VETERANS' HEALTH 

CARE

Preliminary Observations 

on Veterans' Access to 

Choice Program Care

Statement of Statement of Randall B. Williamson, 

Director, Health Care

Testimony 

Before the Committee on Veterans' 

Affairs, House of Representatives

For Release on Delivery 

Expected at 7:30 p.m. ET

Tuesday, March 7, 2017

GAO-17-397T

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-17-397T, a testimony 

before the Committee on Veterans' Affairs, 

House of Representatives

March 7, 2017

VETERANS' HEALTH CARE

Preliminary Observations on Veterans' Access to 

Choice Program Care

What GAO Found

Under the Veterans Choice Program (Choice Program), veterans may receive 

care from non-Veterans Health Administration (VHA) health care providers when 

timely care from VHA providers is not available or readily accessible. The 

Department of Veterans Affairs (VA) uses two contractors—or third party 

administrators (TPA)—to administer the program. Among other things, the TPAs 

schedule most veterans’ Choice Program appointments after receiving referrals 

from VA medical centers (VAMC). GAO’s preliminary analysis indicates that

veterans who are referred to the Choice Program for routine care because 

services are not available at VA in a timely manner could potentially wait up to 81 

calendar days to obtain care if VAMCs and the TPAs take the maximum amount 

of time VA allows to accomplish its appointment scheduling process. 

GAO’s preliminary analysis also indicates that VHA cannot determine the 

average overall wait times veterans have actually experienced under the Choice 

Program because it lacks complete, reliable data to do so. For example, VHA’s 

data do not capture (1) the time it takes VAMCs to prepare veterans’ referrals 

and send them to the TPAs, or (2) the time spent by TPAs in accepting referrals 

and contacting veterans to opt them in to the Choice Program. 

Illustration of How VHA’s Data Capture Only a Portion of the Choice Program Scheduling 

Process

GAO’s preliminary analysis indicates that selected veterans experienced lengthy 

overall wait times for Choice Program care in 2016. For example, among the 

non-generalizable sample of 55 routine care authorizations GAO reviewed, 

VAMCs took an average of 24 calendar days to send veterans’ referrals to the 

TPAs, and the TPAs took an average of 14 calendar days to accept these

referrals and opt veterans in to the program. An average of 26 calendar days 

elapsed after the TPAs scheduled appointments until veterans’ initial 

appointments for routine care occurred. For the 53 urgent care authorizations in 

GAO’s sample, it took an average of 27 calendar days for VAMCs to send the 

referrals to the TPAs, 18 calendar days for the TPAs to accept the referrals and 

opt the veterans in, and 18 calendar days after the TPAs scheduled veterans’

initial Choice Program appointments until they occurred. 

View GAO-17-397T. For more information, 

contact Randall B. Williamson at (202) 512-

7114 or williamsonr@gao.gov.

Why GAO Did This Study

Congress created the Choice Program

in 2014 to address longstanding 

challenges with veterans’ access to

care at VA medical facilities. While the 

existing Choice Program will expire on 

or before August 7, 2017, VHA has 

submitted to Congress a plan for 

consolidating several programs that 

provide similar care through non-VA 

providers into a new, single VA 

community care program in fiscal year 

2018.

This statement provides GAO’s 

preliminary observations about, among 

other things, (1) VA’s process for 

scheduling Choice Program 

appointments for routine care, and (2) 

what is known about the timeliness of 

veterans’ Choice Program 

appointments for routine care and 

urgent care. This statement is based 

on ongoing work for which GAO 

reviewed applicable laws and 

regulations, VA’s TPA contracts, and 

relevant VHA policies and guidance. 

GAO also visited 6 of 168 VAMCs and 

reviewed a random, non-generalizable 

sample of 196 Choice Program 

authorizations. These authorizations 

were for veterans who were referred to 

the Choice Program by the 6 VAMCs 

between January 2016 and April 2016. 

GAO also interviewed VA, VHA, and 

TPA officials. Results from GAO’s 

analysis cannot be generalized to all 

Choice Program authorizations or all 

VAMCs. 

When GAO completes its ongoing 

work, it will make recommendations as 

appropriate.
Letter

Page 1 GAO-17-397T

Chairman Roe, Ranking Member Walz, and Members of the Committee:

I am pleased to be here today to discuss our ongoing work related to 

veterans’ access to health care services through the Veterans Choice 

Program (Choice Program). The majority of veterans utilizing health care 

services delivered by the Veterans Health Administration (VHA) of the 

Department of Veterans Affairs (VA) receive care in VHA-operated 

medical facilities, including 168 VA medical centers (VAMC) and more 

than 1,000 outpatient facilities. However, some VHA medical facilities 

have long wait times for veterans to obtain appointments or do not offer 

certain specialty care services on site. In recent years, we and others 

have expressed concerns about VHA’s ability to provide health care 

services within its own facilities in a timely manner.1 In some cases, the 

delays in care or VHA’s failure to provide care reportedly have resulted in 

harm to veterans. Due to these and other concerns, we concluded that 

VA health care is a high-risk area and added it to our High Risk List in 

2015.2

These serious and longstanding problems with veterans’ access to care 

were highlighted in a series of congressional hearings in the spring and 

summer of 2014, when a well-publicized series of events raised additional 

concerns about VHA’s ability to deliver health care services in a timely 

manner. In response to these concerns, the Veterans Access, Choice, 

and Accountability Act of 2014 (Choice Act) was enacted on August 7, 

 1

See, for example, VA Health Care: Reliability of Reported Outpatient Medical 

Appointment Wait Times and Scheduling Oversight Need Improvement, GAO-13-130 

(Washington, D.C.: Dec. 21, 2012); GAO, VA Health Care: Management and Oversight of 

Consult Process Need Improvement to Help Ensure Veterans Receive Timely Outpatient 

Specialty Care, GAO-14-808 (Washington, D.C.: Sept. 30, 2014); GAO, Primary Care: 

Improved Oversight Needed to Better Ensure Timely Access and Efficient Delivery of 

Care, GAO-16-83 (Washington, D.C.: Oct. 8, 2015); and GAO, VA Mental Health: Clearer 

Guidance on Access Policies and Wait-Time Data Needed, GAO-16-24 (Washington, 

D.C.: Oct. 28, 2015). See also: Department of Veterans Affairs, Office of Inspector 

General, Healthcare Inspection: Gastroenterology Consult Delays, William Jennings Bryan 

Dorn VA Medical Center, Columbia, South Carolina, Report No. 12-04631-313 

(Washington, D.C.: Sept. 6, 2013) and Department of Veterans Affairs, Office of Inspector 

General, Veterans Health Administration, Review of Alleged Patient Deaths, Patient Wait 

Times, and Scheduling Practices at the Phoenix VA Health Care System, Report No. 14-

02603-267 (Washington, D.C.: Aug. 26, 2014).

2

GAO, High-Risk Series: An Update, GAO-15-290 (Washington, D.C.: Feb. 11, 2015). 

GAO maintains a high-risk program to focus attention on government operations that it 

identifies as high risk due to their greater vulnerabilities to fraud, waste, abuse, and 

mismanagement or the need for transformation to address economy, efficiency, or 

effectiveness challenges.

Letter
Page 2 GAO-17-397T

2014. This law provided temporary authority and $10 billion in funding 

through August 7, 2017 (or sooner, if those funds are exhausted) for

veterans to obtain health care services from non-VA community providers 

to address long wait times, lengthy travel distances, or other challenges 

accessing care at VA medical facilities.3 Under this authority, VA 

introduced the Choice Program in November 2014, and as of October 1, 

2016, about $4.5 billion of the $10 billion originally appropriated remained 

available for the program.

