Department of Homeland Security 

Office of Inspector General 

The U.S. Immigration and Customs Enforcement 


Process for Authorizing Medical Care for 


Immigration Detainees
 

OIG-10-23 December 2009 
 

Office of Inspector General 

U.S. Department of Homeland Security

Washington, DC 20528 

 December 3, 2009 

Preface 

The Department of Homeland Security (DHS) Office of Inspector General (OIG) was 

established by the Homeland Security Act of 2002 (Public Law 107-296) by amendment 

to the Inspector General Act of 1978. This is one of a series of audit, inspection, and 

special reports prepared as part of our oversight responsibilities to promote economy, 

efficiency, and effectiveness within the department. 

This report addresses the strengths and weaknesses of the Treatment Authorization 

Request process that U.S. Immigration and Customs Enforcement uses to arrange and pay 

for the medical care of immigration detainees. We based the report on interviews with 

employees and officials of relevant agencies and institutions, direct observations, and a 

review of applicable documents. 

The recommendations herein have been developed to the best knowledge available to our 

office, and have been discussed in draft with those responsible for implementation. We 

trust this report will result in more effective, efficient, and economical operations. We 

express our appreciation to all of those who contributed to the preparation of this report. 

Richard L. Skinner 


Inspector General 

Table of Contents/Abbreviations 

Executive Summary.............................................................................................................1
 

Background..........................................................................................................................2
 

Results of Review ................................................................................................................4
 

Strategic Redirection of the Authorization Process Is Needed......................................5 


Managed Care Coordinators Face a Variety of Challenges...........................................9 


Detention Facilities Need Assistance Working With Providers .................................12 


Management Comments and OIG Analysis ......................................................................17 


Appendixes 

Appendix A: Purpose, Scope, and Methodology.......................................................22 


Appendix B: Management Comments to the Draft Report.......................................24 


Appendix C: Major Contributors to This Report ......................................................27 


Appendix D: Report Distribution ..............................................................................28 


Abbreviations 

DIHS Division of Immigration Health Services 


DRO Office of Detention and Removal Operations 


FSC Financial Services Center 


ICE Immigration and Customs Enforcement 


MCC Managed Care Coordinator 


OIG Office of Inspector General 


OPLA Office of Principal Legal Advisor 


TAR Treatment Authorization Request 

OIG
 

Department of Homeland Security 

Office of Inspector General 

Executive Summary 

United States Immigration and Customs Enforcement must provide 

or arrange for the medical care of immigration detainees. For 

nonemergency care, facilities are required to submit a Treatment 

Authorization Request when detainees need health services. 

Managed care coordinators evaluate these requests based on 

existing coverage policy. We evaluated the effectiveness of the 

process used to authorize care for immigration detainees. 

The managed care coordinators expressed concern regarding 

insufficient staffing to meet the workload. From October 2006 

through March 2009, Immigration and Customs Enforcement 

received more than 110,000 requests for offsite medical care. We 

identified a variety of limitations that hinder the processing of 

requests, such as administrative burdens and incomplete 

submissions. 

We determined that the existing medical treatment request process 

can be improved through a reduction in the amount of preauthorization review, expansion of case management functions, 

and improvement in relationships with outside medical providers 

who deliver care to immigration detainees. We are making 10 

recommendations to improve the process for authorizing medical 

care for immigration detainees. 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 1 
 

Background 

ICE Required to Provide Health Care 

U.S. Immigration and Customs Enforcement (ICE) is responsible for 

protecting national security by enforcing customs and immigration laws. 

The Immigration and Nationality Act authorizes ICE to arrest, detain, and 

remove certain aliens.1 ICE detains more than 32,000 aliens on an average 

day. Within ICE, the Office of Detention and Removal Operations (DRO) 

ensures safe and humane conditions of confinement. This includes an 

obligation to provide adequate health care for detainees. 

Although the government must act with deliberate indifference to the 

serious medical needs of a detainee in order for any defect in the provision 

of medical care to rise to the level of a constitutional violation,2

 ICE’s 

Office of the Principal Legal Advisor (OPLA), attempts to ensure that 

detention facilities exceed constitutional standards when providing 

medical care. Further, although defects in care resulting from either 

medical malpractice or negligent conduct do not necessarily meet the 

“deliberate indifference” standard for a constitutional violation, such 

conduct could potentially give rise to liability under the Federal Tort 

Claims Act, which allows the government to be sued “under circumstances 

where the United States, if a private person, would be liable to the 

claimant.”3 

The Division of Immigration Health Services (DIHS) is the ICE medical 

authority. In an October 2007 agreement between ICE and the 

Department of Health and Human Services, DIHS clinicians were detailed 

to ICE. They provide care at ICE-owned Service Processing Centers and 

Contract Detention Facilities that private organizations manage. County 

facilities that detain immigrants may use DIHS personnel, but usually 

provide onsite care to detainees through contracted medical providers or 

county health department staff. 

The health program for ICE detainees employs a managed care model. As 

part of this model, DIHS adopted a Covered Services Package to outline 

general medical coverage policies.4

 The package was implemented in 

2005, before DIHS became a part of ICE. OPLA believes that the 

Covered Services Package allows sufficient discretion for providers and 

physicians to obtain medically necessary treatment, even for services not 

1 8 USC § 1226, 1227, 1229, and 1357. 


2 Despaigne v. Crolew, 89 F.Supp.2d 582, 585-6 (E.D. Pa. 2000). 
 3 28 U.S.C. § 1346(b) 


4 http://www.icehealth.org/ManagedCare/Combined%20Benefit%20Package%202005.doc.
 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 2 
 

specifically covered. Some cases of delayed authorization have occurred, 

prompting interest groups to allege that ICE has difficulty providing 

necessary care to immigration detainees. 

