VETERANS CHOICE 

PROGRAM 

Improvements 

Needed to Address 

Access-Related 

Challenges as VA 

Plans Consolidation of 

its Community Care 

Programs 

Report to Congressional Addressees

June 2018

GAO-18-281

United States Government Accountability Office
United States Government Accountability Office

 

Highlights of GAO-18-281, a report to 

congressional addressees

June 2018

VETERANS CHOICE PROGRAM

Improvements Needed to Address Access-Related 

Challenges as VA Plans Consolidation of its 

Community Care Programs

What GAO Found

Through the Veterans Choice Program (Choice Program), eligible veterans may 

receive care from community providers when it is not readily accessible at 

Veterans’ Health Administration (VHA) medical facilities. The Department of 

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

(TPA)—to schedule most veterans’ Choice Program appointments after 

receiving referrals from VA medical centers (VAMC). GAO found 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 70 calendar 

days for care if VAMCs and the TPAs take the maximum amount of time VA 

allows to complete its appointment scheduling process. This is not consistent 

with the statutory requirement that veterans receive Choice Program care within 

30 days of their clinically indicated date (when available), which is the soonest 

date that it would be appropriate for the veteran to receive care, according to a 

VHA clinician. Without designing appointment scheduling processes that are 

consistent with this requirement, VA lacks assurance that veterans will receive 

Choice Program care in a timely manner.

GAO and VHA found that selected veterans experienced lengthy actual wait 

times for appointments in 2016, after manually reviewing separate samples of 

Choice Program authorizations. For example, when GAO analyzed 55 routine 

care authorizations that were created between January and April of 2016, it 

found that the process took at least 64 calendar days, on average. When VHA 

analyzed about 5,000 authorizations created between July and September of 

2016, it took an average of 51 calendar days for veterans to receive care. 

Average Wait Times for Choice Program Appointments in 2016, According to Separate NonGeneralizable Analyses by GAO and the Veterans Health Administration (VHA)a

a

GAO excluded from its analysis the amount of time the TPA took to schedule the appointment and 

the overall wait time because its sample selection methodology differed from VHA’s in a way that 

would have skewed these two averages but not the averages for the other segments of the process. 

Why GAO Did This Study

Congress created the Choice Program 

in 2014 to address longstanding 

challenges with veterans’ access to 

care at VHA medical facilities. The 

Joint Explanatory Statement for the 

Consolidated Appropriations Act, 2016 

included provisions for GAO to review 

veterans’ access to care through the 

Choice Program. 

This report examines for Choice 

Program care (1) VA’s appointment 

scheduling process, (2) the timeliness 

of appointments and the information 

VHA uses to monitor veterans’ access; 

and (3) the factors that have adversely 

affected veterans’ access and the 

steps VA and VHA have taken to 

address them for VA’s future 

community care program.

GAO reviewed applicable laws and 

regulations, VA’s TPA contracts, and 

relevant VHA policies and guidance.

Absent reliable national data, GAO 

also selected 6 of 170 VAMCs 

(selected for variation in geographic 

location and the TPAs that served 

them) and manually reviewed a 

random, non-generalizable sample of 

196 Choice Program authorizations. 

The authorizations were created for 

veterans who were referred to the 

program between January and April of 

2016, the most recent period for which 

data were available when GAO began 

its review. The sample of 

authorizations included 55 for routine 

care, 53 for urgent care, and 88 that 

the TPAs returned without scheduling 

appointments. GAO also obtained the 

results of VHA’s non-generalizable 

analysis of wait times for a nationwide 

sample of about 5,000 Choice Program 

authorizations that were created for 

selected services between July and 

September of 2016. 
GAO also found that VHA cannot systematically monitor the timeliness of 

veterans’ access to Choice Program care because it lacks complete, reliable 

data to do so. The data limitations GAO identified include: 

• A lack of data on the timeliness of referring and opting veterans in to 

the program. GAO found that the data VHA uses to monitor the timeliness of 

Choice Program appointments do not capture the time it takes VAMCs to 

prepare veterans’ referrals and send them to the TPAs, nor do they capture 

the time spent by the TPAs in accepting VAMCs’ referrals and opting 

veterans in to the Choice Program. VHA has implemented an interim solution 

to monitor overall wait times that relies on VAMC staff consistently and 

accurately entering unique identification numbers on VHA clinicians’ requests 

for care and on Choice Program referrals, a process that is prone to error. 

• Inaccuracy of clinically indicated dates. GAO found that clinically 

indicated dates (which are used to measure the timeliness of care) are 

sometimes changed by VAMC staff before they send Choice Program 

referrals to the TPAs, which could mask veterans’ true wait times. GAO 

found that VAMC staff entered later clinically indicated dates on referrals for 

about 23 percent of the 196 authorizations it reviewed. It is unclear if VAMC 

staff mistakenly entered incorrect dates manually, or if they inappropriately 

entered later dates when the VAMC was delayed in contacting the veteran, 

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

• Unreliable data on the timeliness of urgent care. GAO found that VAMCs 

and TPAs do not always categorize Choice Program referrals and 

authorizations in accordance with the contractual definition for urgent care. 

According to the contracts, a referral is to be marked as “urgent,” and an 

appointment is to take place within 2 days of the TPA accepting it, when a 

VHA clinician has determined that the needed care is (1) essential to 

evaluate and stabilize the veteran’s condition, and (2) if delayed would likely 

result in unacceptable morbidity or pain. GAO reviewed a sample of 53 

urgent care authorizations and determined that about 28 percent of the 

authorizations were originally marked as routine care authorizations but were 

changed to urgent by VAMC or TPA staff, in an effort to administratively 

expedite appointment scheduling. 

Without complete, reliable data, VHA cannot determine whether the Choice 

Program has helped to achieve the goal of alleviating veterans’ wait times for 

care. 

GAO found that numerous factors adversely affected veterans’ access to care 

through the Choice Program. These factors include: (1) administrative burden 

caused by complexities of referral and appointment scheduling processes, (2) 

poor communication between VHA and its VAMCs, and (3) inadequacies in the 

networks of community providers established by the TPAs, including an 

insufficient number, mix, or geographic distribution of community providers. VA 

and VHA have taken numerous actions throughout the Choice Program’s 

operation that were intended to help address these factors, though not all access 

factors have been fully resolved. For example, to help address administrative 

burden and improve the process of coordinating veterans’ Choice Program care, 

VA established a secure e-mail system and a mechanism for TPAs and 

community providers to remotely access veterans’ VA electronic health records. 

However, these mechanisms only facilitate a one-way transfer of necessary 

information. They do not provide a means by which VAMCs or veterans can view 

the TPAs’ step-by-step progress in scheduling appointments or electronically 

receive medical documentation associated with Choice Program appointments. 

While the Choice Program will soon end, VA anticipates that veterans will 

continue to receive community care under a similar program that VA plans to 

implement, which will consolidate the Choice Program and other VA community

care programs. Incorporating lessons learned from the Choice Program into the 

implementation and administration of the new program could help VHA avoid 

similar challenges. 

What GAO Recommends

For VA’s future consolidated 

community care program, GAO is 

making 10 recommendations, which 

include: 

• establishing an achieveable waittime goal for the community care 

program that will permit VHA to 

monitor whether veterans are 

receiving care within time frames 

that are comparable to the amout 

of time they would otherwise wait 

for care at VHA medical facilities; 

• designing an appointment 

scheduling process that (1) is 

consistent with the wait-time goal 

and (2) sets forth time frames

within which veterans’ referrals 

must be processed, appointments 

must be scheduled, and 

appointments must occur; 

• implementing mechanisms to:

• allow VHA to systematically 

monitor the amount of time 

taken to prepare referrals, 

schedule appointments, and 

complete appointments; 

• prevent veterans’ clinically

indicated dates from being 

modified by individuals other 

than VHA clinicians; and

• separate clinically urgent 

referrals and authorizations 

from those for which the 

VAMC or the TPA has decided 

to expedite appointment 

scheduling for administrative 

reasons; and

• establishing a system that will help 

facilitate seamless, efficient care 

coordination and exchanges of 

information among VAMCs, VHA 

clinicians, TPAs, community 

providers, and veterans.

VA generally agreed with all but one of 

GAO’s recommendations, which was to 

separate clinically urgent referrals from 

those that are administratively 

expedited. GAO maintains that 

implementing this recommendation will 

help improve future monitoring of 

urgent care timeliness for reasons 

explained in the report. 

View GAO-18-281. For more information, 

contact Sharon M. Silas at (202) 512-7114 or 

silass@gao.gov or A. Nicole Clowers at (202) 

512-7114 or clowersa@gao.gov. 
Page i GAO-18-281 Veterans Choice Program

Letter 1

Background 6

Time Allowed to Complete VA’s Choice Program Appointment 

Scheduling Process Significantly Exceeds the Choice Act’s 

Required 30-Day Time Frame for Routine Care 22

Actual Wait Times for Choice Program Care Have Been Lengthy 

for Selected Veterans, and VHA’s Monitoring of Veterans’ 

Access Is Limited by Incomplete and Unreliable Data 30

Multiple Factors Have Adversely Affected Veterans’ Access to 

Care under the Choice Program, Providing Potential Lessons 

Learned for VA’s Future Community Care Program 46

Conclusions 59

Recommendations for Executive Action 61

Agency Comments and Our Evaluation 62

Appendix I Scope and Methodology for Examining 

Choice Program Wait Times and the Data 

VHA Uses to Monitor Access 67

Appendix II Process for Veterans to Obtain Department 

of Veterans Affairs (VA) Choice Program Care 

if They Are Time-Eligiblea 72

Appendix III Process for Veterans to Obtain Department 

of Veterans Affairs (VA) Choice Program Care 

if They Are Distance-Eligiblea 73

Appendix IV Comparison of Processes for Arranging 

Choice Program and Individually 

Authorized Community Care 74

Contents
Page ii GAO-18-281 Veterans Choice Program

Appendix V Process for Obtaining the Clinical Results 

of Choice Program Appointments 75

Appendix VI Selected Actions Taken by VA and VHA to Address 

Choice Program Access Issues 76

Appendix VII Comments from the Department 

of Veteran’s Affairs 81

Appendix VIII GAO Contacts and Staff Acknowledgments 93

Related GAO Products 94

Tables

Table 1: Process for Veterans to Obtain Department of Veterans 

Affairs (VA) Choice Program Care if They Are Timeeligible 10

Table 2: Process for Veterans to Obtain Department of Veterans 

Affairs (VA) Choice Program Care if They Are Distanceeligible 12

Table 3: History of Annual Obligations for Health Care Services 

Provided Through the Veterans Choice Program (Choice 

Program) and Other Department of Veterans Affairs (VA) 