In accordance with the law, VHA had up to 90 days to prepare for Choice 

Program implementation from the time the Choice Act was enacted. To 

cope with the compressed implementation timeframe, VA modified 

contracts it had previously established with Health Net Federal Services 

(Health Net) and TriWest Healthcare Alliance (TriWest) for the 

administration of a different VA community care program to give them 

responsibility for Choice Program administration. Each contractor—or 

third party administrator (TPA)—is responsible for delivering Choice 

Program care in a specific multi-state region, where they establish 

networks of community providers, schedule appointments for eligible 

veterans, and pay community providers for their services. Recent media 

reports and congressional hearings have highlighted weaknesses 

affecting the Choice Program, such as insufficient provider networks, 

significant delays in scheduling appointments, and a lack of timely 

payments to network providers.4

My statement today will draw from our ongoing work examining the 

timeliness of veterans’ access to care through the Choice Program. We 

plan to issue a final report on our review in spring 2017. In particular, this 

statement reflects our preliminary observations examining:

1. the process VA has established for scheduling Choice Program 

appointments for routine care;

 3

Pub. L. No. 113-146, 128 Stat. 1754 (2014).

4

See, for example, Lawrence Quil, Eric Whitney, and Michael Tomsic, “Despite $10B ‘Fix,’

Veterans Are Waiting Even Longer To See Doctors.” Morning Edition (radio program), 

May 16, 2016. Accessed January 27, 2017. http://www.npr.org/sections/healthshots/2016/05/16/477814218/attempted-fix-for-va-health-delays-creates-newbureaucracy. Also see Lee Romney, “Veterans Choice is flawed, but Congress is stymied 

on a solution,” The Center for Investigative Reporting, September 28, 2016. Accessed 

January 27, 2017. https://www.revealnews.org/article/veterans-choice-is-flawed-butcongress-is-stymied-on-a-solution.
Page 3 GAO-17-397T

2. what is known about the timeliness of veterans’ Choice Program 

appointments for routine care and urgent care; and

3. VHA’s recent actions and plans to improve the timeliness with which 

veterans receive health care services through the Choice Program.

As part of our ongoing work, we reviewed applicable laws and 

regulations; VA’s contracts with the TPAs; relevant VA and VHA policy 

directives, guidance, and training materials for VAMCs; and relevant VHA 

documentation about Choice Program improvement projects, such as 

summaries and fact sheets. We also interviewed a VA contracting official 

and officials from VHA’s Office of Community Care (the office responsible 

for implementing and overseeing the Choice Program), as well as officials 

from the two Choice Program TPAs, Health Net and TriWest.

In addition, we examined non-generalizable samples of six VAMCs and 

196 authorizations for veterans who were referred to the Choice Program 

by those six VAMCs between January 2016 and April 2016.5 We selected 

our sample of VAMCs to include variation in geographic location, three 

VAMCs that serve rural veteran populations, three VAMCs that serve 

urban veteran populations, three VAMCs that were served by Health Net, 

and three that were served by TriWest. (See table 1.)

Table 1: Non-Generalizable Sample of Veterans Affairs Medical Centers (VAMC) GAO Visited for Review of the Veterans 

Choice Program (Choice Program)

Choice Program third party administrator that 

serves the VAMC

VAMC (location) Rural or urbana Health Net Federal 

Services

TriWest Healthcare 

Alliance

Togus VAMC (Augusta, ME) rural ✓

Muskogee VAMC (Muskogee, OK) rural ✓

Alaska VA Health Care System 

(Anchorage, AK)

urban – location

rural l – population served

✓

VA Eastern Colorado Health Care System 

(Denver, CO)

urban ✓

VA Northern California Health Care 

System (Mather, CA)

urban ✓

Durham VAMC (Durham, NC) urban ✓

Source: GAO | GAO-17-397T

 5

These were the most recent Choice Program authorization data that were available when 

we began our ongoing review. 
Page 4 GAO-17-397T

a

In this table, urban and rural classifications are based on U.S. Census measures of the population 

density where the VAMC is located, unless otherwise noted.

To select our random, non-generalizable sample of 196 Choice Program 

authorizations, we obtained VA data on all authorizations created by the 

TPAs between January and April 2016 for veterans who were referred to 

the program by the six VAMCs we visited. The 196 authorizations 

included 55 randomly selected authorizations for routine care and 53 

randomly selected urgent care authorizations for which the TPAs 

succeeded in scheduling appointments for veterans.6 We selected our 

sample of routine and urgent authorizations to include only authorizations 

for which the TPAs did not meet VA’s appointment scheduling goals at 

one phase of the appointment scheduling process: when the TPAs 

attempt to schedule appointments after the veterans have opted in to the 

program.7 This was to ensure that our sample included only 

authorizations for which scheduling was delayed, so that we could 

examine the potential causes of appointment scheduling delays, whether 

delays also occurred at other phases of the process (such as when 

VAMCs were preparing the veterans’ referrals or when the TPAs were 

attempting to reach the veterans to opt them into the program), and the 

veterans’ overall wait times for Choice Program care.8 The 196 

authorizations also included 88 randomly selected authorizations that the 

TPAs returned to VA without scheduling appointments for any one of the 

 6

Under VA’s contracts with the TPAs, Choice Program referrals and authorizations are to 

be marked as “urgent” when a VA clinician has determined that the veteran needs care 

that (1) is considered essential to evaluate and stabilize conditions and (2) if not provided 

would likely result in unacceptable morbidity or pain when there is a significant delay in 

evaluation or treatment. Under VA’s Choice Program contracts, urgent care is not the 

same as care provided for a medical emergency, which is covered through different VA 

community care programs. Urgent care (rather than emergent care) delivered through the 

Choice Program is care that is delivered when there is no threat to the veteran’s life, limb, 

or vision but the veteran’s condition needs attention to prevent it from becoming a serious 

risk to the veteran’s health. 

7

Under VA’s contracts with the TPAs, VA requires that the TPAs schedule routine Choice 

Program appointments within 5 business days after veterans opt into the Choice Program. 

VA also requires that the TPAs schedule veterans’ urgent Choice Program appointments 

and ensure that veterans attend them within 2 business days after veterans opt in to the 

Choice Program. 

8

As we discuss later in this statement, VHA could not provide complete, reliable data that 

would have allowed us to include authorizations in our sample that were delayed at other 

points of the Choice Program appointment scheduling process, such as the period when 

VAMCs prepare referrals for the TPAs or the period between the TPAs’ receipt of referrals 

and initiation of appointment scheduling.
Page 5 GAO-17-397T

following three reasons—(1) VA requested the authorization be returned, 

(2) VA data was missing from the referral, and (3) the veteran declined or 

did not want Choice Program care.9 For all 196 Choice Program 

authorizations in our sample, we reviewed VHA documentation 

(specifically, the veterans’ VA electronic health records) and TPA 

documentation to track the number of calendar days that elapsed at each 

step of the Choice Program appointment scheduling process.10 For the 

authorizations that the TPAs returned to the VAMCs without making 

appointments, we examined VHA and TPA documentation to determine 

whether the veterans eventually obtained care through other means—

such as through another VA community care program, a different Choice 

Program referral, or at a VA medical facility—and how long it took to 

receive that care. To assess the reliability of the authorization data we 

used, we interviewed knowledgeable agency officials, manually reviewed 

the content of the data, and electronically tested it for missing values. We 

concluded that these data were sufficiently reliable for the purposes of our 

reporting objectives. The findings from our review of Choice Program 

authorizations cannot be generalized beyond the VAMCs and the 

veterans’ Choice Program authorizations we reviewed.

We are conducting the work upon which this statement is based 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 preliminary 

findings and conclusions based on our audit objectives.

We shared the information in this statement with VA to obtain its views. 

Officials provided us with technical comments, which we have 

incorporated as appropriate. When we complete our ongoing work, we 

will also make recommendations related to improving the timeliness of 

veterans’ Choice Program care as appropriate.

 9

We limited our sample of returned authorizations to these three return reasons because 

we wanted to determine if the return reasons entered by the TPAs could be substantiated 

by evidence from the veterans’ VA electronic health records. 

