Federal and  tribal CHS programs in each of these areas pay for services from external  providers if services are not available directly through IHS-funded  facilities, if patients meet certain requirements, and if funds are available. IHS’s Oversight of Data Collection Does Not Ensure the Accuracy of the Data Used for Estimating CHS Program Need

Due to deficiencies in IHS’s oversight of data collection, the unfunded  services data on deferrals and denials that IHS used to estimate program  need are incomplete and inconsistent. Of the 103 tribal CHS  programs that responded to our survey, 30 indicated that they collected  data on unfunded services and submitted these data to their area offices  in response to IHS’s annual request in fiscal year 2009. IHS officials told us that both deferral and denial data were  used in IHS’s needs assessment. IHS has initiated steps to examine these weaknesses in its current data  and explore other sources of data to estimate CHS program need. Officials indicated that they expected the Workgroup  to issue a final report to the Director for approval by the end of calendar  year 2011. However, as of September 2011, IHS officials told us that  the agency had not determined whether it would make improvements to  the collection of deferral and denial data because it had not determined  how such data would be used if the FDI method is adopted. In addition,  some federal CHS programs reported using problematic funds  management practices. Federal CHS programs we spoke with reported using a variety of  strategies to help patients receive services outside of the CHS program in  order to maximize the care that they could purchase. For example,  strategies noted by some CHS programs included helping patients locate  free or low-cost health care or negotiating reduced rates with providers on  the patient’s behalf. They also suggest significant  inconsistencies in the administration of federal CHS programs. Most Tribal CHS Programs Reported That They Did Not Have CHS Funds Available to Pay for All Services but Many Used Other Strategies to Expand Access to Care

Of the 103 tribal CHS programs that responded to our survey, most  reported they did not have CHS funds available to pay for all services for  patients who otherwise met eligibility and administrative requirements,  with 73 reporting that they depleted their CHS funds at some point during  fiscal year 2009. Forty-six of the 103  tribal CHS programs that responded to our survey reported  supplementing their CHS programs’ funding with tribal funds—funds  earned from tribal businesses or enterprises. Providers stated that these  challenges contributed to patient and provider burdens. IHS officials said that denials may occur for a  patient who has a referral if the patient presented for care at the external  provider before the referral was approved by the CHS program  committee. Eighteen providers noted challenges receiving communications from IHS  about CHS policies and procedures related to payment, including having  had few, if any, formal meetings with program staff and a lack of training  and guidance. Conclusions

IHS’s CHS program serves as an important resource for American Indian  and Alaska Native individuals who need health care services not available  at IHS-funded federal and tribal facilities. As acknowledged by IHS officials,  the complexity of the CHS program makes this communication  particularly important. Recommendations for Executive Action

To develop more accurate data for estimating the funds needed for the  CHS program and improving IHS oversight, we recommend that the  Secretary of Health and Human Services direct the Director of IHS to take  the following eight actions:    ensure that area offices submit data on unfunded services from all  conduct outreach and technical assistance to tribal CHS programs to  encourage and support their efforts to voluntarily provide data that can  be used to better estimate the needs of tribal CHS programs;    develop an annual data reporting template that requires area offices  to report available deferral and denial counts for each federal and  tribal CHS program;    develop a plan and timeline for improving the agency’s deferral and    develop written guidance, provide training, and conduct oversight  activities necessary to ensure unfunded services data are consistently  and completely recorded by federal CHS programs;    develop a written policy documenting how IHS evaluates need for the  CHS program and disseminate it to area offices and CHS programs to  ensure they understand how unfunded services data are used to  estimate overall program needs;    provide written guidance to CHS programs on a process to use when  funds are depleted and there is a continued need for services, and  monitor to ensure that appropriate actions are taken; and    develop ways to enhance CHS program communication with  providers, such as providing regular trainings on patient eligibility and  claim approval decisions to providers. Appendix I: Scope and Methodology