Community Care Programs 19

Table 4: History of Veterans Health Administration (VHA) Annual 

Obligations of Veterans Choice Program (Choice 

Program) Funds, Fiscal Year 2015 through Fiscal Year 

2017 21

Table 5: Department of Veterans Affairs (VA) Medical Centers 

(VAMC) GAO Selected for Its Review of the Veterans 

Choice Program (Choice Program) 68

Table 6: Actions Taken by the Department of Veterans Affairs 

(VA) and the Veterans Health Administration (VHA) 
Page iii GAO-18-281 Veterans Choice Program

between November 2014 and August 2017 to Address 

Choice Program Access Issues 76

Figures

Figure 1: Multi-state Regions Covered by the Veterans Choice 

Program’s Third Party Administrators (TPA) 7

Figure 2: Most Common Reasons Veterans with Scheduled 

Choice Program Appointments Were Referred to the 

Program, Fiscal Years 2015 through 2016 14

Figure 3: Potential Wait Time for Time-Eligible Veterans to Obtain 

Routine Care through the Choice Program Appointment 

Scheduling Process 26

Figure 4: Illustration of How the Veterans Health Administration’s 

(VHA) Data Capture Only a Portion of the Choice 

Program Process for Obtaining Care 39

Figure 5: Process for Veterans to Obtain Department of Veterans 

Affairs (VA) Choice Program Care if They Are TimeEligible 72

Figure 6: Process for Veterans to Obtain Department of Veterans 

Affairs (VA) Choice Program Care if They Are DistanceEligible 73

Figure 7: Comparison of Processes for Arranging Choice Program 

and Individually Authorized Department of Veterans 

Affairs (VA) Community Care 74

Figure 8: Process for the Department of Veterans Affairs (VA) to 

Obtain the Clinical Results of Veterans’ Choice Program 

Appointments 75
Page iv GAO-18-281 Veterans Choice Program

Abbreviations

MRI magnetic resonance imaging

PC3 patient-centered community care

REFDOC referral documentation

RFP request for proposals

TPA third-party administrator

VA Department of Veterans Affairs

VAMC VA medical center

VHA Veterans Health Administration

VISN Veterans Integrated Service Network 

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Page 1 GAO-18-281 Veterans Choice Program

441 G St. N.W.

Washington, DC 20548

June 4, 2018

Congressional Addressees

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 170 

VA medical centers (VAMC) and more than 1,000 outpatient facilities. In 

recent years, we and others have expressed concerns about the ability of 

VHA’s medical facilities to provide health care services in a timely 

manner.1 Serious and long-standing problems with veterans’ access to 

care were also highlighted in a series of congressional hearings in the 

spring and summer of 2014, after several well-publicized events raised 

additional concerns about wait times for appointments at VHA medical 

facilities. In some cases, delays in care or VHA’s failure to provide care 

reportedly have resulted in harm to veterans.2 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 2015.3

 

1

See, for example, GAO, 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, VA 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

See 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. 

3

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-18-281 Veterans Choice Program

In response to the problems with veterans’ access to care at VHA medical 

facilities that were highlighted during the 2014 congressional hearings, 

Congress enacted the Veterans Access, Choice, and Accountability Act 

of 2014 (Choice Act) on August 7, 2014. Among other things, the law 

established a temporary program—called the Veterans Choice Program 

(Choice Program)—and provided up to $10 billion in funding for veterans 

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

they faced long wait times, lengthy travel distances, or other challenges 

accessing care at VHA medical facilities.4 The temporary authority and 

funding for the Choice Program was separate from that of other 

previously existing programs through which VA has the option to 

purchase care from community providers. Legislation enacted in August 

and December of 2017 provided an additional $4.2 billion for the Veterans

Choice Fund.5 VA may continue to authorize Choice Program care until 

all amounts in the Choice Fund are exhausted.6 Currently, VA is in the 

process of planning its future community care program, which (as 

described in an October 2015 plan VA submitted to Congress) will 

consolidate the Choice Program and six other VA community care 

programs into one program.7

In accordance with the Choice Act, VA and 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 time frame,

VA modified contracts it had previously established with Health Net 

Federal Services (Health Net) and TriWest Healthcare Alliance (TriWest) 

to administer a different VA community care program and gave them 

 

4

Pub. L. No. 113-146, §§ 101, 802, 128 Stat. 1754, 1755-1765, 1802-1803 (2014).

5

VA Choice and Quality Employment Act of 2017, Pub. L. No. 115-46, § 101, 131 Stat. 

958, 959 (Aug. 17, 2017) (providing an additional $2.1 billion for the Veterans Choice 

Fund); Department of Homeland Security Blue Campaign Authorization Act of 2017, Pub. 

L. No. 115-96. Div. D, § 4001, 131 Stat. 2044, 2052-53 (Dec. 22, 2017) (providing an 

additional $2.1 billion for the Veterans Choice Fund).

6

Pub. L. No. 115-26, § 1,131 Stat. 129 (2017), amending section 101(p)(2) of the Choice 

Act, Pub. L. No. 113-146, 128 Stat. at 1763. 

7

In this report, when we discuss VA’s future community care program, we are referring to 

the plan for consolidating the Choice Program and VA’s other community care programs 

that VA submitted to Congress on October 15, 2015. See Department of Veterans Affairs, 

Plan to Consolidate Programs of Department of Veterans Affairs to Improve Access to 

Care, (Washington, D.C.: Oct. 30, 2015). However, as of May 23, 2018, both Houses of 

Congress had passed S. 2371, the “VA Maintaining Internal Systems and Strengthening 

Integrated Outside Networks Act of 2018” (VA MISSION Act of 2018), which would 

establish a permanent community care program for veterans, among other purposes.
Page 3 GAO-18-281 Veterans Choice Program

certain responsibilities related to Choice Program administration, 

including the scheduling of routine and urgent care appointments for 

veterans needing care in the community.8 VA and VHA refer to Health 

Net and TriWest as third-party administrators (TPA). The Choice Program

implementation tasks included designing a framework to administer the 

program (which involved dividing responsibilities between VAMCs and 

TPAs), negotiating contract modifications to add Choice Program 

administration responsibilities to the TPAs’ existing contracts with VA, 

designing referral and appointment scheduling processes for VAMCs and 

the TPAs, strengthening the community provider networks the TPAs had 

established under their existing VA contracts, creating TPA call centers, 

training VAMC and TPA staff, producing and distributing Veterans Choice 

Cards to veterans, and educating veterans and community providers 

about the new program.

External reviews, media reports, and congressional hearings held over 

the course of the Choice Program’s implementation and operation have 

highlighted programmatic weaknesses, such as insufficient provider 

networks, significant delays in scheduling appointments, and a lack of 

timely payments to network providers.9 The Joint Explanatory Statement 

for the Consolidated Appropriations Act, 2016 included two provisions for 

us to review veterans’ access to care and the delivery of health care 

 

8

Choice Program appointments that have not been categorized as “urgent” are considered 

to be appointments for routine care. Under VA’s contracts with the TPAs, veterans’ 

appointments are categorized as “urgent” when a clinician determines 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. 

9

See, for example, Department of Veterans Affairs Office of Inspector General, Veterans 

Health Administration: Audit of the Timeliness and Accuracy of Choice Payments 

Processed Through the Fee Basis Claims System, Report No. 15-03036-47 (Washington, 

D.C.: Dec. 21, 2017); Quil Lawrence, 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/health-shots/2016/05/16/477814218/attempted-fix-for-va-healt

h-delays-creates-new-bureaucracy; and 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-but-congress-is-stymied-ona-solution. 
Page 4 GAO-18-281 Veterans Choice Program

services through the Choice Program, with a focus on rural areas.10 In 

addition, you asked us to conduct a comprehensive review of the Choice 

Program, focusing on (among other things) the effect the Choice Program 

has had on reducing veterans’ wait times for care. In March 2017, we 

presented preliminary observations from this work at a hearing of the 

House Committee on Veterans’ Affairs.11 This report updates our 

preliminary findings and examines:

1. the potential wait times for veterans to receive routine care through 

the Choice Program, according to VA’s appointment scheduling 

process;

2. selected veterans’ actual wait times to receive routine care and urgent 

care through the Choice Program and the information VHA uses to 

monitor access to care under the program; and

3. the factors, if any, that have adversely affected veterans’ access to 

care under the Choice Program and the actions, if any, that VA and 

VHA have taken to address them for VA’s future community care 

program.

To examine the potential wait times for veterans to receive routine care 

through the Choice Program according to VA’s appointment scheduling 

process, we reviewed applicable laws and regulations; VA’s contracts 

with the TPAs; and relevant VA and VHA policy directives, guidance, and 

training materials for VAMCs. In addition, we exchanged written 

correspondence with VA’s Office of General Counsel about the 

application of VHA’s wait time goals to the Choice Program. 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.12 We analyzed this evidence in the 

 

10164 Cong. Rec. H10378, H10394 (daily ed. Dec. 17, 2015) (Explanatory Statement for 

Division J of the Consolidated Appropriations Act, 2016, Pub. L. No. 114-113 (2015)).

11See GAO, Veterans’ Health Care: Preliminary Observations on Veterans’ Access to 

Choice Program Care, GAO-17-397T (Washington, D.C.: March 7, 2017). 

12Officials 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.
Page 5 GAO-18-281 Veterans Choice Program

context of the federal internal control standard for control activities, which 

includes the design of policies and procedures that will help an entity 

achieve its objectives and respond to risks.13

To examine selected veterans’ actual wait times to receive routine care 

and urgent care through the Choice Program and the information VHA 

uses to monitor access to care under the program, we took five key steps. 

We (1) analyzed Choice Program appointment wait times for selected 

veterans using a sample of 196 Choice Program authorizations for routine 

and urgent care; (2) reviewed VHA’s analysis of appointment wait times

for a sample of about 5,000 Choice Program authorizations; (3) reviewed 

data VHA uses to monitor the timeliness of Choice Program care and 

reasons that the TPAs have returned Choice Program referrals without 

making appointments; (4) interviewed VA, VHA, and TPA officials; and (5) 

reviewed federal internal control standards.14 See Appendix I for more 

information on these methodological steps.

To examine the factors, if any, that have adversely affected veterans’ 

access to care under the Choice Program and the actions, if any, that VA 

and VHA have taken to address them for VA’s future community care 

program, we reviewed documentation and interviewed officials from VA, 

VHA, and the TPAs; as well as leadership officials and community care 

managers and staff from six selected VAMCs.15 (See Appendix I for 

information about how we selected the six VAMCs.) In cases where we 

identified actions VA and VHA had taken to address factors that 

adversely affected veterans’ access, we interviewed VA and VHA officials 

 

13See GAO, Standards for Internal Control in the Federal Government, GAO-14-704G 

(Washington, D.C.: Sept. 2014). Internal control is a process effected by an entity’s 

oversight body, management, and other personnel that provides reasonable assurance 

that the objectives of an entity will be achieved. 

14For the Choice Program, the TPA generates an authorization after an eligible veteran 

has opted in to the program. Among other things, the authorization informs the community 

provider of the veteran’s medical needs and the specific services that will be covered, as 

well as the period of validity (i.e., beginning and ending dates) for the episode of care. 

Each authorization may result in multiple appointments, and a single veteran may have 

multiple Choice Program authorizations.

