United States General Accounting Office GAO Report to the Committees on Armed Services, U.S. Senate and House of Representatives July 1999 DEFENSE HEALTH CARE Improvements Needed to Reduce Vulnerability to Fraud and Abuse GAO/HEHS-99-142 United States GAO General Accounting Office Washington, D.C. 20548 Health, Education, and Human Services Division B-282038 July 30, 1999 The Honorable John W. Warner Chairman The Honorable Carl Levin Ranking Minority Member Committee on Armed Services United States Senate The Honorable Floyd D. Spence Chairman The Honorable Ike Skelton Ranking Minority Member Committee on Armed Services House of Representatives In fiscal year 1998, the Department of Defense (DOD) spent about $2.5 billion through contracts to provide health care in civilian settings to about 1.5 million beneficiaries, including dependents of active duty personnel, military retirees, and their dependents. As with other health care systems, fraud and abuse threaten DOD with significant financial loss and may adversely affect the quality of care delivered if beneficiaries are exposed to unnecessary care or not treated at all. The military health care system is administered by the military services in partnership with civilian contractors (see app. I). TRICARE, DOD’s managed health care program, was established to improve beneficiaries’ access to health care while maintaining quality and controlling costs in a time of military downsizing and budgetary concerns. DOD, including its Office of Inspector General, and its civilian contractors work together to prevent and detect TRICARE fraud and abuse. Senate Report 105-189, accompanying the National Defense Authorization Act for fiscal year 1999, expressed congressional concerns regarding the impact of fraud on military health care and directed that we evaluate DOD efforts to combat it. In response, we (1) analyzed DOD estimates of the extent of health care fraud and abuse, (2) evaluated DOD efforts to reduce health care fraud and abuse in civilian settings, and (3) identified initiatives and incentives that could improve DOD’s antifraud efforts. We conducted our work between August 1998 and June 1999 in accordance with generally accepted government auditing standards (see app. II for details on our scope and methodology). Page 1 GAO/HEHS-99-142 Defense Health Care Fraud B-282038 It is impossible to precisely quantify the amount lost to health care fraud Results in Brief and abuse given the nature of such activities, but there is general consensus in DOD and the health care industry that fraud and abuse could account for 10 to 20 percent of all health care costs. Given TRICARE managed care contract expenditures of $5.7 billion between 1996 and 1998, DOD could have lost over $1 billion to fraud and abuse during this period. In addition to the financial loss, health care fraud and abuse can also adversely affect the quality of care provided and may cause serious harm to patients’ health. For instance, when a provider fabricates test results instead of actually conducting the tests for which it bills DOD, patients can receive incorrect diagnoses and inadequate medical treatment. DOD and its contractors have had limited success in identifying TRICARE fraud and abuse. For example, contractors have identified a negligible number of potential fraud cases: of the approximately 50 million claims that contractors processed between 1996 and 1998, they referred only about 100 potential fraud cases to DOD for further investigation. This low level of fraud identification has occurred, in part, because DOD contracts do not require contractors to aggressively identify and prevent fraud and abuse. During this same period, DOD recovered about $14 million in fraudulent payments out of the $5.7 billion spent. To its credit, DOD recognizes the need to reduce its vulnerability to fraud and abuse and has identified a number of revisions it could make to its antifraud policies and requirements. However, it has been slow to implement these policy revisions, which collectively would require contractors to put into place a more aggressive fraud and abuse identification program. Once these revisions are implemented, existing contracts can be modified to include specific results-oriented goals and performance measures, thus putting DOD in a better position to evaluate contractors’ progress in identifying and reducing fraud and abuse. Given the magnitude of potential financial loss and harm to patients’ health, it is important that DOD place a high priority on, and establish a concerted strategy for, reining in health care fraud. DOD’s strategic plan for the military health system, prepared in response to the Government Performance and Results Act of 1993, provides an appropriate vehicle for articulating DOD’s strategy and establishing how the agency will identify and prevent TRICARE fraud and abuse. This report makes recommendations to the Secretary of Defense for reducing TRICARE’s vulnerability to fraud and abuse. Page 2 GAO/HEHS-99-142 Defense Health Care Fraud B-282038 The mission of the military health care system is to maintain the health of Background active duty service personnel and provide health care during military operations. The system also offers health care to non-active duty beneficiaries, including dependents of active duty personnel and military