GAO: Improvements Needed for Tracking Coordination of Specialty Care Referrals for TRICARE Prime Beneficiaries

“Why GAO Did This Study

Specialty care referrals are a key component of care coordination for TRICARE Prime beneficiaries. Each Prime beneficiary is assigned to a primary care manager either at an MTF or within the civilian provider network. Primary care managers are responsible for overseeing all aspects of their patients’ care, which includes making referrals for specialty care when needed…”

“What GAO Found

The Department of Defense’s (DOD) Defense Health Agency (DHA) has limited information about the extent to which the referral management process facilitates the coordination of primary and specialty care for beneficiaries enrolled in TRICARE Prime—a managed care option—because information about their specialty care referrals is not always complete or accurate…

We found the system DOD uses to track referrals contained incomplete and inaccurate information, which could disrupt patients’ care. DOD has begun transitioning to a new system, but we also have concerns about whether staff are adequately trained in it to ensure data accuracy…”

“What GAO Recommends

GAO recommends that the Secretary of Defense ensure that (1) MTF referral staff are trained to process and accurately document information in MHS Genesis about specially care referrals and (2) MHS Genesis is configured to produce reports with reliable data on the referral process. DOD concurred with both of these recommendations…”

Read the full 30-page report here.

Source: Improvements Needed for Tracking Coordination of Specialty Care Referrals for TRICARE Prime Beneficiaries – June 12, 2019. GAO.

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