10In this statement, “days” refers to calendar days, unless otherwise indicated.
Page 6 GAO-17-397T

As stated in VA’s December 2015 guidance, the Choice Program allows 

eligible veterans to obtain health care services from the TPAs’ network 

providers rather than from VHA providers when the veterans meet any of 

the following criteria:

• the next available medical appointment with a VHA provider is more 

than 30 days from the veteran’s preferred date or the date the 

veteran’s physician determines he or she should be seen;

• the veteran lives more than 40 miles driving distance from the nearest 

VHA facility with a full-time primary care physician;

• the veteran needs to travel by air, boat, or ferry to the VHA facility that 

is closest to his or her home;

• the veteran faces an unusual or excessive burden in traveling to a 

VHA facility based on geographic challenges, environmental factors, 

or a medical condition;11

• the veteran’s specific health care needs, including the nature and 

frequency of care needed, warrants participation in the program;12 or

• the veteran lives in a state or territory without a full-service VHA 

medical facility.13

In addition, in May and October of 2015, VHA issued policy memoranda 

to its VAMCs requiring them to offer eligible veterans referrals to the 

 11A determination about whether the veteran meets this criterion will be made in 

conjunction with staff at the veteran’s local VHA medical facility.

12A determination about whether the veteran meets this criterion will be made in 

conjunction with staff at the veteran’s local VHA medical facility.

13Specifically, veterans who reside in Alaska, Hawaii, New Hampshire, or a U.S. territory 

would be eligible for the program under this criterion. Veterans residing in New Hampshire 

are only eligible if they reside more than 20 miles away from the White River Junction 

VAMC, which is located in Vermont.

Background

Choice Program Eligibility 

and Required Referral 

Hierarchy
Page 7 GAO-17-397T

Choice Program before they authorize care through other VA community 

care programs.14

From fiscal year 2015 through fiscal year 2016 (the first two years of the 

Choice Program’s implementation), data we obtained from the TPAs 

indicate that more than half of the veterans who were referred to the 

Choice Program and for whom the TPAs scheduled appointments were 

referred because the services they needed were not available at a VA 

medical facility.15 The second-most-common reason for referral was that 

the wait time for an appointment at a VA medical facility exceeded 30 

days. (See figure 1.)

 14Specifically, when services are unavailable or the veteran cannot receive an 

appointment within 30 days; these memoranda require VAMCs to determine whether 

needed services are available in a timely manner from another VA medical facility or from 

a facility with which the VAMC has a sharing agreement, such as a Department of 

Defense, Indian Health Service, or Tribal Health facility. If care cannot be arranged in this 

manner, VAMCs must offer eligible veterans the opportunity to receive care through the 

Choice Program before attempting to arrange care through any other VA community care 

program.

15Prior to obtaining these data from the TPAs, we requested data from VHA on the 

number of veterans who were referred to the Choice Program because (1) services were 

unavailable, (2) there was a greater than 30-day wait, or (3) the veteran resided more than 

40 miles from a VA facility or faced other travel burdens. However, VHA officials stated 

that VHA’s data grouped veterans who were referred to the Choice Program because 

services were unavailable together with the veterans who were referred because of 30-

day wait times. Only the TPAs could break these groups of veterans out separately, so we 

are instead reporting the TPAs’ data here. 

Choice Program Utilization 

from Fiscal Year 2015 

through Fiscal Year 2016
Page 8 GAO-17-397T

Figure 1: Most Common Reasons Veterans with Scheduled Choice Program 

Appointments Were Referred to the Program, Fiscal Years 2015 through 2016

Note: This excludes 7,198 veterans with scheduled appointments who were referred to the Choice 

Program in fiscal year 2015 and fiscal year 2016 because they faced an unusual or excessive travel 

burden to access care at a VA medical facility. Only one of the two third party administrators (TPA)

could separately report veterans who were referred under this Choice Program eligibility criterion. The 

other TPA does not distinguish veterans who were referred for unusual or excessive travel burden 

from the other three Choice Program referral reasons listed here.
Page 9 GAO-17-397T

Through its policies and standard operating procedures for VAMCs and 

its contracts with the TPAs, VA has established a process for Choice 

Program appointment scheduling.16 The process differs depending on the 

criterion under which a veteran is utilizing the Choice Program. Table 2 

below provides an overview of the appointment scheduling process that 

applies when a veteran is referred to the program because the veteran 

cannot obtain an appointment within 30 days. VA’s contracts require that 

routine care appointments for these time-eligible veterans shall take place 

within 30 days of the clinically indicated date on the VAMC’s referral to 

the TPA, which is consistent with VA’s wait-time goal for care at a VA 

medical facility.17

 16Officials from VA’s Denver Acquisition and Logistics Center are responsible for 

developing and managing Choice Program contracts with the TPAs. Contracting officer’s 

representatives in VHA’s Office of Community Care are responsible for monitoring the 

TPAs’ performance. VHA’s Office of Community Care is also responsible for developing 

policies and standard operating procedures, communicating contract modifications and 

other programmatic changes to VAMCs, and providing training for VAMC managers and 

staff on their roles in coordinating veterans’ Choice Program care. 

17The clinically indicated date on the VAMC’s referral is the date that it would be clinically 

appropriate for the appointment to occur, as determined by the sending VA provider. The 

clinically indicated date determination is based upon the needs of the patient and should 

be the soonest date that it would be clinically appropriate for the veteran to receive care. 

While appointments for routine care for time-eligible veterans must occur with 30 days of 

the clinically-indicated date on the VAMC’s referral, VA’s contracts require that these 

veterans’ appointments for urgent care shall take place within 2 business days of the TPA 

accepting the VAMC’s referral.

Process for Choice 

Program Appointment 

Scheduling
Page 10 GAO-17-397T

Table 2: Process for Veterans to Obtain Choice Program Care if They Are Time-eligiblea

Steps of the Choice Program scheduling process Steps 

completed by 

staff at VA 

medical center 

(VAMC)

Steps 

completed by 

staff at Choice 

Program third 

party 

administrator 

(TPA)

Steps 

completed by 

the veteran

1. A Veterans Affairs (VA) clinician determines the veteran needs care. ✓

2. VAMC staff confirm the veteran’s eligibility for Choice Program care and 

begin contacting the veteran to offer a referral to the Choice Program.

✓

3. The veteran agrees to be referred to the Choice Program. ✓

4. VAMC staff compile relevant clinical information (including a description of 

the specific services and type of medical specialist the veteran needs) and 

submit the veteran’s referral to the TPA.

✓

5. TPA staff review the veteran’s Choice Program referral to ensure it contains 

information needed to proceed with appointment scheduling and accept the 

referral if the information is sufficient.

✓

6. TPA staff contact the veteran by telephone to confirm that they want to opt 

in to the Choice Program. If the veteran is not reached by telephone, the 

TPA sends a letter requesting that the veteran contact the TPA to opt in to 

the program. 

✓

7. If the veteran opts into the Choice Program, TPA staff create an 

authorization and begin efforts to schedule an appointment with a 

community provider. 

✓

8. TPA staff schedule an appointment with a community provider. The 

authorization (which contains relevant clinical information, a description of 

authorized services, and a period of validity) is sent to the community 

provider. The veteran is informed of the date and time of the appointment. 

✓

9. The veteran attends the initial appointment with the Choice Program 

community provider. 

✓

Source: GAO analysis of VA and VHA documents. | GAO-17-397T

Note: VA’s contracts require that Choice Program appointments for routine care for time-eligible

veterans shall take place within 30 days of the clinically indicated date on the VAMC’s referral to the 

TPA. The clinically indicated date on the VAMC’s referral is the date that it would be clinically 

appropriate for the appointment to occur, as determined by the sending VA provider. The clinically 

indicated date determination is based upon the needs of the patient and should be the soonest date 

that it would be clinically appropriate for the veteran to receive care. While appointments for routine 

care for time-eligible veterans must occur with 30 days of the clinically-indicated date on the VAMC’s 

referral, VA’s contracts require that Choice Program appointments for urgent care take place within 2 

business days of the TPA accepting the VAMC’s referral.

a

Veterans are time-eligible for the Choice Program when no VA appointments are available within 30 

days.

