Federal Employees Health Benefits Program: Additional Actions Needed to Address Significant Risks in Verifying Provider Eligibility

What GAO Found

Limitations in control activities allowed potentially ineligible providers to participate in the Federal Employees Health Benefits (FEHB) program. The Office of Personnel Management (OPM) and its Office of the Inspector General (OIG) have a variety of control activities for identifying ineligible providers. However, GAO found limitations in these control activities. GAO's data analyses identified FEHB claims from approximately 400 providers who were deceased and over 2,000 additional claims from providers who were excluded from federal programs. While such claims are a small proportion of annual FEHB claims, they represent a risk the agency could mitigate. Taking additional steps to identify providers who are deceased or excluded from other federal programs would help OPM and OPM OIG prevent fraud and improper payments in the FEHB program. For example, comparing death data with FEHB claims could help prevent improper payments or fraud in FEHB claims payments.

Selected FEHB carriers do not always comply with requirements for identifying and excluding suspended or debarred providers. GAO found that selected FEHB carriers-which operate health benefit plans-do not always notify patients that their providers are suspended or debarred, as required. Carriers also did not notify OPM OIG when providers may warrant suspension or debarment, as required by OPM OIG policy. Clarifying requirements would help OPM and OPM OIG ensure that patients are not exposed to risks related to suspended or debarred providers.

Why GAO Did This Study

The FEHB program is the largest employer-sponsored health insurance program in the United Sates. OPM is responsible for managing fraud and improper payment risks in the FEHB program, including risks associated with ineligible health care providers. Ineligible providers can increase costs and may pose safety risks to patients.

GAO was asked to review OPM's efforts to manage provider-related fraud risks in the FEHB program. This report examines the extent to which (1) program control activities allow potentially ineligible providers to participate in the FEHB program; and (2) selected FEHB carriers comply with requirements for identifying and excluding suspended or debarred providers, among other objectives.

GAO performed analyses comparing FEHB claims data with various data sets indicating that providers may be ineligible, such as data on deceased providers or providers excluded from other federal programs. GAO also reviewed documents and interviewed officials from OPM, OPM OIG, and FEHB carriers. GAO compared this information with applicable regulations, guidelines, and federal standards for internal control.