15S. 2372, VA MISSION Act of 2018, was passed by both Houses of Congress after the 

completion of our audit fieldwork, and therefore, we did not incorporate it in our review of 

VA’s future community care program. We evaluated the future community care program in 

light of the law current at the time of our audit and considering VA’s 2015 plan for 

consolidating the Choice Program and VA’s other community care programs, and tracked 

various legislative proposals for VA community care.
Page 6 GAO-18-281 Veterans Choice Program

and reviewed documentation they provided to gain a better understanding 

of their rationale for taking those actions and the extent to which they had 

evaluated the outcomes or effectiveness of selected actions. Between 

May and September of 2016, we interviewed community care managers 

and staff at the six selected VAMCs, and we followed up with the 

managers in June and July of 2017. During these interviews, we 

discussed certain actions VA and VHA had taken and obtained their 

perspectives on implementation of the actions and the extent to which 

these actions improved veterans’ access to Choice Program care. We 

examined the actions VA and VHA took in the context of federal 

standards for internal control.16

We conducted this performance audit from April 2016 through May 2018

in accordance with generally accepted government accounting 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.

In October 2014, VA modified its existing contracts with two TPAs that 

were administering another VA community care program to add certain 

administrative responsibilities associated with the Choice Program. For 

the Choice Program, each of the two TPAs—Health Net and TriWest—is 

responsible for delivering care in a specific multi-state region (See figure 

1.). Specifically, the TPAs are responsible for establishing networks of 

community providers, scheduling appointments with community providers 

for eligible veterans, and paying community providers for their services.

 

16GAO-14-704G. 

Background

Responsibilities of the 

Choice Program TPAs
Page 7 GAO-18-281 Veterans Choice Program

Figure 1: Multi-state Regions Covered by the Veterans Choice Program’s Third Party Administrators (TPA)

Note: TriWest Healthcare Alliance is the TPA for American Samoa, Guam, and the Northern Mariana 

Islands. Health Net Federal Services is the TPA for Puerto Rico and the U.S. Virgin Islands.
Page 8 GAO-18-281 Veterans Choice Program

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

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

network providers rather than from VHA medical facilities when the 

veterans are enrolled in the VA health care system and meet any of the 

following criteria:17

• the next available medical appointment with a VHA clinician 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;18

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

frequency of care needed, warrants participation in the program;19 or

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

medical facility.20

Over the life of the Choice Program, VA has taken various approaches to 

care for veterans for whom services are not available at a particular VHA 

medical facility. In May and October of 2015, VHA issued policy 

memoranda to its VAMCs that required them to offer veterans referrals to 

the Choice Program before they authorized care through one of VA’s 

other community care programs, which existed prior to the creation of the 

 

17Department of Veterans Affairs, Veterans Health Administration, Veterans Choice 

Program Eligibility Details (Washington, D.C.: Dec. 1, 2015).

18A determination about whether the veteran meets this criterion will be made in 

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

19A determination about whether the veteran meets this criterion will be made in 

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

20Specifically, 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.

Choice Program Eligibility 

Criteria
Page 9 GAO-18-281 Veterans Choice Program

Choice Program.21 Before May 2015, VA provided VAMCs the flexibility to 

decide on a case-by-case basis whether to refer veterans to the Choice 

Program or one of VA’s other community care programs when services 

were not available. In June 2017, VHA issued another policy 

memorandum that rescinded the referral hierarchy that required VAMCs 

to refer to the Choice Program first. It directed VAMCs to refer veterans to 

the Choice Program only if they met the Choice Act’s wait-time, distance, 

and geographic eligibility criteria, and to instead use other VHA medical 

facilities, facilities with which VA has sharing agreements, and other VA 

community care programs to deliver care to veterans when services were 

not available at a VHA medical facility and veterans did not qualify under 

the Choice Act’s eligibility criteria. In August 2017, after Congress 

provided an additional $2.1 billion for the Choice Program, VHA again 

changed its guidance on referral patterns for the Choice Program and 

VA’s other community care programs.22 Specifically, VA issued a fact 

sheet saying that the new funding will allow VAMCs to refer veterans to 

the Choice Program to the maximum extent possible.23 This allowed 

VAMCs to again offer veterans Choice Program referrals when services 

are unavailable at VHA medical facilities (until available funds have been 

exhausted), and also permitted VAMCs to refer veterans to other VA 

community care programs when services are unavailable.

Through policies and standard operating procedures for VAMCs and 

contracts with the TPAs, VA and VHA have established two separate 

processes for Choice Program routine and urgent appointment 

 

21See Veterans Health Administration, VA Care in the Community (Non-VA Purchased 

Care) and Use of the Veterans Choice Program, VHA Memoranda (May 12, 2015 and 

Oct. 1, 2015). Specifically, when services were unavailable or the veteran could not 

receive an appointment within 30 days, these memoranda required VAMCs to determine 

whether needed services are available in a timely manner from another VHA 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 could not be 

arranged in this manner, VAMCs had 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. 

22VA Choice and Quality Employment Act of 2017, Pub. L. No. 115-46, § 101, 131 Stat. 

958, 959 (2017).

23See Department of Veterans Affairs, Extension of Veterans Choice Program Funding,

VA Fact Sheet (August 2017). 

Process for Choice 

Program Appointment 

Scheduling
Page 10 GAO-18-281 Veterans Choice Program

scheduling: one process for time-eligible veterans and another for 

distance-eligible veterans.24

Table 1 provides an overview of the appointment scheduling process that 

applies when a veteran is referred to the Choice Program because the 

veteran is time-eligible. (Appendix II contains additional detail about the 

Choice Program appointment scheduling process for time-eligible 

veterans—including differences between the routine and urgent care 

appointment scheduling process.)

Table 1: Process for Veterans to Obtain Department of Veterans Affairs (VA) Choice Program Care if They Are Time-eligiblea

Steps of the 

Choice Program 

scheduling process 

Completed by VA 

medical center 

(VAMC) staff

Completed by 

Choice Program third 

party administrator 

(TPA) staff

Completed by 

the veteran

A Veterans Health Administration (VHA) 

clinician determines the veteran needs care. ✓

VAMC staff confirm the veteran’s eligibility for 

Choice Program care and begin contacting the 

veteran to offer a referral to the Choice Program.

✓

The veteran agrees to be referred to the 

Choice Program. ✓

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.

✓

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.

✓

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. 

✓

 

24For the purposes of this report, the terms “time-eligible” and “distance-eligible” refer to 

the Choice Program processes used to schedule veterans’ appointments. VHA uses the 

time-eligible appointment scheduling process when the services needed are not available 

at a VHA medical facility or are not available within allowable wait times. During this 

review, we did not evaluate VA’s determination that veterans for whom services were 

unavailable were eligible for the Choice Program. VHA uses the distance-eligible 

appointment scheduling process when veterans reside more than 40 miles from a VHA 

medical facility or meet other travel-related criteria. 
Page 11 GAO-18-281 Veterans Choice Program

Steps of the 

Choice Program 

scheduling process 

Completed by VA 

medical center 

(VAMC) staff

Completed by 

Choice Program third 

party administrator 

(TPA) staff

Completed by 

the veteran

If the veteran opts in to the Choice Program, TPA staff 

create an authorization and begin efforts to schedule 

an appointment with a community provider. 

✓

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. 

✓

The veteran attends the initial appointment with the 

Choice Program community provider. ✓

Source: GAO analysis of VA and VHA documents. | GAO-18-281

a

VHA uses the time-eligible appointment scheduling process when the services needed are not 

available at a VHA medical facility or are not available within allowable wait times.

When veterans reside more than 40 miles from a VHA medical facility or 

meet other travel-related criteria, VHA uses the appointment scheduling 

process it developed for distance-eligible veterans. The process for 

distance-eligible veterans differs from that for time-eligible veterans in that 

VAMCs do not prepare a referral and send it to the TPA. Instead, 

distance-eligible veterans contact the TPA directly to request Choice 

Program care. See table 2 for an overview of the Choice Program 

appointment scheduling process that applies for distance-eligible 

veterans. (See appendix III for additional detail about the Choice Program 

appointment scheduling process for distance-eligible veterans—including 

differences between the routine and urgent care appointment scheduling 

process.)
Page 12 GAO-18-281 Veterans Choice Program

Table 2: Process for Veterans to Obtain Department of Veterans Affairs (VA) Choice Program Care if They Are Distanceeligiblea

Steps of the 

Choice Program 

scheduling process 

Completed by VA 

medical center 

(VAMC) staff

Completed by 

Choice Program third 

party administrator 

(TPA) staff

Completed by 

the veteran

The veteran contacts the TPA to request 

Choice Program care. ✓

TPA staff verify that the veteran is eligible for Choice 

Program care and that the requested care is medically 

appropriate. 

✓

TPA staff create an authorization and begin efforts to 

schedule an appointment with a community provider. ✓

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. 

✓

The veteran attends the initial appointment with 

the Choice Program community provider. ✓

Source: GAO analysis of VA and VHA documents. | GAO-18-281

a

VHA uses the distance-eligible appointment scheduling process when veterans reside more than 40 

miles from a VHA medical facility or meet other travel-related eligibility criteria.

Data we obtained from the TPAs indicate that VHA and the TPAs used 

the time-eligible appointment scheduling process about 90 percent of the 

time from fiscal year 2015 through fiscal year 2016 (the first 2 years of the 

Choice Program’s implementation). 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 VHA medical facility.25 The second-most-common reason 

for referral was that the wait time for an appointment at a VHA medical 

facility exceeded 30 days. (See figure 2.) The distance-eligible 

appointment scheduling process was used for about 10 percent of the 

 

25Prior 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 VHA 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 not 

meeting 30-day wait times. Only the TPAs could break these groups of veterans out 

separately, so we are instead reporting the TPAs’ data. 

Choice Program Utilization 

from Fiscal Year 2015 

through Fiscal Year 2016
Page 13 GAO-18-281 Veterans Choice Program

veterans who used the Choice Program between fiscal year 2015 through 

fiscal year 2016.
Page 14 GAO-18-281 Veterans Choice Program

Figure 2: 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 VHA 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 15 GAO-18-281 Veterans Choice Program

In coordinating the furnishing of care to eligible veterans under the Choice 

Program, VA is required to ensure that veterans receive appointments for 

Choice Program care within the wait-time goals of VHA for the furnishing 

of hospital care and medical services.26 Although the Choice Act defined 

VHA’s wait-time goals as not more than 30 days from the date a veteran 

requests an appointment from the Department, the Choice Act gave VA 

the authority to change this definition if it did not reflect VHA’s actual waittime goals. If VA wanted to exercise this authority, it was required to notify 

Congress of VHA’s actual wait-time goals within 60 days of the law’s 

enactment (i.e., by October 6, 2014).27 VA did so in an October 3, 2014, 

report to Congress.28 To “ensure that care provided through the Veterans 

Choice Program is delivered within clinically appropriate timeframes,” VA 

notified Congress that VHA’s wait-time goals were “not more than 30 

days from either the date that an appointment is deemed clinically 

appropriate by a VA health care provider, or if no such clinical 

determination has been made, the date a Veteran prefers to be seen for 

hospital care or medical services.” By incorporating VHA’s reported waittime goal, the Choice Act required VA to ensure the furnishing of care to 

eligible veterans within 30 days of the clinically indicated date or, if none 

existed, within 30 days of the veteran’s preferred date.29

 

26Pub. L. No. 113-146, § 101(a)(3), 128 Stat. at 1756.