When veterans are eligible for the Choice Program because they reside 

more than 40 miles from a VA medical facility, VA’s contract requires the 

TPA to schedule an appointment within 30 days of the veteran’s preferred 
Page 11 GAO-17-397T

appointment date. For these veterans, VAMCs do not prepare a referral 

and send it to the TPA. Instead, these veterans can contact the TPA 

directly to request Choice Program care. See table 3 for an overview of 

the Choice Program appointment scheduling process that applies for 

distance-eligible veterans.

Table 3: Process for Veterans to Obtain Choice Program Care if They Are Distance-eligible

Steps of the Choice Program scheduling process Steps completed 

by staff at VA 

medical center 

(VAMC) 

Steps completed 

by staff at Choice 

Program third 

party 

administrator 

(TPA)

Steps completed 

by the veteran

1. The veteran contacts the TPA to request Choice Program care. ✓

2. TPA staff verify that the veteran is eligible for the Choice Program 

care and that the requested care is medically appropriate.

✓

3. TPA staff create an authorization and begin efforts to schedule an 

appointment with a community provider.

✓

4. TPA staff schedule an appointment with a community provider. 

The authorization (which contains relevant clinical information, a 

description of authorized services, and a period of validity) is sent 

to the community provider. The veteran is informed of the date 

and time of the appointment.

✓

5. The veteran attends the initial appointment with the Choice 

Program community provider.

✓

Source: GAO analysis of VA and VHA documents. | GAO-17-397T

The VA Budget and Choice Improvement Act, which was enacted on July 

31, 2015, required VA to develop a plan for consolidating all nonDepartment provider programs (currently about 10) into a new, single 

program to be known as the “Veterans Choice Program.”18 VHA 

submitted this plan to Congress on October 30, 2015, and according to 

this plan, the agency expects to implement a consolidated community 

care program in fiscal year 2018. While the existing Choice Program will 

 18Pub. L. No. 114-41, § 4002, 129 Stat. 443, 461 (2015). In addition to the Choice 

Program, VHA has purchased health care services from community providers through 

other programs since as early as 1945. The primary means by which VHA has traditionally 

purchased care is through individual authorizations. In addition, VHA purchases 

community care (for example) through two different emergency care programs and 

through the Patient-Centered Community Care Program, which is also administered by 

Health Net and TriWest. For more information about VA’s other community care 

programs, see GAO, Veterans’ Health Care: Proper Plan Needed to Modernize System 

for Paying Community Providers, GAO-16-353 (Washington, D.C.: May 11, 2016).

Future Consolidation of VA 

Community Care 

Programs
Page 12 GAO-17-397T

expire on or before August 7, 2017, the consolidated community care 

program VHA described in its October 2015 plan and in the December 

2016 request for proposals (RFP) issued by VA’s Denver Acquisition and 

Logistics Center is similar to the current Choice Program in certain 

respects. For example, VHA’s consolidated community care program 

would be partly administered by TPAs, which would establish regional 

“high-performing networks” of community providers and process 

payments to those providers. However, the RFP states that staff at 

VAMCs will have responsibility for appointment scheduling. The RFP also 

indicates that the department is planning to award contracts before the 

end of fiscal year 2017. To support VHA’s planned consolidation of its 

community care programs, VA has requested that Congress enact 

legislation to streamline and simplify veterans’ community care eligibility 

requirements.

Our preliminary analysis of VA’s process indicates that veterans who are 

referred to the Choice Program for routine care because services are not 

available in a timely manner at VA could potentially wait up to 81 calendar 

days to obtain care. This is in contrast to VA’s wait time goal for the 

Choice Program, which is that time-eligible veterans receive routine care 

no more than 30 calendar days from the date an appointment is deemed 

clinically appropriate by a VA health care provider (referred to as the 

clinically indicated date), or if no such determination has been made, 30 

calendar days from the date the veteran prefers to receive care. In 

practice, the maximum potential wait time of about 81 calendar days 

encompasses 21 or more calendar days for VAMCs to prepare veterans’

Choice Program referrals, 30 calendar days for TPAs to schedule 

appointments, and another 30 calendar days for appointments to occur, 

as follows:

• VAMCs’ process and timeframes for preparing routine Choice 

Program referrals. According to VHA policies and guidance, VAMC 

staff have at least 21 calendar days to confirm that veterans want to

VA Has Established a 

Choice Program 

Appointment 

Scheduling Process 

Under Which 

Veterans’ Wait Times 

for Routine Care 

Could Exceed VA’s 

30-Day Goal
Page 13 GAO-17-397T

be referred to the Choice Program and to send veterans’ referrals to 

the TPAs:19

• They have up to 7 calendar days after a VA clinician has 

determined the veteran needs care to begin contacting an eligible 

veteran by telephone to offer them a referral to the Choice 

Program.

• They have up to 14 calendar days after initiating contact to reach 

the veteran by telephone or letter and confirm that they want to be 

referred to the Choice Program.

• After confirming that a veteran wants to be referred to the Choice 

Program, however, VA has not set a limit on the number of days 

VAMCs should take to compile relevant clinical information and 

send referrals to the TPAs.

• TPAs’ Choice Program appointment scheduling process. Through 

its contracts with the TPAs, VA has established a process that allows 

the TPAs about 21 business days (or approximately 30 calendar 

days) after receiving VAMCs’ Choice Program referrals to schedule 

veterans’ routine care appointments:20

• 2 business days to review the VAMC’s referral and accept it if it 

contains sufficient information to proceed with appointment 

scheduling,

• 4 business days to contact the veteran by telephone and confirm 

they want to opt in to the Choice Program (which means that the 

veteran wants to receive care through the Choice Program and 

have the TPA proceed with appointment scheduling),

 19According to officials from VHA’s Office of Community Care, VAMC staff are to follow 

VHA’s policy directive for consult management when they are preparing veterans’ Choice 

Program referrals. See VHA Directive 1232(1), Consult Processes and Procedures (Aug. 

24, 2016, as amended on Sept. 23, 2016). VHA’s Office of Community Care has provided 

further guidance related to the responsibilities of VAMC staff in preparing Choice Program 

referrals through standard operating procedures and training materials. The 21-calendarday time period begins with the date the veteran’s VA clinician signaled the veteran’s need 

for care by entering a consult into the veteran’s VA electronic health record. A consult is a 

request entered by a VA clinician on behalf of a patient seeking an opinion, advice, or 

expertise regarding evaluation or management of a specific problem.

20The contractual requirement that Choice Program appointments for routine care shall 

take place within 30 calendar days of the clinically indicated date does not account for the 

potential 21 days that may have already elapsed during VAMCs’ process for preparing 

Choice Program referrals.
Page 14 GAO-17-397T

• if the veteran is not reached by telephone, 10 business days for 

the veteran to respond to a letter confirming that they want to opt 

in, and

• 5 business days to contact providers and successfully schedule 

the veteran’s Choice Program appointment.21

• VA’s method for monitoring the timeliness of appointment 

completion. When VHA monitors the timeliness with which Choice 

Program appointments for routine care occur, the date it uses as a 

starting point varies. Although VA’s contracts require routine care 

appointments for time-eligible veterans to take place within 30 days of 

the clinically indicated date in the veteran’s referral, VA does not 

always use the clinically indicated date to monitor the TPAs’

timeliness of appointment completion. If the clinically indicated date 

on VA’s referral occurred before the date the TPA received the 

referral—as was the case for about 76 percent of the Choice Program 

authorizations in the sample we reviewed—VA uses the date on 

which the TPA succeeded in scheduling the veteran’s initial 

appointment as the starting point for determining whether veterans’

Choice Program appointments for routine care occur in a timely 

manner.22 In these cases, VA considers an appointment to be timely if 

it occurred within 30 days of the date the TPA scheduled it.23

See figure 2, below, for an illustration of the 81-day potential wait time for 

veterans to receive routine care through the Choice Program.

