Report to Congressional Committees 

United States General Accounting Office 

GAO 

July 2003 DEFENSE HEALTH 

CARE 

Oversight of the 

TRICARE Civilian 

Provider Network 

Should Be Improved 

GAO-03-928 
For the 8.7 million TRICARE beneficiaries, DOD relies on the civilian 

provider network to supplement health care delivered by its military 

treatment facilities. To ensure the adequacy of the civilian provider 

network, DOD has standards for the number and mix of providers, both 

primary care and specialists, necessary to satisfy TRICARE Prime 

beneficiaries’ needs. In addition, DOD has standards for appointment wait, 

office wait, and travel times to ensure that TRICARE Prime beneficiaries 

have timely access to care. DOD has delegated oversight of the civilian 

provider network to the local level through regional TRICARE lead agents. 

DOD’s ability to effectively oversee the TRICARE civilian provider network 

is hindered in several ways. First, the measurement used to determine if 

there is a sufficient number and mix of providers in a geographic area does 

not always account for the total number of beneficiaries who may seek care 

or the availability of providers. This may result in an underestimation of the 

number of providers needed in an area. Second, incomplete contractor 

reporting on access to care makes it difficult for DOD to assess compliance 

with these standards. Finally, DOD does not systematically collect and 

analyze beneficiary complaints, which might assist in identifying 

inadequacies in the civilian provider network. However, DOD has tools, 

such as surveys of network providers and automated reporting systems 

which, while not designed specifically for monitoring the civilian provider 

network, could, if modified, improve DOD’s ability to oversee the network. 

DOD and its contractors have reported that a lack of providers in certain 

geographic locations, low reimbursement rates, and administrative 

requirements contribute to potential civilian provider network inadequacy. 

DOD and contractors have reported long-standing provider shortages in 

some geographic areas. In areas where DOD determines that access to care 

is severely impaired, DOD has the authority to increase reimbursement 

rates. Since 2002, DOD has used its reimbursement authority to increase 

rates in Alaska and Idaho in an attempt to entice more providers to join the 

network. DOD officials told us that the contractors have achieved some 

success in recruiting additional providers by using this authority. 

Additionally, civilian providers have expressed concerns that TRICARE’s 

reimbursement rates are generally too low and administrative requirements 

too cumbersome. However, while reimbursement rates and administrative 

requirements may have created provider dissatisfaction, it is not clear how 

much this has affected civilian provider network adequacy except in limited 

geographic locations, because the information contractors provide to DOD is 

not sufficient to measure network adequacy. 

Testifying before Congress in 2002, 

military beneficiary groups 

described problems accessing care 

from TRICARE’s civilian medical 

providers. Providers also testified 

on their dissatisfaction with the 

TRICARE program, specifying low 

reimbursement rates and 

administrative burdens. 

The Bob Stump National Defense 

Authorization Act of 2003 required 

GAO to review the oversight of the 

TRICARE network of civilian 

providers. Specifically, GAO 

describes how the Department of 

Defense (DOD) oversees the 

adequacy of the civilian provider 

network, evaluates DOD’s 

oversight of the civilian provider 

network, and describes the factors 

that have been reported to 

contribute to network inadequacy. 

GAO analyzed TRICARE Prime—

the managed care component of 

TRICARE. To describe and 

evaluate DOD’s oversight, GAO 

reviewed and analyzed information 

from reports on network adequacy 

and interviewed DOD and 

contractor officials in 5 of 11 

TRICARE regions. 

GAO recommends that DOD 

improve its oversight of the civilian 

provider network by ensuring 

sufficient information is reported 

and by exploring options for 

evaluating beneficiary complaints 

and improving provider survey 

data. DOD concurred with the 

recommendations. 

www.gao.gov/cgi-bin/getrpt?GAO-03-928.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Marjorie Kanof 

at (202) 512-7101. 

Highlights of GAO-03-928, a report to 

congressional committees 

July 2003 

DEFENSE HEALTH CARE 

Oversight of the TRICARE Civilian 

Provider Network Should Be Improved 
Page i GAO-03-928 TRICARE Civilian Provider Network 

Letter 1

Results in Brief 3

Background 4

DOD Has Standards for Network Adequacy and Requires 

Contractors’ Compliance 8

DOD’s Oversight of the Civilian Provider Network Has 

Weaknesses, But Additional Tools May Help 10

DOD and Contractors Report Three Factors That May Contribute 

to Civilian Provider Network Inadequacy 14

New Contracts May Address Some Network Concerns, But May 

Create Others 17

Conclusions 18

Recommendations for Executive Action 19

Agency Comments and Our Evaluation 19

Appendix I Scope and Methodology 21 

Appendix II Comparison of Current and Future TRICARE 

Regions 23 

Appendix III Comments from the Department of Defense 25 

Appendix IV GAO Contacts and Staff Acknowledgments 29 

GAO Contacts 29

Acknowledgments 29

Figures 

Figure 1: Areas of the United States with a TRICARE Network of 

Civilian Providers 7

Figure 2: Current TRICARE Regions 23

Figure 3: Future TRICARE Regions After TNEX Implementation 24

Contents 
Page ii GAO-03-928 TRICARE Civilian Provider Network 

Abbreviations 

ATC Access To Care Project 

DOD Department of Defense 

EWRAS Enterprise Wide Referral and Authorization System 

HCSDB Health Care Survey of DOD Beneficiaries 

JCAHO Joint Commission on Accreditation of Healthcare 

 Organizations 

MOAA Military Officers Association of America 

MTF military treatment facility 

NCQA National Committee for Quality Assurance 

PCM primary care manager 

TMA TRICARE Management Activity 

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Page 1 GAO-03-928 TRICARE Civilian Provider Network 

July 31, 2003 

The Honorable John Warner 

Chairman 

The Honorable Carl Levin 

Ranking Minority Member 

Committee on Armed Services 

United States Senate 

The Honorable Duncan L. Hunter 

Chairman 

The Honorable Ike Skelton 

Ranking Minority Member 

Committee on Armed Services 

House of Representatives 

The primary mission of TRICARE, the Department of Defense’s (DOD) 

health care system, is to provide care for eligible active duty personnel, 

retirees, and dependents. These beneficiaries, currently numbering more 

than 8.7 million, can receive their care through military hospitals and 

clinics called military treatment facilities (MTFs) or through TRICARE’s 

civilian provider network. The civilian provider network is developed by 

managed care support contractors and is designed to complement the 

availability of care offered by MTFs.1

DOD faces new challenges in ensuring that the TRICARE civilian provider 

network can provide adequate access to care that complements the 

capabilities of MTFs. In 2003, DOD intends to award new contracts for the 

delivery of care in the civilian provider network because the current 

contracts will expire. As a result, the providers who choose to participate 

in the network may change, while those who remain will operate under 

new policies and procedures. During this transition, DOD is still 

responsible for ensuring that the civilian provider network provides 

adequate access to care, even if beneficiaries must change providers. 