27Pub. L. No.113-146, § 101(s), 128 Stat. at 1764.

28Department of Veterans Affairs, “Report to Congress on the Veterans Choice Program 

Authorized by Section 101 of the Veterans Access, Choice, and Accountability Act of 2014 

(Pub. L. No. 113-146),” (Oct. 3, 2014). VA subsequently published the definition submitted 

to Congress in this report in the Federal Register, as required by section 101(s)(2)(B) of 

the Choice Act. See Department of Veterans Affairs: Wait-Time Goals of the Department 

for the Veterans Choice Program, 79 Fed. Reg. 62519-20 (October 17, 2014).

29The Choice Act’s wait-time requirements apply to the furnishing of care to veterans who 

are eligible for the program under any of the Act’s eligibility categories. Pub. L. No. 113-

146, § 101(a)(3), (b), (s)(2)(A), 128 Stat. at 1756-57, 1764. According to VHA policy, the 

clinically indicated date is the date that it would be clinically appropriate for the 

appointment to occur, as determined by the VHA clinician who identified the veteran’s 

need for care. 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. See Veterans Health Administration, Consult Processes and 

Procedures, VHA Directive 1232(1) (Aug. 24, 2016, as amended on Sept. 23, 2016).

Choice Act Wait-Time 

Requirements for Care 

Furnished Under the 

Program
Page 16 GAO-18-281 Veterans Choice Program

VA has purchased health care services from community providers 

through various programs since as early as 1945. Currently, there are six 

community care programs other than the Choice Program through which 

VA purchases hospital care and medical services for veterans. These six 

community care programs offer different types of services and have 

varying eligibility criteria for veterans and community providers.30 VA’s six 

non-Choice community care programs include:

• Individually authorized VA community care. The primary means by 

which VHA has traditionally purchased community care is through 

individual authorizations, where local VAMC staff determine veteran 

eligibility, create authorizations, and assist veterans in arranging care 

with community providers that are willing to accept VA payment. 

Traditionally, VAMCs have approved the use of individually authorized 

community care when a veteran cannot access a particular specialty 

care service from a VHA medical facility because the service is not 

offered or the veteran would have to travel a long distance to obtain it 

from a VHA medical facility. (See appendix IV for an illustration of how 

appointment scheduling and care coordination processes for the 

Choice Program compare to those for individually authorized VA 

community care.)

• Two emergency care programs. When VA community care is not 

preauthorized, VA may reimburse community providers for emergency 

care under two different community care programs: 1) emergency 

care for a condition related to a veteran’s service-connected disability 

and 2) emergency care for a condition not related to a veteran’s 

service-connected disability, commonly referred to as Millennium Act 

emergency care.31 For emergency care to be covered through these 

two programs, a number of criteria must be met, including (1) 

community providers must file claims in a timely manner (within 2 

 

30These six community care programs are the ones that VA proposed consolidating in the 

2015 plan it submitted to Congress. See Department of Veterans Affairs, Plan to 

Consolidate Programs of Department of Veterans Affairs to Improve Access to Care. For 

more information about some of these VA community care programs, including differences 

in eligibility requirements and payment rates, see GAO, Veterans’ Health Care: Proper 

Plan Needed to Modernize System for Paying Community Providers, GAO-16-353 

(Washington, D.C.: May 11, 2016). There are other VA community care programs not 

described here—such as those that provide long-term care—that VA has not proposed 

including in its consolidation.

31The Veterans Millennium Health Care and Benefits Act, Pub. L. No. 106-117, § 111, 113 

Stat. 1545, 1553-1556 (1999), codified, as amended, at 38 U.S.C. § 1725.

VA’s Other Community 

Care Programs and 

Planned Consolidation
Page 17 GAO-18-281 Veterans Choice Program

years of the date services were rendered for service-connected 

emergency care and within 90 days for Millennium Act emergency 

care); (2) the veteran’s condition must meet the prudent layperson 

standard of an emergency; and (3) a VA or other federal medical 

facility must not have been feasibly available to provide the needed 

care, and an attempt to use either would not have been considered 

reasonable by a prudent layperson.32

• Patient-Centered Community Care (PC3). In September 2013, VA 

awarded contracts to Health Net and TriWest to develop regional 

networks of community providers to deliver specialty care, mental 

health care, limited emergency care, and maternity and limited 

newborn care when such care is not feasibly available from a VHA 

medical facility. VA and the TPAs began implementing the PC3 

program in October 2013, and it was fully implemented nationwide as

of April 2014—prior to the creation of the Choice Program. In August 

2014, VA expanded the PC3 program to allow community providers of 

primary care to join the PC3 networks. PC3 is a program VA created 

under existing statutory authorities, not a program specifically 

designed by law. To be eligible to obtain care from PC3 providers, 

veterans must meet the same criteria that are required for individually 

authorized VA care in the community services.

• Agreements with federal partners and academic affiliates. When 

services are not available at VHA medical facilities, VA may also 

obtain specialty, inpatient, and outpatient health care services for 

veterans through two types of sharing agreements—those with other 

federal facilities (such as those operated by the Department of 

Defense and the Indian Health Service), and those with university-

 

32For both of VA’s emergency care programs, a medical emergency exists when the 

condition is of such a nature that a prudent layperson would reasonably expect that delay 

in seeking immediate medical attention would be hazardous to life or health. The standard 

would be met if there was an emergency medical condition manifesting itself by acute 

symptoms of sufficient severity (including severe pain) that a prudent layperson who 

possesses an average knowledge of health and medicine could reasonably expect the 

absence of immediate medical attention to result in placing the health of the individual in 

serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any 

bodily organ or part. See 38 C.F.R. § 17.1002(b) (2015). The prudent layperson standard 

emphasizes the patient’s presenting symptoms, rather than the final diagnosis, when 

determining whether to pay emergency medical claims. The Millennium Act emergency 

care program has criteria in addition to those listed here that must be met in order for VA 

to pay claims from community providers. For more information about these criteria, see 

GAO, VA Health Care: Actions Needed to Improve Administration and Oversight of VA’s 

Millennium Act Emergency Care Benefit, GAO-14-175 (Washington, D.C.: March 6, 2014). 
Page 18 GAO-18-281 Veterans Choice Program

affiliated hospitals, medical schools, and practice groups (known as 

academic affiliates).

• Dialysis contracts. In June 2013, VA awarded contracts to numerous 

community providers nationwide to deliver dialysis—a life-saving 

medical procedure for patients with end-stage renal disease 

(permanent kidney failure). When dialysis services are not feasibly 

available at VHA medical facilities, veterans may be referred to one of 

VA’s contracted dialysis providers, and veterans may receive dialysis 

at local clinics on an outpatient basis, or at home (if the contractors 

offer home-based dialysis services).

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

31, 2015, required VA to develop a plan for consolidating all of its 

community care programs into a new, single program to be known as the 

“Veterans Choice Program.”33 VHA submitted this plan, including 

proposed legislative changes, to Congress on October 30, 2015. VA has 

moved forward with some aspects of the planned community care 

program consolidation that it believes can be accomplished without 

statutory changes. In December 2016, VA issued a request for proposals 

(RFP) for contractors to help administer the consolidated community care 

program, through “community care network” contracts. The consolidated 

community care program VA described in the October 2015 plan it 

submitted to Congress and the December 2016 RFP, as amended, would 

be similar to the current Choice Program in certain respects. For 

example, VA is planning to award community care network contracts to 

TPAs, which would establish regional networks of community providers 

and process payments to those providers. In contrast, other aspects of 

the consolidated community care program VA has planned may differ 

from the existing Choice Program. For example, VA’s RFP for the 

community care network contracts, as amended, requires VAMCs—rather 

than TPAs—to carry out appointment scheduling, unless they exercise a 

contract option for the TPAs to provide such services.34

 

33Pub. L. No. 114-41, § 4002, 129 Stat. 443, 461 (2015). 

34A May 26, 2017 amendment to VA’s December 2016 RFP gave VA the option of 

contracting with the TPAs to carry out the appointment scheduling process for VAMCs that 

request these services. 
Page 19 GAO-18-281 Veterans Choice Program

In fiscal year 2015, the first year of the Choice Program’s implementation, 

total obligations for Choice Program health care services accounted for 

about 4.7 percent of the $8.7 billion VA obligated for all community care 

services that year. 35 However, as more care was provided through the 

Choice Program in fiscal years 2016 and 2017, obligations for Choice 

Program care grew steadily, while obligations for care delivered through 

other VA community care programs decreased. In fiscal year 2017, total 

obligations for Choice Program health care services accounted for about 

39 percent of the $11.16 billion VA obligated for all community care 

services that year. See table 3.

Table 3: History of Annual Obligations for Health Care Services Provided Through the Veterans Choice Program (Choice 

Program) and Other Department of Veterans Affairs (VA) Community Care Programs

Obligations by fiscal year (in billions)

Program 2015 2016 2017 

Choice Program $0.41 $1.50 $4.37

Other VA community care programsa 8.29b 7.49 6.79

Total 8.70 8.98 11.16

Source: GAO analysis of VHA data. Ɩ GAO-18-281

Note: The dollar figures in this table have been rounded to the nearest $10 million.

a

Amounts in this row do not include obligations for VA-administered community care programs that 

serve veterans’ dependents or family members, rather than veterans themselves. Such programs 

include the Civilian Health and Medical Program of the Department of Veterans Affairs, which is for 

family members of veterans who either (1) are rated by VA as permanently and totally or disabled, or 

(2) died from VA-rated service-connected disabilities. Also excluded from these amounts are 

obligations for VA’s Primary Family Caregivers program and the Camp Lejeune Family Member 

Program because they also serve veterans’ family members, rather than veterans.

b

This amount includes $1.93 billion in Choice Program funds used by VA between May 1, 2015 and 

September 30, 2015 for other VA community care programs. Congress granted VA authority to use 

Choice Program funds for this purpose in July 2015. See Pub. L. No. 114-41, § 4004(a), 129 Stat. 

443, 463 (2015). We have included these amounts as obligations of other VA community care 

programs because they were used for care through the other programs.

As shown in Table 4, below, of the $10.37 billion in Choice Program funds 

that were obligated between fiscal year 2015 and fiscal year 2017, $6.28 

billion (or about 61 percent) of the funds were obligated for Choice 

 

35An obligation is defined as a “definite commitment that creates a legal liability of the

government for the payment of goods and services ordered or received, or a legal duty on 

the part of the United States that could mature into a legal liability by virtue of actions on 

the part of the other party beyond the control of the United States.” GAO, A Glossary of 

Terms Used in the Federal Budget Process, GAO-05-734SP (Washington, D.C.: 

September 2005), p. 70. 

