Defense Health Care: Opportunities to Improve Future TRICARE Managed Care Support Contract Transitions
Released: 2019-11-21T00:00:00

Letter

Background

TRICARE T-2017 Contracts and Transition Process

Under T-2017, DHA reduced the number of TRICARE regions by merging the North and South regions to form the East region, which has approximately 6 million beneficiaries, while the West region remained the same with approximately 3.4 million beneficiaries (see figure 1). In July 2016, DHA awarded the East region contract to Humana Government Business, the incumbent South region contractor, and the West region contract to Health Net Federal Services, the incumbent North region contractor. The T-2017 contracts include five 1-year performance periods and are scheduled to expire on December 31, 2022.

As a result of the changes in regional structure, the T-2017 contract transition included a transition from Health Net Federal Services (North region) and Humana Government Business (South region) to Humana Government Business in the East region as well as a transition from UnitedHealth Military & Veterans to Health Net Federal Services in the West Region. The start of the T-2017 transition was initially planned for August 2016, with a health care delivery start date of August 2017. However, due to bid protests filed against each contract, the transition start date was pushed out to January 1, 2017 with a health care delivery start date of October 1, 2017.

To manage the T-2017 transition, DHA assigned individuals to lead the transition in each region, who were responsible for coordinating all major transition activities. The transition leads were supported by other staff, including contracting officers, contracting officer representatives, and subject matter experts. In addition, DHA established an organizational structure comprised of several groups to oversee the T-2017 transition from day-to-day oversight to leadership updates.

The TRICARE Operations Manual, which is part of the managed care support contract, establishes transition guidance that includes requirements for both the incoming and outgoing contractors. The T- 2017 transition guidance focused on the incoming contractors’ readiness to perform in seven critical areas: (1) provider network, (2) referral management, (3) enrollment, (4) medical management, (5) claims processing, (6) customer service, and (7) management.

For the T-2017 transition, DHA introduced two new oversight methods to ensure contractors’ readiness in the seven critical areas prior to the start of health care delivery. These methods and other guidance are outlined in the TRICARE Operations Manual and T-2017 contracts.

The performance readiness validation (PRV) and performance readiness assessment and verification (PRAV)—referred to as PRV/PRAV—tested contractors’ functionality in the seven critical areas outlined in the TRICARE Operations Manual. For the PRV, contractors validated their own readiness for specific requirements within each area. For example, the contractor had to validate that it had a complete provider directory online and operational 60 days prior to the start of health care delivery at a 95 percent accuracy rate. The number of requirements varied by critical area. For the PRAV, DHA subsequently assessed and verified contractors’ validation prior to the start of health care delivery.

DHA also established financial penalties—referred to as transition performance guarantees—for five of the seven critical areas. The T- 2017 contracts specify that if a contractor does not meet a transition- in requirement in any one of these five areas, DHA will assess a financial penalty (see table 1).

In December 2016—prior to the start of the transition—DHA held transition specification meetings with the incoming and outgoing contractors to begin planning critical T-2017 transition activities. The incoming contractors were also required to provide DHA with an integrated master plan and an integrated master schedule outlining processes and specific steps for the transition as well as a risk management plan that identified risks to the successful execution of the contractor’s schedule. Contractors were required to provide weekly updates to DHA on the status of their transition schedule progress.

In April 2018—several months after the transition had ended—DHA produced an “after action” report to identify best practices, lessons learned, and recommendations to improve future TRICARE contract transitions. DHA is currently in the process of developing its fifth generation of contracts, referred to as the T-5 contracts.

TRICARE Select

As required by the NDAA 2017, DHA established a new preferred provider benefit option called TRICARE Select and terminated the TRICARE Standard and Extra benefit options by January 1, 2018. Prior to 2018, beneficiaries primarily had a choice between three basic options— TRICARE Prime (a managed care option), TRICARE Standard (a fee-for- service option), or TRICARE Extra (a preferred provider organization option). The TRICARE Standard and Extra options did not require beneficiaries to enroll. However, beneficiaries who choose the TRICARE Select option must enroll during an annual open enrollment period or within 90 days of experiencing a qualifying life event. Beneficiary cost sharing responsibilities were also modified for the new benefit option.

DHA Delayed Time Frames for Key Transition Activities to Implement TRICARE Select

The implementation of TRICARE Select delayed timeframes for the T- 2017 transition and was the primary challenge of the T-2017 transition, according to DHA and contractor officials. Because the T-2017 contracts were awarded prior to the enactment of the NDAA 2017, DHA had to incorporate TRICARE Select requirements into the ongoing T-2017 transition process, including developing updated guidance for contractors. As a result of the time needed to plan for and implement a new benefit, DHA delayed timeframes for the following key transition activities.