 1

MTFs supply most of the health care services TRICARE beneficiaries receive. The military 

health system was funded at about $26.4 billion for fiscal year 2003. Approximately 20 

percent of this amount, $5.2 billion, was budgeted for the TRICARE civilian provider 

network. 

United States General Accounting Office

Washington, DC 20548 
Page 2 GAO-03-928 TRICARE Civilian Provider Network 

TRICARE also faces beneficiary and provider dissatisfaction with the 

existing civilian provider network. During April 2002 testimony before the 

Subcommittee on Personnel of the House Armed Services Committee, 

beneficiary groups described problems with access to care from 

TRICARE’s civilian providers. Also, providers testified about their 

dissatisfaction with the TRICARE program, specifying low reimbursement 

rates and administrative burdens. 

In response to these concerns, the Bob Stump National Defense 

Authorization Act of 2003 required that we review DOD’s oversight of the 

adequacy of the TRICARE civilian provider network.2

 As agreed with the 

committees of jurisdiction we focused on DOD’s oversight and did not 

assess the adequacy of the network. Also, we analyzed TRICARE Prime, 

the managed care component of the TRICARE health delivery system. 

Specifically, we agreed to (1) describe how DOD oversees the adequacy of 

the civilian provider network, (2) evaluate DOD’s oversight of the 

adequacy of the civilian provider network, (3) describe the factors that 

have been reported to contribute to network inadequacy, and (4) describe 

how the new contracts might affect network adequacy. We testified before 

the Subcommittee on Total Force of the House Committee on Armed 

Services on March 27, 2003, about our findings at that time.3

To describe and evaluate DOD’s oversight of the TRICARE civilian 

provider network, we reviewed and analyzed information from five 

network adequacy reports submitted between June and October of 2002. 

We reviewed at least one report from each of the contractors who develop 

and maintain the network of providers to augment the care provided by 

MTFs. We also interviewed DOD regional officials, known as lead agents, 

and MTF officials from 5 of 11 TRICARE regions. In addition, we 

interviewed officials from each of the four contractors. As part of our 

assessment of DOD’s oversight, we reviewed surveys of beneficiaries and 

providers, as well as DOD data collection initiatives that could be used by 

DOD to oversee its civilian provider network. We did not validate the data 

in the surveys or collection initiatives. We also interviewed officials at 

TRICARE Management Activity (TMA) in Falls Church, Va., the office with 

responsibility for ensuring that DOD health policy is implemented, and 

 2

Pub. L. No. 107-314, § 712, 116 Stat. 2458, 2588 (2002). See also, H.R. Rep. No. 107-436. 

3

U.S. General Accounting Office, Defense Health Care: Oversight of the Adequacy of 

TRICARE’s Civilian Provider Network Has Weaknesses, GAO-03-592T (Washington, D.C.: 

Mar. 27, 2003).
Page 3 GAO-03-928 TRICARE Civilian Provider Network 

officials at TMA-West, the office that carries out contracting functions, 

including monitoring the civilian contracts and writing the requests for 

proposals for the future contracts. To describe factors that may contribute 

to network inadequacy, we interviewed DOD, contractor, and professional 

health association officials. In addition, we met with groups representing 

TRICARE beneficiaries to discuss their concerns. Finally, we reviewed 

DOD’s request for proposals for the new health care contracts and 

interviewed DOD and contractor officials to determine how the new 

contracts might affect network adequacy. Appendix I contains more 

details about our scope and methodology. We conducted our work from 

June 2002 through July 2003 in accordance with generally accepted 

government auditing standards. 

To oversee the adequacy of the civilian provider network, DOD has 

standards that are designed to ensure that the network has a sufficient 

number and mix of providers, both primary care and specialists, to satisfy 

TRICARE Prime beneficiaries’ needs. In addition, DOD has standards for 

appointment wait, office wait, and travel times that are designed to ensure 

that TRICARE Prime beneficiaries have adequate access to care. DOD has 

delegated oversight of the civilian provider network to lead agents, who 

are responsible for ensuring that these standards have been met. 

DOD’s ability to effectively oversee the TRICARE civilian provider 

network is hindered in several ways. First, the measurement used to 

determine if there is a sufficient number of providers for the beneficiaries 

in an area does not always account for the actual number of beneficiaries 

who may seek care or the availability of providers. In some cases, this may 

result in an underestimation of the number of providers needed in an area. 

Second, incomplete contractor reporting on access to care makes it 

difficult for DOD to assess compliance with these standards. Finally, DOD 

does not systematically collect and analyze beneficiary complaints, which 

might assist in identifying inadequacies in the TRICARE civilian provider 

network. However, DOD has surveys of TRICARE beneficiaries and 

network providers and automated reporting systems on appointments and 

referrals that, while not designed specifically for monitoring the civilian 

provider network, could provide information and potentially improve 

DOD’s ability to oversee the civilian provider network. 

DOD and its contractors have reported three factors that may contribute 

to potential civilian provider network inadequacy: lack of providers in 

certain geographic locations, low reimbursement rates, and administrative 

requirements. DOD and contractors have reported long-standing provider 

Results in Brief 
Page 4 GAO-03-928 TRICARE Civilian Provider Network 

shortages in some geographic areas because providers in certain areas 

may refuse to join any network. In areas where DOD determines that 

access to care is severely impaired, DOD has the authority to increase 

reimbursement rates. Since 2002, DOD has used this authority to increase 

reimbursement rates in Alaska and Idaho in an attempt to remedy such 

provider shortages. DOD told us that the contractors have achieved some 

success in recruiting additional providers by using this authority. 

Additionally, civilian providers have expressed concerns about TRICARE’s 

reimbursement rates being too low and administrative requirements being 

too cumbersome. However, while reimbursement rates and administrative 

requirements may have created dissatisfaction among providers, it is not 

clear that these factors have resulted in insufficient numbers of providers 

in the civilian network because the information contractors provide to 

DOD is not sufficient to measure network adequacy. 