The Process of Providing Health Care to Immigration Detainees 

Although the ICE detainee population differs from enrollees in 

commercial managed care organizations, DIHS management views the 

managed care model as necessary for immigration detainees. ICE 

detainees generally have poor health status; many have not had access to 

regular care for years, if ever.5 A managed care approach allows for some 

level of case management that can track an individual’s care, ensure 

proper follow-up, and improve overall health status. 

The medical clinics that are part of immigration detention facilities can 

provide different kinds of care to detainees. Onsite medical personnel 

conduct a detainee’s intake medical exam and the physical exam that is 

required within 14 days of a detainee’s arrival at the detention facility. 

Pursuant to ICE detention standards, facilities must provide detainees an 

“unrestricted opportunity to freely request health services.”6 This ongoing 

period for detainees to request care is referred to as sick call. A detainee 

may request health care that onsite clinicians can provide without further 

review from DIHS headquarters in Washington, D.C. However, when the 

sick call process identifies a need for care that exceeds the capability of 

the onsite clinic, the facility submits a Treatment Authorization Request 

(TAR) via an online system called TARWeb. The system is used to 

authorize payment for detainees’ offsite medical care. 

TARs serve two important purposes: They limit nonemergency offsite 

medical treatment to that within the Covered Services Package, and they 

guarantee eventual payment to the offsite medical service provider. 

Emergency care does not require prior authorization. In emergencies, the 

TAR is submitted as soon as possible after treatment, to facilitate 

subsequent payment to the health care provider. 

Managed care coordinators (MCCs), nurses assigned to DIHS 

headquarters, review TARs to ensure that the requested care is within the 

scope of the Covered Services Package. When a TAR submission is 

incomplete, the MCC will deny it. However, the detention facility can 

amend and resubmit the request. When the TAR is complete and appears 

5

 ICE testimony from Congressional hearing on “Medical Care and Treatment of Immigration Detainees 


and Deaths in DRO Custody,” March 3, 2009. 
 6 ICE/DRO Detention Standard: Medical Care, page 16.
 

http://www.ice.gov/doclib/PBNDS/pdf/medical_care.pdf.
 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 3 
to be within the Covered Services Package, an MCC will approve the 

request. When the TAR is complete, but the requested treatment appears 

to be outside the Covered Services Package, the MCC will deny the 

request. When this happens, the facility can resubmit the request with 

more medical justification, or discuss the request with the DIHS Medical 

Director; in either case, the TAR might then be approved. 

After care is approved, facilities schedule medical appointments, generally 

with doctors or hospitals in surrounding communities. Figure 1 illustrates 

the TAR process. 

Figure 1. The Treatment Authorization Request Process for Nonemergency 

Care 

Source: Office of Inspector General, derived from multiple sources. 

MCCs are critical to the interaction between ICE and offsite medical 

providers. MCCs can lessen problems that facilities and health care 

providers encounter, such as difficulty locating an appropriate specialist, 

difficulty obtaining a timely appointment, or slow payment of a claim. 

Results of Review 

Our review focused on the process to authorize offsite medical treatment, rather 

than an evaluation of the treatment provided. Since more than 97% of TARs are 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 4 
currently approved, the TAR process should be changed to decrease the amount 

of pre-service review. In addition, the role of the MCC should be changed to 

ensure more case management for detainees and more support to detention 

facilities. ICE also must ensure that its medical claims processor receives needed 

funding more rapidly. This will decrease the amount of interest paid to providers 

for overdue medical claims and improve the relationships between ICE and the 

medical professionals who provide care to immigration detainees. 

Strategic Redirection of the Authorization Process Is Needed 

The Current Process Is Inefficient 

The current TAR process places a great deal of pressure on the 

MCCs, for limited gain. Based on data for the 30 months from 

October 2006 through March 2009, detention facilities and Border 

Patrol stations submitted 110,538 TARs. This was an average of 

850 TARs per week. Few of these requests were denied. Initially, 

MCCs denied only 8,106 (7.3%) of these TARs, but even this low 

rate significantly overstates the frequency of care denial. 

Denied TARs frequently lacked information needed for processing, 

even though the requests for care were legitimate. ICE data 

demonstrated that thousands of TARs were denied initially because 

the facility did not include the detainee’s Alien Number. MCCs 

said that facilities would resubmit denied TARs that did not 

include an Alien Number or other necessary information, such as 

greater detail about the detainee’s medical needs. After the 

facilities provide additional information, the MCC often grants 

approval. Thus, at many facilities actual denials of care are very 

uncommon. No facility staff we interviewed expressed concern 

that the TAR process was denying medically necessary care. 

The percentage of denied TARs has declined, as illustrated in 

figure 2. 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 5 
Figure 2. Rate of TAR Denials, October 2006–March 2009 

10.0%

9.0%

8.0%

7.0%

6.0%

Percentage 5.0%

4.0%

3.0%

2.0%

1.0%

0.0%

FY07

FY08

Fiscal Year 

Source: DIHS. 

In FY 2007, 4,584 TARs were denied, an average of 382 per 

month. In contrast, in the first half of FY 2009, only 589 were 

denied, fewer than 100 per month. We believe that the decrease is 

in part attributable to the training Border Patrol employees 

received in October 2008, which exposed them to the correct 

procedure for submitting TARs. This helped the Border Patrol 

reduce TAR denials. Additionally, facilities noted that MCCs no 

longer review TARs that a physician at the detention center has 

authorized. 

Nonetheless, MCCs and facility staff offered examples of how the 

TAR process is burdensome. Some ambulance companies have 

expressed problems with payment because transportation often is 

not authorized before the services are rendered. This delays 

payment for legitimate services provided to support care that had 

already been approved through the TAR process. Also, additional 

TARs are required for follow-up care to complete a course of 

treatment that an MCC has authorized. 

