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Claims Forms

The principal anguish for CHAMPUS beneficiaries concerns that bureaucratic revenge, the claims form. There will be found in the hearings copies of the claims form and instruction for its use used by the Social Security Administration for medicare and copies of the claims forms and instructions used by the CHAMPUS program. A comparison of these side by side is very informative.

The social security program covers approximately 19 million people. If they can handle that load with such a simplified, easy to read form and clear instruction sheet, it would seem that the OCHAMPUS could improve its own complex forms and its totally inadequate instructions for their use.

The subcommittee appreciates that the problem is complicated somewhat by different categories of beneficiaries and that some information is required of military beneficiaries which would not be required by the social security program. However, the subcommittee believes that the CHAMPUS claims form could be simplified, and it recommends that such a restructuring be undertaken.

What especially concerns the subcommittee is that some useful suggestions made in the Army Audit Agency's excellent study have not been initiated. The Columbia University study also pointed to the claims form as a major problem area.

The Columbia study comments as follows on the present form: A first priority in this area should be re-examination of the CHAMPUS claims forms. The staff study encountered widespread criticism of the forms among personnel of the fiscal agents, mostly concerning what the critics alleged to be undue complexities in forms design.

The subcommittee would note that the Army Audit Agency study was completed in February 1969, and commented on the fact that in mid-1968, 2 years after the revised program went into effect, a serious concern was expressed over the high rate of claims being returned. The study pointed out that during the first 9 months of 1968, 24 percent of all claims were returned for further information. Even that late in the program, it seemed to be an excessively high rate of return and with obvious confusion and red tape for beneficiaries, fiscal agents, and OCHAMPUS alike.

The subcommittee was dismayed, therefore, to learn that at the present time roughly the same rate of return exists—about 22 percent. General Hackett testified, “I attribute it largely to the carelessness with which claims forms are submitted *** the claims form, if examined closely, is really not too complicated as far as the beneficiaries are concerned.”

The subcommittee cannot agree with General Hackett that the problem is due to beneficiary carelessness. The subcommittee does not believe that judgment can be made that military families are, as a whole, more careless in submitting Government forms than beneficiaries under the social security program. Nor does the subcommittee believe that all of the complexity of the CHAMPUS claim form is due to requirements of the law. In this regard, the Army Audit Agency, which was aware of the law, pointed out some unnecessary duplication, such as the requirement for both social security number and serial number of the sponsor and an identification number of the beneficiary. There was no explanation as to why these numbers could not be the same.

The subcommittee also noted that the Army Audit Agency report indicated that the Command—that is, the OCHAMPUS—concurred in its findings that the claims form was too complex and difficult to understand and should be simplified. However, the OCHAMPUS was quoted in the Army Audit Agency report as indicating "corrective action would be deferred pending certain events and other considerations." Upon inquiry, the subcommittee determined that the "events and other considerations” referred to the hope of the CHAMPUS office that certain legislative proposals that have been brought forth would be enacted which would, in turn, make the need for certain information unnecessary. It is significant that apparently none of the legislative proposals reached the stage where they were supported by the Department of Defense and submitted to the Congress. The subcommittee would say that waiting for hoped for legislation was not adequate reason for delay in taking corrective action. Information Program: A Vacuum in Initiative and Responsibility

The subcommittee would now like to discuss what it believes is the single most important reason why many military dependents are not getting the benefit of the expanded dependent medical care program. They don't know about it. They don't know about the benefits because they haven't been properly informed.

The subcommittee was shocked to learn of surveys showing that more than 40 percent of married enlisted personnel were unaware of the CHAMPÚS. Those who are aware of it seem not to have clear information on how it works.

This lack of a proper information program has been compounded by inexcusable delays in publishing appropriate information and has continued although the problem was clearly spotlighted some time

ago.

All three of the studies of the CHAMPUS cited in this report concluded that one of the major problems facing the CHAMPUS administration was the lack of an adequate information program-both for the users and providers of care.