The new contracts, which DOD expects to award during the summer of 

2003, may result in improved civilian provider network participation by 

addressing some network providers’ concerns about administrative 

requirements. For example, the new contracts may simplify requirements 

for provider credentialing and referrals, two administrative procedures 

providers have complained about. However, according to contractors, the 

new contracts may also create requirements that could discourage 

provider participation, such as the new requirement that all network 

claims submitted by civilian providers be filed electronically. Currently, 

only about 25 percent of such claims are submitted electronically. 

We are recommending that the Secretary of Defense direct the Assistant 

Secretary of Defense for Health Affairs to improve DOD’s oversight of the 

civilian provider network by ensuring sufficient information is reported to 

assess network adequacy and by exploring options for evaluating 

beneficiary complaints and improving provider survey data. In 

commenting on a draft of this report, DOD concurred with the report’s 

recommendations. 

TRICARE has three options for its eligible beneficiaries: 

• TRICARE Prime, a program in which beneficiaries enroll and receive care 

in a managed network similar to a health maintenance organization; 

• TRICARE Extra, a program in which beneficiaries receive care from a 

network of preferred providers; and 

• TRICARE Standard, a fee-for-service program that requires no network 

use. 

Background 
Page 5 GAO-03-928 TRICARE Civilian Provider Network 

The programs vary according to the amount beneficiaries must contribute 

toward the cost of their care and according to the choices beneficiaries 

have in selecting providers. In TRICARE Prime,4

 the program in which 

active duty personnel generally must participate, the beneficiaries must 

select a primary care manager (PCM)5

 who either provides care or 

authorizes referrals to specialists. Most beneficiaries who enroll in 

TRICARE Prime select their PCMs from MTFs, while other enrollees select 

their PCMs from the civilian provider network. Regardless of their 

status—military or civilian—PCMs may refer Prime beneficiaries to 

providers in either MTFs or TRICARE’s civilian provider network.6

Both TRICARE Extra and TRICARE Standard require copayments, but 

beneficiaries do not enroll with or have their care managed by PCMs. 

Beneficiaries choosing TRICARE Extra use the same civilian provider 

network available to those in TRICARE Prime, and beneficiaries choosing 

TRICARE Standard are not required to use providers in any network. 

TRICARE Extra and Standard beneficiaries may receive care at an MTF 

when space is available. 

The Office of the Assistant Secretary of Defense for Health Affairs (Health 

Affairs) establishes TRICARE policy and has overall responsibility for the 

program. TMA, under Health Affairs, is responsible for awarding and 

monitoring the TRICARE contracts. DOD has delegated oversight of the 

civilian provider network to regional TRICARE lead agents. The lead agent 

for each region coordinates the services provided by MTFs and civilian 

network providers. The lead agents respond to direction from Health 

Affairs, but report directly to their respective Surgeons General. In 

overseeing the network, lead agents have staff assigned to MTFs to 

provide the local interaction with contractor representatives and respond 

to beneficiary complaints as needed and report back to the lead agent. 

 4

Out of more than 8.7 million eligible beneficiaries, nearly half are enrolled in TRICARE 

Prime. 

5

A primary care manager is a provider or team of providers at an MTF or a provider in the 

civilian network to whom a beneficiary is assigned for primary care services when he or 

she enrolls in TRICARE Prime. Enrolled beneficiaries agree to initially seek all 

nonemergency, nonmental health care services from these providers. 

6

DOD’s policy is to optimize the use of the MTF. Accordingly, when a referral for specialty 

care is made by a civilian PCM, the MTF retains the “right of first refusal” to accommodate 

the beneficiary within the MTF or refer the beneficiary to the civilian provider network for 

the needed medical care. 
Page 6 GAO-03-928 TRICARE Civilian Provider Network 

Currently, DOD employs four civilian health care companies or 

contractors that are responsible for developing and maintaining the 

civilian provider network that complements the care delivered by MTFs. 

The contractors recruit civilian providers into a network of PCMs and 

specialists who provide care to beneficiaries enrolled in TRICARE Prime. 

Contractors are required to establish and maintain the network of civilian 

providers in the following locations: all catchment areas,7

 base 

realignment and closure sites,8

 other contract-specified areas, and 

noncatchment areas where a contractor deems it cost effective. These 

locations are called prime service areas. In the remaining areas, a network 

is not required. (See fig. 1.) 

 7

Catchment areas are geographic areas determined by the Assistant Secretary of Defense 

for Health Affairs that are defined by five-digit zip codes, usually within an approximate 40-

mile radius of MTFs with inpatient care. 

8

Base realignment and closure sites are military installations that have been closed or 

realigned as the result of decisions made by the Commissions on Base Realignment and 

Closure. 
Page 7 GAO-03-928 TRICARE Civilian Provider Network 

Figure 1: Areas of the United States with a TRICARE Network of Civilian Providers 

Note: Shaded areas represent zip codes in which there was a TRICARE network of civilian providers 

as of May 2003. 

Source: DOD.
Page 8 GAO-03-928 TRICARE Civilian Provider Network 

This network of civilian providers also serves as the network of preferred 

providers for beneficiaries who use TRICARE Extra. In 2002, contractors 

reported that the civilian provider network included about 37,000 PCMs 

and 134,000 specialists. 

The contractors are also responsible for ensuring adequate access to 

health care, referring and authorizing beneficiaries for health care, 

educating providers and beneficiaries about TRICARE benefits, ensuring 

that providers are credentialed, and processing claims. In their network 

agreements with civilian providers, contractors establish reimbursement 

rates and certain requirements for submitting claims. Reimbursement 

rates cannot be greater than Medicare rates unless DOD authorizes a 

higher rate. 

DOD’s four contractors manage the delivery of care to beneficiaries in 11 

TRICARE regions. DOD is currently analyzing proposals to award new 

civilian health care contracts, and when they are awarded in 2003, DOD 

will reorganize the 11 regions into 3—North, South, and West—with a 

single contract for each region. Contractors will be responsible for 

developing a new civilian provider network that will become operational 

in April 2004. Under these new contracts DOD will continue to emphasize 

maximizing the role of MTFs in providing care. See appendix II for maps 

depicting the current and future regions. 