Decreasing the number of TAR denials can help detention facilities 

and the MCCs. Some facility clinicians told us that the TAR 

process creates difficulties, especially when additional clinical 

information is deemed necessary before care can be authorized. 

FY09

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 6 
ICE has made an effort to decrease the administrative workload 

that the TAR process creates. Automatic approval of some TARs, 

for example, has lessened the work required for services that were 

not previously denied. Facility staff praised the decision to 

automatically approve TARs for chest x-rays to test for 

tuberculosis. Staff noted that such approvals decrease staff burden, 

especially when large numbers of detainees arrive at a facility on 

the same day. MCCs and some facility staff recommended that 

basic lab services also receive automatic approval. 

Such a change is sensible. However, a more extensive shift in the 

TAR process is warranted. Because of the low level of TAR 

denials that actually lead to cost savings through rejection of 

payment for non-covered medical care, ICE should change the 

TAR process so that pre-authorization is required only for the most 

costly services. This could be accomplished through automatic 

approval of most services or elimination of the TAR submission 

for most services. A dramatic reduction in the pre-authorization 

burden would save resources currently used to deny a very small 

number of requests. 

In 1999, United HealthCare, the Nation’s second largest managed 

care company, ended pre-authorization for its managed care 

enrollees. The company, which served 14.5 million enrollees in 

1999, determined that the pre-authorization process cost $128 

million to administer while denying less than 1% of requested care. 

Post care utilization reviews are conducted to ensure that providers 

are not delivering uncovered services and to track which providers 

are using an inordinate level of care.7 As previously stated, there 

are significant differences between the health care needs of 

enrollees in a commercial managed care company and immigration 

detainees, but this example and other studies demonstrate that preauthorization can be an unnecessary burden on a managed care 

8 program.

Managed care organizations that have elected to change preauthorization policies can still use the practice in limited cases. 

Some companies maintain a pre-authorization requirement based 

on the frequency of service. Other companies maintain the 

7

 “Managed Retreat,” The Economist, November 13, 1999; “How One Big HMO Capitulated,” Time,
 

November 22, 1999. 


8

 “Prior Authorization of Newer Insomnia Medications in Managed Care: Is It Cost Saving?” J Clin Sleep 


Med. 2007 June 15; 3(4): 393–398
 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 7 
requirement for the most costly services, such as inpatient hospital 

admissions.9 

A challenge to the successful transition from the current TAR 

process is the wording of the Covered Services Package, which 

establishes coverage policy for detainee medical care. More 

precise coverage guidance would be necessary if care preauthorizations were decreased or eliminated. An MCC informed 

us that a system with little or no pre-authorization must have more 

specific coverage guidance to prevent “creative” facilities or 

providers from arranging for or providing care that is not within 

the scope of coverage. 

The Covered Services Package resembles the documents that 

managed care companies use to inform enrollees of their coverage 

options. For example, the document is organized around different 

types of health services, such as cardiology, general surgery, and 

hearing services. However, current coverage guidance is 

somewhat contradictory. For general surgery, for example, DIHS 

has established that “Scheduled, non-emergency surgical services 

are not a covered benefit. Requests will be reviewed on a case by 

case basis.” Similar guidance appears for various other services. 

DIHS staff we interviewed said that the current Covered Services 

Package, finalized in 2005, is outdated. Revisions to the document 

should account for changes in technology and accepted medical 

practice. 

We recommend that the Assistant Secretary, U.S. Immigration and 

Customs Enforcement: 

Recommendation #1: End or greatly reduce the amount of preauthorization required under the Treatment Authorization Request 

process. 

Recommendation #2: Revise the Covered Services Package to 

provide more guidance on coverage policy for a process that 

minimizes pre-authorization of most services. 

9 “Old Techniques Never Die, Nor Even Fade Away,” Managed Care, January 2006; “New Imaging 

Controls Strict, But May Be Easier On Doctors,” Managed Care, November 2007. 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 8 
Managed Care Coordinators Face a Variety of Challenges 

Staffing Limitations Hinder the Coordinator’s Efficiency 

All MCCs said that the volume of TAR submissions is 

overwhelming, resulting in a high turnover rate among MCCs. 

MCC staffing levels have declined dramatically since April 2006, 

when there were eight MCCs. Since 2006, four MCCs have handled 

the TAR workload. The decline in the number of MCCs is one 

reason for the strain on the remaining MCCs. At the conclusion of 

our fieldwork, we were informed that two of the four remaining 

MCCs would soon be taking other positions. Plans to replace the 

two departing MCCs and add two more were in development, but 

concern existed that the training and transition period for new MCCs 

would create new short-term burdens for the remaining MCCs. 

The coordinators reported that the high number of TAR 

submissions caused a great deal of stress. If pre-authorization 

work could be reduced, MCCs could become more involved in 

care coordination and provider retention. This offers a much 

greater value to ICE than placing the MCCs in a high-stress 

environment that approves nearly all TARs—about 850 per week. 

Even with this pressing workload, most TARs are approved 

quickly. Between the start of FY 2005 and the end of FY 2008, the 

maximum average amount of time needed to approve or deny a 

TAR request was slightly more than 4 days. Facility experts we 

interviewed said that most approvals take 1 or 2 days. 

MCCs expressed frustration with their collateral duty of resolving 

general system-related issues for TARWeb users. The MCCs are 

the point of contact for connection or password problems. MCCs, 

who are registered nurses, not computer systems experts, said that 

they spend too much time on system-related issues. DIHS officials 

said that the DIHS systems support office is also understaffed and 

reluctant to make system changes or process requests for TARWeb 

access without authorization from management. Individuals other 

than the MCCs should resolve system-related problems. The 

MCCs would then be able to focus on their core responsibilities. 