The Columbia University report comments on this point as follows:

The problems of inadequate knowledge and understanding of the CHAMPUS among persons who are eligible for its benefits can for the most part he traced to a vacuum in initiative and responsibility for beneficiary education which has existed in the administrative structure.

The Columbia report comments further on the fragmented and unsystematic approach to CHAMPUS information and the needs in terms of the population being dealt with as follows:

The beneficiary who unwittingly pays his doctor in excess of a reasonable charge for a service, the beneficiary who shows up among the 45 percent of eligible persons who are unaware of the program's existence these cases are in their several ways byproducts of a fragmented and unsystematic approach to the special problem under the CHAMPUS of explaining a relatively complex program to a client population which is for the most part young and relatively inexperienced in health insurance matters.

The Army Audit Agency report commented more than 15 months ago as follows:

The lack of understanding of the uniformed services health benefits progran by beneficiaries contributed to an increase in complaints, inquiries, and claims returned for additional information. Lack of program understanding was due principally to (i) late and incomplete distribution of an official pamphlet explaining major program changes made in 1966, (ii) uncontrolled issuance of many supplemental publications, and (iv) lack of formal training for counselors at military installations and information centers. We believe that dissemination of the authoritative and understandable information necessary to program understanding can only be assured by placing responsibility for the operation of a continuing information and education program in a single organization * * *

The Army Surgeon General's management study commented on this point:

The Office of the Civilian Health and Medical Program of the Uniformed Seryices, although relieved of responsibility for preparing the information pamphlet, did not aggressively pursue an information program which should have been a massive undertaking in news media, radio, television, as well as an official information program within each uniformed service.

The Surgeon General's management study recommended a full-time information program. The Columbia University study recommended a more attractive pamphlet, a better distribution system, and the use of other communications media. The Army Audit Agency report stressed that the beneficiaries needed a single publication that was both clearly written and authoritative. All of the studies pointed out that not only was the material provided inadequate, but the distribution system was limited or faulty.

The Army Audit Agency report was issued in February 1969. The Surgeon General's report was made in March 1968. The subcommittee was surprised by the indication in these studies that the lack of information was still so blatant 2 years after the expanded program went into effect. Survey of Beneficiary Knowledge

Concern over this matter led the Army staff in May 1968 to conduct a survey (OPOPM Report No. 38–68-E, “Survey Estimate of Knowledge of Coverage Under the CHAMPÚS, as Experienced by Army Male Personnel").

Briefly, the results of the survey indicated that 31 percent of the married officers queried were unaware of the CHAMPUS and that 52 percent were aware of the program but did not possess any detailed information regarding it. Of the married enlisted men queried, 44 percent said they were unaware of the CHAMPUS and another 44 percent said that, although they were aware of the CHAMPUS, they did not possess any detailed information regarding it.

It is pitiable that as many as one-third of young enlisted families, those who need the program most, may be entirely unaware of the benefits that Congress has voted for them. The Left Hand Syndrome

The subcommittee found the problem had not been solved, although it had existed for 2 years. In seeking to determine why, the subcommittee learned that little, if any, improvement has been made in the situation since the last of the cited reports was issued.

The chronology of indecision on the CHAMPUS information program is appalling.

The subcommittee found a lack of clear understanding as to who was responsible for the information program at all. CHAMPUS had been given by the Surgeon General the responsibility of developing an information program but insisted that the responsibility of inform

ing beneficiaries was in the hands of the individual services. The services, when they attempted to work on the problem at all, often put out their own information which was frequently incomplete or incorrect and often distributed on a hit-or-miss basis. The Defense Department had an office responsible for preparing material but seemed to feel that the decision on when and how much distribution belonged to somebody else.

There was available a booklet on the CHAMPUS program. It began by telling people that it was neither authoritative or comprehensive and referring them to service regulations. These service regulations would be difficult for most dependents to procure and impossible for most of them to understand. The Army Audit Agency called the booklet inadequate.