DOD has standards intended to ensure that its civilian provider network 

enhances and supports the capabilities of the MTFs in providing care to 

millions of TRICARE Prime beneficiaries. DOD requires that contractors 

have a sufficient number and mix of providers, both primary care and 

specialists, to satisfy the needs of beneficiaries enrolled in the Prime 

option. Specifically, it is the responsibility of the contractors to ensure that 

each prime service area in the network has at least one full-time equivalent 

PCM for every 2,000 TRICARE Prime enrollees and one full-time 

equivalent provider (both PCMs and specialists) for every 1,200 TRICARE 

Prime enrollees.9

 9

In addition, all four contractors generally follow the Graduate Medical Education National 

Advisory Committee recommendation for determining the specialty mix requirements for 

their network. 

DOD Has Standards 

for Network 

Adequacy and 

Requires Contractors’ 

Compliance 
Page 9 GAO-03-928 TRICARE Civilian Provider Network 

In addition, DOD has access-to-care standards that are designed to ensure 

that Prime beneficiaries receive timely care from providers.10 Under these 

standards 

• appointment wait times shall not exceed 24 hours for urgent care, 1 week 

for routine care, or 4 weeks for well-patient and specialty care; 

• office wait times shall not exceed 30 minutes for nonemergency care; and 

• travel times shall not exceed 30 minutes for routine care and 1 hour for 

specialty care.11

Lead agents are responsible for ensuring that the civilian provider network 

meets these standards so that all TRICARE Prime beneficiaries in their 

region have adequate access to health care. To do so, lead agents told us 

they use network adequacy reports that contractors provide each quarter 

as the primary tool to oversee the network. According to DOD’s operations 

manual, these reports are to contain information on the status of the 

network, such as the number and type of specialists; data on adherence to 

the access standards; a list of civilian and military primary care managers; 

and the number of their enrollees. The reports may also contain 

information on steps contractors have taken to address any network 

inadequacies. 

However, because the reporting requirements do not specify a standard 

process for collecting information on network adequacy, contractors vary 

in how they obtain this information. For example, lead agents told us that 

one contractor conducts visits of providers’ offices to review appointment 

wait times, while another contractor uses an automated appointment 

tracking system to collect this information. 

Lead agents told us they also rely on beneficiary complaints to oversee the 

adequacy of the civilian provider network. Beneficiaries may complain 

directly to DOD, the contractor, lead agent, or MTF. DOD officials said 

that when they receive a beneficiary complaint, they direct the complaint 

to either the contractor, lead agent, or MTF, depending on the subject of 

the complaint. 

 10DOD does not specify access standards for eligible beneficiaries who do not enroll in 

TRICARE Prime. However, DOD requires that contractors provide information and/or 

assist all beneficiaries—regardless of which option they choose—in finding a participating 

provider in their area. 

1132 C.F.R. § 199.17(p)(5)(i), (ii), (iv) and (v) (2002). 
Page 10 GAO-03-928 TRICARE Civilian Provider Network 

In addition to these tools, lead agents periodically monitor contractor 

compliance by reviewing performance related to specific contract 

requirements, including requirements related to network adequacy. Lead 

agents also told us they periodically schedule reviews of special issues 

related to network adequacy, such as conducting telephone surveys of 

providers to determine whether they are accepting TRICARE Prime 

patients. In addition, lead agents stated they meet regularly with MTF and 

contractor representatives to discuss network adequacy. 

If lead agents determine that the network is inadequate, the lead agents or 

TMA may issue enforcement actions to encourage contractors to address 

deficiencies in their region. However, lead agents told us that few 

enforcement actions have been issued. During our review, three 

enforcement actions related to network adequacy were open for the five 

regions we visited.12 Lead agents said they prefer to address deficiencies 

informally rather than take formal actions, particularly in areas where they 

do not believe the contractor can correct the deficiency because of local 

market conditions. For example, rather than taking a formal enforcement 

action, one lead agent worked with the contractor to arrange for a 

specialist from one area to travel to another area periodically. 

DOD’s ability to effectively oversee the TRICARE civilian provider 

network is hindered by (1) flaws in its required provider-to-beneficiary 

ratios, (2) incomplete reporting on beneficiaries’ access to providers, and 

(3) the absence of a systematic assessment of complaints. Although DOD 

has required the network to meet established ratios of providers to 

beneficiaries, the ratios may underestimate the number of providers 

needed in an area. Similarly, although DOD has certain requirements 

governing Prime beneficiary access to available providers, the information 

reported to DOD on this access is often incomplete—making it difficult to 

assess compliance with the requirements. Finally, when beneficiaries 

complain about availability or access in the network, these complaints can 

be directed to different DOD entities, with no guarantee that the 

complaints will be compiled and analyzed in the aggregate to identify 

possible trends or patterns and correct network problems. However, DOD 

has existing surveys and automated reporting systems that, while not 

 12All three enforcement actions were for lack of available providers in certain geographical 

areas. For example, there were shortfalls of orthopedic surgeons and neurosurgeons in 

Spokane, Washington. 

DOD’s Oversight of 

the Civilian Provider 

Network Has 

Weaknesses, But 

Additional Tools May 

Help 
Page 11 GAO-03-928 TRICARE Civilian Provider Network 

designed specifically for monitoring the civilian provider network, could 

provide valuable information and potentially improve DOD’s ability to 

oversee the civilian provider network. 

The provider-to-beneficiary ratios contractors report to DOD for a prime 

service area do not always accurately reflect the potential health care 

workload for that area or the provider capability to deliver the care. In 

some cases, the provider-to-beneficiary ratios underestimate the number 

of providers, particularly specialists, needed in an area. This 

underestimation occurs because in calculating the ratios, some 

contractors do not include the total number of Prime enrollees within the 

area. Instead, in some areas contractors base their ratio calculations on 

the total number of beneficiaries enrolled with civilian PCMs and do not 

count beneficiaries enrolled with PCMs in MTFs. The ratio is most likely to 

result in an underestimation of the need for providers in areas in which the 

MTF is a clinic or small hospital with a limited availability of specialists. 

For example, the Air Force clinic at Grand Forks, N. Dak. has few 

specialists on staff and must rely on the civilian provider network for a 

large proportion of specialist care. In fiscal year 2002, 90 percent of its 

specialist appointments were referred to the network. In contrast, a large 

MTF, such as Wright Patterson Medical Center in Dayton, Ohio, has many 

specialist providers on staff and referred only 2 percent of its specialty 

appointments to the civilian provider network during fiscal year 2002. 

