	H.R. 4401: The Health Care Infrastructure Investment Act of 2000

H.R. 4401 would establish a Health Care Infrastructure Commission within the Department of Health and Human Services (HHS) to design, construct, and implement an immediate claim, administration, payment resolution, and data collection system that would initially be used by the Medicare part B program.This system would (1) immediately advise each provider and supplier of coverage determination; (2) immediately notify each provider and supplier of any incomplete or invalid claims, including the identification of missing data and coding errors; (3) immediately process clean claimsso that a provider or supplier may provide a written explanation of medical benefits, including costs and coverage to any beneficiary at the point of care; and (4) allow electronic payment of claims for which payment is not made on a periodic payment basis. 4401 would affect FEHBP—the federal government’s health benefits program for employees and retirees—which is run by the Office of Personnel Management (OPM). H.R. 4401 calls for the establishment of an advanced informational infrastructure for “ederal health benefits programs which consists of an immediate claim, administration, payment resolution, and data collection system . Actions to Minimize Risks Necessary Before Developing an Immediate Claim, Administration, Payment Resolution, and Data Collection System

While the development of an immediate claim, administration, payment resolution, and data collection system to be used by the Medicare part B program might be feasible, it would significantly change the government’s current processes because it would require the real-time processing of certain elements of the claims process that are currently performed in batch mode or manually.In the abstract, a real-time Medicare part B claims process could be achievable if appropriate systems development policies and techniques are used. H.R. Developing a Single Real-Time Claims Processing System for Both Medicare Part B and FEHBP Would Be Challenging

Because Medicare part B and FEHBP are substantially different programs, it would be difficult to design and implement a single system to process claims under both programs, as called for by H.R. 4401 requires that (1) OPM adapt the immediate claim, administration, payment resolution, and data collection system for use by the FEHBP and (2) carriers participating in FEHBP use the system to satisfy certain minimum requirements for claim submission, processing, and payment. Although all plans offer inpatient hospital and outpatient medical coverage as well as certain OPM-required services, specific benefits vary. These differences would make it challenging and costly to design and implement a real-time claims processing system for both programs. If a real-time claims processing system is to be developed, as envisioned by the bill, consideration should be given to including key HCFA and carrier officials with health care claims processing, program integrity, and financial management expertise on the commission.
Why GAO Did This Study

Pursuant to a congressional request, GAO discussed the Health Care Infrastructure Investment Act of 2000 (H.R. 4401), which calls for the development of an immediate claim, administration, payment resolution, and data collection system, focusing on the: (1) effects of the system on the claims process of both the Medicare part B program and the Federal Employees Health Benefits Program (FEHBP); and (2) the role and composition of a proposed Health Care Infrastructure Commission.

What GAO Found

GAO noted that: (1) H.R. 4401 would establish an Infrastructure Commission within the Department of Health and Human Services to design, construct, and implement an immediate claim, administration, payment resolution, and data collection system that would initially be used by the Medicare part B program; (2) this system would: (a) immediately notify each provider and supplier of coverage determination; (b) immediately notify each provider and supplier of any incomplete or invalid claims, including the identification of missing data and coding errors; (c) immediately process clean claims so that a provider or supplier may provide a written explanation of medical benefits, including costs and coverage to any beneficiary at the point of care; and (d) allow electronic payment of claims for which payment is not made on a periodic payment basis; (3) one outcome of developing an immediate claim, administration, payment resolution, and data collection system would be faster Medicare part B claims payments; (4) while the development of an immediate claim, administration, payment, resolution, and data collection system to be used by the Medicare part B program might be feasible, it would significantly change the government's current processes because it would require the real-time processing of certain elements of the claims process that are performed in batch mode or manually; (5) H.R. 4401 would also affect FEHBP, which is run by the Office of Personnel Management (OPM); (6) H.R. 4401 requires that: (a) OPM adapt the immediate claim, administration, payment resolution, and data collection system for use by the FEHBP; and (b) carriers participating in FEHBP use the system to satisfy certain minimum requirements for claim submission, processing, and payment; (7) because Medicare part B and FEHBP are substantially different programs, it would be difficult to design and implement a single system to process claims under both programs, as called for by H.R. 4401; (8) although all health plans offer inpatient hospital and outpatient medical coverage as well as certain OPM-required services, specific benefits vary; (9) these differences would make it challenging and costly to design and implement a real-time claims processing system for both programs; and (10) if a real-time claims processing system is to be developed, consideration should be given to including key Health Care Financing Administration (HCFA) and carrier officials with health care claims processing, program integrity, and financial management expertise on the Infrastructure Commission, as well as OPM and providers, since the system would affect HCFA, OPM, and the providers.