VA SPINA BIFIDA 

PROGRAM

Outreach to Key 

Stakeholders and 

Written Guidance 

for Claims Audit 

Follow-up Activities 

Needed

Report to Congressional Requesters

June 2014

GAO-14-564

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-564, a report to 

congressional requesters

June 2014

VA SPINA BIFIDA PROGRAM

Outreach to Key Stakeholders and Written Guidance 

for Claims Audit Follow-up Activities Needed

Why GAO Did This Study

VA provides health care benefits to 

children diagnosed with spina bifida—a 

birth defect that can cause physical 

and neurological issues—born to 

Vietnam and certain other veterans. 

Legislation requires the provision of 

certain health care benefits—including 

home care, hospital care, outpatient 

care, and case management—for 

spina bifida beneficiaries. VHA 

administers the Spina Bifida Health 

Care Program for enrolled 

beneficiaries by processing and paying 

claims for covered services from 

private sector providers. 

GAO was asked to evaluate VHA’s 

administration of spina bifida health 

care benefits. In this report, GAO 

examined for the spina bifida program: 

(1) the extent to which VHA conducts 

outreach about available benefits, 

(2) what is known about health care 

claims that have been processed, and 

(3) what, if any, oversight, VHA 

conducts of the claims process. GAO 

reviewed the spina bifida program 

handbook and claims audit reports, 

analyzed data on submitted, paid, and 

denied claims from fiscal years 2009 

through 2013, and interviewed VHA 

officials and representatives from key 

stakeholder organizations.

What GAO Recommends

GAO recommends that VA conduct 

outreach with key stakeholder groups 

regarding the spina bifida program and 

its benefits, and develop written 

guidance for completing and 

documenting the status of follow-up 

activities related to claims audits. VA 

concurred with GAO’s 

recommendations.

What GAO Found

The Department of Veterans Affairs’ (VA) Veterans Health Administration (VHA) 

provides information and updates on covered health care services to 

beneficiaries enrolled in its spina bifida program, but has conducted limited 

outreach with key stakeholder organizations. VHA provides information on health 

care benefits to enrolled beneficiaries through the program website, for example. 

However, VHA has conducted limited outreach with key stakeholder 

organizations—such as the Spina Bifida Association—that have relationships 

with individuals who are potentially eligible for the spina bifida program and its 

benefits but are not enrolled. Representatives of these organizations told GAO 

this has contributed to lack of awareness of eligibility and available benefits. 

Without this outreach, VHA may miss important opportunities to help potentially 

eligible individuals obtain health care benefits to which they may be entitled.

For the spina bifida program, both total claims payments, as well as the total 

number of claims paid, increased by more than 40 percent from fiscal year 2009 

through fiscal year 2013. VHA officials attributed the increase to a 2008 

legislative expansion of health care coverage under the program, and growing 

health care costs for beneficiaries as they age. During this 5-year period, paid 

claims represented about 90 percent of all claims submitted each fiscal year.

Disposition of Spina Bifida Health Care Program Claims, Fiscal Years 2009 through 2013

VHA primarily uses claims audits to oversee its spina bifida claims process. 

Auditors review a sample of claims and prepare a report with the audit’s findings 

and any necessary follow-up activities. However, VHA does not have written 

guidance on how staff are to document the status of these follow-up activities to 

ensure their completion. Without such written guidance, VHA cannot be assured 

that these activities have been successfully completed or that any 

recommendations outlined in audit reports have been appropriately implemented.

View GAO-14-564. For more information, 

contact Debra A. Draper at (202) 512-7114 or 

draperd@gao.gov.
Page i GAO-14-564 VA Spina Bifida Program

Letter 1 

Background 5

VHA Informs Enrolled Beneficiaries about Covered Services, but 

Has Conducted Limited Outreach with Key Stakeholders 7

VHA Uses an Automated System Augmented by Administrative 

and Clinical Reviews to Process Spina Bifida Claims 11

Total Spina Bifida Claims Payments and Number of Claims Paid 

Have Increased from Fiscal Years 2009 through 2013, with 

Outpatient Services Making Up the Majority of Claims 13

VHA Primarily Uses Claims Audits to Oversee Its Spina Bifida 

Claims Process, but Does Not Have Written Guidance for Audit 

Follow-up 20

Conclusions 22

Recommendations for Executive Action 23

Agency Comments 23

Appendix I Comments from the Department of Veterans Affairs 25

Appendix II GAO Contact and Staff Acknowledgments 27

Table

Table 1: Spina Bifida Health Care Program Payments, Fiscal 

Years 2009 through 2013 14

Figures

Figure 1: Disposition of Spina Bifida Health Care Program Claims, 

Fiscal Years 2009 through 2013 15

Figure 2: Percentage of Paid Claims and Claims Payments for the 

Spina Bifida Health Care Program, by Service Category, 

Fiscal Year 2013 17

Contents
Page ii GAO-14-564 VA Spina Bifida Program

Abbreviations

CBOPC Chief Business Office for Purchased Care

SBA Spina Bifida Association

VA Department of Veterans Affairs

VBA Veterans Benefits Administration

VHA Veterans Health Administration

VVA Vietnam Veterans of America

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. The published product may be reproduced and distributed in its entirety 

without further permission from GAO. However, because this work may contain 

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Page 1 GAO-14-564 VA Spina Bifida Program

441 G St. N.W.

Washington, DC 20548

June 23, 2014

The Honorable Bernard Sanders

Chairman

The Honorable Richard Burr

Ranking Member

Committee on Veterans’ Affairs

United States Senate

The Honorable Joe Donnelly

United States Senate

The Department of Veterans Affairs (VA) provides health care benefits, as 

well as other benefits, to children diagnosed with spina bifida born to 

Vietnam and certain other veterans. Spina bifida is a type of birth defect 

that results from the neural tube (the embryonic structure that eventually 

develops into the brain and spinal cord) failing to develop or close 

properly in utero, which can cause a range of physical and neurological 

defects. The majority of individuals with spina bifida live well into 

adulthood with proper treatment.