 21The TPAs would have 29 calendar days to complete the appointment scheduling 

process if the VAMC sent the referral on a Monday, Tuesday, Wednesday, or Thursday 

and 31 calendar days if the VAMC sent the referral on a Friday. If there are holidays, the 

total number of calendar days permitted to elapse may be greater than 29 or 31 calendar 

days.

22Our 76 percent calculation is based on 134 of the 196 Choice Program authorizations in 

our sample. We could not identify either VA’s clinically indicated date or the date the TPA 

received the referral for a total of 62 of the authorizations in our sample because (for 

example) the authorizations were for distance-eligible veterans who self-referred to the 

Choice Program or they were related to requests for additional services after veterans had 

already initiated an episode of Choice Program care.

23According to VA’s contracts with the TPAs, performance metrics for timeliness start with 

a valid authorization for services and specifically state that the contractor will not be 

penalized in its metrics for delays caused by VA.
Page 15 GAO-17-397T

Figure 2: Potential Wait Time for Veterans to Obtain Routine Care through the Choice Program Process

Note: This figure illustrates potential wait times for veterans who are referred to the Choice Program 

because services are not available in a timely manner at a Department of Veterans Affairs (VA) 

medical facility. Veterans who are using the Choice Program because they reside more than 40 miles 

from a VA medical facility would begin the appointment scheduling process by contacting the third 

party administrator (TPA) directly to request an appointment. For these veterans, the appointment 

scheduling process would begin at step 7 in the figure above. Because these veterans do not have 

referrals from VA medical centers (VAMC), VA measures the timeliness of routine appointment 

scheduling and completion for these veterans on the basis of whether the initial Choice Program 

appointment occurred within 30 days of the date the veteran preferred to receive care.
Page 16 GAO-17-397T

a

VAMCs must attempt to contact veterans at least once by phone, and if the veterans are not 

reached, VAMCs must then send letters to the veterans and wait up to 14 calendar days for the 

veterans to respond that they want to be referred to the Choice Program.

b

The 30-calendar-day appointment completion timeframe begins with the date the TPA scheduled the 

appointment only if the TPA receives the VAMC’s referral for routine care after the clinically indicated 

date for a time-eligible veteran has already passed. If the TPA receives a referral before the clinically 

indicated date has passed, VHA measures timeliness of Choice Program appointment completion on 

the basis of whether the veteran’s appointment occurred within 30 days of the clinically indicated 

date.

c

The potential wait time attributable to TPAs would be 59 calendar days if the VAMC sent the referral 

on a Monday, Tuesday, or Wednesday and 61 calendar days if the VAMC sent the referral on a 

Thursday or Friday. If there are holidays, the total number of calendar days permitted to elapse may 

be greater than 59 or 61 calendar days.

Our preliminary analysis indicates that VHA lacks complete, reliable data 

to monitor the overall timeliness with which veterans have received 

routine and urgent care through the Choice Program. Our analysis of a 

random, non-generalizable sample of 196 Choice Program authorizations 

indicates that the data VHA uses to monitor appointment wait times in the 

Choice Program have several key limitations, which include (1) an 

inability to monitor VAMCs’ timeliness in preparing Choice Program 

referrals, (2) a lack of data on the TPAs’ timeliness in accepting referrals 

and opting veterans in to the Choice Program, (3) issues with the 

reliability of clinically indicated dates on VAMCs’ Choice Program 

referrals, and (4) VAMCs’ and TPAs’ miscategorization of routine Choice 

Program referrals as urgent care referrals.

VHA’s Monitoring of 

the Overall 

Timeliness of Choice 

Program Care is 

Limited, and Selected 

Veterans Have 

Experienced Lengthy 

Waits for Routine and 

Urgent Care

Data Limitations Hamper 

VHA’s Monitoring of 

Veterans’ Overall Wait 

Times for Choice Program 

Care
Page 17 GAO-17-397T

Our preliminary analysis indicates that the data VHA currently uses to 

monitor the timeliness of Choice Program appointment scheduling and 

completion do not capture the days it takes for VAMCs to prepare 

veterans’ referrals and send them to the TPAs. This is because VHA has 

not standardized the manner in which VA clinicians and VAMC staff 

categorize consults that lead to Choice Program referrals.24 We observed 

inconsistency in the titles of consults that were associated with the nongeneralizable sample of Choice Program authorizations we reviewed. For 

example,

• consult titles sometimes included the word “Choice,” but in other 

cases they included the words “non-VA care.”

• Some of the consult titles indicated the criterion under which the 

veteran was eligible for the Choice Program and the type of care the 

veteran needed (for example, “Choice-First Physical Therapy”), while 

other consult titles only indicated the type of care the veteran needed 

(for example, “pain management”).

25

We observed this variability among consult titles both within single 

VAMCs and across all six of the VAMCs we visited.

In the absence of standardized consult titles, VHA has no automated way 

to electronically extract data from VA’s electronic health record and 

calculate the average number of days it takes for VAMC staff to prepare 

veterans’ Choice Program referrals after veterans have agreed to be 

referred to the program. Further, without standardized consult titles, VHA 

cannot monitor veterans’ overall wait times—from the time VA clinicians 

 24A consult is an electronic request entered in VA’s electronic health record by a VA 

clinician who is seeking an opinion, advice, or expertise regarding evaluation or 

management of a veteran’s condition. For the purposes of the Choice Program, the 

consult entry date is the date a veteran’s need for care was originally identified. When 

there is a wait for a VA appointment or services are unavailable at VA, staff at the VAMC 

use information from the consult—such as the clinically indicated date determined by the 

VA clinician and a description of needed services—to prepare veterans’ Choice Program 

referrals.

25The term “Choice-First” pertains to veterans who are referred to the Choice Program 

because services are unavailable at a VA medical facility or the veteran cannot receive an 

appointment at a VA medical facility or another federal medical facility within VHA’s 

timeliness standards. It comes from VHA’s May and October 2015 policy memoranda, 

which required VAMCs to offer eligible veterans the opportunity to receive care through 

the Choice Program before attempting to arrange care through any other VA community 

care program.

VHA Cannot Calculate the 

Average Number of Days 

VAMCs Take to Prepare 

Choice Program Referrals
Page 18 GAO-17-397T

determine veterans need care until the veterans attend their first 

appointments with Choice Program providers.

The lack of standardized consult titles also prevents VHA from tracking 

average overall wait times and monitoring the timeliness of care for 

veterans whose Choice Program authorizations are returned by the TPAs 

without scheduled appointments. When authorizations are returned, 

VAMC staff must attempt to arrange care either at a VA medical facility, 

through the Choice Program by initiating a new Choice Program referral, 

or through another VA community care program.

Our preliminary analysis indicates that the data VHA currently uses to

monitor the timeliness of Choice Program appointments for routine and 

urgent care capture only a portion of the process that the TPAs carry out 

to schedule veterans’ appointments after they receive referrals from 

VAMCs. Specifically, VHA’s data reflect the timeliness of appointment 

scheduling and completion after the TPAs create authorizations in their 

appointment scheduling systems, which (according to VA’s contracts) the 

TPAs must do only after they have received all necessary information 

from VA and the veteran has opted in to the Choice Program. Therefore, 

VHA’s timeliness data do not capture the time TPAs spend (1) reviewing 

and accepting VAMCs’ referrals, and (2) contacting veterans to confirm 

that they want to opt into the Choice Program.

During our ongoing work, when we asked how they are monitoring the 

timeliness of Choice Program appointments, VHA officials provided us the 

following types of data on the TPAs’ appointment scheduling timeliness, 

all of which reflect the time that elapses only after veterans have opted 

into the Choice Program and the TPAs have created authorizations:

• the average number of business days the TPAs take after creating 

authorizations to schedule appointments for routine and urgent care,

• the percentage of appointments for routine care that the TPAs 

schedule within 5 business days after they create authorizations, and

• the percentage of appointments for urgent care that the TPAs 

schedule within 2 business days after they create authorizations.

