHS GENESIS and its new billing component; contractor officials; and officials from six MTFs selected for variety in military service, use of MHS GENESIS, and amount of OHI payment received in 2018 through 2020—the most recent data available.