As reported in our prior work, a longitudinal study conducted by the Air 

Force found increased incidence of spina bifida in the children of 

servicemembers exposed to herbicides, including Agent Orange, in 

Vietnam.1

 

1

See GAO, Agent Orange: Actions Needed to Improve Communications of Air Force 

Ranch Hand Study Data and Results, 

Subsequently, Congress passed legislation, commonly known 

as the Agent Orange Benefits Act, to provide for the special needs of 

veterans’ children born with spina bifida that possibly resulted from the 

exposure of one or both parents to herbicides during active service in 

GAO/NSIAD-00-31 (Washington, D.C.: Dec. 17, 

1999). See also GAO, Agent Orange: Persisting Problems With Communication of Rand 

Hand Study Data and Results, GAO/T-NSIAD-00-117 (Washington, D.C.: Mar. 15, 2000).

Agent Orange is an herbicide mixture that contains a highly toxic form of the chemical 

dioxin. The Air Force Ranch Hand study, begun in 1982, was a 25-year study of the health 

and mortality rates of a cohort of Air Force personnel exposed to herbicides in Vietnam.
 

Page 2 GAO-14-564 VA Spina Bifida Program

Vietnam.2 This legislation authorized VA to provide certain health care 

benefits and other benefits (including a monthly monetary allowance) 

effective January 1, 1997.3 Additional legislation expanded these benefits, 

and, as of October 10, 2008, health care benefits were no longer limited 

to health care services and supplies directly associated with the spina 

bifida condition.4

VA’s Veterans Health Administration (VHA) administers the Spina Bifida 

Health Care Program (spina bifida program), which provides health care 

benefits to enrolled beneficiaries by processing and paying claims for 

covered services from private sector providers. VHA is the exclusive 

payer for health care services provided to spina bifida beneficiaries; 

beneficiaries are not responsible for any copayments or deductibles. As 

of October 2013, 1,228 beneficiaries were enrolled for coverage under 

the spina bifida program.

Accordingly, VA has stated that comprehensive health 

care benefits are available to eligible veterans’ children with spina bifida 

for services and supplies considered medically necessary and 

appropriate for all disabilities and diseases, not simply those related to 

spina bifida.

You raised questions as to whether eligible beneficiaries are receiving all 

the benefits to which they are entitled, and whether all eligible 

beneficiaries are aware of available benefits, and asked us to evaluate 

how VHA provides health care benefits under the spina bifida program. 

This report examines for the spina bifida program (1) the extent to which 

VHA conducts outreach about available benefits, (2) how VHA processes 

claims, (3) what is known about claims that have been processed, and 

(4) what, if any, oversight, VHA conducts of the claims process.

 

2

See Pub. L. No. 104-204, § 421(b), 110 Stat. 2874, 2923 (1996) (adding chapter 18 to 

part II of title 38, U.S.C., codified at 38 U.S.C. §§ 1801 et seq.). Children are presumed 

eligible for benefits if they are diagnosed with spina bifida and a biological parent served in 

Vietnam or, pursuant to a subsequent amendment, Korea, during the specified time 

periods. See Pub. L. No. 108-183, § 102, 117 Stat. 2651, 2653 (2003) (codified at 

38 U.S.C. § 1821).

3

Other benefits available for eligible spina bifida beneficiaries include vocational 

rehabilitation and education services.

4

See Pub. L. No. 110-387, § 408, 122 Stat. 4110, 4130 (codified at 38 U.S.C. 1803). 

Spina bifida is defined as all forms or manifestations of spina bifida except spina bifida 

occulta, which is a mild form of spina bifida that is often not associated with disability. 

38 U.S.C. § 1802.
 

Page 3 GAO-14-564 VA Spina Bifida Program

To determine the extent to which VHA conducts outreach about available 

spina bifida program benefits, we reviewed VHA documents and 

interviewed VHA officials and representatives from stakeholder 

organizations. Specifically, we reviewed materials VHA provides to 

enrolled beneficiaries, including VHA’s spina bifida program handbook. 

We also reviewed documentation and interviewed officials from VHA 

about their outreach efforts, including outreach to inform enrolled 

beneficiaries and potentially eligible individuals about available health 

care benefits. We interviewed representatives from Vietnam Veterans of 

America (VVA) and the Spina Bifida Association (SBA)—the two key 

stakeholder organizations that have relationships with Vietnam era 

veterans and individuals with spina bifida, respectively. We evaluated 

VHA’s outreach efforts within the context of federal internal control 

standards, as documented in GAO’s Standards for Internal Control in the 

Federal Government.

5

To describe how VHA processes claims for the spina bifida program, we 

reviewed VHA documentation, analyzed claims data, and interviewed 

VHA officials. Specifically, we reviewed documentation of VHA’s spina 

bifida claims process—including VHA’s automated claims processing 

system and the business rules that it follows—and the claims 

reconsideration and appeals process.

To describe what is known about spina bifida program claims that have 

been processed, we analyzed VHA spina bifida claims data, including 

data on both paid and denied claims, for fiscal years 2009 through 2013. 

We focused the scope of our review on data from these fiscal years to 

ensure consistency in our analysis because the scope of covered 

services for spina bifida beneficiaries expanded at the beginning of fiscal 

year 2009. We further analyzed claims data for outpatient procedures 

reimbursed in fiscal year 2013 for spina bifida beneficiaries to identify 

examples of the types of services commonly received by beneficiaries, 

using the most recent available data. To identify these examples, we 

obtained the counts for outpatient procedure codes that were reimbursed 

in fiscal year 2013 from VHA,6

 

5

GAO, Internal Control: Standards for Internal Control in the Federal Government, 

listed by frequency, and we grouped 

GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999).

6

When submitting claims, providers use procedure codes that are part of the Healthcare 

Common Procedure Coding System, which provides a basis for standardized billing for 

health care claims nationwide.
 

Page 4 GAO-14-564 VA Spina Bifida Program

individual codes by type of service or supply. To identify examples of the 

reasons and the types of services for which claims were denied, we 

reviewed a sample of 10 denied outpatient claims from fiscal year 2013, 

selected for a variety of denial reasons and service types. We also 

reviewed documentation associated with this sample of claims—including 

the submitted claim, the explanation of benefits, and VHA’s internal 

claims processing report for the claim. We interviewed VHA officials about 

spina bifida program claims data, including about how the data is 

maintained and any limitations to the data, and determined that these 

data were sufficiently reliable for our purposes. We also interviewed VHA 

officials to obtain their perspective on trends in claims payments and 

number of claims for fiscal years 2009 through 2013, as well as 

projections for future changes, if any. In addition, we spoke with officials 

from SBA and reviewed relevant literature to understand the health care 

needs of adults with spina bifida.