retirees and their dependents, through various military-operated hospitals and clinics worldwide; the system is supplemented through contracts with civilian health care providers. TRICARE, the name given to the program providing this care, is a triple-option benefit program designed to give beneficiaries a choice among a health maintenance organization, a preferred provider organization, and a fee-for-service benefit. Five managed care support contractors create networks of civilian health care providers. These providers submit claims, either individually or as part of a group practice, to contractors for payment of medical care they have provided to DOD beneficiaries. Fraud occurs when health care providers knowingly submit claims containing false information. Common types of provider fraud and abuse include billing for services not rendered, misrepresentation of services, and conducting unwarranted medical procedures. Multiple players support DOD’s health care fraud identification and prevention efforts. DOD’s TRICARE Management Activity’s (TMA) Program Integrity Branch serves as the centralized administrative hub for TRICARE fraud and abuse activity worldwide. Its primary responsibilities include (1) developing policies and procedures for the prevention, detection, investigation, and control of TRICARE fraud and abuse; (2) educating beneficiaries, health care providers, and others about various health care fraud and abuse issues; (3) initiating administrative remedies, such as sanctioning fraudulent providers; and (4) coordinating with other DOD and external investigative agencies, such as the Federal Bureau of Investigation, to assist in investigations of health care fraud and abuse. TMA staff are also responsible for overseeing and ensuring that the five contractors comply with contractual antifraud requirements. Each DOD TRICARE contractor is responsible for establishing a program for identifying and reporting potential health care fraud and abuse to DOD. To help with this effort, the contractors have subcontracted with one of two companies to process TRICARE claims. In conjunction with their claims processing duties, the subcontractors provide various prepayment controls and perform postpayment reviews that are designed, among other things, to identify erroneous billings, duplicate claims, and unusual or excessive patterns of care. Page 3 GAO/HEHS-99-142 Defense Health Care Fraud B-282038 DOD’s health care fraud identification and prevention efforts are further supported by investigators from the Defense Criminal Investigative Service (DCIS), the investigative unit of DOD’s Office of Inspector General. While DCIS is involved in some efforts to identify fraudulent activity through undercover operations, the vast majority of cases it investigates are referred from other sources, such as TMA and whistleblowers. While the exact extent of health care fraud and abuse can never be DOD Could Be Losing precisely quantified, the general consensus, based on the experience of Hundreds of Millions public and private sector organizations such as DOD, the Health Care of Dollars to Fraud Financing Administration (HCFA), the U.S. Chamber of Commerce, the Health Insurance Association of America, and the National Health Care and Abuse Anti-Fraud Association, is that fraud and abuse could account for 10 to 20 percent of all health care costs. Applying this percentage to TRICARE contract expenditures of about $5.7 billion between 1996 and 1998, DOD could have lost between $570 million and $1.14 billion to fraud and abuse over the last 3 years. As health care costs increase over time, fraud and abuse can be expected to increase proportionally. Health care fraud and abuse also affect the quality of care provided and may cause serious harm to patients’ health. For example, illegal practices such as “sink testing,” which involves throwing out patients’ blood and urine specimens and fabricating test results, rather than actually performing the necessary tests, can result in improper diagnoses and either no medical treatment or unnecessary treatment. Another health care fraud scheme that may affect patients’ health involves individuals who provide unauthorized care by falsely representing themselves as licensed medical providers. DOD and its contractors have had limited success in identifying TRICARE DOD Has Had Limited fraud and abuse. To date, contractors have referred relatively few cases to Success in Identifying TMA for further investigation and development, in part, because DOD’s Fraud and Abuse contracts do not require contractors to establish a focused, aggressive antifraud program. Furthermore, DOD has recovered only a relatively small portion of its estimated losses to fraud and abuse. DOD Contractors Have DOD depends on its contractors to help it combat fraud and abuse. Up to Referred Few Fraud Cases this point, however, contractors have identified and referred relatively few to TMA potential fraud cases to TMA. Table 1 shows that, of approximately Page 4 GAO/HEHS-99-142 Defense Health Care Fraud B-282038 50 million claims processed between 1996 and 1998, contractors referred only about 100 potential fraud cases to TMA for further investigation, 92 of which were referred by the contractor with the most TRICARE experience. Although DOD has not established a specific number of cases its contractors