Incorporating MTF provider capability and the total number of Prime 

enrollees into the network assessment would give DOD a more complete 

and accurate assessment of the adequacy of the network for a 

geographical area. 

Moreover, in reporting whether the network meets the established ratios, 

contractors do not make the same assumptions about the level of 

participation on the part of civilian network providers. Contractors 

generally assume that between 10 to 20 percent of their providers’ 

practices are dedicated to TRICARE Prime beneficiaries. Therefore, if a 

contractor assumes 20 percent of all providers’ practices are dedicated to 

TRICARE Prime rather than 10 percent, the contractor will need half as 

many providers in the network in order to meet the prescribed ratio 

standard. These assumptions may or may not be accurate, and the 

assumptions have a significant effect on the number of providers required 

in the network. 

Provider-to-Beneficiary 

Ratios May Not Account 

for Actual Number of 

Beneficiaries or 

Availability of Providers 
Page 12 GAO-03-928 TRICARE Civilian Provider Network 

In the network adequacy reports we reviewed, the contractors did not 

always report all the information required by DOD to assess compliance 

with the access standards. Specifically, for the network adequacy reports 

we reviewed from 5 of the 11 TRICARE regions, we found that contractors 

reported less than half of the required information on access standards for 

appointment wait, office wait, and travel times. Some contractors reported 

more information than others, but none reported all the required access 

information. Contractors said they had difficulties in capturing and 

reporting information to demonstrate compliance with the access 

standards. They stated that it was not practical or feasible to document 

every appointment and office wait time because some beneficiaries make 

their own appointments directly and provider offices are spread 

throughout the geographic area. 

Most of the DOD lead agents we interviewed told us that because 

information on access standards is not fully reported, they monitor 

compliance with the access standards by reviewing beneficiary 

complaints. Lead agents and contractors said such complaints may include 

a beneficiary’s inability to get an appointment, having to drive long 

distances for care, or a provider not accepting new TRICARE Prime 

patients. Because beneficiary complaints are received through numerous 

venues, often handled informally on a case-by-case basis, and not centrally 

evaluated, it is difficult for DOD to assess the extent of any systemic 

access problems. Separately, TMA has a database of complaints that 

includes some complaints about access to care. TMA has received these 

complaints either directly, through DOD’s beneficiary survey, or from 

letters sent by beneficiaries to their congressional representatives. 

However, the usefulness of the database is limited because it does not 

capture complaints sent to MTFs, lead agents, or contractors. 

While contractor and lead agent officials told us they have received few 

complaints about network access problems, this small number of 

complaints could indicate either an overall satisfaction with care or a 

general lack of knowledge about how or to whom to complain. 

Additionally, a small number of complaints, particularly when spread 

among many sources, limits DOD’s ability to identify any specific trends of 

systemic problems related to network adequacy within TRICARE. 

The next generation of contracts, called TNEX, may result in a more 

structured approach to collecting complaint information when 

implemented in 2004. Under TNEX, the civilian provider network must be 

accredited in each region by a nationally recognized accrediting 

Information Reported on 

Access Standards Was 

Incomplete 

Beneficiary Complaints 

Are Not Systematically 

Collected and Evaluated 
Page 13 GAO-03-928 TRICARE Civilian Provider Network 

organization, such as the National Committee for Quality Assurance 

(NCQA) or the Joint Commission on Accreditation of Healthcare 

Organizations (JCAHO). These organizations typically require procedures 

for addressing beneficiary complaints. For example, NCQA guidance 

requires procedures for registering, responding to, and investigating 

complaints. It also requires documentation of actions taken to address 

complaints. JCAHO guidance has similar requirements. Such procedures 

could provide DOD with a basic structure that in turn could lead to a more 

systematic means of collecting and evaluating complaint data at the prime 

service area and regional levels. 

DOD has some tools that, while not designed specifically for monitoring 

the civilian provider network, could be useful for oversight. For example, 

the Health Care Survey of DOD Beneficiaries (HCSDB) could be used as a 

source of information for overseeing civilian provider network adequacy 

at the national level.13 This quarterly survey contains specific questions on 

all beneficiaries’ experiences related to access to care.14 For example, our 

analysis of the 2000 HCSDB data for all Prime beneficiaries receiving care 

from civilian providers indicates that over one-third of these beneficiaries 

waited more than DOD’s standard of 1 day for access to a provider for an 

illness or an injury. However, the survey’s sample design does not 

generally allow for assessing the adequacy of the civilian provider network 

in most prime service areas and the survey’s response rate of 35 percent 

further limits its usefulness.15

In addition to DOD’s beneficiary survey, contractors conduct surveys of 

providers that could assist in DOD’s oversight of the civilian provider 

network. These surveys are intended to assess providers’ satisfaction with 

contractors’ performance and other TRICARE requirements. However, 

 13This survey was required by the National Defense Authorization Act for Fiscal Year 1993, 

Pub. L. No. 102-484, § 724, 106 Stat. 2315, 2440 (1992). 

14These questions ask how many days a beneficiary had to wait to see a provider for regular 

or routine care and how long they had to wait to receive treatment for an injury or illness, 

among other things. Also, DOD recently added questions to the survey specifically aimed at 

beneficiaries receiving care from civilian providers. These questions ask how difficult it 

was to obtain care and locate a doctor, and whether a civilian provider had left the 

network. 

15Even though DOD samples 180,000 beneficiaries annually, the 35 percent response rate 

reduces the sample to about 63,000. As a result the survey estimates may be biased if those 

who responded to the survey are not representative of the entire surveyed population. 

Potential Network 

Oversight Tools 
Page 14 GAO-03-928 TRICARE Civilian Provider Network 

these surveys have very low response rates, ranging from 4 to 19 percent, 

and in some cases they reflect unrepresentative samples of providers. For 

example, one contractor surveyed only those providers who participated 

in a contractor-sponsored seminar. Also, we found considerable variation 

among the survey instruments, with some assessing provider satisfaction 

more thoroughly than others. Despite these weaknesses, if improved, the 

surveys could reveal concerns providers may have about participating in 

the TRICARE network. This in turn could help DOD address these 

concerns and mitigate problems that might affect the adequacy of the 

network. 