To determine what, if any, oversight VHA conducts of the spina bifida 

program claims process, we reviewed VHA documentation related to 

audits of the claims process and interviewed VHA officials. Specifically, 

we reviewed spina bifida claims audit plans and reports for claims paid in 

fiscal years 2011, 2012, and 2013, to provide examples of audit findings 

from the 3 most recent years available. We also interviewed VHA officials 

about the claims audit process, efforts to implement claims audit findings 

and recommendations, and other ongoing monitoring activities. We 

evaluated VHA’s oversight of the spina bifida program claims process 

within the context of federal internal control standards, as documented in 

GAO’s Standards for Internal Control in the Federal Government.

7

We conducted this performance audit from December 2013 to June 2014 

in accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

 

7

GAO/AIMD-00-21.3.1.
 

Page 5 GAO-14-564 VA Spina Bifida Program

SBA officials estimate that, nationally, there are more than 160,000 

individuals living with spina bifida. The proportion of those individuals who 

are children of Vietnam veterans is unknown, due to a lack of data on the 

prevalence of spina bifida in this population. As of October 2013, there 

were 1,228 beneficiaries enrolled for coverage under the spina bifida 

program, ranging from 13 to 50 years of age; the majority of beneficiaries 

were adults aged 35 through 45.

Spina bifida is a complex congenital disorder that affects multiple body 

systems. People with spina bifida experience a variety of health 

problems, including difficulty with lower body mobility, lack of bowel and 

bladder control, hydrocephalus (a condition in which fluid builds up in the 

brain), and learning disabilities. As a result, these individuals require care 

from providers in a variety of specialties, such as orthopedics, urology, 

neurosurgery, and psychiatry.

Individuals with spina bifida face additional health concerns as they age, 

including a higher risk for obesity and obesity-related illnesses, 

depression, early osteoporosis, and pressure ulcers. Many of these 

health concerns are linked to the diminished mobility that comes with 

physical disability. In addition to physical disability, adults with spina bifida 

often face difficulty with executive function. Executive function is defined 

as a set of mental processes that helps connect past experience with 

present action, and is used to perform activities such as planning, 

organizing, strategizing, paying attention to and remembering details, and 

managing time and space. Difficulty with these mental processes can 

inhibit the independence of individuals with spina bifida, and their ability to 

manage their own care. Although studies have found that adults with 

spina bifida would benefit from access to coordinated care provided in 

multidisciplinary clinics because of their complex health needs, the 

availability of such care for adults is extremely limited.8

VA’s Veterans Benefits Administration (VBA) determines eligibility for 

spina bifida benefits, including both health care and other benefits. Once 

a beneficiary is deemed eligible for benefits, VBA assigns a disability 

 

8

See, for example, T.S. Webb, “Medical Care of Adults with Spina Bifida,” Journal of 

Pediatric Rehabilitation Medicine: An Interdisciplinary Approach 2, (2009).

Background

Spina Bifida Condition and 

Related Health Care 

Needs

VA’s Spina Bifida Benefits
 

Page 6 GAO-14-564 VA Spina Bifida Program

rating using criteria outlined in regulation,9 which entitles beneficiaries to 

monthly monetary payments similar to those provided to disabled 

veterans, as well as vocational rehabilitation and education services 

provided through VBA.10 Regardless of disability rating, beneficiaries are 

then automatically enrolled for health care benefits in VHA’s spina bifida 

program, which is operated by VHA’s Chief Business Office for 

Purchased Care (CBOPC).11

VA is required to provide certain health care benefits—including home 

care, hospital care, nursing home care, outpatient care, preventive care, 

habilitative and rehabilitative care, case management, and respite care—

for spina bifida beneficiaries.12 Regulations for the spina bifida program 

provide additional details on covered services and supplies and outline 

preauthorization requirements for certain services.13 VHA recently sought 

to clarify the scope of its authority to provide home care and custodial 

care services under the spina bifida program.14

 

9

See 38 C.F.R. § 3.814 (2013). VBA assigns each spina bifida beneficiary a rating from 1 

through 3, with 3 representing the most severe level of physical and mental disability. The 

rating is used for determining the amount of monthly monetary payments. The disability 

rating scale VA uses for spina bifida beneficiaries is different than the one VA uses to 

determine a veteran’s disability status for benefit purposes.

In June 2013, VA’s 

General Counsel issued an opinion confirming that VHA is required to 

provide coverage for these services, as needed, in the beneficiary’s home 

or other place of residence (such as a residential group home or assisted10Vocational rehabilitation and education services are designed to help eligible 

beneficiaries obtain suitable employment, and include training, tuition, payment for books 

and supplies, vocational counseling, and placement and adjustment counseling.

11In addition to the spina bifida program, CBOPC operates several other health care 

programs for veterans’ family members and for veterans to receive care from private 

sector providers, including the Civilian Health and Medical Program of the Department of 

Veterans Affairs, the Children of Women Vietnam Veterans Health Care Program, and the 

Foreign Medical Program.

1238 U.S.C. § 1803. The term “home care” is defined as outpatient care, habilitative and 

rehabilitative care, preventive health services, and health-related services furnished to an 

individual in the individual’s home or other place of residence.

13See 38 C.F.R. §§ 17.900 through 17.905 (2013).

14Custodial care is non-medical care that helps an individual with his or her Activities of 

Daily Living, such as assistance with walking, bathing, dressing, and feeding.
 

Page 7 GAO-14-564 VA Spina Bifida Program

living facility). As of April 2014, VHA was in the process of drafting a 

proposed rule incorporating this clarification into regulations.15

VHA provides information and updates on covered health care services to 

enrolled spina bifida beneficiaries. However, VHA has conducted limited 

outreach with key stakeholder groups that have a relationship with 

potentially eligible individuals who are not already enrolled.

VHA provides information on the available health care benefits to 

beneficiaries who are enrolled in its spina bifida program using three 

primary methods: (1) the initial mailing of information upon program 

enrollment, (2) the program website, and (3) contact with beneficiaries 

regarding updates to covered services.