Annual Obligations for the 

Choice Program and 

Other VA Community Care 

Programs
Page 20 GAO-18-281 Veterans Choice Program

Program health care services. About $1.76 billion (or 17 percent) of total 

Choice Program funds obligated between fiscal year 2015 and fiscal year 

2017 were obligated for administrative costs. The remaining $2.33 billion 

(about 22 percent) were obligated for medical services other than those 

authorized under the Choice Program. As we previously reported, VHA 

experienced a projected funding gap in its medical services appropriation 

account in fiscal year 2015, largely due to lower-than-expected 

obligations for the Choice Program, higher-than-expected obligations for 

other VA community care programs, and unanticipated obligations for 

hepatitis C drugs.36 To address the projected funding gap, on July 31, 

2015, VA obtained temporary authority to use Choice Program funds 

between July 31, 2015 and September 30, 2015 for amounts obligated on 

or after May 1, 2015 to furnish medical services other than those that it 

authorized under the Choice Program. Later, in fiscal year 2016 and fiscal 

year 2017, VA de-obligated about $420 million of the Choice Program 

funds it had obligated for other VA community care programs and 

hepatitis C drugs in fiscal year 2015 because they were never expended.

 

36See GAO, VA’s Health Care Budget: In Response to a Projected Funding Gap in Fiscal 

Year 2015, VA Has Made Efforts to Better Manage Future Budgets, GAO-16-584 

(Washington, D.C.: Jun. 3, 2016). Prior to fiscal year 2017, VA’s medical services 

appropriation funded VA health care services other than those authorized under the 

Choice Program—including services provided through VA’s other community care 

programs. In fiscal year 2017, VA began funding non-Choice health care services through 

its annual medical services and medical community care appropriations, while services 

provided through the Choice Program were still funded through the Veterans Choice 

Fund. 
Page 21 GAO-18-281 Veterans Choice Program

Table 4: History of Veterans Health Administration (VHA) Annual Obligations of Veterans Choice Program (Choice Program) 

Funds, Fiscal Year 2015 through Fiscal Year 2017

Obligation 

purpose

Amount of annual obligations, 

by fiscal year (in billions) Total obligations,

fiscal year 2015 through 

2015 2016 2017 fiscal year 2017 (in billions)

Choice Program 

health care services

$0.41 $1.50 $4.37 $6.28

Choice Program 

administrationa 0.34 0.68 0.74 1.76

Other VA community 

care programsb 2.34 (.17) (.23) 1.93

Hepatitis C drugsb 0.41 (.01) — .40

Total 3.50 2.0 4.87 10.37

Source: GAO analysis of VHA data. Ɩ GAO-18-281

Note: The dollar figures in this table have been rounded to the nearest $10 million.

a

These amounts include obligations for the implementation and administration of the Choice Program 

contracts as well as information technology support for the program.

b

In fiscal year 2015, Congress authorized VHA to use Choice Program funds to address a projected 

funding gap of $2.75 billion, attributed to $2.34 billion in higher-than-expected obligations for VA’s 

other community care programs and $0.41 billion in unanticipated obligations for hepatitis C drugs. 

Later, in fiscal year 2016 and fiscal year 2017, VA de-obligated about $0.42 billion of the Choice 

Program funds it had obligated for other VA community care programs and hepatitis C drugs in fiscal 

year 2015.
Page 22 GAO-18-281 Veterans Choice Program

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

referred to the Choice Program for routine care because they are timeeligible could potentially wait up to 70 calendar days to obtain care, if 

VAMCs and TPAs take the maximum amount of time allowed by VA’s 

process.37 About 90 percent of Choice Program referrals in fiscal years 

2015 and 2016 were scheduled under the time-eligibility process, which 

means that the majority of veterans referred to the program would have 

been subject to this potential wait time for an appointment for routine 

care.38 This 70-day potential wait time is in contrast to the Choice Act’s 

required time frame, which is that eligible veterans receive Choice 

Program care no more than 30 days from the date an appointment is 

deemed clinically appropriate by a VHA clinician (referred to as the 

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

days from the date the veteran prefers to receive care. According to VHA 

policy, a VHA clinician’s clinically indicated date determination must be 

based upon the needs of the patient, and it should be the earliest date 

that it would be clinically appropriate for the veteran to receive care.39

Therefore, if there is no clinical reason that care should be delayed, a 

 

37We updated our previous preliminary analysis of veterans’ potential wait times, as 

reported in GAO-17-397T, because VA issued a relevant contract modification, guidance 

to the TPAs, and a VAMC policy memorandum after we testified before the Committee on 

Veterans’ Affairs of the House of Representatives in March 2017. Previously, the overall 

potential wait time was 81 calendar days, but this contract modification, guidance, and 

policy memorandum reduced the overall potential wait time to 70 calendar days. 

38In contrast, only about 10 percent of Choice Program authorizations created by the 

TPAs in fiscal years 2015 and 2016 were for distance-eligible veterans, which is why we 

did not separately examine potential wait times for these veterans. Under the TPA 

contracts, distance-eligible veterans are required to receive care within 30 days of their 

preferred dates, and they do not need to obtain referrals from VAMCs before contacting 

the TPAs to request appointments, which means that their overall wait times could 

potentially be less than 70 calendar days.

39See Veterans Health Administration, Consult Processes and Procedures, VHA Directive 

1232(1) (Aug. 24, 2016, as amended on Sept. 23, 2016). 

Time Allowed to 

Complete VA’s 

Choice Program 

Appointment 

Scheduling Process 

Significantly Exceeds 

the Choice Act’s 

Required 30-Day 

Time Frame for 

Routine Care
Page 23 GAO-18-281 Veterans Choice Program

veteran’s clinically indicated date could be the same date that the VHA 

clinician determined the veteran needed care.40

The potential wait time of about 70 calendar days for time-eligible 

veterans to receive routine care through the Choice Program 

encompasses 18 or more calendar days for VAMCs to prepare veterans’ 

Choice Program referrals and potentially another 52 calendar days for 

appointments to occur through the TPAs’ scheduling process, as follows:

• VAMCs’ process for preparing routine Choice Program referrals.

According to VHA policies and guidance, VAMC staff have at least 18 

calendar days to confirm that veterans want to be referred to the 

Choice Program and to send veterans’ referrals to the TPAs:41

• They have 2 business days (or up to 4 calendar days) after a VHA 

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 the veteran 

wants 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 

 

40Among the sample of 196 Choice Program authorizations we reviewed, the clinically 

indicated date was the same date that the VHA clinician determined the veteran needed 

care about 60 percent of the time—in 82 out of the 134 authorizations for which we were 

able to identify clinically indicated dates. We could not identify VA’s clinically indicated 

dates for a total of 62 of the authorizations in our sample. There were no clinically 

indicated dates for these 62 authorizations because (for example) they were for distanceeligible 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.

41According 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 Veterans Health Administration, Consult Processes and 

Procedures, VHA Directive 1232(1) (Aug. 24, 2016, as amended on Sept. 23, 2016) and a 

June 5, 2017 memorandum communicating new process timeliness scheduling 

requirements. 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 18-calendar-day time period begins with 

the date the veteran’s VHA 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 

VHA clinician on behalf of a patient seeking an opinion, advice, or expertise regarding 

evaluation or management of a specific problem.
Page 24 GAO-18-281 Veterans Choice Program

VAMCs should take to compile relevant clinical information and 

send referrals to the TPAs.

• TPAs’ process for scheduling routine Choice Program

appointments. Through its contracts with the TPAs, VA has 

established a process under which a veteran could potentially wait 

another 52 calendar days from the date the TPA receives the VAMC’s 

Choice Program referral for a routine care appointment to take place. 

This includes up to 16 business days (or 22 calendar days) after 

receiving a referral to confirm the veteran’s decision to opt in to the 

Choice Program and create an authorization. The contracts further 

state that, for time-eligible veterans, an appointment shall take place 

within 30 calendar days of the clinically indicated date, the 

authorization creation date, or the veteran’s preferred date, whichever 

occurs later:

• The TPA has 2 business days to review the VAMC’s referral and 

accept it if it contains sufficient information to proceed with 

appointment scheduling.

• The TPA has 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).

• If the veteran is not reached by telephone, the TPA has 10 

business days for the veteran to respond to a letter confirming that 

they want to opt in, at which point the TPA creates the Choice 

Program authorization.

• If the authorization is created after the veteran’s preferred date or 

after the clinically indicated date on the VAMC’s referral has 

already passed, the TPA has 30 calendar days from the 

authorization creation date for an appointment for routine care to 
Page 25 GAO-18-281 Veterans Choice Program

take place.42 The TPA can use up to 15 business days of this 30-

calendar-day time frame to contact providers and successfully 

schedule the veteran’s Choice Program appointment.43

See figure 3 for an illustration of the potential wait time of approximately 

70 calendar days for time-eligible veterans to receive routine care through 

the Choice Program.

 

42Among the sample of Choice Program authorizations we reviewed, the clinically 

indicated date had already passed before the TPA received the referral (and therefore 

before the authorization was created) in about 76 percent of the authorizations. This 

percentage is not surprising, given that VHA’s consult policy directive instructs VHA 

clinicians to enter the earliest date an appointment is deemed clinically appropriate, which 

could be the same date that the veteran was first seen by the VHA clinician. Our 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. At the time the authorizations in our 

sample were created, time-eligible veterans’ preferred dates were not taken into 

consideration by VA for the purposes of determining whether veterans’ appointments for 

routine care occurred in a timely manner. Therefore, we could not determine what 

percentage of authorizations in our sample had preferred dates that had already passed 

before the TPA received the referral. 

43Although the TPAs’ contracts state that they must schedule veterans’ appointments for 

routine care within 5 business days after the veterans opt in to the Choice Program or 

return the referrals to VAMCs if appointments have not been scheduled by the 10th

business day, VA contracting officials sent a letter to the TPAs on June 15, 2017, to 

advise them of a temporary relaxation of that standard. Specifically, VA notified the TPAs 

that—until further notice—the TPAs will be allowed up to 15 business days to schedule 

appointments after veterans have opted in to the Choice Program and the TPAs have 

created authorizations. If appointments are not scheduled within 15 business days, the 

TPAs must return Choice Program referrals to the VAMCs so that they can attempt to 

arrange veterans’ care through other means. According to VA contracting officials, they 

decided to relax the 5-day scheduling standard after the TPAs began returning a 

substantial volume of un-appointed referrals after the 10th business day, due to a variety of

reasons that were outside the TPAs’ control (such as community providers requesting 

additional medical documentation before agreeing to schedule appointments). 
Page 26 GAO-18-281 Veterans Choice Program

Figure 3: Potential Wait Time for Time-Eligible Veterans to Obtain Routine Care through the Choice Program Appointment 

Scheduling Process

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

because VA determines they are time-eligible, if VAMCs and TPAs take the maximum amount of time 

allowed by VA’s process. The terms “time-eligible” and “distance-eligible” refer to the Choice Program 

processes used to schedule veterans’ appointments. VHA uses the time-eligible appointment 

scheduling process when the services needed are not available at a VHA medical facility or are not 

available within allowable wait times.