In this report, we examined (1) the extent to which the Indian Health  Service (IHS) ensures the data it collects on unfunded services are  accurate to determine a reliable estimate of contract health services  (CHS) program need, (2) the extent to which federal and tribal CHS  programs report having funds available to pay for contract health  services, and (3) the experiences of external providers in obtaining  payment from the CHS program.
Why GAO Did This Study

The Indian Health Service (IHS), an agency in the Department of Health and Human Services (HHS), provides health care to American Indians and Alaska Natives. When care at an IHS-funded facility is unavailable, IHS's contract health services (CHS) program pays for care from external providers if the patient meets certain requirements and funding is available. The Patient Protection and Affordable Care Act requires GAO to study the adequacy of federal funding for IHS's CHS program. To examine program funding needs, IHS collects data on unfunded services--services for which funding was not available--from the federal and tribal CHS programs. GAO examined (1) the extent to which IHS ensures the data it collects on unfunded services are accurate to determine a reliable estimate of CHS program need, (2) the extent to which federal and tribal CHS programs report having funds available to pay for contract health services, and (3) the experiences of external providers in obtaining payment from the CHS program. GAO surveyed 66 federal and 177 tribal CHS programs and spoke to IHS officials and 23 providers.

What GAO Found

Due to deficiencies in IHS's oversight of data collection, the data on unfunded services that IHS uses to estimate CHS program need were not accurate. Specifically, the data that IHS collected from CHS programs were incomplete and inconsistent. For example, 5 of the 66 federal and 30 of the 103 tribal CHS programs that responded to GAO's survey reported that they did not submit these data to IHS in fiscal year 2009. Also, the format of IHS's annual request has not provided the agency with complete information to determine which programs submitted these data. In addition, individual CHS programs reported inconsistencies in how they recorded information about a specific type of unfunded service that IHS uses in its assessment of need. A reliable estimate of need will require complete and consistent data from each of the individual CHS programs. In November 2010, IHS created a workgroup to examine weaknesses in its current data and explore other sources of data to estimate need. IHS officials expect the workgroup to make a recommendation to the IHS Director by the end of calendar year 2011 that IHS adopt a new method of estimating need. As of September 2011, IHS was continuing to develop this new method and officials indicated that deferral and denial data would continue to be collected until it makes further decisions about its needs assessment methodology. Sixty of the 66 federal and 73 of the 103 tribal CHS programs that responded to GAO's survey reported that in fiscal year 2009 they did not have CHS funds available to pay for all services for which patients otherwise met requirements. Some federal CHS programs reported continuing to approve services for patients when sufficient funds were not available; IHS officials told us they were unaware this practice was occurring. In contrast, other federal CHS programs reported using a variety of strategies to help patients receive services outside of the CHS program in order to maximize the care that they could purchase. For example, some federal CHS programs reported helping patients locate free or low-cost health care. Tribal CHS programs reported using a variety of strategies not available to federal CHS programs. For example, 46 of 103 tribal CHS programs that responded to GAO's survey reported supplementing their CHS programs' funding with tribal funds, which are earned from tribal businesses or enterprises. Most external providers that GAO interviewed described challenges in the CHS program payment process. For example, when patients presented for emergency services, 13 of 23 providers reported challenges determining which services would be approved for payment because, unlike other payers, they cannot check a patient's eligibility electronically. Eighteen providers noted challenges receiving communications from IHS about CHS policies and procedures related to payment, including having had few, if any, formal meetings with program staff and a lack of training and guidance. IHS officials acknowledged that the complexity of the CHS program makes provider education important. Most providers said that these challenges contributed to patient and provider burden.

What GAO Recommends

GAO recommends that HHS direct IHS to ensure unfunded services data are accurately recorded, CHS program funds management is improved, and provider communication is enhanced. HHS noted how IHS would address the recommendations; describing the proposed new method to estimate need. IHS's steps will address some recommendations, but immediate steps are needed to improve the collection of unfunded services data to determine program need.