Initial contact by mail. After beneficiaries are enrolled in the 

spina bifida program, VHA’s CBOPC staff mail beneficiaries (1) a 

program identification card (similar to an insurance card from a 

private insurer) that providers can use to bill VHA directly,16

 

15According to VHA officials, it may take up to 2 years for the regulations to be finalized. 

VHA officials told us that they recently asked VA’s General Counsel to assist in clarifying 

the scope of the department’s authority to provide coverage for preventive dental care 

under the program; under current policy, VHA provides coverage for dental services 

needed to help treat a covered medical benefit. As of April 2014, VHA had not received an 

opinion from the General Counsel.

and 

(2) a copy of the program handbook, which contains information 

on services covered and services that are generally excluded from 

coverage, as well as contact information and the website address 

for the program. VHA officials told us they enroll, on average, 

about one or two new beneficiaries per month.

16While most bills or claims are submitted directly to VHA by providers, beneficiaries may 

also submit claims to VHA, such as for reimbursement of covered travel expenses or 

supplies.

VHA Informs Enrolled 

Beneficiaries about 

Covered Services, 

but Has Conducted 

Limited Outreach with 

Key Stakeholders

VHA Provides Information 

and Updates to Enrolled 

Spina Bifida Beneficiaries 

on Covered Health Care 

Services
 

Page 8 GAO-14-564 VA Spina Bifida Program

Program website. The spina bifida program website includes 

links to the program handbook, the policy manual—which provides 

additional details on coverage and exclusions for specific 

services—and other program documents such as guidance on 

how to submit claims. VHA officials told us they consider the 

program website to be the primary means of outreach with 

beneficiaries.

Phone or mail contact to provide updates on covered 

services. VHA has recently shared changes to its spina bifida 

program with beneficiaries through telephone calls, and VHA 

officials told us they plan to share updates made between 

handbook printings through mailings to beneficiaries. Specifically, 

beginning in November 2013, VHA’s call center17 placed phone 

calls to enrolled spina bifida beneficiaries to gauge their interest in 

obtaining case management services.18

In addition to asking about case management services, VHA 

officials told us that during these calls, they also provided 

clarification that the program covers home care and custodial care 

services.

According to VHA, as of 

March 2014, the call center successfully made contact with 579 

beneficiaries (47 percent of those enrolled) and 129 of them 

expressed interest in obtaining case management services.

19 After the program regulations are updated to reflect the 

June 2013 opinion from VA’s General Counsel regarding 

coverage of these services, the program handbook will be 

updated and mailed out to enrolled beneficiaries, according to 

VHA officials.

 

17VHA’s CBOPC manages a call center to address questions from beneficiaries and 

providers regarding any of the programs operated by CBOPC, including the spina bifida 

program.

18VHA officials told us that VHA plans to begin assisting interested spina bifida 

beneficiaries in obtaining case management services provided by private sector providers. 

As of April 2014, VHA officials told us they are in the process of hiring staff to proactively 

work with interested beneficiaries to ensure they can obtain these services.

19Officials told us that they also plan to follow up with a letter in May 2014 to provide 

clarification on the program’s coverage for home care and custodial care services, as well 

as case management.
 

Page 9 GAO-14-564 VA Spina Bifida Program

VHA has conducted limited outreach with key stakeholder organizations, 

and representatives of these organizations told us that this has 

contributed to lack of awareness among some individuals who may be 

eligible to receive health care benefits under the spina bifida program. 

VHA’s outreach with stakeholder organizations has been limited primarily 

to providing materials on the program to veteran service organizations for 

distribution at conferences. For example, VHA officials told us they 

provided materials for conferences held by four different veteran service 

organizations in the summer of 2013.20

Limited outreach with key stakeholder organizations has contributed to 

the lack of awareness about available health care benefits among some 

individuals who may be eligible to enroll in the spina bifida program, 

according to representatives from these organizations. Specifically, 

representatives from VVA told us that through VVA’s Agent Orange 

Education Campaign they identified new individuals who were potentially 

eligible for VHA’s spina bifida program and its benefits, but were not 

However, VHA has not conducted 

outreach with VVA and SBA—the two key stakeholder organizations that 

we contacted—in recent years. Specifically, representatives from VVA—

an organization that represents veterans who served in Vietnam and 

advocates on their behalf regarding a variety of issues, including health 

care—told us that VHA has not reached out to them regarding its spina 

bifida program, and has not provided them any materials regarding 

available health care benefits to distribute to their membership. VHA 

officials told us that they have met with VVA officials to explain updates to

covered services, but stated that their outreach efforts with stakeholder 

organizations are driven by requests from the organizations, and they 

were not certain if VVA had requested further outreach. VHA’s most 

recent coordination with SBA—an organization with direct contact with 

individuals with spina bifida, their families, and the providers who treat 

them—was in 2009. VHA officials told us that they coordinated with SBA 

that year by staffing a resource education booth at SBA’s annual 

conference. VHA officials also told us that limits on travel spending have 

prevented them from attending or participating in the conference in recent 

years.

 

20According to VHA officials, they provided materials for distribution at conferences held 

by Disabled American Veterans, Veterans of Foreign Wars, American Legion, and 

National Association of County Veterans Service Officers.

VHA Has Conducted 

Limited Outreach with Key 

Stakeholders regarding 

Spina Bifida Benefits
 

Page 10 GAO-14-564 VA Spina Bifida Program

aware of them.21

Federal internal control standards state that agency management should 

ensure there are adequate means of communicating with, and obtaining 

information from, external stakeholders that may have a significant impact 

on the agency achieving its goals.

In addition, representatives from SBA told us they are 

regularly contacted by individuals who have questions about VHA’s spina 

bifida program benefits and do not know where to go for more 

information. Although SBA includes information on its website about 

VHA’s spina bifida program benefits, when we reviewed this page in April 

2014, we found that it contained outdated information.

