Defense Health Care: Information on DOD's Processing of TRICARE Claims from Behavioral Health Providers : Government Accountability Office (GAO) , May , 2025
Defense Health Care: Information on DOD's Processing of TRICARE Claims from Behavioral Health Providers : Government Accountability Office (GAO) , May , 2025
From the document: "The Department of Defense’s (DOD) two managed care support contractors generally processed TRICARE claims for care provided between 2018 and 2023 within required timeliness standards. The claims process involves determining payment amounts to civilian health care providers, including behavioral health providers. DOD’s timeliness standards require contractors to process 98 percent of TRICARE claims within 30 days, and 100 percent of claims within 90 days.
Although DOD does not apply these standards to specific provider types, GAO separately analyzed the nearly 28 million claims from behavioral health providers over the 6-year period. GAO found that almost 90 percent were processed in 30 days. In addition, the percentage of claims processed within 30 and 90 days generally increased each year (see figure for the 3 most recent years).
To oversee TRICARE payment accuracy, DOD monitored internal and external audit reports of randomly sampled claims from all types of providers, including behavioral health providers. DOD assessed contractor performance on all audited claims against the payment accuracy standards—which require payment error rates to not exceed between 2 and 1.75 percent, depending on the year of the contract—and took action when necessary. Across the audit reports from 2018 through 2023, claims from behavioral health providers made up between 1 and 8 percent of audited claims.
DOD’s oversight actions were consistent with its oversight goal for early identification and resolution of performance issues, and with a recommended practice from the Office of Management and Budget and prior GAO work that federal agencies use multiple sources of evidence to support decision-making."
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