Defense Health Agency: Improved Oversight of Contractors Needed to Better Ensure the Quality of TRICARE Network Providers

What GAO Found

The Department of Defense's (DOD) Defense Health Agency (DHA) oversees TRICARE, its regionally structured health care program, and the managed care support contractors for the two U.S. TRICARE regions—East and West. DHA requires the contractors to verify the credentials of TRICARE providers prior to allowing them in the network and at least every 3 years thereafter. This includes querying federal databases, such as the National Practitioner Data Bank, that contain information about adverse actions taken against providers, some of which may be disqualifying. The TRICARE contractors can delegate these responsibilities for verifying providers' credentials to other entities.

GAO reviewed a nongeneralizable sample of 100 TRICARE network provider credentials files and found that the TRICARE contractors generally adhered to 12 selected procedures when credentialing providers from 2018 through 2023. However, the adherence rate was lower for some procedures GAO reviewed. For example, one contractor did not always document verification that the providers in GAO's review were not listed in a federal database of providers excluded from participating in federal programs. Overall, GAO found that about half of the files it reviewed with at least one deficiency were credentialed by delegated entities, and that DHA does not have a mechanism to assess contractors' oversight of delegated entities.

GAO also compared the full list of 1.1 million TRICARE providers to the database of excluded providers and reviewed a sample of 42 TRICARE network providers reported to the National Practitioner Data Bank. GAO found six providers in the TRICARE network that should have been ineligible to participate. (See figure.) As of June 2024, of the six providers in GAO's review found ineligible to participate, two providers in the database of excluded providers had been removed from the TRICARE network, one provider in the National Practitioner Data Bank had left the network, and the other three providers' licenses were no longer restricted.

Results of GAO Comparison of TRICARE East and West Provider Network Lists Against Databases for Ineligible Providers, by Database and TRICARE Contractor (2023)

Source: GAO analysis. | GAO-24-106434

GAO also found that TRICARE contractors credentialed an additional nine providers who had previous DHA adverse actions taken against them. GAO found that DHA (1) has not established policy on whether and when to exclude providers with DHA adverse actions from the TRICARE network, and (2) lacks a mechanism to inform contractors about these actions. Without such clarification and information, DHA may be placing TRICARE beneficiaries at risk for receiving care that does not meet DOD's quality and safety standards by allowing these providers in the network.

Why GAO Did This Study

DHA and TRICARE East and West regional contractors are responsible for ensuring that the 1.1 million TRICARE network providers are competent to deliver quality health care to DOD beneficiaries.

Senate Report 117-130 accompanying the James M. Inhofe National Defense Authorization Act for Fiscal Year 2023 includes a provision for GAO to assess the quality assurance program for contracted TRICARE network providers. In this report, GAO assessed for network providers (1) TRICARE contractors' adherence to selected credentialing procedures and DHA's monitoring of the contractors; and (2) TRICARE contractors' exclusion of ineligible providers.

From the 1.1 million TRICARE network providers, GAO reviewed a sample of 100 credentials files for adherence to 12 required DHA and contractor credentialing procedures. GAO selected the files based on TRICARE region size and provider type. GAO also analyzed information from three federal exclusionary and adverse action databases. GAO interviewed DHA officials and TRICARE contractors.