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.
Page 27 GAO-18-281 Veterans Choice Program

b

Although the TPAs’ contracts state that they must schedule veterans’ appointments for routine care 

within 5 business days after the veterans opt in to the Choice Program or return the referrals to 

VAMCs if appointments have not been scheduled by the 10th business day, VA contracting officials 

have temporarily relaxed that standard. Specifically, VA notified the TPAs via letter on June 15, 2017, 

that—until further notice—the TPAs will be allowed up to 15 business days to schedule appointments 

after veterans have opted in and the TPAs have created authorizations. If appointments are not 

scheduled within 15 business days, the TPAs must return Choice Program referrals to the VAMCs so 

that they can attempt to arrange veterans’ care through other means.

c

The 30-calendar-day appointment completion time frame begins with the date the TPA created the 

authorization only if the TPA creates the authorization for routine care after the clinically indicated 

date for a time-eligible veteran or the veteran’s preferred date has already passed. Otherwise, 

appointments must occur within 30 calendar days of the clinically indicated date or the veteran’s 

preferred date, whichever occurs later.

d

The maximum potential wait time would be 68 calendar days if the veteran’s need for care is 

identified on a Monday or Tuesday, and 70 calendar days if the veteran’s need for care is identified 

on a Wednesday, Thursday, or Friday. If there are holidays, the total number of calendar days 

permitted to elapse may be greater than 68 or 70 calendar days.

The process VA established for time-eligible veterans to receive routine 

care through the Choice Program—which could potentially take 70 days 

to complete—is not consistent with the requirement that veterans receive 

care within 30 days of their clinically indicated dates (where available) as 

applicable under the Choice Act. Furthermore, according to the federal 

internal control standard for control activities, agencies should design 

control activities—such as through policies and procedures—that will help 

ensure federal programs meet their objectives and respond to any risks to 

meeting those objectives.44

A key reason that veterans’ overall wait times for Choice Program care 

could potentially exceed the Choice Act’s 30-day wait-time requirement is 

that the process VA and VHA designed did not include a limit on the 

number of days VAMCs have to complete a key step of the process—

compiling relevant clinical information and sending referrals to the TPAs 

after veterans have agreed to be referred to the Choice Program. While 

the process sets forth time frames for the other steps VAMCs and TPAs 

must complete to process referrals and schedule appointments, VA and 

VHA have not specified how many days VAMCs have to send veterans’ 

Choice Program referrals to the TPAs. VHA has no comprehensive policy 

directive for the Choice Program, and neither its consult management 

directive nor its outpatient appointment scheduling directive specifies an 

 

44GAO-14-704G. 
Page 28 GAO-18-281 Veterans Choice Program

amount of time within which VAMCs should prepare Choice Program 

referrals.45

Another reason that veterans’ overall wait times for Choice Program care 

could potentially exceed the Choice Act’s 30-day wait-time requirement is 

that after VA and VHA implemented their policies, they did not review and 

address risks that were identified through their actual experience in 

operating the program. In response to a letter we sent in March 2017, 

VA’s Deputy General Counsel for Legal Policy said that, based on VA’s 

and VHA’s experiences with actual operation of the Choice Program 

since November 2014, “the practical reality” has been that the 30-day 

wait-time goal VA established just prior to the program’s implementation 

cannot always be met.

VA has not disclosed what timeliness goals it would apply under a future 

consolidated community care program. We note, however, that VA 

currently has no timeliness goals for its existing individually authorized 

community care program and cannot determine the amount of time 

veterans wait, on average, to receive care through that program, which 

has accounted for a significant portion of veterans’ community care 

utilization. We recommended in May 2013 that VA analyze the amount of 

time veterans wait to see providers in its individually authorized 

community care program and apply the same wait-time goals to that care 

that it uses to monitor wait times at VHA medical facilities.46 VA concurred 

with the recommendation to conduct an analysis and reported that it was 

in the process of building wait-time indicators to measure wait-time 

performance for individually authorized VA community care. VHA has 

since updated its wait-time goal for care delivered within VHA medical 

facilities—which is that care must be delivered within 30 days of veterans’ 

clinically indicated dates (where available). However, VA has not applied 

 

45In October 2016, VHA issued a policy directive for the Choice Program, but it was not 

comprehensive because (among other things) it did not specify the number of days within 

which VAMCs’ community care staff are required to send veterans’ referrals to the TPAs 

after veterans have agreed to be referred to the Choice Program. See Veterans Health 

Administration, Veterans Choice Program, VHA Directive 1700 (Oct. 25, 2016). VHA’s 

policy directive for consult management, which officials from VHA’s Office of Community 

Care told us applies to the Choice Program, also does not specify this time frame. See 

Veterans Health Administration, Consult Processes and Procedures, VHA Directive 

1232(1) (Aug. 24, 2016, as amended on Sept. 23, 2016). 

46See GAO, VA Health Care: Management and Oversight of Fee Basis Care Need 

Improvement, GAO-13-441 (Washington, D.C.: May 31, 2013). 
Page 29 GAO-18-281 Veterans Choice Program

that same goal to its individually authorized VA community care program 

nor begun measuring wait-time performance for that program.

Timeliness of appointments is an essential component of quality health 

care; delays in care have been shown to negatively affect patients’ 

morbidity, mortality, and quality of life. Without specifying wait-time goals 

that are achievable, and without designing appointment scheduling 

processes that are consistent with those goals, VA lacks assurance that 

veterans are receiving care from community providers in a timely manner. 

It also lacks a means for comparing the timeliness of veterans’ community 

care with that of care delivered within VHA medical facilities.
Page 30 GAO-18-281 Veterans Choice Program

To examine selected veterans’ actual wait times to receive routine care 

and urgent care through the Choice Program, we conducted a manual 

review of a random, non-generalizable sample of 196 Choice Program 

authorizations. The TPAs created these authorizations between January 

2016 and April 2016 in response to referrals sent by six selected 

VAMCs.47 Our manual review of veterans’ VA electronic health records 

and the TPAs’ records for our non-generalizable sample of 55 routine 

care authorizations and 53 urgent care authorizations for which the TPAs 

succeeded in scheduling appointments identified the following review 

times:

• For the 55 routine care authorizations in our sample, 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 

 

47The sample of authorizations we reviewed included only authorizations for which VHA’s 

data indicated there were delays when the TPAs attempted to schedule appointments 

after the veterans had opted in to the program; however, our analysis of these 

authorizations indicates that delays occurred at other phases of the referral and 

appointment scheduling process as well. We found that 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 in to the Choice Program.

Actual Wait Times for 

Choice Program Care 

Have Been Lengthy 

for Selected 

Veterans, and VHA’s 

Monitoring of 

Veterans’ Access Is

Limited by Incomplete 

and Unreliable Data

In 2016, Selected 

Veterans Experienced 

Lengthy Overall Wait 

Times to Receive Routine 

Care and Urgent Care 

through the Choice 

Program
Page 31 GAO-18-281 Veterans Choice Program

an average of 27 calendar days for the VAMCs to complete these 

actions for the 53 urgent care authorizations in our sample.48

• For these routine care authorizations, it took the TPAs an average of 

14 calendar days to accept referrals and reach veterans by telephone 

or letter for the veterans to opt 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 

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.

 

48We 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. 
Page 32 GAO-18-281 Veterans Choice Program

Source: GAO analysis of VHA and TPA documentation. | GAO-18-281

Note: The above examples come from our 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.

We also found that veterans in our sample experienced lengthy overall 

wait times to receive care when the TPAs returned their authorizations to 

the VAMC 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 another VHA medical 

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

determined that 53 veterans eventually received care through other 

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 Health Administration (VHA) medical facility. It took almost 3 weeks for 

Department of Veterans Affairs (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 followup appointment with a VHA neurosurgeon was at risk of being rescheduled 

because the VAMC had not received the results of the MRI after the appointment 

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

with the VHA neurosurgeon—where the imaging results and treatment options 

were discussed—did not occur until almost 6 months after the VHA clinician 

originally identified the need for the MRI. 

• One veteran was referred to the Choice Program because she needed maternity 

care, which is generally not available at VHA medical facilities. Almost a month 

and a half elapsed from the time VAMC staff 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 make an 

unsuccessful attempt to contact the veteran to schedule a prenatal appointment; 

by that point, she was almost 15 weeks pregnant. The veteran called the TPA 

back, but when the TPA had yet to schedule an appointment by the time she was 

18 weeks pregnant, the veteran finally scheduled her initial prenatal appointment 

herself, almost 3 months after her pregnancy was confirmed by VAMC staff. 

• One veteran was referred to the Choice Program for thoracic surgery to address a 

growth on his lung because there was a wait for care at a VHA medical facility. 

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.
Page 33 GAO-18-281 Veterans Choice Program

means after their authorizations were returned.49 These 53 veterans 

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

determined they needed care until their first appointment with a VHA 

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.

 

49These 53 veterans received care either at a VHA 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 followed up on 

these cases to ensure that the veterans got needed care and that patients were not 

harmed by any delay in care. 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. Determining whether veterans in our sample experienced clinical 

harm or adverse clinical outcomes because of delays in the VAMCs’ or TPAs’ processing 

of their referrals and authorizations was outside the scope of our review; however, VHA 

officials with clinical expertise reviewed these cases and concluded that the patients’ 

deaths did not result from any delay in 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 34 GAO-18-281 Veterans Choice Program

Source: GAO analysis of VHA and TPA documentation. | GAO-18-281

Note: The above examples come from our random, non-generalizable sample of 88 Choice Program 

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

After we shared the results of our preliminary analysis with VHA officials 

in December 2016, VHA required its medical facilities to manually review 

a sample of about 5,000 Choice Program authorizations that were 

created in July, August, and September of 2016 for four types of Choice 

Program care—mammography, gastroenterology, cardiology, and 

neurology. The purpose of this review was to analyze (1) the timeliness 

with which VAMCs sent referrals to the TPAs, and (2) veterans’ overall 

wait times for Choice Program care. VHA calculated the average wait 

Examples of Delays Experienced by Veterans Whose Authorizations Were 

Returned to Department of Veterans Affairs Medical Centers (VAMC) by the 

Choice Program Third Party Administrators (TPA) 

The VAMC took almost 3 1⁄2 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 it 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 1⁄2 months to attend her first appointment. Overall, this 

veteran waited more than 8 months to receive physical therapy.

• One veteran who was eligible for the Choice Program because he resided more 

than 40 miles from a VHA medical facility contacted the TPA to request an 

appointment with a urologist. More than a month later, the TPA contacted the 

VAMC via its web-based portal to request a referral for the veteran. VAMC staff 

responded to the TPA two days later and stated (correctly) that because the 

veteran was distance-eligible, no referral was required. Four days after receiving 

the VAMC’s response, the TPA succeeded in scheduling an appointment. 

However, the veteran declined it because the TPA had scheduled the 

appointment with a neurologist (a specialist who treats conditions affecting the 

brain, spinal cord, and nerves) rather than a urologist (a specialist who treats 

conditions affecting the urinary tract and male reproductive organs). Ultimately, 

the veteran ended up seeing a urologist at a VAMC nearly 5 months after he 

originally contacted the TPA to request care.