22

Representatives from both VVA and SBA stated that they would be willing 

to coordinate with VHA on efforts that could improve awareness and 

understanding of VHA’s spina bifida program. For example, VVA officials 

told us that they could help VHA promote the health care benefits 

available through the spina bifida program, including providing information 

on the benefits through their weekly emails to subscribers. VVA officials 

also suggested that outreach with providers or provider organizations 

would be beneficial because it would increase awareness of the 

connection between military service and certain health issues, such as 

spina bifida, among individuals who are the “first line” in interacting with 

patients. Similarly, according to an SBA representative, SBA could 

facilitate the connection between VHA and health care providers who 

serve individuals with spina bifida. These providers could help identify 

According to VHA officials, the goal 

of the spina bifida program is to provide for the special needs of Vietnam 

and certain other veterans’ birth children who have been diagnosed with 

spina bifida. Key stakeholder organizations are well-positioned to provide

information to these individuals on available benefits because of their 

established relationships with veterans and individuals with spina bifida 

and their health care providers. However, VHA has not leveraged these 

organizations’ relationships with potentially eligible individuals to further 

VHA’s goal of providing for the special needs of beneficiaries with spina 

bifida.

 

21VVA’s Agent Orange Education Campaign provides information on the effects of 

exposure to Agent Orange on veterans and their children, as well as information on 

available resources for individuals with health concerns related to exposure to Agent 

Orange. Information is provided through regional town hall meetings, as well as through 

online social media such as Facebook and Twitter.

22GAO/AIMD-00-21.3.1.
 

Page 11 GAO-14-564 VA Spina Bifida Program

spina bifida patients who have a Vietnam-era veteran parent, and provide 

those individuals with information about VHA’s health care benefits for 

which they may be eligible.

VHA uses an automated system, augmented by administrative and 

clinical reviews, to process spina bifida claims. The claims process begins 

when a provider or beneficiary submits an electronic or paper claim to 

VHA.23 Upon receipt, the claim’s information is to be entered into an 

automated claims processing system maintained by VHA’s CBOPC.24

Automated claims processing. CBOPC’s automated claims 

processing system uses business rules to compare the 

information in the claim against the spina bifida program’s policies 

and regulations for eligibility and covered services. For example, 

VHA officials told us the system checks the date of service against 

the date the beneficiary was determined to be eligible for the spina 

bifida program.

If 

necessary, staff members conduct administrative or clinical reviews 

before denial or payment decisions are made. VHA also has a process for 

reconsideration of denied claims.

Administrative and clinical review. If the automated system 

cannot complete the processing of a claim because it detects an 

error or needs additional documentation or approval to continue 

with processing, VHA officials told us a CBOPC staff member 

conducts an administrative or clinical review. In an administrative 

review, a staff member examines a claim to ensure that required 

documentation (e.g., required preauthorization for mental health 

services) has been received. In a clinical review, the claim is 

reviewed by a clinical nurse reviewer to ensure that medical 

 

23Providers and beneficiaries have up to 1 year from the date of an outpatient service or 

hospital discharge to submit a claim.

24This claims system also processes claims for three other CBOPC health care programs: 

(1) the Civilian Health and Medical Program of the Department of Veterans Affairs; (2) the 

Children of Women Vietnam Veterans Health Care Program; and (3) the Foreign Medical 

Program. 

VHA Uses an 

Automated System 

Augmented by 

Administrative and 

Clinical Reviews to 

Process Spina Bifida 

Claims
 

Page 12 GAO-14-564 VA Spina Bifida Program

documentation included is sufficient for processing the claim.25

Payment or denial. Once the automated system has completed 

its checks, and any needed administrative or clinical reviews are 

completed, the claim is either routed for payment or it is denied. 

For a denied claim, the automated system or reviewer assigns a 

denial reason code to the claim, which provides a brief description 

of the cause of the denial (e.g., missing documentation or the 

service billed was not a covered service). This information is 

included in the explanation of benefits document mailed to the 

provider and beneficiary.

For 

example, a clinical nurse reviewer could examine documentation 

included with a claim for specialized durable medical equipment to 

ensure it is sufficient to support the request, and request 

additional documentation if necessary.

Resubmission or request for reconsideration. A provider or 

beneficiary who disagrees with the amount of payment or the 

decision to deny the claim can resubmit the claim for 

reprocessing, or submit a request for reconsideration of the claim 

to CBOPC within 1 year of the original decision. Resubmission of 

claims for reprocessing is separate from the claims 

reconsideration process. A resubmitted claim must include the 

original explanation of benefits and any other relevant 

documentation or corrections for consideration, and resubmitted 

claims are sent through the claims processing system as new 

claims.26 VHA officials told us that requests for reconsideration are 

processed outside of the automated claims processing system, 

and are reviewed by CBOPC staff with consultation from clinical 

nurse reviewers as needed.27

 

25One of VHA’s qualification standards for clinical nurse reviewers is that they be licensed 

registered nurses, and VHA officials told us that each reviewer on staff as of December 

2013 had between 7 and 10 years of experience with the program. VHA officials told us 

that reviewers do not question the clinical judgment of providers; rather, they ensure there 

is sufficient clinical documentation included to support the need for the service being 

requested or provided.

A request for reconsideration that is 

26VHA officials told us that certain denial codes, such as those denoting missing 

documentation, are more likely to be associated with a resubmitted claim than others, 

such as those denoting non-covered services.

27If a request for reconsideration results in the overturn of the original denial, the claim can 

be sent back into the automated system for processing and payment.
 

Page 13 GAO-14-564 VA Spina Bifida Program

subsequently denied can be submitted for a second review within 

90 days.28 Each claim’s explanation of benefits document provides 

contact information for CBOPC and the mailing address for 

requests for reconsideration.29

VHA updates the business rules used by its automated claims processing 

system in accordance with changes to the applicable laws and 

regulations that govern coverage of specific services. VHA officials told us 

that these updates are not made until the rulemaking process is complete 

and applicable rules have been published in the Federal Register, a 

process that can take years. In the interim, officials said affected claims—

such as those for home care services provided in an assisted-living 

facility, which VHA recently clarified as covered—would be processed 

manually to ensure they are not incorrectly denied by the automated 

system. 

From fiscal years 2009 through 2013, total payments for spina bifida 

claims increased by 43 percent—from about $19.4 million to about 

$27.8 million. (See table 1.) The number of beneficiaries who had claims 

paid increased by 10 percent, from 803 to 883, and the number of paid 

claims increased by 45 percent, from 58,560 to 84,702.

