Document Type



The purpose of the study was to provide estimates of potential IHS reimbursements from Medicaid, Medicare, and private health insurance companies and to identify factors that may have an impact on IHS third-party reimbursements. In addition, factors impacting primarily upon Medicare and Medicaid reimbursements as well as factors impacting primarily upon private insurance reimbursements were noted. Basic research approaches were qualitative in nature using historical data from the Service Unit level up, rather than the Headquarters level down for greater reliability. While statistical methods were employed to analyze data, at times Macro Systems judgementally changed the bases for projection to eliminate the extreme variability in averages. Methodology involved three phases: 1) first, the development of the initial Medicare and Medicaid estimates using average percentage change methodology applied to available secondary source data and adjusted to correct for variability; 2) second, the refinement of the initial Medicaid and Medicare estimates using additional analytical techniques, including linear trend modeling, and stepwise regression analysis; further data collection (site visits and telephone calls) to identify factors influencing reimbursement; and subsequent subjective adjustment to account for these impacts; 3) third, the development of private insurance billing estimates using simulation techniques incorporating area office collection data; data from HHS and Interior on federally employed, privately insured Indians; and the IHS population, utilization, and reimbursement data. Findings of the research are presented in the form of organizational charts, tables of figures, and tables of data elements accompanied by definitions. Estimates of the potential Medicare/Medicaid reimbursements for FY'84 through FY'87, private insurance reimbursements for FY '84, and private insurance billings for FY'84 through FY'87 for facilities directly operated by IHS show that IHS can substantially increase the amounts of third-party reimbursement over the next several years; however, the rate of increase will be more gradual than previously estimated. Five factors impact on the third-party reimbursement. IHS third party billings and revenue collections are limited by inconsistent billing policies and procedures among the IHS Areas and Service Units. Prompt billing and projections for third-party reimbursement depend largely upon IHS's capabilities to automate its billing and collection functions. Methods used by Area Offices to distribute third-party revenues act as both an incentive and a disincentive for third-party revenue generation. IHS third-party revenues tend to decrease when Indians who have third-party coverage have access to private health care providers. IHS recovery of third party revenues is hindered by the difficulty in identification, eligibility, and enrollment of the third party. Present legislation prohibits IHS from recovering reimbursement for services provided in a number of its facilities. A variety of cost containment approaches at both the Federal and State levels tend to limit the potential for IHS recovery of third party monies. There are inherent barriers in private health insurance policies that preclude IHS from recovering significant reimbursement. Conclusions: No recommendations appear to be provided; however, it may be that recommendations are substantially imbedded within the findings of the study.

Publication Date



Indian Health Service, Staff Office of Planning, Evaluation and Research, Rockville, MD 20857 (E-52).