We recommend that the Assistant Secretary, U.S. Immigration and 

Customs Enforcement: 

Recommendation #3: Make appropriate policy changes so that 

managed care coordinators are no longer responsible for facilities’ 

TARWeb system access and password reset issues. 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 9 
Improvements to TARWeb Would Enhance the Process 

Although TARWeb collects a large amount of data, facilities staff 

noted the system’s minimal analytical capabilities. TARWeb does 

not provide facilities with information such as detailed reports on 

detainee health care trends. Some detention facilities have created 

their own internal detainee health care tracking tools. If TARWeb 

provided data analysis reporting, the facilities would be better able 

to understand the services provided to detainees. We encourage 

DIHS to solicit information regarding specific reports to ensure 

that the reporting function meets facilities staff needs. 

Also needed is a method to prioritize TAR submissions. Larger 

immigration detention facilities can experience a sizeable number 

of detainee intakes in a single day. Although care for emergency 

conditions does not require pre-authorization, routine TARs can be 

of varying severity levels. TARs are reviewed on an as-received 

basis. TARWeb does not have a method to indicate which requests 

are more urgent. A prioritization function would decrease the 

volume of calls MCCs receive for expedited review of particular 

TARs and create a more efficient workflow. 

We recommend that the Assistant Secretary, U.S. Immigration and 

Customs Enforcement: 

Recommendation #4: Develop TARWeb data reporting 

capabilities that incorporate the suggestions of facilities’ staff. 

Recommendation #5: Develop a prioritization system in 

TARWeb for facilities to identify more urgent detainee medical 

care requests. 

Expanded MCC Work in Case Management Is Necessary 

The MCCs are overwhelmed with TARs and other duties that 

diminish their ability to function as case managers. Nonetheless, 

case management is important for some ICE detainees. For 

example, cancer patients require detailed case management to 

understand the ongoing clinical issues of each case. Follow-up 

care is a vital part of ongoing health maintenance for various 

medical conditions. The current TAR process allows for case 

management, but an expansion of the MCC role in the process is 

necessary. 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 10 
Case management is an essential component of any managed care 

system. The Case Management Society of America defines case 

management as: 

A collaborative process of assessment, planning, facilitation 

and advocacy for options and services to meet an individual’s 

health needs through communication and available resources 

to promote quality cost-effective outcomes. 

An online job description listed case management as a primary 

function of the MCC position. Through work with detention 

facilities and medical providers, MCCs collaborate to develop care 

plans for detainees who have specific health problems, such as 

cancer or chronic diseases. Case management can benefit ICE as 

well as detainees, since it can help to identify providers who can 

provide follow-up health services. Although many detained aliens 

are in ICE custody for only a few days, those with severe health 

problems can benefit from case management. 

Case management can be time-consuming because of the variables 

in each detainee’s medical history and condition. MCCs noted that 

additional training on case management is necessary. Currently, 

MCCs are not required to be certified case managers. One 

clinician said that, owing to the pressing nature of other MCC 

duties, “true case management does not happen in some cases.” 

More MCC staff and a reduction in the pre-authorization workload 

would ensure that the case management principle is fully 

implemented for ICE detainees. 

MCCs described the case management process as a burden in some 

instances. Additional staffing would help MCCs evaluate 

detainees’ health conditions, develop and implement discharge 

plans, coordinate medical resources, and monitor detainee 

progress. MCCs said that they do not have enough time to manage 

the cases of some detainees. Moreover, a large amount of work 

can be necessary to coordinate with hospitals and facility staff to 

understand the ongoing condition of a particular detainee. 

Detention facility staff had a variety of opinions on the case 

management process. In many cases, facilities are not very 

involved in the process, which frustrates some onsite clinicians. 

Conversely, one facility staff member concluded that clinical staff 

at the detention facility is “drowning” in the details of some cases 

because of interaction with hospitals, discharge planning, and 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 11 
patient information requests. MCCs can interact daily with 

hospital and facility staff regarding each detainees’ case. More 

case management will help MCCs support the managed care 

program and will ensure more consistent involvement in case 

management across detention facilities. The case management 

process is important for effective detainee care. 

We recommend that the Assistant Secretary, U.S. Immigration and 

Customs Enforcement: 

Recommendation #6: Develop policies that formalize necessary 

training and an expanded case management role for the managed 

care coordinators. 

Detention Facilities Need Assistance Working With Providers 

Maintenance of Outside Provider Relationships Is Difficult 

ICE must compete with other health plans and payers for access to 

outside medical services. This is an inherent difficulty for ICE. 

Detention facility staff cited cases where health care providers 

elected not to treat ICE detainees any longer. Some providers, 

staff believed, felt that their other patients would find it 

uncomfortable to share a waiting room with someone wearing a 

prison uniform and in hand and leg restraints. Also, delays in 

claims payment were a concern of providers. Physicians and 

hospitals may elect not to treat ICE detainees if several months 

pass before they receive payment for authorized care. ICE officers 

we interviewed said that they occasionally receive calls from 

collection agencies because of unpaid medical bills. One frustrated 

TAR expert at a facility said, “No one wants to take this 

insurance.” 

TAR experts at the facilities we visited provided details on care 

access concerns. Even facilities in urban areas can have problems 

finding providers who will care for ICE detainees. These problems 

are compounded when facilities are located far from concentrations 

of hospitals or physicians. Ensuring that certain specialists, such 

as neurologists or psychiatrists, remain interested in seeing ICE 

detainees is of concern across several facilities. Even when 

providers are located, some specialist visits require that detainees 

be transported to urban areas distant from the facility. 