 

28The department’s decision on second review will inform claimants of their right to appeal 

to the Board of Veterans Appeals. See 38 C.F.R. § 17.904 (note) (2013). According to the 

spina bifida program policy manual, the second review decision can be appealed to the 

Board of Veterans Appeals based on administrative requirements, such as eligibility 

determinations.

29The process for requesting reconsideration of claims is also described in the program 

handbook mailed to beneficiaries when they enroll in the spina bifida program, and in the 

policy manual on the program’s website.

Total Spina Bifida

Claims Payments and 

Number of Claims 

Paid Have Increased 

from Fiscal Years 

2009 through 2013, 

with Outpatient 

Services Making Up 

the Majority of Claims
 

Page 14 GAO-14-564 VA Spina Bifida Program

Table 1: Spina Bifida Health Care Program Payments, Fiscal Years 2009 through 2013

Fiscal year

2009 2010 2011 2012 2013

Total claims payment amount $19,443,456 $21,396,037 $22,880,337 $25,198,620 $27,802,339

Number of beneficiaries with paid claims 803 847 858 888 883

Average payment per beneficiary $24,214 $25,261 $26,667 $28,377 $31,486

Source: GAO analysis of VHA data. | GAO-14-564

VHA officials told us they attribute the growth in the spina bifida program 

to an increasing number of claims and payments in the years following 

the 2008 legislative expansion of health care coverage under the 

program, as well as increasing health care costs for beneficiaries as they 

age and their health care needs become more varied and complex. 

Officials told us that, in the future, they expect spending on health care 

services to continue to increase due to new services being offered, such 

as custodial care. However, they do not expect significant increases in 

the number of beneficiaries because there are few new children with 

spina bifida born to Vietnam-era veterans and currently proposed 

expansions of coverage to new eligibility groups are not likely to add 

significantly to program enrollment.30

In fiscal years 2009 through 2013, the percentages of paid and denied 

claims remained steady, with paid claims representing about 90 percent 

of all claims submitted each fiscal year. For example, out of 95,149 claims 

submitted in fiscal year 2013,31

 

30Proposed legislation would expand eligibility for the Spina Bifida Health Care Program to 

children of veterans who served in Thailand from January 9, 1962, to May 7, 1975. See S. 

1950, 113th Cong. § 107 (2014). VHA officials told us if this legislation passes, there would 

be a small number of new enrollees who likely would have a negligible impact on total 

program enrollment and payments.

84,702 (89 percent) were paid. (See 

fig. 1.)

31The total number of submitted claims includes new claims as well as resubmitted claims 

received for reprocessing after initial payment and denial decisions.
 

Page 15 GAO-14-564 VA Spina Bifida Program

Figure 1: Disposition of Spina Bifida Health Care Program Claims, Fiscal Years 2009 

through 2013

Note: Each year’s total number of submitted claims includes new claims, as well as resubmitted 

claims received for reprocessing after initial payment and denial decisions.

About two-thirds of the total number of paid claims in each year from 

fiscal years 2009 through 2013 were for outpatient services, the largest of 

the six categories tracked by VHA.32

 

32VHA tracks spina bifida claims data in six service categories: (1) outpatient; 

(2) pharmacy; (3) durable medical equipment; (4) inpatient; (5) travel; and (6) dental. 

Outpatient care includes care and treatment, including preventive health care services, 

furnished to an individual outside hospital or nursing home settings. The outpatient 

category of claims also includes claims for supplies. The inpatient service category 

includes hospitalization and discharge-related services, and does not include ancillary 

care visits while admitted, or ambulance services, which would be included in the 

outpatient and travel service categories, respectively. The travel service category includes 

reimbursement for travel expenses—including taxi services and mileage—to and from 

certain health care providers. Ambulance services, meals, and lodging may also be 

covered under this category in certain conditions.

For example, in fiscal year 2013, 
 

Page 16 GAO-14-564 VA Spina Bifida Program

63 percent of the total number of paid claims were for outpatient services. 

(See fig. 2.) Outpatient services represented nearly 50 percent of total 

payments made that year. In contrast, inpatient claims represented less 

than 1 percent of the total number of paid claims in fiscal year 2013, but 

31 percent of total claims payments that fiscal year.
 

Page 17 GAO-14-564 VA Spina Bifida Program

Figure 2: Percentage of Paid Claims and Claims Payments for the Spina Bifida 

Health Care Program, by Service Category, Fiscal Year 2013

Notes: VHA tracks spina bifida claims data in six service categories: (1) dental; (2) travel; 

(3) inpatient; (4) durable medical equipment; (5) pharmacy; and (6) outpatient. Percentages and 

dollar amounts do not sum to totals due to rounding.
 

Page 18 GAO-14-564 VA Spina Bifida Program

Each beneficiary can access more than one category of service in a year; therefore, the total number 

of beneficiaries with a paid claim in fiscal year 2013 (883) does not equal the sum of the total unique 

beneficiaries listed for each individual service category.

a

The travel service category includes reimbursement for travel expenses—including taxi services and 

mileage—to and from certain health care providers. Ambulance services, meals, and lodging may 

also be covered under this category in certain conditions.

b

The inpatient service category includes hospitalization and discharge-related services, and does not 

include ancillary care visits while admitted, or ambulance services, which would be included in the 

outpatient and travel service categories, respectively.

c

The outpatient service category includes care and treatment services provided to an individual 

outside of hospital or nursing home settings, including preventive care services. The outpatient 

category of claims also includes claims for supplies.

In our analysis of VHA’s outpatient procedure code data, we determined 

that home care services, physician visits, physical therapy services, and 

catheters and other incontinence supplies for spina bifida beneficiaries 

were commonly reimbursed outpatient services in fiscal year 2013. 

Studies we reviewed and experts we interviewed confirmed that these 

services and supplies were consistent with the health care needs of 

adults with spina bifida.

Home care services. Although the specific health care needs of 

adults with spina bifida can vary widely based on the severity of 

their condition, officials from SBA told us that home-based 

services are important because of the challenges these individuals 

face with executive functioning and limited mobility. Since many 

adults with spina bifida rely on wheelchairs and have varying 

degrees of mobility,33

Physician visits. Due to the various health problems associated 

spina bifida (including musculoskeletal, neurological, and 

urological health care needs), medical care for adults with spina 

bifida involves visits to numerous physicians—both for primary 

and specialty care.

traveling to medical appointments can be 

challenging.