In addition, VHA officials have provided us data on the timeliness with 

which Choice Program appointments have occurred. Specifically, VHA 

has provided the following types of data, almost all of which reflect the 

timeliness with which appointments occur only after veterans have opted 

Available VHA Data Do Not 

Capture the Time Spent By 

TPAs in Accepting VAMCs’

Referrals and Opting Veterans 

into the Choice Program
Page 19 GAO-17-397T

into the Choice Program and the TPAs have either created authorizations 

or successfully scheduled veterans’ appointments:

• the average number of business days after the TPAs create 

authorizations in which appointments for routine and urgent care 

occur,

• the percentage of appointments for routine care that are completed 

within 30, 60, 90, and 120 business days or more after the TPAs 

create an authorization,

• the percentage of appointments for routine care that are completed 

within 30 calendar days of either (1) the TPAs scheduling 

appointments, (2) the clinically indicated date on the VAMC’s referral, 

or (3) the veteran’s preferred date, and26

• the percentage of appointments for urgent care that are completed 

within 2 calendar days of the TPAs creating the authorizations.

Because, as previously explained, VHA lacks data on the average 

timeliness with which VAMCs prepare Choice Program referrals, and

VHA also lacks data on the average amount of time that elapses between 

when the TPAs receive VAMCs’ referrals and when veterans opt in with 

the TPAs, our preliminary analysis indicates that VHA cannot track 

veterans’ overall wait times for Choice Program care—from the time VA 

clinicians determine that veterans need care until the veterans attend 

their first appointments with Choice Program providers. In addition, the 

lack of data on the timeliness with which the TPAs have (1) accepted 

VAMCs’ referrals and (2) opted veterans in to the program also prevents 

 26If a veteran is using the Choice Program because services at VA are unavailable or 

cannot be accessed in a timely manner, VHA’s method for determining whether 

appointments for routine care occur in a timely manner is dependent upon whether the 

clinically indicated date on the VAMC’s referral occurs before or after the date the TPA 

received the referral. If the clinically indicated date on the VAMC’s referral occurred before 

the date the TPA received the referral—as was the case for about 76 percent of the 134

Choice Program authorizations in our sample for which we could identify clinically 

indicated dates—VHA uses the date the TPA succeeded in scheduling the appointment as 

the starting point for monitoring the timeliness of appointment completion. If the clinically 

indicated date on the VAMC’s referral occurs after the date the TPA received the referral, 

VA considers an appointment for routine care as having occurred in a timely manner if it 

occurs within 30 days of the clinically indicated date on the VAMC’s referral. If veterans 

are using the Choice Program because they reside more than 40 miles from a VA medical 

facility, VHA measures the timeliness with which appointments for routine care are 

completed on the basis of whether the initial Choice Program appointments occurred 

within 30 days of the date the veterans preferred to receive care.
Page 20 GAO-17-397T

VHA from assessing whether the TPAs’ average timeliness in completing 

these actions has improved over time.

Our preliminary analysis of a sample of 196 Choice Program 

authorizations shows that another limitation of available VHA data is that 

the clinically indicated dates included on referrals that VAMCs send to the 

TPAs may not be identical to the clinically indicated dates that were 

originally entered by the VA clinicians who treated the veterans. The 

clinically indicated date is the earliest date an appointment is deemed 

clinically appropriate by a VA clinician. It could be the same as the date 

the VA clinician determined the veteran needed care, if there is no clinical 

reason that the veteran should delay care. If VAMCs’ Choice Program 

referrals have clinically indicated dates that are different from than the 

ones VA clinicians originally entered, there is risk that VHA’s data will not 

accurately reflect veterans’ actual wait times.

VHA’s policy directive on consult management and its Choice Program 

standard operating procedure for VAMCs state that the clinically indicated 

date is to be determined by the VA clinician who is treating the veteran. 

However, in reviewing VA’s electronic health records for our sample of 

Choice Program authorizations, we identified 60 cases where the 

clinically indicated dates VAMC staff entered on Choice Program referrals 

they sent to the TPAs differed from the clinically indicated dates that were 

originally entered by VA clinicians.27 We could not conclusively determine 

the reason the dates differed. It is possible that VAMC staff mistakenly 

entered incorrect dates when they manually entered clinically indicated 

dates on the veterans’ Choice Program referrals. It is also possible that 

VAMC staff inappropriately entered later clinically indicated dates when 

they sent the referrals to the TPAs because the VAMC staff were delayed 

in completing the necessary steps of contacting the veteran, compiling 

relevant clinical information, and sending the referral to the TPA.

 27We were able to identify clinically indicated dates for 134 of the 196 Choice Program 

authorizations in our sample. We could not identify VA’s clinically indicated dates for a 

total of 62 of the authorizations in our sample. Clinically indicated dates were missing for 

these 62 authorizations because (for example) they were for distance-eligible veterans 

who self-referred to the Choice Program or the authorizations were related to requests for 

additional services after veterans had already initiated an episode of Choice Program 

care.

Clinically Indicated Dates Are 

Sometimes Changed by VAMC 

Staff
Page 21 GAO-17-397T

Our preliminary results indicate that another limitation of VHA’s available 

data on the timeliness of Choice Program care is that VAMCs and TPAs 

do not always adhere to the Choice Program’s contractual definition for 

urgent care when they are processing referrals and scheduling 

appointments. If Choice Program referrals for routine care are 

inappropriately categorized as urgent care referrals, VHA’s data on the 

timeliness of urgent appointment scheduling and completion will not 

accurately reflect the TPAs’ performance.

Among the sample of 53 Choice Program authorizations for urgent care 

we reviewed, VHA and TPA documentation showed that 39 

authorizations (about 74 percent) did not consistently apply VA’s 

contractual definition for urgent care authorizations. According to VA’s 

contracts with the TPAs, Choice Program referrals are to be marked as 

“urgent” when a VA clinician has determined that the veteran needs care 

that (1) is considered essential to evaluate and stabilize conditions and 

(2) if not provided would likely result in unacceptable morbidity or pain 

when there is a significant delay in evaluation or treatment.28 It is VA’s 

goal that the TPAs schedule appointments for urgent care and ensure 

that they take place within 2 business days after veterans opt in to the 

Choice Program. In some cases, VA clinicians marked consults as routine 

but VAMC staff changed the status to urgent when they sent the referrals 

to the TPAs. In other cases, TPA staff changed the referrals from routine 

to urgent after receiving them from the VAMCs. Based on our preliminary 

analysis of the authorizations, it appeared in some cases that these 

changes were made in an effort to administratively expedite appointment 

scheduling when the VAMCs or TPAs were delayed in sending referrals 

and scheduling veterans’ Choice Program appointments.

 28Under VA’s Choice Program contracts, urgent care is not the same as care provided for 

a medical emergency, which is covered through different VA community care programs. 

Urgent care (rather than emergent care) delivered through the Choice Program is care 

that is delivered when there is no threat to the veteran’s life, limb, or vision but the 

veteran’s condition needs attention to prevent it from becoming a serious risk to the 

veteran’s health.