Detention facility personnel said that they are actively working to 

maintain provider networks with hospitals and doctors that treat 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 12 
detainees. This requires frequent e-mails or conversations about 

providers’ problems, usually related to claims payment. One 

facility expert, who feels like a “telemarketer” when trying to 

convince providers to treat detainees, noted that thank-you notes 

and holiday cards are sent to providers to ensure continued access 

to certain services. MCCs may sometimes be involved in 

resolving provider issues. Imminent collapse of provider access 

does not seem likely across the facilities we visited. However, 

efforts are needed to ensure more timely and frequent access to 

authorized care. 

Correcting delays in provider payments can also save federal 

funds. Experts at the Veterans Affairs Financial Services Center 

(FSC), which processes claims for ICE, said that the FSC requires 

a revenue flow to make timely payments to providers. However, 

quarterly payment by ICE to the FSC is sometimes delayed. In 

those situations, provider payments are not processed within the 

30-day period required under the Prompt Payment Act. Claims 

paid after 30 days accrue interest that must be paid to providers. 

FSC data established that interest payments resulting from delays 

in the ICE funding transfer amounted to $110,081 from October 

2007 through March 2009, an average of $6,115 per month. This 

is a waste of tax dollars, as well as a source of payment delays to 

providers, which can decrease their desire to treat ICE detainees. 

Difficulty finding medical providers increases the amount of time 

between authorization of a TAR and the provision of needed health 

services. We asked for any analysis or studies that have tracked 

the length of time between approval of a TAR and the medical 

appointment. ICE has not completed such an analysis. Data 

related to the gap between TAR approval and receipt of health 

services would identify facilities that are having difficulty 

arranging for outside detainee care. Such analysis could detect 

when more effort is needed to establish or maintain provider 

relationships. Shortages in outside medical providers could be 

corrected at some facilities through the use of DIHS clinical 

personnel. 

We recommend that the Assistant Secretary, U.S. Immigration and 

Customs Enforcement: 

Recommendation #7: Expand managed care coordinator support 

to detention facilities to improve maintenance of relationships with 

outside care providers. 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 13 
Recommendation #8: Ensure more timely transfer of funds to the 

Financial Services Center to increase compliance with the Prompt 

Payment Act and to decrease interest paid on authorized medical 

claims. 

More Provider Education Would Enhance the Overall Process 

Outside medical providers furnish necessary medical care to 

immigration detainees. These providers work with a wide range of 

public and private insurance, but often do not know ICE’s 

coverage rules or how to submit claims properly after an approved 

TAR denotes that care can be reimbursed. This leads to 

unnecessary payment denials and frustration among providers. 

Enhanced efforts to educate providers about the payment process 

would have a positive effect on ICE’s relationships with providers. 

For the first 6 months of FY 2009, the FSC denied 38.5% of 

medical claims submitted for ICE detainees. During our interview 

with FSC staff, they suggested that ICE create a handout for 

medical providers that would describe elements of the TAR 

process and claims payment rules. ICE officers who transport 

detainees to provider offices may not be able to convey the details 

of medical coverage policies or information required for payment 

of claims. A written document presented to hospitals or physicians 

should improve providers’ understanding of the process. 

Detention facility and FSC staff said that claims often do not 

include required information, such as the Alien Number, used to 

identify detainees. Another important part of a claim that can be 

missing is the date of service. This is necessary to ensure that the 

individual was an ICE detainee when services were rendered. We 

were told that some providers did not submit claims within the 

deadline established in policy. The additional information should 

also be available on the DIHS website. 

We recommend that the Assistant Secretary, U.S. Immigration and 

Customs Enforcement: 

Recommendation #9: Create provider education materials to 

ensure better understanding of the ICE detainee health care process 

and the need for accurate and timely submission of claims. 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 14 
Local or Regional MCCs Would Offer Various Benefits 

Currently, MCCs are based at DIHS headquarters. A limited 

number of local or regional MCCs would provide an important 

presence to augment detention facilities’ staff efforts to work with 

providers and supplement case management. DIHS clinicians in 

headquarters and at detention facilities expressed support for the 

establishment of regional MCC positions. Use of regional MCCs 

should not eliminate the need for a certain number of MCCs at 

DIHS headquarters. Having some MCCs in Washington, DC is 

sensible, especially since meetings with the DIHS Medical 

Director and ICE detention staff are an important part of an MCC’s 

overall role. 

Regional MCCs would be the conduit for local issues between 

detention facilities and ICE. Provider retention and education 

efforts would be another obvious role for regional MCCs. Facility 

staff we interviewed said that recruiting new providers or 

maintaining existing networks is a vital, but burdensome, aspect of 

the detainee health care process. Regional MCCs would contribute 

to facilities’ provider relations efforts. 

Figure 3 shows two groups of four facilities that combined 

accounted for 23.4% of TAR submissions in the first 6 months of 

FY 2009. Regional MCCs based in both areas could function as 

the primary contact for care authorizations, medical records issues, 

and claims problems. 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 15 
Figure 3. Possible Jurisdictions for Two Regional MCCs 

Source: OIG, derived from multiple sources. 

DIHS field MCCs could also perform Covered Services Package 

education efforts that would be necessary if ICE shifts to decreased 

pre-authorization. This additional education would be national in 

scope, but a regional MCC would offer direct support for it at a 

small number of nearby facilities. Regional MCCs could also 

work with ICE officers who receive inquiries about health 

coverage or medical claims to support resolution of problems and 

expand outreach to those medical providers. 

We recommend that the Assistant Secretary, U.S. Immigration and 

Customs Enforcement: 

Recommendation #10: Implement a regional managed care 

coordinator staffing plan and develop supplemental policies that 

describe the roles and responsibilities of these new personnel. 