DHA postponed the start of health care delivery by 3 months.

DHA moved the start of health care delivery from October 1, 2017 to January 1, 2018 (see fig. 2). According to DHA officials, DHA made this change to align the start of health care delivery with the implementation of TRICARE Select to minimize the impact that two, successive changes could have had on the continuity of care for beneficiaries. On March 30, 2017—three months into the transition— DHA sent a letter to the contractors informing them of this decision.

DHA also directed its incoming contractors to submit modified transition schedules and risk management plans.

DHA had to delay the start of a planned enrollment freeze and lengthen its duration. According to DHA officials, in a typical transition, DMDC requires 3 to 4 days to make adjustments to beneficiaries’ records in the Defense Enrollment Eligibility Reporting System, including assigning beneficiaries to incoming contractors and regions for the T-2017 contracts. During this time, which is referred to as an enrollment freeze, contractors cannot access this system to process any enrollments. For the T-2017 transition, DHA and DMDC officials stated that, given the termination of two benefit options and the new enrollment requirements for TRICARE Select, DMDC needed additional time to adjust every beneficiary enrollment record (over 9 million). Therefore, DHA delayed the start of the T-2017 enrollment freeze from August to December 2017 and increased its duration from 3 to 4 days to 19 days—December 1-19, 2017 (see fig. 2).

Contractors had less time to process enrollments and make other system changes. Once an enrollment freeze has ended, incoming and outgoing contractors have a designated period of time, referred to as a dual operations period, to process beneficiaries’ enrollments and make other systems changes, such as assigning Prime beneficiaries to a primary care manager (PCM). Due to the extended enrollment freeze, contractors had a shorter dual operations period—less than 2 weeks in December 2017 rather than 6 to 8 weeks beginning in August 2017 (see fig. 2). According to contractors, the shorter dual operations period for T-2017 transition contributed to a backlog of enrollment requests and PCM assignments that they were unable to process prior to the start of health care delivery. To mitigate the financial effect on beneficiaries, DHA issued point of service waivers and waived referral requirements for TRICARE Prime enrollees for both regions and provided an enrollment grace period for beneficiaries so they did not have to pay higher copayments for receiving care from non-network providers or care that was not referred by a PCM.

DHA’s communications to TRICARE beneficiaries were delayed. TRICARE Select complicated and delayed DHA’s communications to beneficiaries about TRICARE program changes, which led to customer service problems after the start of health care delivery. DHA engaged in various efforts to inform beneficiaries of the new changes, such as through website updates, blog posts, and direct mailings. However, DHA’s “after action” report acknowledged that on multiple occasions its communication division posted incorrect information on its website because of changing policy language. In addition, DHA planned to send a direct mailing to beneficiaries to inform them of TRICARE program changes in October 2017. However, DHA and DMDC officials told us that this date was delayed due to the additional time needed to prepare for TRICARE Select. As a result, DHA mailed information to beneficiaries starting in December 2017, and some beneficiaries did not receive this mailing until after the start of health care delivery, according to DHA. An organization representing TRICARE beneficiaries told us that some beneficiaries were unaware of the various benefit changes that went into effect on January 1, 2018 because of inadequate communication from DHA. Contractors also told us that the delayed communication to beneficiaries contributed to the high volume of customer service calls they received after the start of health care delivery.

DHA officials told us that they took several steps to minimize the risks these delays and the implementation of TRICARE Select created, including the use of various transition oversight meetings to discuss and track related challenges. For example, the regional transition management staff participated in a monthly Risk Review Board meeting to discuss concerns related to the schedule of transition activities, such as the impact of TRICARE Select on the time needed for performance testing in critical areas. DHA also discussed transition risks related to TRICARE Select during weekly meetings with contractors throughout the transition. Furthermore, in August 2017, DHA hosted an Enrollment Summit for all stakeholders involved with the transition and implementation of TRICARE Select, where they discussed the schedule of transition steps and the coordination needed to implement the interrelated T-2017 and NDAA 2017 requirements.

In addition, DHA kept contractors informed about TRICARE Select as they developed the related policies. Beginning in June 2017, DHA provided contractors with draft guidance on the new benefit to keep them informed of potential changes and obtain their feedback. According to DHA, this also allowed contractors to plan for and begin implementing the program changes they would be required to make once the policies were finalized. DHA issued the final TRICARE Select policies to its contractors in late October 2017, which left contractors with less than 3 months to implement the finalized changes prior to the start of health care delivery on January 1, 2018. According to DHA officials and contractors, contractors ideally would have had the final TRICARE policies at the start of the 9-to-12 month transition period.