• It took about 2 1⁄2 weeks for the VAMC to send one veteran’s referral for pain 

management to the TPA after a VHA 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 web-based 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 1⁄2 months for pain 

management services.
Page 35 GAO-18-281 Veterans Choice Program

times across these four types of care for each of its 18 Veterans 

Integrated Service Networks (VISN).50

VHA’s analysis of data collected by VAMCs identified the following 

average review times when veterans were referred to the Choice 

Program because there was a greater-than-30-day wait time for an 

appointment at a VHA medical facility.

• Referral wait times. VISN-level averages ranged from 6 to 53 days 

for VAMC staff to contact veterans and confirm that they wanted to be 

referred to the Choice Program, compile relevant clinical information, 

and send veterans’ referrals to the TPAs. The national average was 

19 days.

• Overall wait times. From the time veterans’ need for care was 

identified until they attended initial Choice Program appointments, 

average overall wait times ranged from 34 to 91 days across VHA’s 

18 VISNs. The national average was 51 days.

When veterans were referred to the Choice Program because services 

were unavailable at a VHA medical facility, VHA’s analysis of VAMCs’ 

self-reported data identified the following average review times:

• Referral wait times. VISN-level averages ranged from 6 to 21 days 

for VAMC staff to contact veterans and confirm that they wanted to be 

referred to the Choice Program, compile relevant clinical information, 

and send veterans’ referrals to the TPAs. The national average was 

15 days.

• Overall wait times. From the time veterans’ need for care was 

identified until they attended initial Choice Program appointments, 

average overall wait times ranged from 39 to 56 days across VHA’s 

18 VISNs. The national average was 47 days.

 

50VHA’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. 

Currently, there are 18 VISNs nationwide. 
Page 36 GAO-18-281 Veterans Choice Program

Our analysis indicates that VHA’s ability to monitor Choice Program 

access is limited because the data VHA uses are not always accurate 

and reliable, and VHA lacks certain data that are needed to effectively 

monitor the program. As discussed below, multiple factors contribute to 

these data limitations. According to federal internal control standards for 

information and communication and for monitoring, agencies should use 

quality information to achieve the entity’s objectives, internally and 

externally communicate quality information, and establish activities to 

monitor the quality of performance over time and evaluate the results.51

Without complete, reliable Choice Program data, VHA cannot determine 

whether the Choice Program has achieved the goals of (1) alleviating the 

wait times veterans have experienced when seeking care at VHA medical 

facilities, and (2) easing geographic burdens veterans may face to access 

care at VHA medical facilities.

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 VHA 

clinicians and VAMC staff categorize consults that lead to Choice 

Program referrals.52

We observed inconsistency in the titles of consults that were associated 

with the non-generalizable 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 

 

51GAO-14-704G. 

52A consult is an electronic request entered in VA’s electronic health record by a VHA 

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 an appointment at a VHA medical facility, staff at the VAMC use 

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

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

referrals. 

VHA’s Monitoring of 

Veterans’ Access to 

Choice Program Care Is

Limited by a Lack of 

Complete, Reliable Data

VHA Cannot Systematically 

Calculate the Average Number 

of Days VAMCs Take to 

Prepare Choice Program 

Referrals
Page 37 GAO-18-281 Veterans Choice Program

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

(for example, “pain management”).53

We observed this variability among consult titles both within single 

VAMCs and across all six of the VAMCs we selected for review.

According to documentation VHA officials provided to us in December 

2016, they planned on implementing a process for standardizing the 

consult titles associated with Choice Program referrals over the course of 

calendar year 2017. Originally, they planned on piloting the process at 

four VAMCs beginning in February 2017 and expected to gradually roll 

out standardized consult titles across all other VAMCs over the remainder 

of calendar year 2017. However, in late June and early July 2017, we 

followed up with the six VAMCs in our sample, and at that time, managers 

from only one of the VAMCs said that they had implemented the new 

process for standardizing consult titles associated with Choice Program 

referrals. When we interviewed VHA officials again in September 2017, 

they acknowledged that they had been delayed in implementing 

standardized consult titles, and they provided documentation indicating 

that they were just beginning to roll out the new process nationwide.

In the absence of standardized consult titles for the Choice Program, 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 VHA clinicians 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.

 

53The term “Choice-First” pertains to veterans who are referred to the Choice Program 

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

an appointment at a VHA 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.
Page 38 GAO-18-281 Veterans Choice Program

The data VHA currently uses to monitor the timeliness of Choice Program 

appointments 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, as 

of June 1, 2016) 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 in to the Choice 

Program.

• Data related to the timeliness of Choice Program appointment 

scheduling. When we asked how they monitor the timeliness of 

Choice Program appointment scheduling, VHA officials provided us 

the following types of data, all of which reflect the time that elapses 

only after veterans have opted in to 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.

• Data related to the timeliness with which initial Choice Program 

appointments occur. VHA officials provided us data on the 

timeliness with which initial Choice Program appointments have 

occurred; however, as shown below, almost all of these data reflect 

the timeliness with which appointments occur only after veterans have 

opted in to 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;

Available VHA Data Do Not 

Capture the Time Spent By

TPAs in Accepting VAMCs’ 

Referrals and Opting Veterans 

in to the Choice Program
Page 39 GAO-18-281 Veterans Choice Program

• the percentage of appointments for routine care that are 

completed within 30 calendar days of either (1) the TPA’s 

scheduling of the appointment, (2) the clinically indicated date on 

the VAMC’s referral, or (3) the veteran’s preferred date; and

• the percentage of appointments for urgent care that are completed 

within 2 calendar days of the TPAs creating the authorizations.

See figure 4 for an illustration of how VHA’s data capture only a portion of 

the Choice Program process to obtain care.

Figure 4: Illustration of How the Veterans Health Administration’s (VHA) Data 

Capture Only a Portion of the Choice Program Process for Obtaining Care

In September 2017, VHA officials told us that they recently began 

implementing an interim solution that would allow them to track veterans’ 

overall wait times for Choice Program and other VA community care—

from the time VHA clinicians determine veterans need the care until the 

veterans attend their first appointments with community providers. 

Specifically, this interim solution requires VAMC staff to enter unique 

identification numbers on VHA clinicians’ requests for care and on the 

Choice Program referrals they send to the TPAs. This unique 

identification number is then carried over to the Choice Program 

authorizations that are created in the TPAs’ systems. According to VHA 

officials, the unique identification number creates a link between VHA’s 

data and the TPAs’ data, so that VHA can monitor the timeliness of each 

step of the Choice Program referral and appointment scheduling process. 

However, the success of VHA’s interim solution relies on VAMC staff 

consistently and accurately entering the unique identification numbers on 

both the VHA clinicians’ requests for care and on Choice Program 
Page 40 GAO-18-281 Veterans Choice Program

referrals, a process that is prone to error. VHA officials said it is their longterm goal to automate the process by which VHA’s data are linked with 

TPAs’ data in the consolidated community care program they are 

planning to implement.

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, VHA cannot track veterans’ overall wait times for Choice 

Program care—from the time VHA 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) determined 

that veterans wish to opt in to the program also prevents VHA from 

assessing whether the TPAs’ average timeliness in completing these 

actions has improved over time.

Our analysis of a sample of 196 Choice Program authorizations shows 

that another way in which VHA’s monitoring of veterans’ access to care is 

limited by available data is that the clinically indicated dates included on 

referrals that VAMCs send to the TPAs may not be accurate. We found 

that the clinically indicated dates on VAMCs’ referrals were not always 

identical to the clinically indicated dates that were originally entered into 

VA’s electronic health record by the VHA clinicians who treated the 

veterans.

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 VHA clinician who is treating the veteran. 

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

196 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 VHA clinicians.54 In 46 of these 60 cases, VAMC 

 

54We 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. There were no clinically indicated dates 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 Before They Send Choice 

Program Referrals to the TPAs
Page 41 GAO-18-281 Veterans Choice Program

staff entered clinically indicated dates on the Choice Program referrals 

that were later than the dates originally determined by the VHA clinicians, 

which would make the veterans’ wait times appear to be shorter than they 

actually were.

VHA could not explain why the dates differed. Clinically indicated dates 

are manually entered on VAMCs’ electronic referrals to the TPAs, a 

practice that is subject to error or manipulation. It is unclear if VAMC staff 

mistakenly entered incorrect dates, or if they inappropriately entered later 

dates when the VAMC was delayed in contacting the veteran, compiling 

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

VAMCs’ Choice Program referrals have clinically indicated dates that are 

different from the ones VHA clinicians originally entered without additional 

supporting documentation, there is a risk that VHA’s data will not 

accurately reflect veterans’ actual wait times. Specifically, VHA will not be 

able to determine how often veterans receive Choice Program care within 

the Choice Act’s required 30-day time frame.

Another limitation of VHA’s monitoring of veterans’ access to Choice 

Program care is that VAMCs and TPAs do not always categorize referrals 

in accordance with the contractual definition for urgent care when they 

are processing referrals and scheduling appointments for veterans. 

According to VA’s contracts with the TPAs, Choice Program referrals are 

to be marked as “urgent” when a VHA 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.55 It is VA’s goal that the TPAs schedule 

appointments for urgent care and ensure that they take place within 2 

business days of accepting the referrals from VA.

Among the sample of 53 Choice Program authorizations for urgent care 

we reviewed, VHA and TPA documentation showed that in 35 cases 

(about 66 percent), VHA clinicians originally determined that veterans 

needed routine care, but VAMC or TPA staff later re-categorized the 

 

55Under 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 

Re-Categorize Routine Choice 

Program Referrals as Urgent 

Referrals, Sometimes 

Inappropriately
Page 42 GAO-18-281 Veterans Choice Program

referrals or authorizations as urgent. In 4 of these 35 cases, we found 

documentation showing that VHA clinicians had reviewed the pending 

referrals and determined that the veterans’ clinical conditions or 

diagnoses warranted re-categorizing the veterans’ routine care referrals 

or authorizations as urgent.56 In 31 other cases we reviewed, however, 

we found no documentation indicating that a VHA clinician had identified 

a clinical reason for the veteran to receive care faster. In at least 15 of 

these 31 cases, it appeared that the VAMC or TPA staff changed the 

status of the referral or authorization in an effort to administratively 

expedite appointment scheduling when they were delayed in sending 

referrals and scheduling veterans’ Choice Program appointments.

According to the VA contracting officer who is responsible for the Choice 

Program contracts, VA’s contracts with the TPAs do not include 

provisions for separating clinically urgent Choice Program referrals and 

authorizations from those that the VAMC or the TPA has decided to 

expedite for administrative reasons (such as when the veteran or VAMC 

staff has expressed frustration with a delay in the referral or appointment 

scheduling process). If Choice Program referrals for routine care are 

inappropriately categorized as urgent care referrals under the Choice 

Program, VHA’s data on the timeliness of urgent appointment scheduling 

and completion will not accurately reflect the extent to which veterans 

who have a clinical need for urgent care are receiving it within the time 

frames required by the TPAs’ contracts.