VAMCs and TPAs Frequently 

Miscategorize Routine Choice 

Program Referrals as Urgent 

Referrals
Page 22 GAO-17-397T

The sample of 196 Choice Program authorizations we reviewed included 

only authorizations for which there were delays when the TPAs attempted 

to schedule appointments after the veterans had opted into the program; 

however, our preliminary analysis of these authorizations indicates that 

delays occurred at other phases of the referral and appointment 

scheduling process as well. Many veterans in our sample experienced 

lengthy overall wait times for Choice Program care—as measured from 

the time their need for care was identified until they attended their initial 

appointments—and only a portion of the overall wait time could be 

explained by the TPA’s delay in scheduling an appointment after the 

veteran opted into the Choice Program. Our analysis of veterans’ VA 

electronic health records and the TPAs’ records for a sample of 55 routine 

care authorizations and 53 urgent care authorizations for which the TPAs 

succeeded in scheduling appointments identified the following average 

review times:

• It took VAMC staff an average of 24 calendar days after the veterans’

need for routine care was identified to contact the veterans and 

confirm that they wanted to be referred to the Choice Program, 

compile relevant clinical information, and send veterans’ referrals to 

the TPAs. It took an average of 27 calendar days for the VAMCs to 

complete these actions for the urgent care authorizations in our 

sample.29

• For the routine care authorizations in our sample, it took the TPAs an 

average of 14 calendar days to accept referrals and reach veterans by 

telephone or letter to opt them in to the Choice Program. It took the 

TPAs an average of 18 calendar days to complete these actions for 

the urgent care authorizations in our sample.

• After the TPAs succeeded in scheduling veterans’ appointments for 

routine care, an average of 26 calendar days elapsed before veterans 

in our sample completed their initial appointments with Choice 

 29Our calculation for the average number of days it took VAMCs to send Choice Program 

authorizations for routine care to the TPAs is based on 41 of the 55 routine authorizations 

in our sample, and our calculation for authorizations for urgent care is based on 36 of the 

53 authorizations in our sample. We could not include in our calculations all the 

authorizations in our sample because either the date the veteran’s need for care was 

identified or the date the VAMC sent the referral to the TPA was missing. We also could 

not determine what portion of the total time it took VAMCs to prepare veterans’ Choice 

Program referrals was accounted for by the interim steps of contacting the veteran or 

compiling relevant clinical documentation because we could not find in VA’s electronic 

health record sufficient evidence of the dates these actions were completed for all of the 

authorizations in our sample.

Selected Veterans 

Experienced Lengthy 

Overall Wait Times for 

Choice Program Care in 

2016
Page 23 GAO-17-397T

Program providers. For urgent care authorizations in our sample, it 

took an average of 18 days for the veterans to complete their initial 

appointments after the TPAs scheduled them.

See the following text box for specific examples of the overall wait times 

experienced by some veterans in the samples of routine and urgent 

Choice Program authorizations we reviewed.

Examples of Delays Experienced by Veterans for whom the Choice Program Third Party Administrators (TPA) Scheduled 

Appointments

• One veteran was referred to the Choice Program for magnetic resonance imaging (MRI) of the neck and lower back because 

these services were unavailable at a Veterans Affairs (VA) medical facility. It took almost 3 weeks for VA medical center (VAMC) 

staff to prepare his Choice Program referral for routine care and send it to the TPA, and then it took an additional 2 months after 

the VAMC sent the referral for the veteran to receive care. Notes in the veteran’s VA electronic health record indicated that his 

follow-up appointment with a VA neurosurgeon was at risk of being rescheduled because VA had not received the results of the 

MRI after the appointment with the Choice Program provider occurred. Ultimately, the veteran’s appointment with the VA 

neurosurgeon—where the imaging results and treatment options were discussed—did not occur until almost 6 months after the 

VA clinician originally identified the need for the MRI. 

• One veteran was a diabetic who was referred to the Choice Program for his annual retinal exam because there was a wait for 

services at a VA medical facility. However, it was not until 30 days after the VA clinician determined the veteran needed this care 

that VAMC staff sent the Choice Program referral to the TPA. It then took the TPA 36 additional days to reach the veteran and

confirm he wanted to opt in to the Choice Program. In all, the veteran waited almost 5 months after his VA clinician determined 

he needed this routine care until his appointment with a Choice Program provider occurred.

• Three veterans were referred to the Choice Program because they needed maternity care, which is generally not available at VA 

medical facilities. For one of these veterans, almost a month and a half elapsed from the time VA confirmed her pregnancy 

(when she was 6 weeks pregnant) to when the VAMC sent the Choice Program referral for urgent care to the TPA. It then took 2 

additional weeks for the TPA to attempt to schedule a prenatal appointment; by that point, she was almost 15 weeks pregnant. 

At 18 weeks pregnant, the veteran finally scheduled her initial prenatal appointment herself, almost 3 months after her pregnancy 

was confirmed at a VA medical facility. 

• One veteran was referred to the Choice Program for thoracic surgery to address a growth on his lung because there was a wait 

for VA care. TPA documentation we reviewed indicated that VAMC staff contacted the TPA four times to inquire about the status 

of the veteran’s appointment, and the TPA contacted five Choice Program providers in its unsuccessful attempts to schedule the 

urgent appointment for the veteran. Ultimately, the veteran scheduled his own initial appointment with a thoracic surgeon in the 

community and informed the TPA that he had done so. The veteran’s initial appointment occurred 3 weeks after the VAMC sent 

his referral to the TPA.

Source: GAO analysis of VHA and TPA documentation. | GAO-17-397T

Note: The above examples come from GAO’s random, non-generalizable sample of 55 authorizations 

for routine care and 53 authorizations for urgent care for which the Choice Program TPAs scheduled 

appointments between January 2016 and April 2016.

Our preliminary results also show that veterans in our sample 

experienced lengthy overall wait times to receive care when the TPAs 

returned their authorizations without scheduling appointments. When 

veterans’ Choice Program authorizations are returned, VAMCs must 

attempt to arrange care through other means—such as through another 

VA community care program, a new Choice Program referral, or at a VA 
Page 24 GAO-17-397T

medical facility. Among the 88 returned authorizations in our sample, we 

determined that 53 veterans eventually received care through other 

means after their authorizations were returned.30 These 53 veterans 

ended up waiting an average of 111 days after the VA clinician originally 

determined they needed care until their first appointment with a VA 

clinician or with a community provider occurred. See the text box below 

for some examples of delays experienced by veterans in the sample of 88 

returned Choice Program authorizations we reviewed.

Examples of Delays Experienced by Veterans Whose Authorizations were Returned to Veterans Affairs Medical Centers 

(VAMC) by the Choice Program Third Party Administrators (TPA) 

• The VAMC took almost 3-and-a-half months to refer one veteran to a physical therapist to address her pelvic floor prolapse. When 

the preferred provider listed in the VAMC’s referral was outside the TPA’s network, the TPA sent a message to the VAMC via its 

Web-based portal to ask if they should try scheduling the appointment with a different provider. By the time VAMC staff responded 

to the message in the TPA’s portal, the TPA had already returned the authorization—almost 2 weeks after accepting it. Two 

months later, the VAMC realized that the veteran still needed this care and sent a new Choice Program referral to the TPA. It then 

took the veteran another 2-and-a-half months to attend her first appointment. Overall, this veteran waited more than 8 months to 

receive physical therapy.

• It took about 2-and-a-half weeks for the VAMC to send one veteran’s referral for pain management to the TPA after a VA clinician 

originally determined he needed these services. However, information the TPA needed for scheduling the Choice Program 

appointment was missing from the VAMC’s referral. The TPA requested the information from the VAMC twice using its Webbased portal, but VAMC staff did not reply, and the TPA returned the authorization 2 weeks after receiving it. It then took another 

month before the veteran ended up receiving pain management services at a VAMC. Overall, this veteran waited almost 2-and-ahalf months for pain management services.

Source: GAO analysis of VHA and TPA documentation. | GAO-17-397T

Note: The above examples come from GAO’s random, non-generalizable sample of 88 Choice 

Program authorizations that the TPAs returned to six VAMCs between January 2016 and April 2016.