In addition to these existing surveys, DOD is piloting two initiatives for 

collecting information on meeting access standards that could help in the 

oversight of network adequacy. The first, the Enterprise Wide Referral and 

Authorization System (EWRAS), which is currently being tested in the 

Washington D.C. area, captures information on specialty care 

appointments in MTFs and information on some specialty care 

appointments in the civilian provider network. DOD officials said they 

expect EWRAS to be fully implemented in Spring 2004. The second 

initiative, the Access to Care (ATC) Project, gathers information on 

appointments and specialty referrals at or originating from MTFs. 

Specifically, it captures data on whether beneficiaries had a referral, 

declined an appointment that was available, cancelled an appointment, or 

left without being seen. It also records the average number of days 

between when the appointment was made and when the beneficiary was 

seen, as well as clinic cancellations and future appointments. This 

information can help indicate the extent to which MTFs are meeting the 

appointment wait-time access standards. Although the ATC Project is 

currently being piloted at four MTFs, a similar system, if modified to 

accommodate the requirements of the contractors for the civilian provider 

network, could provide valuable information on appointment wait time 

standards—information that is necessary for overseeing the adequacy of 

the network. 

DOD and its contractors have reported three factors that may contribute 

to potential civilian provider network inadequacy: lack of providers in 

certain geographic locations, low reimbursement rates, and administrative 

requirements. First, DOD and contractors have reported regional 

shortages for certain types of specialists in rural areas. For example, they 

reported shortages for endocrinologists in the Upper Peninsula of 

Michigan, dermatologists in New Mexico, and neurologists and allergists in 

Mountain Home, Idaho. Additionally, in these instances, TRICARE officials 

DOD and Contractors 

Report Three Factors 

That May Contribute 

to Civilian Provider 

Network Inadequacy 
Page 15 GAO-03-928 TRICARE Civilian Provider Network 

and contractors have reported difficulties in recruiting providers into the 

TRICARE Prime network because in some areas providers, notably 

specialists, will not join managed care programs. For example, contractor 

network data indicate that there have been long-standing specialist 

shortages in TRICARE in areas such as Alaska or eastern New Mexico, 

where the lead agent stated that the providers in those locations have 

repeatedly refused to join any managed care network. 

There are certain geographic locations in which DOD has confirmed 

shortages of providers and has raised TRICARE’s reimbursement rates as 

a means of remedying such shortages. Although by statute DOD generally 

cannot pay TRICARE network providers more than they would be paid 

under the Medicare fee schedule,16 DOD may make payments of up to 115 

percent of the Medicare fee to ensure the availability of an adequate 

number of qualified healthcare providers.17 In 2000, DOD increased 

reimbursement rates in rural Alaska in an attempt to entice more 

providers to join the network. Similarly, in 2002, DOD increased 

reimbursement rates for the rest of Alaska, and in 2003, DOD increased the 

rates for selected specialists in Idaho to address documented network 

shortcomings. These three instances are the only times DOD has used its 

authority to pay above the Medicare rate in order to address local area 

provider shortages,18 and the increases have had mixed success. In 2001, 

for instance, we found that the 2000 rate increase in rural Alaska had not 

increased provider participation.19 On the other hand, DOD officials told us 

that with the 2002 increase in Alaska and the 2003 increase in Idaho, 

contractors were experiencing some success in recruiting providers in 

those areas. According to DOD officials, for example, six neurosurgeons in 

Boise, Idaho agreed to join the network, eliminating the neurosurgeon 

shortfall in that prime service area. In Alaska, DOD officials reported that 

 1610 U.S.C. § 1079(h)(1) (2000). 

1710 U.S.C. § 1097b (2000). 

18DOD officials told us that all requests received by Health Affairs to increase rates have 

been approved. Additionally, there are two other instances in which DOD increased its 

reimbursement rates above Medicare’s, but these increases did not address local area 

shortages. In 1997, DOD increased national reimbursement rates for obstetrical care. In 

April 2002, DOD adopted a policy that will authorize a 10 percent bonus payment to 

selected TRICARE providers working in medically underserved areas as defined by the 

Health Resources and Services Administration, consistent with Medicare payment policy. 

DOD plans to implement the bonus payment in July 2003. 

19U.S. General Accounting Office, Defense Health Care: Across-the-Board Physician Rate 

Increase Would Be Costly and Unnecessary, GAO-01-620 (Washington, D.C.: May 24, 2001). 
Page 16 GAO-03-928 TRICARE Civilian Provider Network 

since the reimbursement rate increased, providers for radiology, thoracic 

surgery, pediatrics, and other specialties have stated they will participate 

in TRICARE. 

The general levels of TRICARE’s reimbursement rates are another factor 

that DOD and contractor officials told us may contribute to civilian 

provider network inadequacy. Specifically, according to contractor 

officials, civilian network providers have expressed concerns about the 

decline in Medicare fees in 2002 and the potential for further reductions, 

which they have said will affect their participation in the network. In 

addition, there have been reported instances in which groups of providers 

have banded together and refused to accept TRICARE Prime patients due 

to their concerns with low reimbursement rates. One contractor identified 

low reimbursement rates as the most frequent cause of provider 

dissatisfaction. In addition to provider complaints, beneficiary advocacy 

groups, such as the Military Officers Association of America (MOAA), have 

cited instances of providers refusing care to beneficiaries because of low 

reimbursement rates. However, while TRICARE’s reimbursement rates 

may have created dissatisfaction among providers, it is not clear how 

much this has affected civilian provider network adequacy except in 

limited geographic locations, because the information contractors provide 

to DOD is not sufficient to measure network adequacy. Additionally, there 

are indications that reimbursement rates have little influence on providers’ 

decisions to leave the TRICARE network. Data from one contractor 

indicated that out of the 2,156 providers who left the network between 

June 2001 and May 2002, 900 providers cited reasons for leaving and only 

10 percent of these cited reimbursement rates as a reason for leaving the 

network. 

Contractors report that providers have also expressed dissatisfaction with 

some TRICARE administrative requirements, such as credentialing and 

preauthorizations and referrals—but the effect of these requirements on 

civilian provider network adequacy is also unclear. For example, many 

providers have complained about TRICARE’s credentialing requirements. 

In TRICARE, a provider must get recredentialed every 2 years, compared 

to every 3 years for the private sector. Providers have said that this places 

cumbersome administrative requirements on them. 

Another widely reported concern about TRICARE administrative 

requirements relates to preauthorization and referral requirements. 