Challenges Experienced during the T-2017 Transition Process Reflect Weaknesses in DHA’s Guidance and Oversight

Lack of Specificity and Accuracy in DHA’s Guidance Contributed to Disagreements between Contractors, Which DHA Failed to Resolve in a Timely Manner

During the T-2017 transition, outgoing and incoming contractors had disagreements over data transfers. According to DHA officials and contractors, DHA’s transition guidance to contractors was not always specific or accurate regarding the amount and type of data to be shared, as well as how these data should be transferred. Furthermore, according to contractors, DHA did not always resolve contractors’ guidance-related disagreements in a timely manner. Contractors said this contributed to delays in implementing some transition steps and problems after the start of health care delivery. DHA faced challenges related to the following data transfer issues:

Referral and authorization data. The contractors in the West region disagreed on how many years of historical referral and authorization data the outgoing contractor would provide the incoming contractor because this was not specified in the guidance, according to the contractors and DHA’s contracting officers. While the contractors in the East region mutually agreed on the years of data to transfer, the West region contractors did not. As a result, the incoming West region contractor reached out to DHA for resolution on August 2, 2017 by letter, and continued to discuss it with DHA officials during weekly meetings, as documented in meeting minutes we reviewed. However, DHA did not address the issue until December 12, 2017, at which point DHA rejected the incoming contractor’s request for additional historical data because the outgoing contractor would not have enough time to provide it by the start of health care delivery on January 1, 2018. The incoming contractor reported that not receiving the anticipated historical referral information contributed to several problems related to referrals after the start of health care delivery. First, it contributed to delays in processing referrals within timeliness standards. Second, the lack of data made it difficult for contractors to help MTFs address customer referral inquiries, which negatively affected the contractor’s relationship with MTFs. Finally, the contractor had limited ability to resolve beneficiaries’ customer service questions related to referrals and had to reissue authorizations for some referrals.

Claims data. The incoming and outgoing West region contractors also disagreed on which elements of claims data needed to be transferred. For example, the incoming contractor requested information from the claims notes section, which the outgoing contractor stated contained some proprietary information. According to the incoming contractor, this section typically contains information important for claims processing, such as medical necessity reviews— medical record reviews to determine that health care services are appropriate for payment. When the outgoing contractor refused to provide the claims notes, the incoming contractor raised the issue several times to DHA during weekly meetings and through letters, as documented in meeting minutes and correspondence we reviewed. However, DHA determined that the outgoing contractor did not need to provide the information requested, as the non-proprietary information was available in other claims data sections. According to the incoming contractor, without access to more detailed historical information from the claims notes, there were instances in which they were unable to adjust payment determinations for certain claims paid prior to transition, which resulted in provider and beneficiary dissatisfaction.

Beneficiary payment information. The incoming contractors faced challenges obtaining payment information for TRICARE beneficiaries who paid their health insurance premiums using credit cards or electronic funds transfers. According to a contracting officer, DHA initially directed the outgoing contractor to transfer beneficiary payment data to the incoming contractor. However, the outgoing contractors told us that they were unable to transfer this data due to banking laws and proprietary information security standards. DHA agreed that the outgoing contractors could not legally transfer this information and resolved the problem by requiring incoming contractors to reach out directly to beneficiaries to obtain the payment information. According to incoming contractor officials, this created additional, unanticipated effort, since they had to contact beneficiaries for this information directly, which diverted transition resources, such as enrollment staff, away from ongoing transition activities. In addition, contractors reported that this put certain TRICARE plan beneficiaries at risk since those who did not resubmit their payment information risked disenrollment and gaps in health care coverage. The contractors and DHA made attempts to notify affected beneficiaries that they needed to contact the contractor to reestablish their automated premium payments. However, approximately 224,000 beneficiaries’ credit card or electronic funds transfer enrollments for premium payments did not continue after January 1, 2018. To give beneficiaries more time to provide this information, DHA provided a 150-day grace period for premium payments. Still, certain beneficiaries were disenrolled from TRICARE plans for failure to establish a recurring form of payment. For example, more than 15,000 beneficiaries were disenrolled in the East region.