 30These 53 veterans received care either at a VA medical facility, through another VA

community care program, or through a new Choice Program authorization. We could not 

conclusively determine whether 20 of the 88 veterans in our sample received the care 

they needed after the TPAs returned their Choice Program authorizations. We provided 

these veterans’ names to VHA officials in December 2016, and the officials said they 

would follow up on these cases. In addition, 14 of the 88 veterans in our sample either 

declined care or no longer needed the care that was authorized. Three of those 14 

veterans no longer needed care because they died before the TPAs or VAMCs could 

schedule appointments. Two veterans had been diagnosed with cancer, had emergency 

inpatient admissions after they were referred to the Choice Program, and died before the 

TPAs could schedule appointments. The third veteran had been referred to the Choice 

Program for in-home physical therapy but also had a series of inpatient admissions that 

made it difficult for the TPA to arrange his care. The one remaining veteran in our sample 

was no longer eligible for services, which is why the TPA returned her authorization to VA.
Page 25 GAO-17-397T

During the course of our ongoing work, VHA officials told us about several 

recent actions they have taken or that they plan to take that are intended 

to improve the timeliness of veterans’ Choice Program care. Below is a 

chronological summary of several such actions, along with VHA’s 

progress in implementing them.31 Many of VHA’s changes have been 

implemented within the last calendar year, and so far, implementation of 

these actions has often been limited to a few VAMCs or to the VAMCs 

that are located in a few Veterans Integrated Service Networks (VISN).32

• Co-Locating TPA staff at selected VAMCs. In November 2015, VA 

modified the Choice Program contracts to allow for TPA staff to be colocated at selected VAMCs—an action that VHA officials said could 

help improve communication between VAMC and TPA staff as they 

work to schedule veterans’ Choice Program appointments. For 

example, VHA officials expect that one potential benefit of co-locating 

TPA staff will be that fewer veterans’ Choice Program referrals will be 

returned to VAMCs due to missing clinical information because TPA 

staff can help resolve such issues locally before the TPA returns 

referrals. As of December 2016, TPA staff were working at 54 of 

VHA’s 168 VAMCs—or about one third of all VAMCs. However, 

according to VHA documentation, only 13 of those 54 VAMCs had colocated TPA staff prior to October 1, 2016, which means that the 

majority of the 54 VAMCs with co-located TPA staff have only recently 

received such support.

• Automating VAMCs’ preparation of Choice Program referrals.

VHA is in the process of establishing a Web-based tool that it says 

would automate the process by which VAMC staff compile clinical 

information for veterans’ Choice Program referrals. Currently, VAMC 

staff must manually retrieve and collate key clinical and contact 

information from veterans’ VA electronic health records. If there are 

mistakes or missing information, the TPAs may either contact the 

VAMC to correct or obtain the missing information or return the 

referral to VA without attempting to schedule an appointment, and this 

 31VHA has taken actions to address various other Choice Program weaknesses. In this 

statement, we are highlighting our preliminary observations on those actions which relate 

most directly to improving the timeliness of veterans’ access to care. 

32VHA’s health care system is divided into areas called VISNs, each responsible for 

managing and overseeing medical facilities within a defined geographic area. VISNs 

oversee the day-to-day functions of VA medical facilities that are within their boundaries. 

Each VA medical facility is assigned to a single VISN. At the start of fiscal year 2016, 

there were 21 VISNs, but VA is in the process of consolidating some networks so that by 

the end of fiscal year 2018, there will be 18 networks.

VHA Is Taking Steps 

to Improve the 

Timeliness of 

Veterans’ Choice 

Program Care, 

Although Nationwide 

Implementation of 

these Actions Has 

Been Limited
Page 26 GAO-17-397T

could delay veterans’ access to Choice Program care. In early 2016, 

to decrease the rate of returned authorizations and speed up the 

process for VAMCs to prepare veterans’ Choice Program referrals, 

staff from two VAMCs developed a Web-based tool—called the 

“referral documentation” (REFDOC) tool—which, according to VHA 

documentation, automates the process of gathering necessary 

information and assembling it in a standardized format. VHA’s initial 

analyses of the REFDOC tool’s effectiveness found that it sped up the 

process of preparing Choice Program referrals by about 20 minutes 

per referral. VHA officials we interviewed said they intend to roll out 

the REFDOC tool across all VAMCs, but nationwide implementation 

has been slowed by limitations of VA’s information technology 

systems. As of November 2016, according to documentation provided 

by VHA, the REFDOC tool had been implemented at only 18 of VHA’s 

168 VAMCs. Officials have stated that they expect to implement the 

REFDOC tool at all VAMCs in March 2017.

• Requiring TPAs to return referrals if appointments are not 

scheduled within required timeframes. A June 2016 VA contract 

modification requires the TPAs to return Choice Program 

authorizations to VAMCs when the TPAs do not meet standards set 

forth in the contract related to the timeliness with which they review 

and accept referrals and schedule appointments after veterans have 

opted into the program. Previously, the TPAs had to return referrals if 

veterans had not opted in 10 days after the TPA sent a letter, but 

there was no requirement for the TPAs to accept referrals within a 

certain timeframe or to return authorizations if the TPAs had not 

scheduled appointments within required timeframes after veterans 

opted in. This contract modification has the potential to limit 

appointment scheduling delays that would be attributable to the TPAs, 

but it does not affect the timeframes by which VAMCs are required to 

prepare veterans’ Choice Program referrals and send them to the 

TPAs.

• VAMC scheduling pilots. In July 2016 and October 2016, VHA 

began implementing pilot projects at two VAMCs, whereby staff at the 

VAMCs have taken over the responsibility of scheduling veterans’

Choice Program appointments from the TPAs, according to VHA 

officials. Specifically, VA modified its contracts with TriWest and 

Health Net to implement the two VAMC scheduling pilots at the 

Alaska VA Health Care System and the Fargo VA Health Care 

System, respectively. In these two locations, VAMC staff schedule 

veterans’ appointments and send relevant clinical documentation to 

the Choice Program providers, and the TPAs send authorizations to 

the Choice Program providers before veterans attend their 
Page 27 GAO-17-397T

appointments. VHA officials told us that they plan to make similar 

contract modifications to implement pilots at four other VAMCs prior to 

the Choice Program’s expiration. They also plan to evaluate the 

implementation of the appointment scheduling pilots and use the 

findings of those evaluations to help inform the design of the VAMC 

appointment scheduling process they plan to include in the 

consolidated VA community care program they intend to implement 

after the Choice Program expires.

• Real-time, Web-based communication tool for VAMCs and TPAs.

Between August and October of 2016, VA implemented a real-time 

communication tool (specifically, a Web-based chat program) at 

VAMCs in five VISNs. VHA officials and VAMC staff can use the tool 

to communicate with TPA officials about problems that have arisen 

with specific Choice Program referrals (such as missing clinical 

information), or patterns of problems that have emerged with Choice 

Program referrals. VHA officials told us that they planned to 

implement the chat room at all VAMCs nationwide by the end of 

January 2017.

• Planned standardization of consult titles for Choice Program 

referrals. According to documentation VHA officials provided to us in 

December 2016, they plan to implement a process for standardizing 

the consult titles associated with Choice Program referrals over the 

course of calendar year 2017. They planned to pilot the process at 

four VAMCs beginning in February 2017 and expected to gradually 

roll out the standardized consult titles across all other VAMCs over the 

remainder of calendar year 2017. As previously discussed, having 

standardized consult titles associated with Choice Program referrals 

will allow VHA to monitor (1) the timeliness with which its VAMCs 

prepare veterans’ Choice Program referrals and send them to the 

TPAs, and (2) veterans’ overall wait times for Choice Program 

appointments.

Chairman Roe, Ranking Member Walz, and Members of the Committee, 

this concludes my prepared statement. I would be pleased to respond to 

any questions you may have at this time.
Page 28 GAO-17-397T

If you or your staffs have any questions about this statement, please 

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

our Offices of Congressional Relations and Public Affairs may be found 

on the last page of this statement. GAO staff who made key contributions 

to this statement include Marcia A. Mann (Assistant Director), Alexis C. 

MacDonald (Analyst-in-Charge), Daniel Powers, and Michael Zose. Also 

contributing were Christine Davis, Krister Friday, Jacquelyn Hamilton, and 

Vikki Porter.

GAO Contact and 

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