34

 

33See B.E. Dicianno, et al., “Rehabilitation and Medical Management of the Adult with 

Spina Bifida,” American Journal of Physiology and Medical Rehabilitation, vol. 87, no. 12 

(2008).

34See Dicianno, et al., “Rehabilitation and Medical Management,” 1026; W.O. Walker, 

“Primary Care Providers and Medical Homes for Individuals with Spina Bifida,” Journal of 

Pediatric Rehabilitation Medicine: An Interdisciplinary Approach 1, (2008); and Webb, 

“Medical Care of Adults,” 3-4.
 

Page 19 GAO-14-564 VA Spina Bifida Program

Physical therapy services. A study noted that adults with spina 

bifida commonly report chronic pain as a result of the body 

mechanics involved in wheelchair propulsion.35 Another study 

noted that physical disability, and the reduced physical activity that 

results from it, is a risk factor for early onset osteoporosis in adults 

with spina bifida.36 Physical therapy services can help alleviate 

pain and maintain physical functioning for adults with spina 

bifida.37

Catheters and other incontinence supplies. According to SBA 

officials, a common health care issue for individuals with spina 

bifida is neurogenic bladder and bowel, in which the nerves in this 

area of the body do not function properly, leading to ongoing 

issues with incontinence and urinary tract infections, and 

potentially renal failure in older populations. Studies we reviewed, 

as well as SBA’s spina bifida treatment guidelines, noted the need 

for continence management programs for individuals with spina 

bifida, including daily intermittent catheterization to improve renal 

outcomes.38

Although the majority of claims submitted are paid, denied claims 

represented about 10 percent of submitted claims each year from fiscal 

years 2009 through 2013.39

 

35See Webb, “Medical Care of Adults,” 3.

Most claim denials made during this period 

were for administrative reasons, such as a duplicate claim submission, 

untimely filing (a claim submitted more than 1 year from the date of 

36See Dicianno, et al., “Rehabilitation and Medical Management,” 1032.

37See Dicianno, et al., “Rehabilitation and Medical Management,” 1030-1031; and M.J. 

Merkens, ed., Guidelines for Spina Bifida Health Care Services Throughout the Lifespan, 

3rd ed. (Washington, D.C.: Spina Bifida Association, 2006).

38See Dicianno, et al., “Rehabilitation and Medical Management,” 1035; Webb, “Medical 

Care of Adults,” 7-8; T.S. Webb, “Optimizing Health Care for Adults with Spina Bifida,” 

Developmental Disabilities Research Reviews, vol. 16 (2010); and Merkens, Guidelines 

for Spina Bifida, 41-43.

39VHA officials told us that a claim is considered denied if all procedure codes included in 

the claim are denied; if some procedure codes are paid and some are denied, the claim is 

considered a paid claim. Therefore, the number of denied claims does not reflect all 

procedure codes that were denied in a given year.
 

Page 20 GAO-14-564 VA Spina Bifida Program

service or hospital discharge), or the need for additional documentation.

40

Few denied claims were submitted for reconsideration. Of the 136 

requests for reconsideration in fiscal years 2009 through 2013, 50 

(37 percent) were subsequently paid. Specifically, in fiscal year 2013, 

there were 35 requests for reconsideration, 15 of which were 

subsequently paid.

Specifically, in fiscal year 2013, about 90 percent of denied claims were 

denied for administrative reasons. Few claims were denied because the 

service was not covered or the beneficiary was ineligible for coverage 

(less than 3 percent of all denied claims in fiscal year 2013). For example, 

one denied claim we reviewed was for an eye exam—eye exams and 

glasses are excluded from coverage per spina bifida program policy. 

Another denied claim we reviewed was for durable medical equipment. A 

beneficiary requested payment for a device that, via remote control, could 

automatically open a door in the home. This claim was denied because 

VHA does not provide payment for durable medical equipment that is 

used for housing modification.

VHA conducts annual audits of spina bifida program claims, and VHA 

officials told us these audits and associated audit follow-up activities are 

the primary means of oversight for the claims process.41

VHA officials told us these audits involve auditors retracing all the steps in 

the claims approval and payment process to determine whether all 

claims-related decisions were correct. For example, auditors may review 

comments from clinical nurse reviewers regarding preauthorization 

determinations and re-run automated decision-making associated with 

Auditors from the 

VHA CBOPC’s Department of Audits & Internal Controls conduct audits of 

the spina bifida claims process annually. During the audit, auditors 

examine a statistically valid sample of paid claims from the previous 

quarter. The purpose of these audits is to identify whether claims were 

processed and paid accurately according to spina bifida program policy.

 

40In addition, about 8 percent of denied claims in fiscal year 2013 were assigned multiple 

denial reason codes by VHA, and therefore were not able to be categorized as denied for 

either administrative or coverage reasons. 

41In addition to claims audits, VHA officials told us that staff also regularly monitor claims 

data to help identify trends or outliers that may indicate inconsistencies in processing that 

need to be corrected through programming changes.

VHA Primarily Uses 

Claims Audits to 

Oversee Its Spina 

Bifida Claims 

Process, but Does 

Not Have Written 

Guidance for Audit 

Follow-up
 

Page 21 GAO-14-564 VA Spina Bifida Program

selected claims through a testing program. Any inaccurate processing 

identified by the auditors that results in an improper payment (an over- or 

under-payment on a claim) is recorded as an error and assigned to a 

category, such as duplicate payments, lack of supporting documentation, 

or non-compliance with policies and procedures.42

After the audit is complete, auditors meet with relevant staff to determine 

the underlying causes of improper payments and other inaccuracies. An 

audit representative also presents the audit’s findings to an audit review 

committee, which includes senior CBOPC officials who discuss the root 

causes of findings and decide on any necessary follow-up activities. 

Auditors then complete a report that documents the audit’s findings, 

including corrective actions and recommendations. The audit report’s 

corrective actions directly address the errors found in the audit. For 

example, VHA collects overpayments or pays providers for 

underpayments. Audit report recommendations suggest additional actions 

such as training or additional resources that should be made available to 

increase processing accuracy moving forward.