In its “after action” report, DHA acknowledged that it did not always provide specific and accurate requirements for data transfers in its transition guidance and that this should be addressed for the next transition. However, the report did not address the difficulties related to resolving contractors’ questions and disagreements on these issues. For example, DHA officials told us that they followed an informal process for tracking and handling issues raised by contractors during the transition, which was explained in the initial transition specifications meeting in December 2016. However, the outgoing and incoming contractors in the West region expressed concerns about this process, explaining that it was difficult to resolve issues, particularly with the amount of time it took for DHA to provide a response, such as with the referral and authorization disagreement. Federal standards for internal control note that an agency should implement control activities through policies, such as by providing guidance with greater specificity for data transfers. These standards also indicate that agencies should remediate deficiencies in a timely manner, such as the prompt resolution of contractors’ guidance-related disputes so as to not disrupt the transition schedule. Without more specific guidance and a process that ensures timely dispute resolution, DHA risks disagreements and delays for future contract transitions, which could hinder health care delivery.

Some of DHA’s Requirements for Determining Contractors’ Readiness for Health Care Delivery Were Not Feasible or Effective

DHA experienced challenges executing its new T-2017 transition oversight methods—PRV/PRAV and performance guarantees—as planned because of fundamental problems with how some requirements were written and the implementation of TRICARE Select. As a result, some of the requirements were not feasible or effective in assessing contractors’ readiness for health care delivery. 1. Certain PRV/PRAV requirements were not feasible as originally written or were not aligned with the corresponding performance guarantee, according to DHA officials. For example, one of the PRV requirements in the critical area of medical management focused on testing the contractors’ web-based systems for exchanging information electronically with the government and providers, but this was not always possible as some information continues to be transferred in hard copy, such as by fax. In addition, the performance guarantee related to provider network development did not align with the corresponding PRV/PRAV requirements. A DHA official told us that aligning the performance guarantee and PRV/PRAV requirements would have resulted in a higher financial penalty for one of the contractors. 2. Contractors noted that some PRV/PRAV requirements were not complete or effective measures of readiness. For example, contractors told us that requirements for claims and referrals did not effectively test the actual volume of administrative tasks that they would have to process after the start of health care delivery. According to the West region contractor, one of the referral PRAV tests required contractors to demonstrate that they could process 300 referrals during DHA’s onsite review, whereas they typically need to process 9,000 referrals a day after the start of health care delivery. 3. The original PRV/PRAV requirements did not account for TRICARE Select, since the contracts were awarded prior to the enactment of the NDAA 2017. Furthermore, due to the delayed and extended enrollment freeze that ended on December 19, 2017, DHA determined that contractors could not demonstrate a fully operational enrollment system sixty days prior to the start of health care delivery as originally required. Additionally, the contractors had limited access to DHA’s information technology systems for testing scenarios that included TRICARE Select. As a result, contractors had to test the majority of the critical areas (claims, enrollment, customer service, and referral management) with information technology systems that did not include TRICARE Select, which was not a true test of their readiness.

To address issues with feasibility and TRICARE Select, DHA modified the PRV requirements for four of the seven critical areas during transition. Specifically, DHA modified all of the PRV requirements for enrollment, referral management, and claims processing as well as one PRV requirement for medical management. DHA also waived the corresponding performance guarantees for the three of these critical areas that had such guarantees (enrollment, referral management, and claims processing). As a result, the contractors were not subjected to financial penalties for not meeting the requirements for these critical areas.

According to DHA officials, the problems with the PRV/PRAV requirements experienced during the T-2017 transition occurred in part because DHA subject matter experts did not review the requirements prior to the release of the final request for proposal. As a result, officials said that it was not until after the contracts were awarded that subject matter experts determined that some of the requirements could not be performed as written. Nonetheless, DHA officials and contractors agreed that the PRV/PRAV processes are good conceptual measures, and should continue to be used for the next transition with improvements to their feasibility and effectiveness. Having subject matter experts review contractors’ readiness requirements for feasibility and contract alignment could help ensure that these requirements are appropriate measures of contractor readiness. In addition, DHA’s “after action” report included feedback and lessons learned from officials and contractors on the PRV/PRAV requirements, which DHA could incorporate for future transitions. Federal standards for internal control state that an agency should internally communicate quality information to enable personnel to perform key roles in achieving objectives. By considering lessons learned from this transition and having subject matter experts review the requirements, DHA would be able to better ensure their metrics are appropriate to prepare contractors for health care delivery.