should refer, DOD officials acknowledge that its contractors could be more aggressive in their efforts to identify potentially fraudulent activity. According to DOD officials, this lack of aggressiveness is due, in part, to the fact that DOD contracts do not specify to what extent contractors should be identifying and referring potential fraud cases. Moreover, some contractor program integrity staff told us that they were unclear about the types of potential fraud cases to refer to TMA and that they were not adequately trained to identify fraud and abuse. In addition, DOD officials told us that, because two of the five contractors were relatively new to the TRICARE program, they had not yet compiled sufficient data to identify fraudulent behavior. Table 1: Claims Processed and Potentially Fraudulent Cases Referred Referrals of by TRICARE Contractors, 1996-98 potential fraud Contractor Claims processed casesa Foundation Health Federal Services, Inc. 25,700,000 92 Humana Military Healthcare Services, Inc. 14,500,000 4 TriWest Healthcare Alliance, Inc. 6,100,000 3 Anthem Alliance for Health, Inc. 2,700,000 2 Sierra Military Health Services 1,000,000 0 Total 50,000,000 101 a Potential fraud cases may involve multiple claims. Source: TMA. In addition to their modest efforts specifically associated with identifying and referring potential fraud cases, contractors use claims editing software and other approaches to ensure that accurate payments are made to authorized providers and eligible beneficiaries. Such software and prepayment screens could also serve to deter fraudulent and abusive behavior. While TRICARE contractors prevented various types of erroneous payments totaling about $73 million in 1998 through the use of claims editing software and other prepayment screens and edits, neither TMA nor contractors could quantify what portion of this amount might be associated with fraud and abuse. TMA officials acknowledged that while some of this amount could have been related to fraud and abuse, they believe the vast majority represented payments generated by clerical and Page 5 GAO/HEHS-99-142 Defense Health Care Fraud B-282038 other types of errors. They told us, however, that prepayment screens and edits are likely to deter fraudulent and abusive behavior on the part of some health care providers. DOD Has Recovered a DOD and its contractors’ antifraud efforts have resulted in the recovery of a Small Amount of Its tiny fraction of DOD’s estimated losses from fraud and abuse. For example, Estimated Losses to Fraud as table 2 shows, between 1996 and 1998, DOD recovered only about $14 million in fraudulent payments. This amount is negligible when and Abuse compared with estimated losses of between $570 million and $1.14 billion during the same period. Even though the exact extent of TRICARE fraud and abuse is unknown, the small amount of recoveries indicates that DOD efforts have considerable room for improvement and that DOD’s vulnerability to fraud and abuse is still high. Table 2: Results of TMA Antifraud Efforts, 1996-98 DOD estimates of fraud Fraudulent payments Year and abuse (in millions) recovereda (in millions) 1996 $130-260 $1.2 1997 190-380 7.1 1998 250-500 6.1 Total $570-1,140 $14.4 a These figures may be related to cases identified in previous years. In addition to recovering fraudulent payments, between 1996 and 1998 DOD participated with other organizations in investigations of TRICARE and other government health care programs, such as Medicare and Medicaid, which resulted in penalties, fines, and other assessments totaling approximately $804 million, 199 criminal charges, and 150 civil settlements. TMA officials told us, however, that they could not identify the portion of these penalties, fines, and other assessments associated with the TRICARE program or its funds. While DOD recognizes that it needs to reduce its vulnerability to fraud and Opportunities Exist to abuse, it has been slow to implement revised policies and requirements Improve TRICARE’s directing its contractors to put into place a much more aggressive fraud Antifraud Efforts and abuse identification program. Once these revisions are implemented, DOD’s efforts could also be strengthened by establishing results-oriented goals and performance measures in its managed care contracts and by overseeing contractors to assess their performance against these goals and Page 6 GAO/HEHS-99-142 Defense Health Care Fraud B-282038 measures. In addition, given the potential magnitude of fraud and abuse within TRICARE, DOD top management could better focus and otherwise improve DOD’s antifraud efforts by committing itself to, and developing a concerted strategy for, addressing the problem in its military health system strategic plan. Such plans are mandated by the Government Performance and Results Act of 1993 (also known as the Results Act).1 These steps should improve DOD’s antifraud activities and help reduce the adverse impact fraud and abuse currently have on TRICARE and its beneficiaries. TMA Is in the Process of According to the Chief of TMA’s Program Integrity Branch, DOD’s antifraud Implementing Revised policies and procedures are vague concerning contractors’ Antifraud Requirements responsibilities. She told us that DOD policies do not direct contractors to provide their antifraud staff with training in fraud