Conclusion 

This report focused on the strategic management of the ICE Treatment 

Authorization Request process. Additional case management and 

enhancements to the way ICE authorizes and pays for medical services 

will improve overall detainee health care. A dramatic change to the TAR 

submission process can support expanded case management and a greater 

focus on retaining physicians and hospitals in areas near ICE detention 

facilities. Facility staff and clinicians we interviewed showed a 

commendable devotion to caring for immigration detainees. With a 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 16 
reduction in the administrative burden associated with the TAR process, 

local MCCs, and expanded support to facilities, ICE can better meet its 

legal responsibilities for detainee health care. 

Management Comments and OIG Analysis 

ICE concurred with each of our ten recommendations. We evaluated 

ICE’s written comments and have made changes to the report where we 

deemed appropriate. A summary of the ICE response to our 

recommendations and our analysis is included below. A copy of the ICE 

response, in its entirety, is included as Appendix B. 

We have closed Recommendation #3 because ICE has taken corrective 

action. Our remaining nine recommendations are resolved and open 

pending additional information in the ICE corrective action plan due 

within 90 days of the issuance of this report. 

Recommendation #1: End or greatly reduce the amount of preauthorization required under the Treatment Authorization Request process. 

Management Comments to Recommendation #1 

ICE informed us that DIHS is implementing revisions that will greatly 

reduce the need for pre-authorization for necessary care. DIHS will also 

no longer require a TAR for follow-up visits related to care that was 

already authorized. Additional analysis will be done to reduce the burden 

of the care authorization process. 

OIG Analysis 

This recommendation is resolved and open pending further details on the 

prior authorization process. Additional details on specific changes made 

will demonstrate that the TAR process is being streamlined effectively. 

Recommendation #2: Revise the Covered Services Package to provide 

more guidance on coverage policy for a process that minimizes preauthorization of most services. 

Management Comments to Recommendation #2 

ICE intends to have a draft revision to the CSP prepared soon. This new 

version of the coverage guidance will include information about the move 

toward significantly less prior authorization. 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 17 
OIG Analysis 

This recommendation is resolved and open. As part of the corrective 

action process, ICE should provide the OIG a copy of the revised CSP and 

additional detail on how the CSP will diminish pre-authorization for 

detainees’ medical care. 

Recommendation #3: Make appropriate policy changes so that managed 

care coordinators are no longer responsible for facilities’ TARWeb system 

access and password reset issues. 

Management Comments to Recommendation #3 

In June 2009, changes were implemented that relieved MCCs of the 

responsibility for responding to system access and password problems. 

OIG Analysis 

This recommendation is closed. No further action is required. 

Recommendation #4: Develop TARWeb data reporting capabilities that 

incorporate the suggestions of facilities’ staff. 

Management Comments to Recommendation #4 

ICE noted that work is being done to revise TARWeb data fields and 

integrate staff suggestions. Additional review will take place to determine 

whether suggested changes are feasible. 

OIG Analysis 

This recommendation is resolved and open. In the corrective action 

process, ICE should inform us of changes that have been suggested, and 

actions taken. 

Recommendation #5: Develop a prioritization system in TARWeb for 

facilities to identify more urgent detainee medical care requests. 

Management Comments to Recommendation #5 

ICE acknowledged that this recommendation would improve the 

timeliness of authorizing detainee care. DIHS will explore how a 

prioritization system would work to ensure that MCCs are able to address 

those non-emergency TARs that are a higher priority. 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 18 
OIG Analysis 

This recommendation is resolved and open. We share ICE’s view that a 

prioritization system, even with fewer TARs requiring authorization, can 

improve timeliness of detainee access to health care. However, ICE’s 

formal response did not provide detail on how and when the system will 

be changed to accommodate this change. 

Recommendation #6: Develop policies that formalize necessary training 

and an expanded case management role for the managed care 

coordinators. 

Management Comments to Recommendation #6 

ICE noted that the MCCs are vital to the managed care program. 

Management is interested in facilitating necessary training, including a 

focus on case management, to ensure that MCCs remain informed about 

new information in their field. DIHS will consider a recurrent training 

plan to meet the needs of the MCCs. 

OIG Analysis 

This recommendation is resolved and open. The focus of this 

recommendation is an expanded case management role. Once that is 

developed, MCCs will require formal case management training. We 

request ICE provide information about progress in these areas in its 

Corrective Action Plan. 

Recommendation #7: Expand managed care coordinator support to 

detention facilities to improve maintenance of relationships with outside 

care providers. 

Management Comments to Recommendation #7 

DIHS will evaluate expanding the number of managed care coordinators 

that support this program. Under consideration is providing a minimum of 

two managed care coordinators for each of the three regions. This would 

allow for backup should a coordinator be out of the office. It would also 

allow more support to assist the facilities with case management of some 

of the more complicated medical patients. 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 19 
OIG Analysis 

This recommendation is resolved and open. The ICE Corrective Action 

Plan should provide us with detail about specific new responsibilities 

MCCs will be given to nurture and sustain relationships with providers. 

Recommendation #8: Ensure more timely transfer of funds to the 

Financial Services Center to increase compliance with the Prompt 

Payment Act and to decrease interest paid on authorized medical claims. 

Management Comments to Recommendation #8 

ICE managers welcomed this recommendation in our meetings related to 

the draft report. Action on this recommendation includes review of budget 

and financing procedures related to the transfer of needed funds to the 

FSC. 

OIG Analysis 

This recommendation is resolved and open. ICE’s corrective action plan 

should include data showing the amount of interest paid since our 

fieldwork concluded. Policy changes should focus on fuller compliance 

with the Prompt Payment Act. 

Recommendation #9: Create provider education materials to ensure 

better understanding of the ICE detainee health care process and the need 

for accurate and timely submission of claims. 

Management Comments to Recommendation #9 

ICE’s response noted that DIHS will create the recommended training 

materials. 