DHA Required Contractors to Develop Corrective Action Plans to Address Problems after the Start of Health Care Delivery

DHA reported that the T-2017 contractors had overall better performance meeting contract requirements after the start of health care delivery than the two previous generations of TRICARE contracts. Nonetheless, DHA has acknowledged that both T-2017 contractors did experience some problems meeting certain contract requirements. DHA addressed most of these problems through the issuance of corrective action requests, which require the contractors to submit and implement a corrective action plan (see table 2). One exception where DHA did not issue formal corrective action requests was for problems both contractors experienced with processing enrollment backlogs after the start of health care delivery due to the extended TRICARE Select enrollment freeze during transition.

Although most of the problems have been resolved, some problems have persisted into the second year of health care delivery, which DHA and contractors reported they are continuing to address.

Provider directory accuracy. Both contractors have continued to fall short of the requirement for 95 percent accuracy of their online provider directories—problems they also experienced during the transition. As of June 2019, the West region contractor’s directory was 76 percent accurate and the East region’s was 64 percent accurate, according to DHA officials. Both contractors expressed concern about the methodology used to assess their performance against this requirement and stated that the 95 percent standard is too high. DHA officials acknowledged that the 95 percent standard is high and that the provider directory corrective action requests may remain open indefinitely because of the high standard, though they continue to monitor the corrective action requests.

Claims processing timeliness and accuracy. The East region contractor has struggled to meet timeliness and accuracy standards for processing claims. The contract requires contractors to process 98 percent of claims within 30 calendar days of receipt and 100 percent of claims within 90 days with a 98 percent accuracy rate. As of June 2019, the contractor was meeting the 30 day timeliness requirement and was close to meeting the 90 day timeliness requirement (99.99 percent within 90 days). However, the contractor continued to miss the performance standard for claims processing accuracy, according to DHA officials. DHA officials told us that the department had completed multiple on-site reviews and continues to monitor this issue to ensure the contractor improves its ability to meet claims processing standards. Contractor officials acknowledged that they needed to improve their oversight of claims functions and improve training and job aids with their claims processing subcontractor, which was a new partner for their T-2017 contract.

Conclusions

A smooth transition of health care delivery between outgoing and incoming managed care support contractors helps ensure continuity of care for TRICARE beneficiaries. In the most recent transition, the need to concurrently implement a new benefit option—TRICARE Select— presented some unique challenges that delayed the transition timeline and limited DHA’s ability to ensure contractors’ readiness in certain areas. While the implementation of a new benefit option during the T-2017 contract transition was a one-time occurrence, our review highlighted weaknesses in DHA’s transition guidance and oversight that could pose challenges to future contract transitions. By improving the specificity of its transition guidance, revising its process for resolving contractors’ issues, and ensuring review of PRV/PRAV requirements for feasibility and effectiveness, DOD could mitigate these challenges and thus improve future transitions.

Recommendations for Executive Action

We are making the following three recommendations to DHA:

The Director of DHA should define data sharing requirements with more specificity in its transition guidance for outgoing and incoming contractors, including the time period covered and the types of data that must be shared. (Recommendation 1)

The Director of DHA should revise the process the agency has in place for resolving issues raised between contractors during transition to ensure such issues are resolved within time frames that will not adversely affect the transition schedule. (Recommendation 2)

The Director of DHA should incorporate lessons learned from this transition and ensure that subject matter experts review PRV/PRAV requirements and performance guarantees prior to the issuance of the request for proposal for the next transition. These requirements should be reviewed to ensure their feasibility and effectiveness for assessing contractor readiness. (Recommendation 3)

Agency Comments

We provided a draft of this report to DOD for comment. In its written comments, reproduced in appendix I, DOD generally agreed with our findings and concurred with our recommendations. DOD outlined steps the department will take to improve the next TRICARE contract transition, including revising the TRICARE Operations Manual to better define data sharing requirements, developing a process to ensure that all contractor questions are answered appropriately and in a timely manner, and ensuring SMEs are involved in writing the PRV/PRAV requirements. DOD also provided technical comments, which we incorporated as appropriate We are sending copies of this report to the Secretary of Defense and appropriate congressional committees. In addition, the report will be available at no charge on the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact me at (202) 512-7114 or cosgrovej@gao.gov. Contact points for our Office of Congressional Relations and Office of Public Affairs can be found on the last page of this report. Other major contributors to this report are listed in appendix II.

Appendix I: Comments from the Department of Defense

Appendix II: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

In addition to the contact named above, Bonnie Anderson, Assistant Director; Rebecca Abela, Analyst-in-Charge; Cathleen Hamann; Jacquelyn Hamilton; Rianna Jansen; and Vikki Porter made contributions to this report.