detection and prevention methods, nor do the policies guide contractors as to the level of emphasis they should place on such activities. In an effort to improve the effectiveness of its antifraud efforts, TMA is in the process of implementing revised program integrity policies and procedures to require more aggressive fraud identification activities by its contractors. Although TMA originally intended that its contractors implement these revisions by October 1, 1998, TMA and the contractors have been negotiating for over 8 months to formally implement these changes. As of June 1, 1999, DOD and its contractors had not yet agreed to contract terms. If and when implemented, these changes would include the following requirements of TRICARE contractors: • Develop and publish a corporate antifraud strategy. This strategy, developed and endorsed by corporate management to underscore its commitment to health care fraud detection and prevention, includes plans for (1) maintaining a focus on increased health care fraud awareness, (2) developing processes that identify fraud, (3) aggressively referring health care fraud cases to TMA, (4) assisting in the prosecution of cases, and (5) developing deterrents to health care fraud. TMA officials told us that having a published corporate antifraud strategy would better enable its contractors to focus their fraud prevention and detection activities, as well as generate companywide support for these efforts. • Use new antifraud software. Antifraud software will be used to analyze health care data associated with the type, frequency, duration, and extent of services to identify patterns of probable fraudulent or abusive practices 1 The Results Act (P.L. 103-62) requires agencies to clearly define their missions, set goals, measure performance, and report on their accomplishments. Page 7 GAO/HEHS-99-142 Defense Health Care Fraud B-282038 by providers and beneficiaries. TMA officials told us that using artificial intelligence software would allow contractors to be more effective in identifying fraud and would likely increase the number of fraud cases they referred to TMA. • Establish and maintain an antifraud training program. Specifically, contractors will train their staff to identify abnormal patterns of care, over- or underutilization of services, and other practices that may indicate fraudulent or abusive behavior. According to TMA officials, with new developments in information technology and frequent contractor staff turnover, structured training would help institutionalize contractors’ antifraud activities. Some contractor and subcontractor staff told us they were not adequately trained to effectively identify fraud and abuse and would benefit from a structured, continuously updated antifraud education program. In addition, in an effort to increase beneficiary awareness of health care fraud and abuse, TMA has directed its contractors to include a fraud hot line telephone number and mailing address on beneficiaries’ “explanation of benefits” statement. This information provides beneficiaries with a contact in the event fraudulent activity is suspected or observed. As of April 1999, all five contractors had included an antifraud contact on their explanation of benefits statements. Although TRICARE policy requires that claims be denied when submitted under a clinic or group practice subidentifier, TMA waived this requirement in 1996 in an effort to improve claims processing timeliness. However, our March 1999 testimony raised a concern that TRICARE claims did not always identify the individual provider rendering care, potentially masking fraudulent or abusive activity. In response, as of June 1, 1999, TMA directed all of its contractors to pay only those claims that identify providers individually, rather than their group or clinic affiliation.2 TMA officials told us that information on individual providers is also needed to monitor quality of care. TMA has not established results-oriented goals or performance measures for its managed care contracts, although doing so would help it assess contractors’ performance as well as enable contractors to track their own progress in combating fraud and abuse.3 Comparing contractor 2 Defense Health Care: Management Attention Needed to Make TRICARE More Effective and User-Friendly (GAO/T-HEHS-99-81, Mar. 11, 1999). 3 In 1994, DOD’s Office of Inspector General recommended that DOD establish performance measures related to its health care fraud detection activities. Page 8 GAO/HEHS-99-142 Defense Health Care Fraud B-282038 performance with established goals and measures would enable TMA to identify program deficiencies and help contractors focus their efforts on needed improvements. DOD’s Military Health As required by the Results Act, agencies must articulate, in a strategic System Strategic Plan Does plan, how they will address issues that significantly affect their ability to Not Address TRICARE manage program operations. Given the potential magnitude of health care fraud and abuse within TRICARE, it is important for DOD to address this Fraud and Abuse concern in such a plan. DOD’s current military health system strategic plan, however, does not specify how the agency will combat TRICARE fraud and abuse. A more complete plan would provide better direction and guidance by including an antifraud mission