OIG Analysis 

This recommendation is resolved and open. We require additional details 

on the types of training material created to address this issue. ICE should 

also provide a timeline to show how much new material is planned and 

how it will be made available to providers. 

Recommendation #10: Implement a regional managed care coordinator 

staffing plan and develop supplemental policies that describe the roles and 

responsibilities of these new personnel. 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 20 
Management Comments to Recommendation #10 

ICE’s response focused on future studies regarding the implementation of 

a regional managed care coordinator system. DIHS used regional MCCs 

and the agency remains open to re-implementing that paradigm. 

OIG Analysis 

This recommendation is resolved and open. Although ICE concurred with 

the recommendation, ICE only committed to reevaluate the current model 

and determine the feasibility of reinstituting regional MCCs. It is possible 

that a complete and objective study will reveal costs and benefits that 

argue against our recommended action. In that event, we will close the 

recommendation. In its Corrective Action Plan, ICE should describe the 

methodology and the timeline for the reevaluation analysis. 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 21 
Appendix A 

Purpose, Scope, and Methodology 

We initiated this inspection based on our continued interest in ICE 

detention management operations. We sought to determine whether 

the Treatment Authorization Request process was efficient. Our 

research included legal cases and literature on the health care 

industry and immigration detention. Our review of ICE data 

focused on the 30-month period from October 2006 through March 

2009. 

We conducted 24 interviews, which included MCCs, DIHS 

physicians, and staff in the ICE Office of Professional 

Responsibility and the DHS Office for Civil Rights and Civil 

Liberties. We had a phone interview with experts at the FSC of the 

Department of Veterans’ Affairs in Austin, Texas. We interviewed 

clinical staff at seven detention facilities and had phone 

conversations with five others. The facilities were selected to 

ensure input from geographically diverse locations that had 

submitted a significant number of TARs. 

The seven facilities we visited were: 

•	 Berks County Family Residential Facility, Leesport, 


Pennsylvania
 

•	 El Paso Service Processing Center, El Paso, Texas 

•	 Eloy Contract Detention Facility, Florence, Arizona 

•	 Pinal County Detention Facility, Florence, Arizona 

•	 Port Isabel Service Processing Center, Los Fresnos, Texas 

•	 Willacy Contract Detention Facility, Raymondville, Texas 

•	 York County Prison, York, Pennsylvania 

Our phone conversations were with facility staff at: 

•	 Buffalo Contract Detention Facility, Batavia, New York 

•	 Etowah County Detention Center, Gadsden, Alabama 

•	 Kenosha County Detention Center, Kenosha, Wisconsin 

•	 North Las Vegas Detention Center, North Las Vegas, 

Nevada 

•	 Northwest Detention Center, Tacoma, Washington 

These 12 facilities accounted for 28.7% of TARs submitted in the 

first 6 months of FY 2009 and 20.6% of the TARs submitted 

during the 30-month period of our review. 

We conducted our review between February and June 2009 under 

the authority of the Inspector General Act of 1978, as amended, 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 22 
Appendix A 

Purpose, Scope, and Methodology 

and according to the Quality Standards for Inspections issued by 

President’s Council on Integrity and Efficiency. 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 23 
Appendix B

Mana~ement Comments to the Draft Report

QJjìct 01'"'' "am Sic'L'ft.-'ltH)'

II.S.1L.i~rlll" ,Iiif lL-'e"id St,.rit)'

50012'" Si 'l. SW

W;ishinglmi, DC 20024

u.s. Immigration

and Customs

Enforcement

November 5, 2009

MEMORANDUM FOR: Carlton i. Mann

Offce of Inspector General

FROM: Robert F. De Antonio

Director

Audit Liaison Oflcc

SUBJECT: ICE Response to Offce of Inspector General Draft Report titled, "The

Immigration and Customs Enforcement Process tor Authorizing

Medical Care for Detained Immigrants"

U.S. Immigration and Customs Enforcement (ICE) providcs the following response to the

subject Office of the Inspector General (OIG) dratl report,

010 Reconunendations I: "End or greatly reduce the amount of preauthori:i.ation required under

the Treatment Authorization Request process."

ICE Response to 010 Recommendation i: ICE concurs. The Division of Immigration Health

Services (D1HS) is developing a process that expands the ability for the automatic approval of

some requests by the on-site clinical director or designee. Automatic approval wil save time and

allow faster access to necessary care lor detainees. DIHS is also developing a systein that will

negate the need to submit multiple Treatment Authorization Requests (TARs) for certain

conditions. For example, if a detainee is pregnant, all her prenatal visits, lab WOlk and tests wil

be grouped into one request. There arc many instances where this "grouping" or "bundling" of

services can be utilzed. This wil alleviate the need to submit a TAR for each service, greatly

reducing the number ofT ARs subinitted overalL. D1HS is also exploring other ways to address

this recommendation to realize greater effciencies in providing health services to detainees.

010 Recommendation 2: "Revise the Covered Services Package to provide more guidance on

covcmge policy tor a proccss that minimizes pre-authorization of most services."

The U.S. Immigration and Customs Enforcement Process for

Authorizing Medical Care for Immigration Detainees

Page 24
Appendix B 

Management Comments to the Draft Report 

Subject: ICE Response to 010 Draft Report: "The lnuigration and Customs 

Enforcement Process for Authorizing Medical Care for Detained Inuigrants
 

Page 2 ofJ
 

ICE Response to OiG Recommendation 2: ICE concurs. DIHS has already bcgun this 

proce.qS and expects to have draft guidance prepared by the end of November 2009. The 

new package will milÚmize the need for pre-authorization for a number of serviccs. 

010 Recommendation 3: "Make appropriate policy changes so that managed care 

coordinators are no longer responsiblc for facilties' TARWeb system access and 

password rcset issues." 