For example, the fiscal 

year 2014 audit (of the fourth quarter of fiscal year 2013 claims) had a 

claims processing accuracy rate—the percentage of claims processed 

correctly—of 98.4 percent and a proper payment accuracy rate—the 

percentage of total payments made correctly—of 99.9 percent. 

Specifically, the audit identified three claims with errors—two claims that 

should have been denied as duplicates but were not (resulting in 

overpayments), and one claim where a data entry error resulted in an 

incorrect payment amount.

There is currently no written guidance on how CBOPC staff are to 

document the status of audit follow-up activities—corrective actions and 

recommendations outlined in audit reports—to ensure their completion. 

VHA officials told us that, beginning with the fiscal year 2014 audit, staff 

from CBOPC’s Quality/Corrective Action Program are responsible for 

overseeing the status of audit follow-up activities, including working with 

relevant staff responsible for implementing any corrective actions.43

 

42Any other inaccuracies identified in the course of the audit that do not result in an 

improper payment are recorded as observations—such as mistakes in data entry—and do 

not count towards the calculation of the audit’s accuracy rates.

43According to CBOPC officials, as of April 2014, follow-up activities resulting from the 

2014 audit were in progress.
 

Page 22 GAO-14-564 VA Spina Bifida Program

According to VHA officials, these staff are responsible for determining the 

extent of documentation necessary for audit follow-up activities. Officials 

also stated that these staff store any documentation in non-networked 

files. This can render audit follow-up documentation inaccessible to other 

VHA officials who may need it. Further, although staff maintain 

information on the status of actions taken to implement audit findings and 

the individuals responsible for implementing them, they do not maintain 

information on estimated or actual completion dates for audit follow-up 

activities. There also is no documentation of interactions with staff or 

interim steps taken to ensure that follow-up activities are completed as 

planned. For example, officials told us that for one of the identified 

actions, there would be monthly follow-ups until the action is complete; 

however, there is no documentation to indicate that this interim follow-up 

is taking place. According to VHA officials, one reason for the lack of 

written guidance on completing and documenting audit follow-up activities 

is that their audit follow-up process is new; they anticipate having written 

guidance drafted by August 2014.

Federal internal control standards state that internal controls should be 

documented and all documentation should be properly managed and 

maintained, and readily available for examination.44 These standards also 

state that agencies should have policies and procedures for ensuring that 

the findings of audits and other reviews are promptly resolved. VHA’s lack 

of written guidance for audit follow-up activities places VHA at increased 

risk that these internal control activities may not be performed, may be 

performed inconsistently, or may not be continued when knowledgeable 

employees leave. This can lead to unreliable monitoring of the spina 

bifida claims process, including the inability to ensure that all necessary 

audit follow-up activities are completed.

The legislation that created VA’s spina bifida benefits charged VHA with 

serving the needs of a very vulnerable population. Given the lack of data 

on the prevalence of spina bifida in the children of veterans, and concerns 

from stakeholder organizations that potentially eligible individuals may not 

be aware of available benefits under the spina bifida program, 

stakeholder organizations are uniquely positioned to assist VHA in 

communicating information on spina bifida benefits. By not conducting 

 

44GAO/AIMD-00-21.3.1.

Conclusions
 

Page 23 GAO-14-564 VA Spina Bifida Program

outreach with key stakeholders, VHA may be missing important 

opportunities to increase awareness among potentially eligible 

individuals, and ultimately to help these individuals obtain the benefits to 

which they may be entitled.

In addition, without written guidance for audit follow-up activities related to 

the spina bifida claims process, VHA cannot be assured that these 

activities have been successfully completed or that the corrective actions 

and recommendations outlined in audit reports have been appropriately 

implemented. The lack of written guidance puts VHA at increased risk 

that these activities may be inconsistently performed—or not performed at 

all—if there are personnel changes. By developing written guidance for 

documenting these activities in a manner consistent with federal internal 

control standards, VHA would have greater assurance that audit follow-up 

activities are consistently completed, thereby helping to ensure that spina 

bifida beneficiaries’ health care claims continue to be accurately 

processed.

To improve awareness of the spina bifida program’s health care benefits 

among potentially eligible individuals and to help them obtain the benefits 

to which they may be entitled, we recommend that the Acting Secretary of 

Veterans Affairs direct the Acting Under Secretary for Health to conduct 

outreach with key stakeholder groups regarding the program and its 

benefits.

To help ensure continued accurate claims processing, we recommend 

that the Acting Secretary of Veterans Affairs direct the Acting Under 

Secretary for Health to develop written guidance, consistent with federal 

internal control standards, for completing and documenting the status of 

follow-up activities for the spina bifida program’s claims audits.

We provided a draft of this report to VA for comment. In its written 

comments, reproduced in appendix I, VA generally agreed with our 

conclusions and concurred with our recommendations. In addition, VA 

provided information on its plans for implementing each recommendation, 

with an estimated completion date of December 2014.

Recommendations for 

Executive Action

Agency Comments
 

Page 24 GAO-14-564 VA Spina Bifida Program

We are sending copies of this report to appropriate congressional 

committees, the Acting Secretary of Veterans Affairs, and other interested 

parties. In addition, the report will be available at no charge on the GAO 

Web site at http://www.gao.gov. 

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or at draperd@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. GAO staff who made key contributions to this 

report are listed in appendix II. 

Debra A. Draper

Director, Health Care
Appendix I: Comments from the Department of 

Veterans Affairs

Page 25 GAO-14-564 VA Spina Bifida Program

Appendix I: Comments from the Department 

of Veterans Affairs
Appendix I: Comments from the Department of 

Veterans Affairs

Page 26 GAO-14-564 VA Spina Bifida Program
Appendix II: GAO Contact and Staff 

Acknowledgments

Page 27 GAO-14-564 VA Spina Bifida Program

Debra A. Draper, (202) 512-7114 or draperd@gao.gov

In addition to the contact named above, Janina Austin, Assistant Director; 

Jennie F. Apter; George Bogart; Vikki L. Porter; Julie T. Stewart; and 

Malissa G. Winograd made key contributions to this report.

Appendix II: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(291177)
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