statement, identifying long-term antifraud objectives and describing how DOD would achieve them, and explaining key external factors that could affect achievement of those objectives. In addition, taking a more strategic approach would help TMA establish annual performance goals and measures related to its long-term objectives and determine how it will assess its progress in achieving them. Specific performance measures could include calculating the cost-effectiveness of TMA’s antifraud efforts. By benchmarking and periodically assessing its progress in combating TRICARE fraud and abuse, TMA would be in a better position to measure its vulnerability to such activity, focus its antifraud efforts on the most prevalent types of fraud and abuse, and allocate an appropriate level of resources to combat this problem. Health care fraud and abuse within TRICARE potentially result in the loss Conclusions of hundreds of millions of dollars and adversely affect the health of untold numbers of beneficiaries. Despite TRICARE’s known vulnerability, DOD’s activities thus far have not been very successful in identifying fraud and abuse. Furthermore, as health care costs increase over time, fraud and abuse can be expected to increase proportionally. While DOD recognizes the importance of its contractors’ role in combating fraud and abuse and has been negotiating with them to implement new antifraud requirements, it has been slow in doing so. If effectively implemented, these requirements would help DOD and its contractors increase the effectiveness of their antifraud efforts; in our view, immediate attention should be focused on getting these requirements in place. In addition, by establishing results-oriented goals and performance measures for its contractors, TMA would be in a better position to identify program Page 9 GAO/HEHS-99-142 Defense Health Care Fraud B-282038 deficiencies and help its contractors more effectively target their efforts to reduce fraud and abuse. Given the relatively few dollars DOD has recovered and the magnitude of potential fraudulent activity, DOD would also benefit from adopting a more strategic approach. We believe DOD’s military health system strategic plan provides an appropriate mechanism for articulating this approach and for setting forth the specific goals, objectives, and strategies for reducing DOD’s vulnerability to TRICARE fraud and abuse. Ultimately, the success of DOD’s antifraud efforts will depend on the priority it places on fraud prevention and detection and how effectively it oversees its contractors’ antifraud activities. To reduce TRICARE’s vulnerability to fraud and abuse, we recommend Recommendations that the Secretary of Defense direct the Assistant Secretary of Defense (Health Affairs) to • expedite implementation of TMA’s revised antifraud requirements, including the requirements that contractors develop a corporate antifraud strategy, utilize new antifraud software, and develop an antifraud training program; • modify current contracts to establish specific results-oriented goals and performance measures for contractors; and • include in DOD’s military health system strategic plan how DOD will combat health care fraud and abuse and an assessment of DOD’s performance in combating such activity. In commenting on a draft of this report, the Assistant Secretary of Defense Agency Comments (Health Affairs) stated that the report will provide DOD with invaluable and Our Evaluation assistance as it begins to do more in the area of reducing fraud and abuse in its health care program. In response to our recommendations, DOD agreed to expedite implementation of revised antifraud requirements by requiring contractors to develop a corporate antifraud strategy, utilize antifraud software, and develop an antifraud training program. In addition, DOD agreed to include in the TMA strategic plan how DOD will combat health care fraud and abuse. However, DOD is concerned about establishing specific results-oriented goals and performance measures for its contractors. While DOD agrees that establishing goals and measures is desirable, it states it is unaware of a methodology that would enable it to do so. We recognize that finding the right methodology is challenging, but establishing program-specific goals Page 10 GAO/HEHS-99-142 Defense Health Care Fraud B-282038 and performance measures for key program activities is a fundamental responsibility placed on all agencies by the Results Act. In our view, combating fraud and abuse is a key management activity; therefore, DOD needs to establish goals and measures to assess contractors’ performance, identify program deficiencies, and enable contractors to track their own progress in combating fraud and abuse. DOD also raised concerns about data presentation in two areas. First, it was concerned that a comparison between the number of claims processed and the number of fraud cases identified presupposes a correlation between the two sets of data. DOD stated that no industry standard based on such a correlation exists. We do not dispute that there is no industry standard. However, by virtually any standard, DOD contractor referrals of 101 potential fraud cases out of about 50,000,000 processed claims represent a minimal level of activity. In this context, it seems clear that there is room for the contractors to be more aggressive