Civilian PCM providers are required to get preauthorizations from MTFs 

before referring patients for care. While preauthorization is a standard 

managed care practice, providers complain that obtaining 
Page 17 GAO-03-928 TRICARE Civilian Provider Network 

preauthorization adversely affects the quality of care provided to 

beneficiaries because it takes too much time. In addition, civilian PCMs 

have expressed concern that they cannot refer beneficiaries to the 

specialist of their choice because of MTFs’ “right of first refusal” that gives 

an MTF discretion to care for the beneficiary or refer the care to a civilian 

provider. Nevertheless, there are not direct data confirming that 

administrative burdens translate into widespread civilian provider 

network inadequacies. Further, when reviewing one contractor’s survey of 

providers who left the network, we found that only 1 percent of providers 

responding cited administrative burdens as a factor. 

DOD’s new contracts for providing civilian health care, called TNEX, may 

address some network concerns raised by providers and beneficiaries, but 

may create other areas of concern. Because the new contracts had not yet 

been finalized as of June 2003, the specific mechanisms DOD and the 

contractors will use to ensure network adequacy are not known. Under 

TNEX, DOD plans to retain the requirement that the civilian provider 

network complement the clinical services provided by MTFs; the access 

standards for appointment and office wait times, as well as travel-time 

standards; and the periodic reporting on the adequacy of the network. 

However, the requirement to use provider-to-beneficiary ratios to measure 

network adequacy will be eliminated, although such ratios may be used 

during the network accreditation process. 

Further, TNEX contains a provision intended to encourage contractors to 

develop an adequate civilian provider network. This provision states that 

at least 96 percent of contractor referrals shall be to a MTF or network 

provider with an appointment available within the access standards. 

Failure to achieve the 96 percent standard will affect contractors 

financially. 

TNEX may reduce the administrative burden related to provider 

credentialing and patient referrals. Currently, civilian network providers 

must follow TRICARE-specific requirements for credentialing. In contrast, 

TNEX will allow network providers to be credentialed through a nationally 

recognized accrediting organization. DOD officials stated this approach is 

more in line with industry practices. Patient referral procedures will also 

change under TNEX. Referral requirements will be reduced, but the MTFs 

will still retain the right of first refusal. 

On the other hand, TNEX may be creating a new administrative concern 

for contractors and providers by requiring that all network claims 

New Contracts May 

Address Some 

Network Concerns, 

But May Create 

Others 
Page 18 GAO-03-928 TRICARE Civilian Provider Network 

submitted by civilian providers be filed electronically.20 In fiscal year 2002, 

only 25 percent of processed claims were submitted electronically.21

Contractors stated that such a requirement could discourage providers 

from joining or staying in the network because providers may not be 

willing to modify their systems to submit electronic claims for a small 

volume of TRICARE beneficiaries. DOD states that electronic filing will 

reduce claims-processing costs. 

DOD spends over $5 billion a year for health care delivered by the network 

of civilian providers to complement care provided in the MTFs; however, 

DOD has exercised limited oversight of the adequacy of the civilian 

provider network. The information DOD relies on to assess the network 

does not always accurately reflect the actual numbers of beneficiaries or 

availability of providers. Further, the contractors do not report 

comprehensive data on the network’s compliance with DOD’s access 

standards, which are key benchmarks in assessing network adequacy. This 

information will be important as DOD oversees the transition to the new 

health care delivery contracts. 

Incorporating data on the numbers and types of providers in the MTFs and 

the total number of beneficiaries enrolled in TRICARE Prime would give 

DOD a more accurate and comprehensive report of the potential workload 

the civilian provider network faces in a prime service area and the 

adequacy of the number of PCMs and specialists to deliver that care. 

Similarly, more thorough reporting on beneficiaries’ access to care within 

the standard time frames and development of a more systematic means of 

collecting and evaluating complaint data would help DOD’s oversight of 

the ability of the civilian provider network to deliver timely care to 

beneficiaries. Further, with improvements in response rates and provider 

representation, the civilian provider satisfaction surveys could also be 

useful in identifying actions DOD and the contractors could take to 

address provider concerns and ensure network stability. 

 20The Health Insurance Portability and Accountability Act of 1996 included provisions for 

the establishment of standards and requirements for the electronic transmission of health 

information. Pub. L. No. 104-191, § 262, 110 Stat. 1936, 2021. Effective October 16, 2003, 

Medicare claims generally must be submitted electronically. 

21This percentage does not include pharmacy claims or claims for care provided to 

Medicare-eligible beneficiaries under TRICARE For Life. 

Conclusions 
Page 19 GAO-03-928 TRICARE Civilian Provider Network 

To improve DOD’s oversight of the civilian provider network, we 

recommend that the Secretary of Defense direct the Assistant Secretary of 

Defense for Health Affairs to 

• ensure that MTF capabilities and all enrolled Prime beneficiaries in prime 

service areas are accounted for when assessing and documenting the 

adequacy of the civilian provider network; 

• ensure that the information reported on the required access standards is 

sufficient and reliable; 

• explore ways to ensure that beneficiary complaints are systematically 

evaluated and used to oversee the civilian provider network; and 

• explore options for improving the civilian provider surveys so that the 

results of the surveys could be useful to DOD and the contractors in 

identifying civilian provider concerns and developing actions that might 

mitigate concerns and help ensure the adequacy of the civilian provider 

network. 

DOD provided written comments on a draft of this report. (See app. III.) 

DOD concurred with the report’s recommendations. 

In its written comments, DOD stressed that strong oversight of the civilian 

provider network is necessary and should be continuously monitored for 

improvements. DOD said that the implementation of TNEX will address 

many of the points raised in our report. DOD said TNEX will enhance the 

reporting of information about network adequacy as well as provide 

powerful financial incentives for contractors to optimize the direct care 

system, maximize the extent of civilian provider networks, and achieve the 

highest level of beneficiary satisfaction. However, since the TNEX 

contracts have not been finalized as of July 2003, it is too early to assess 

whether the contracts will result in improved oversight. 

In its written comments DOD also said that the report title might mislead 

some into concluding that we found the TRICARE network to be 

inadequate. As we noted in the draft report, we did not assess the 

adequacy of the civilian provider network but focused our work on DOD’s 

oversight of the network. We believe the title of the report reflects that 

focus. 

DOD also provided technical comments, which we incorporated into the 

report as appropriate. 