A revised version of the booklet was issued. The subcommittee determined that the manuscript for this revised edition of the CHAMPIS booklet (DOD P3B) was prepared by the Army Surgeon General's office and forwarded to the Office of Information for the Armed Forces, Department of Defense. Upon examining the actions taken, the subcommittee found that 10 months elapsed between the time the manuscript was first forwarded to DOD and the time that the revised booklet was first made available for distribution. The job of putting the pamphlet into final form belonged to the Head of Information for the Armed Forces, Mr. John Broger. The subcommittee inquired as to why the revised pamphlet was not given priority status and was informed that it was. When we asked how long it might have taken if it had not been expedited, we were given the straight-faced answer that it might have taken 16 months.

The subcommittee also found that the existence of the serious information problem as regards the CHAMPUS was unknown to the head of the Office of Information for the Armed Forces even though the Army surveys on the matter had received publicity in the press. During the subcommittee hearings, Mr. Broger replied to questions on this point as follows:

Mr. Ford. Have you been aware of these surveys about people not knowing that the program was going on? Mr. BROGER. I have not.

Mr. FORD. You mean when the Army takes the survey and when they find out half of the people don't know a program exists, no one is responsible for disseminating the information to overcome the lack of knowledge?

Mr. BROGER. I was not aware.

Mr. FORD. Then there is a much greater communications breakdown than you realize. Mr. BROGER. I realize it now.

The extent of the communications gap is further illustrated by the fact that 1 year before the subcommittee held its hearings, the Deputy Assistant Secretary of Defense for Health Affairs sent a memorandum to the Deputy Assistant Secretary of Defense for Special Manpower Programs (the deputy who then had jurisdiction over the Office of Information for the Armed Forces) regarding the revised CHAMPI'S pamphlet which stated in part:

We have been experiencing administrative difficulties in the operation of the CHAMPUS over the past year, some of which are attributable to a lack of or incomplete information regarding the program on the part of many of our 6 million beneficiaries.

Distribution of information material has never been adequate and has sometimes been delayed for budgetary purposes. For its 6 million beneficiaries, the Department of Defense made available a total of some 400,000 booklets on the CHAMPUS program. By contrast, for disseminating information on its program which has 19 million eligible beneficiaries, the Social Security Administration distributed hundreds of millions of information booklets.

The subcommittee recommends that the Department of Defense issue directives clearly setting out the responsibility by agency for the various functions associated with the CHAMPUS information program and providing authority for one official to make sure these functions are carried out. The subcommittee further recommends that a vigorous information program be pursued on a continuing basis with improved written material and use of all available media, including Armed Forces radio and TV facilities, troop newspapers, as well as the public press, and with distribution of material sufficient to make an authoritative pamphlet available for each military family as well as for those engaged in providing care.

Part and parcel of an adequate information program is the provision of trained counselors to assist beneficiaries at military installations and information centers. Physicians' Fees

Initially the CHAMPUS program paid doctors according to what was known as “negotiated fee schedules—fixed rates.” These were periodically negotiated and agreed upon by OCHAMPUS and the medical societies in the various States. During the period January 1967 through May 1968, the CHAMPUS phased in a different concept known as the “reasonable fee concept." This is based on the usual and customary fee charged by a doctor as compared to the prevailing fee charged by physicians in his particular geographic area. In switching to this system, the CHAMPUS program was following the lead of the social security medical program.

The Columbia University study pointed out that the social security medical program is so large and, thus, its impact so great that - CHAMPUS would have difficulty maintaining support for a system counter to that of the social security program.

Under the reasonable fee concept, OCHAMPUS does not control the fees. The concept allows the level of charges to rise to whatever prevails in a given area.

The initial impact of the new concept was a large increase to CHAMPUS for physicians' services. Between July 1966 and July 1967, payments by OCHAMPUS for surgical procedures rose by amounts ranging from 5 percent in North Dakota to as much as 53 percent in New Jersey. The median increase was 24 percent.

The big initial increase was due in large part to the fact that charges took a big jump from the earlier negotiated fee schedule to the usual and customary level of fees. However, an additional upward trend can

be expected because the level of physicians' fees has risen appreciably - in recent years.

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