in their efforts to identify fraudulent activity. Further, DOD concurred with our recommendation to expedite the implementation of revised antifraud policies and requirements that place greater demands on contractors to identify and prevent fraud. Second, DOD raised a concern that the report compares gross estimates of potential amounts lost to fraud and abuse with only the amounts recovered in fraud cases. Our report clearly states that DOD was unable to estimate recoveries for abuse but reported that contractors prevented erroneous payments totaling about $73 million. Moreover, most of this $73 million was not attributable to abuse but rather to payments resulting from clerical and other types of errors. DOD’s comments are included as appendix III. Page 11 GAO/HEHS-99-142 Defense Health Care Fraud B-282038 We are sending copies of this report to the Honorable William S. Cohen, Secretary of Defense, and other interested parties. We will also make copies available to others upon request. If you or your staffs have any questions about this report, please contact me at (202) 512-7101 or Michael T. Blair, Jr., Assistant Director, at (404) 679-1944. Jeffrey L. Pounds, Steve D. Morris, and Michael Tropauer also made key contributions to this report. Stephen P. Backhus Director, Veterans’ Affairs and Military Health Care Issues Page 12 GAO/HEHS-99-142 Defense Health Care Fraud Page 13 GAO/HEHS-99-142 Defense Health Care Fraud Contents Letter 1 Appendix I 16 TRICARE Contractors and Subcontractors Responsible for Antifraud Efforts Appendix II 17 Scope and Methodology Appendix III 18 Comments From the Department of Defense Tables Table 1: Claims Processed and Potentially Fraudulent Cases 5 Referred by TRICARE Contractors, 1996-98 Table 2: Results of TMA Antifraud Efforts, 1996-98 6 Abbreviations DCIS Defense Criminal Investigative Service DOD Department of Defense HCFA Health Care Financing Administration TMA TRICARE Management Activity Page 14 GAO/HEHS-99-142 Defense Health Care Fraud Page 15 GAO/HEHS-99-142 Defense Health Care Fraud Appendix I TRICARE Contractors and Subcontractors Responsible for Antifraud Efforts TRICARE regions TRICARE contractors Subcontractors Northwest Foundation Health Federal Wisconsin Physicians Services, Inc. Service Southwest Foundation Health Federal Wisconsin Physicians Services, Inc. Service Southern California, Golden Foundation Health Federal Palmetto Government Gate, and Hawaii-Pacific Services, Inc. Benefits Administrators Southeast and Gulf South Humana Military Healthcare Palmetto Government Services, Inc. Benefits Administrators Central TriWest Healthcare Alliance, Palmetto Government Inc. Benefits Administrators Northeast Sierra Military Health Palmetto Government Services Benefits Administrators Mid-Atlantic and Heartland Anthem Alliance for Health, Palmetto Government Inc. Benefits Administrators Page 16 GAO/HEHS-99-142 Defense Health Care Fraud Appendix II Scope and Methodology To evaluate DOD’s antifraud efforts, we met with DOD officials responsible for planning, managing, and implementing TRICARE’s antifraud program. We reviewed DOD regulations, policies, and requirements pertaining to its program integrity functions, as well as strategic plans developed by DOD. We also reviewed antifraud requirements outlined in contracts with managed care support contractors hired by DOD to administer the TRICARE program regionally. In addition, we visited DOD’s five contractors and their two subcontractors to obtain information on their antifraud efforts. We also interviewed representatives of public and private sector organizations involved in health care fraud issues, including the Health Care Financing Administration; the Federal Bureau of Investigation; and the National Health Care Anti-Fraud Association, whose mission is to improve the private and public sectors’ detection, investigation, and prevention of health care fraud. Page 17 GAO/HEHS-99-142 Defense Health Care Fraud Appendix III Comments From the Department of Defense Page 18 GAO/HEHS-99-142 Defense Health Care Fraud Appendix III Comments From the Department of Defense Now on p. 10. Page 19 GAO/HEHS-99-142 Defense Health Care Fraud Appendix III Comments From the Department of Defense Now on pp. 5-6. (101621) Page 20 GAO/HEHS-99-142 Defense Health Care Fraud Ordering Information The first copy of each GAO report and testimony is free. Additional copies are $2 each. Orders should be sent to the following address, accompanied by a check or money order made out to the Superintendent of Documents, when necessary. VISA and MasterCard credit cards are accepted, also. Orders for 100 or more copies to be mailed to a single address are discounted 25 percent. Orders by mail: U.S. General Accounting Office P.O. Box 37050 Washington, DC 20013 or visit: Room 1100 700 4th St. NW (corner of 4th and G Sts. NW) U.S. General Accounting Office Washington, DC Orders may also be placed by calling (202) 512-6000 or by using fax number (202) 512-6061, or TDD (202) 512-2537. Each day, GAO issues a list of newly available reports and testimony. 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Defense Health Care: Improvements Needed to Reduce Vulnerability to Fraud and Abuse
Published by the Government Accountability Office on 1999-07-30.
Below is a raw (and likely hideous) rendition of the original report. (PDF)