ICE Response to OIG Reconunendation 3: ICE concurs. DIHS has already addresscd 

this reconuendation and our Infonnation Technology (IT) personnel now have this 

responsibility. This change was implementcd Jiinc 19, 2009. 

010 Reconuendation 4: "Develop T ARWeb data reporting capabilities that incorporate 

the suggestions of facilities' stalT. 

ICE Response to 010 Reeommendation 4: ICE concurs, DIHS is already working with 

its IT department to revise fields in TARWeb and will review to detemiine the feasibilty 

of implementing these fields. 

oiG Reconunendation5: "Develop a prioritization system in TARWeb for facilities to 

identifY more urgent detainee medical care requests." 

ICE Response to 010 Recommendation 5: ICE coneurs. This would assist in 

identifYing the requests for non-emergency services that are ofa high priority. DlliS is 

willng to cxplore developing a prioritization system to classify these urgent care services 

and to modify the TAR Web system to be able to prioritize and highlight urgent requests. 

010 Recommendation 6: "Devclop policies that fòniialize necessary training and an 

expanded case management role for the managed care coordinators." 

ICE Response to OIG Recommendation 6: ICE concurs. The strength otthe managed 

carc program model is the nurse case inanagers. Therefore, every effort wil be made for 

the staff to be able to keep abreast of the emerging policies and practices in nursing and 

specifically in the case managemcnt field. D1HS will review the feasibility of adding this 

training to their standard recurrent training 1,lan. 

010 Recommendation 7: "Expand managcd care coordinator support to detention 

làcilities to improve maintenance of relationships with outside care providers." 

ICE Response to 010 Reconunendation 7: ICE concurs. DIHS wíl evaluate expanding 

the number of managed care coordinators that support this program. Under considemtion 

is providing a minimum of two managed care coordinators for each of the three regions. 

This would allow for backup should a coordinator be out of the offce. It would also 

The U.S. Immigration and Customs Enforcement Process for
 

Authorizing Medical Care for Immigration Detainees
 

Page 25 
Appendix B

Management Comments to the Draft Report

Subject: ICE Response to OIG Draft Report: "The Immigration and Customs

Enforcement .Process for Authorizing Medical Care for Detained Immigrants

Page 3 of3

allow more support to assist the facilities with case management of some olthe more

complicated medical patients.

010 Recommendation 8: "Ensure more timely transfer of lùnds to the Financial Services

Center to increase eompliance with the Prompt Payment Act and to deercase interest paid

on authorized medical claims."

ICE Response to 010 Recommcndation 8: ICE concurs. ICE will rcview its budget and

financing procedures to ensure that the funding to support processing of claims through

the Veterans Administration is done in a timely manner.

010 Recommendation 9: "Create provider education materials to ensure better

understanding of the ICE detaince health carc process and the need lor accuratc and

timely submission of claims."

ICE Response to 010 Recommendation 9: ICE concurs. DIBS will develop educational

materials and training lòr the providers that delivcr healthcare to the ICE detainees to

help their administrators better understand this process.

010 Recoinmendation 10: "Implement a regional managed care coordinator staffng

plan and develop supplemental policies that describe the roles and responsibilities of

these new persoruieL"

ICE Response to 010 Recommendation 10: ICE concurs. Wc agrec to provide existing

managed coordinators with clarilcation and infonnation about their roles and

rcsponsibilities. The spccific roles and responsibilties for the nurse case managers will

be reviewed and documented in the D1HS policies and standard operating plans as

appropriate. DlHS previously used regional managed care coordinators. DIBS wil

reevaluate that model to determine ifre-implementing it is lèasible and would result in

effciencies being realizcd.

Should you have questions or concerns, please contact Margurite Barnes, 010 portfolio

manager at (202)732-4 I 6 I or bye-mail at M.i.ilrite.Barnesil)i;t,&\l.

The U.S. Immigration and Customs Enforcement Process for

Authorizing Medical Care for Immigration Detainees

Page 26
Appendix C 

Major Contributors to This Report 

Douglas Ellice, Chief Inspector 

Darin Wipperman, Senior Inspector 

Pharyn Smith, Inspector 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 27 
Appendix D 

Report Distribution 

Department of Homeland Security 

Secretary 

Deputy Secretary 

Chief of Staff for Operations 

Chief of Staff for Policy 

Deputy Chiefs of Staff 

General Counsel 

Executive Secretariat 

Director, GAO/OIG Liaison Office 

Assistant Secretary for Office of Policy 

Assistant Secretary for Office of Public Affairs 

Assistant Secretary for Office of Legislative Affairs 

ICE and DRO Liaisons 

Office of Management and Budget 

Chief, Homeland Security Branch 

DHS OIG Budget Examiner 

Congress 

Congressional Oversight and Appropriations Committees, as 

appropriate 

The U.S. Immigration and Customs Enforcement Process for 


Authorizing Medical Care for Immigration Detainees 


Page 28
 
ADDITIONAL INFORMATION AND COPIES 

To obtain additional copies of this report, please call the Office of Inspector General (OIG) at (202) 254-4100, 

fax your request to (202) 254-4305, or visit the OIG web site at www.dhs.gov/oig. 

OIG HOTLINE 

To report alleged fraud, waste, abuse or mismanagement, or any other kind of criminal or noncriminal 

misconduct relative to department programs or operations: 

• Call our Hotline at 1-800-323-8603; 

• Fax the complaint directly to us at (202) 254-4292; 

• Email us at DHSOIGHOTLINE@dhs.gov; or 

• Write to us at: 

DHS Office of Inspector General/MAIL STOP 2600, 

Attention: Office of Investigations - Hotline, 

245 Murray Drive, SW, Building 410, 

Washington, DC 20528. 

The OIG seeks to protect the identity of each writer and caller.