Recommendations for 

Executive Action 

Agency Comments 

and Our Evaluation 
Page 20 GAO-03-928 TRICARE Civilian Provider Network 

We are sending copies of this report to the Secretary of Defense, 

appropriate congressional committees, and other interested parties. 

Copies will also be made available to others upon request. In addition, the 

report is available at no charge on the GAO Web site at 

http://www.gao.gov. If you or your staff have questions about this report, 

please contact me at (202) 512-7101. Other contacts and staff 

acknowledgments are listed in appendix IV. 

Marjorie E. Kanof 

Director, Health Care—Clinical 

 and Military Health Care Issues 
Appendix I: Scope and Methodology 

Page 21 GAO-03-928 TRICARE Civilian Provider Network 

To describe and evaluate DOD’s oversight of the adequacy of the civilian 

provider network, we reviewed and analyzed the information in the 

quarterly network adequacy reports submitted by each contractor. We 

identified the requirements for the content of these adequacy reports 

based upon the general requirements in the TRICARE Operations Manual 

and the additional requirements in contractors’ Best and Final Offers. We 

reviewed the contents of five of the contractors’ quarterly network 

adequacy reports, submitted between June 2002 and October 2002, and 

compared them to the applicable reporting requirements. Each report was 

evaluated for compliance regarding the provider-to-beneficiary ratios and 

the access-to-care standards. 

Because DOD has delegated the oversight of the network to the regional 

lead agents, we discussed civilian provider network oversight with 

officials in 5 of the 11 TRICARE regions—Northeast, Mid-Atlantic, 

Heartland, Central, and Northwest. To discuss network management, we 

interviewed officials from the four contractors—HealthNet, Humana, 

Sierra, and TriWest—that are responsible for developing and maintaining 

the provider network that augments care provided by DOD’s MTFs. 

Because concerns regarding network adequacy may also be identified at 

the local level, we met with lead agent and contractor officials at MTFs in 

each of the regions we visited. Finally, we interviewed officials at TMA in 

Falls Church, Va., the office that is responsible for ensuring that DOD 

health policy is implemented, and officials at TMA-West in Aurora, Colo., 

the office that carries out contracting functions, including monitoring the 

civilian contracts and writing the request for proposals for the future 

contracts. 

As part of our assessment of DOD’s oversight, we also reviewed surveys of 

beneficiaries and providers, as well as DOD data collection initiatives as 

potential tools for overseeing DOD’s civilian provider network, but did not 

validate the data in the surveys or collection initiatives. Using annual data 

from the 2000 HCSDB, we analyzed beneficiaries’ responses to access-tocare questions for those who were enrolled in Prime and received most of 

their health care in the civilian provider network. We examined the results 

of access-to-care questions based on whether or not these beneficiaries 

were seen within the TRICARE access-to-care standards. Because we 

included only Prime beneficiaries who received care in the civilian 

provider network, our analysis of access to care does not reflect the entire 

survey sample. To examine the provider surveys as potential oversight 

tools, we obtained and reviewed each contractor’s 2001 provider survey 

and assessed the survey’s response rate, sample selection, and the 

Appendix I: Scope and Methodology 
Appendix I: Scope and Methodology 

Page 22 GAO-03-928 TRICARE Civilian Provider Network 

instrument itself. We also discussed DOD initiatives underway and being 

tested with cognizant officials to assess their potential as oversight tools. 

To describe factors that may contribute to network inadequacy, we 

interviewed and obtained documentation from DOD and contractor 

officials regarding current network inadequacies, including their location, 

duration, and the type of specialty needed. We also obtained provider 

termination reports from three of the four contractors,1

 which described 

providers’ reasons for leaving the network. To further explore DOD’s 

response to civilian provider concerns regarding rates, we interviewed 

DOD officials on the use of their authority to raise reimbursement rates. 

We also interviewed officials from the American Medical Association, The 

Military Coalition, the MOAA, the National Association for Uniformed 

Services, and the National Veteran’s Alliance to supplement data on the 

possible causes of network inadequacy. 

Finally, we reviewed DOD’s request for proposals for the future contracts 

and interviewed DOD and contractor officials to describe how the new 

contracts might affect network adequacy. 

We conducted our work from June 2002 through July 2003 in accordance 

with generally accepted government auditing standards. 

 1

One contractor does not collect data on provider terminations. 
Appendix II: Comparison of Current and 

Future TRICARE Regions 

Page 23 GAO-03-928 TRICARE Civilian Provider Network 

The shaded areas in figure 2 represent the 11 current TRICARE geographic 

regions. The shaded areas in figure 3 represent the 3 planned TRICARE 

geographic regions under the TNEX contracts expected to be awarded in 

2003. 

Figure 2: Current TRICARE Regions 

Appendix II: Comparison of Current and 

Future TRICARE Regions 

Mid-Atlantic

Southeast

Gulfsouth

Southwest

Central

Southern

California

Golden

Gate

Northwest

Alaska (Northwest) Hawaii Pacific

Northeast

Heartland

Source: DOD.
Appendix II: Comparison of Current and 

Future TRICARE Regions 

Page 24 GAO-03-928 TRICARE Civilian Provider Network 

Figure 3: Future TRICARE Regions After TNEX Implementation 

West

South

Alaska (West)

North

Hawaii (West)

Source: DOD.
Appendix III: Comments from the Department 

of Defense 

Page 25 GAO-03-928 TRICARE Civilian Provider Network 

Appendix III: Comments from the 

Department of Defense 
Appendix III: Comments from the Department 

of Defense 

Page 26 GAO-03-928 TRICARE Civilian Provider Network 
Appendix III: Comments from the Department 

of Defense 

Page 27 GAO-03-928 TRICARE Civilian Provider Network 
Appendix III: Comments from the Department 

of Defense 

Page 28 GAO-03-928 TRICARE Civilian Provider Network 
Appendix IV: GAO Contacts and Staff 

Acknowledgments 

Page 29 GAO-03-928 TRICARE Civilian Provider Network 

Kristi Peterson, (202) 512-7951 

Allan Richardson, (404) 679-1863 

In addition to those named above, contributors to this report were Louise 

Duhamel, Marc Feuerberg, Krister Friday, Gay Hee Lee, John Oh, and 

Marie Stetser. 

Appendix IV: GAO Contacts and Staff 

Acknowledgments 

GAO Contacts 

Acknowledgments 

(290203) 
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