The authorization creation date is the primary starting point from which 

VHA monitors the TPAs’ timeliness in appointment scheduling and the 

extent to which veterans’ initial Choice Program appointments occur in a 

timely manner. However, when initially implementing the Choice 

Program—beginning in November 2014—the two TPAs had differing 

interpretations of contractual requirements relating to when they should 

create authorizations in their appointment scheduling systems. According 

to VA contracting officials and VHA community care officials we 

interviewed, at the start of the program, one of the TPAs was creating 

authorizations as soon as it accepted referrals from VAMCs, but the other 

was waiting until after veterans opted in to the Choice Program to create 

authorizations. It was not until May 2016 (about 18 months into the 

Choice Program’s implementation) that VA modified its contracts to clarify 

 

56Determining whether veterans in our sample experienced clinical harm or adverse 

clinical outcomes because of delays in the VAMCs’ or TPAs’ processing of their referrals 

and authorizations was outside the scope of our review. 

The TPAs’ Choice Program 

Performance Data Did Not 

Become Comparable until 18 

Months After the Program 

Began, Which Limits VA’s 

Ability to Monitor Whether 

Access Has Improved
Page 43 GAO-18-281 Veterans Choice Program

that the TPAs are to create Choice Program authorizations only after they 

have contacted the veterans and confirmed that they want to opt in to the 

program.

Due to these differing interpretations, VA lacked comparable performance 

data for the two TPAs for the first 18 months of the Choice Program’s 

expected three-year implementation. Therefore, it could not compare the 

timeliness of access nationwide. In addition, since VA modified the TPAs’ 

contracts midway through the Choice Program’s implementation, officials 

can only comparatively examine whether the timeliness of both TPAs’ 

appointment scheduling and completion has improved since June 2016, 

which is when the relevant contract modification took effect.

VHA collects data and monitors various reasons the TPAs return Choice 

Program authorizations to VAMCs without making appointments.57 Each 

month, VA monitors how each TPA performs on Choice Program 

performance measures related to the timeliness of appointment 

scheduling. Authorizations that are returned for reasons that are 

attributable to the TPA—such as a lack of network providers in close 

proximity to the veteran’s residence—negatively impact the TPAs’ 

monthly performance measures.

In our sample, we found that VHA’s data on the TPAs’ reasons for 

returning Choice Program authorizations are not reliable. Specifically, we 

questioned the validity of the TPAs’ return of 20 out of the 88 

authorizations in our sample, for the following reasons:

• In 11 of the 20 cases, we found VHA or TPA documentation that 

substantiated the return, but the TPAs selected the incorrect return 

reasons when they sent the authorizations back to VA. For example, 

in one case, the TPA was unable to schedule an appointment with a 

primary care provider—even after contacting 11 different network 

providers—but the TPA staff returned the authorization to the VAMC 

indicating that the veteran had declined care. TPA officials who 

 

57VA has established through its contracts a set of acceptable reasons for the TPAs to 

return Choice Program authorizations without making appointments. Among other things, 

VA monitors the percentage of authorizations that the TPAs returned because (1) VAMCs’ 

referrals were missing information the TPAs needed to schedule appointments, (2) the 

TPA was unable to reach a network provider who would schedule an appointment and see 

the veteran, (3) the veteran rejected the appointment because the time or location the 

TPA offered was inconvenient, or (4) the veteran decided they no longer wanted to 

receive care through the Choice Program.

TPAs Sometimes Select 

Incorrect Return Reasons or 

Inappropriately Return Choice 

Program Authorizations without 

Making Appointments
Page 44 GAO-18-281 Veterans Choice Program

reviewed this authorization with us agreed that it was inappropriate to 

mark this authorization as having been returned because the veteran 

declined care and that their staff instead should have indicated that 

they had been unable to schedule an appointment with a network 

provider.

• In the remaining 9 of the 20 cases, we could find no VHA or TPA 

documentation to substantiate the reasons the TPAs selected when 

they returned the authorizations to VA, nor any other reasons for 

return. For example, the TPAs incorrectly selected “missing VA data” 

as the reason they returned 5 of these 9 authorizations. Based on 

VHA and TPA documentation we reviewed, the VAMCs’ referrals 

were complete and not missing any of the information the TPAs 

needed to proceed with appointment scheduling.

TPA officials could not explain why their staff selected incorrect return 

reasons or inappropriately returned authorizations for which they should 

have kept attempting to schedule appointments. However, TPA staff must 

manually select return reasons when they send authorizations back to 

VAMCs, a process that is subject to error or manipulation. There is a 

process by which VA’s contracting officer’s representatives validate the 

monthly data submitted by the TPAs, but it cannot identify the data 

reliability issues we found when manually reviewing VHA and TPA 

documentation associated with a sample of returned Choice Program 

authorizations. VHA officials told us that VA’s contracting officer’s 

representatives do not have access to veterans’ electronic health records, 

which means that they cannot check whether VHA documentation 

substantiates the return reasons selected by the TPAs.

Without reliable data on reasons that veterans have been unable to 

obtain appointments through the Choice Program, VHA cannot properly 

target its efforts to address challenges—such as network inadequacy—

that may be causing the TPAs to return authorizations without making 

appointments.58 In addition, the lack of reliable data makes it difficult for 

VA to monitor whether the TPAs are meeting their contractual obligations, 

such as establishing adequate networks of community providers.

 

58Network adequacy relates to the number, mix, and geographic distribution of community 

providers that participate in the TPA’s network. 
Page 45 GAO-18-281 Veterans Choice Program

Another way in which VHA’s monitoring of veterans’ access is limited is 

that VA lacks contract performance measures that would provide VA and 

VHA with data related to veterans’ driving times to access care from the 

TPAs’ Choice Program network providers. Such performance measures 

would help VA monitor the TPAs’ network adequacy. In contrast, for PC3, 

VA does collect data from the TPAs to monitor urban, rural, and highly 

rural veterans’ maximum commute times to specialty care providers, 

providers of higher level care, primary care providers, and mammography 

and maternity care providers.

When we asked why VA had not established driving time performance 

measures for the Choice Program, a VHA official responsible for 

monitoring the Choice Program contracts told us he thought that these 

performance measures had simply been overlooked in the haste to 

implement the Choice Program. VA concurred with a recommendation we 

made in our December 2016 report about VA health care for women 

veterans, in which (among other things) we stated that the department 

should monitor women veterans’ driving times to access sex-specific care 

through the Choice Program and VA’s future community care contracts.59

However, VA stated in its June and October 2017 written updates on 

actions it has taken to address this recommendation that it does not 

intend to modify the current Choice Program contracts to address our 

recommendation because the contracts will be ending soon and it would 

be too costly to do so. Without driving time performance measures for the 

Choice Program, VHA lacks assurance that the TPAs’ networks include a 

sufficient number of community providers in close proximity to where 

veterans live, and it cannot monitor the extent to which veterans’ 

geographic access to care has improved or diminished.

 

59See GAO, VA Health Care: Improved Monitoring Needed for Effective Oversight of Care 

for Women Veterans, GAO-17-52 (Washington, D.C.: December 2, 2016). 

VHA Does Not Have 

Performance Measures for 

Monitoring Average Driving 

Times between Veterans’ 

Homes and the TPAs’ Choice 

Program Network Providers
Page 46 GAO-18-281 Veterans Choice Program

Officials we interviewed from VA’s contracting office, VHA’s Office of 

Community Care, and both of the TPAs, along with leadership officials, 

managers, and staff from the six selected VAMCs told us about various 

factors that have directly or indirectly affected veterans’ access to care 

throughout the Choice Program’s implementation. Chief among these are 

(1) administrative burden associated with the Choice Program’s complex 

referral and appointment scheduling processes; (2) inadequate VAMC 

staffing and poor communication between VHA and the VAMCs; and (3) 

the TPAs’ slow development of a robust provider network. We also 

identified actions VA and VHA have taken to address these factors. (See 

appendix VI for additional information about actions that VA and VHA 

took to address these three access-related issues for the Choice 

Program.) To the extent that these factors persist under the consolidated 

community care program that VA plans to establish, they will continue to 

adversely affect veterans’ access to care.

VHA and TPA officials, as well as managers and staff from the six 

selected VAMCs, told us they encountered administrative burden 

associated with the complexities of the Choice Program’s referral and 

appointment scheduling processes. Further, they lacked care 

coordination tools throughout the time they were operating the Choice 

Program, which affected their ability to provide timely care to veterans.60

Among the main issues cited were the following:

• Manual referral processes and lack of TPA access to veterans’ 

records. To prepare veterans’ Choice Program referrals, VAMC staff 

had to follow a manual, time-consuming process to retrieve and 

collate key contact and clinical information from veterans’ VA 

electronic health records. This was because—throughout most of the 

Choice Program’s implementation—VA had no system for 

automatically generating referral packages that contained all of this 

information; nor did TPA staff have access to veterans’ VA electronic 

 

60The Agency for Healthcare Research and Quality defines care coordination as the 

practice of organizing patient care activities and sharing information among all of the 

participants concerned with a patient’s care to achieve safer, more effective care. 

Participants may share clinical data using manual methods such as faxing paper records, 

but these methods can be time-consuming and costly. Information technology has the 

potential to improve the efficiency of care coordination by allowing VA, the TPAs, 

community providers, and veterans to electronically exchange information for care 

coordination purposes.

Multiple Factors Have

Adversely Affected 

Veterans’ Access to 

Care under the 

Choice Program, 

Providing Potential 

Lessons Learned 

for VA’s Future 

Community Care 

Program

VA and VHA Took Several 

Actions to Address 

Administrative Burden 

Caused by Complex 

Choice Program 

Processes, but 

Opportunities Still 

Exist to Improve 

Care Coordination
Page 47 GAO-18-281 Veterans Choice Program

health records. If VAMC staff made mistakes (such as mistyping or 

inadvertently omitting veterans’ telephone numbers or addresses) or if 

the referrals were missing clinical information that the TPAs needed 

for appointment scheduling purposes, the TPAs had to either contact 

the VAMC to correct or obtain the missing information or return the 

referrals to VA without attempting to schedule appointments. These 

manual processes impeded the VAMCs’ progress in preparing 

referrals and the TPAs’ progress in scheduling veterans’ Choice 

Program appointments.

• Limited availability of care coordination tools and dependence 

on telephone-based customer service for appointment 

scheduling. A lack of care coordination tools and near-constant 

telephone calls also delayed VAMC and TPA staff from efficiently 

processing veterans’ referrals for appointments. For example, the 

Choice Program had no web-based portal through which VAMC staff 

and veterans could view the TPAs’ step-by-step progress in 

scheduling appointments. While both of the TPAs had portals that 

allowed VAMC staff (but not veterans) to obtain certain information—

such as whether the TPA had already scheduled an appointment—the 

portals did not show if, or when, veterans’ referrals had been 

accepted, the dates and times of the TPAs’ attempts to contact 

veterans, or the number of community providers the TPA had 

contacted in its attempts to schedule an appointment. VAMC staff we 

interviewed said that while they could submit written messages to the 

TPAs through the portals, TPA staff did not always answer these 

messages in a timely manner. This, in turn, made telephone calls 

between veterans, the VAMCs, and the TPAs the most effective form 

of follow-up regarding veterans’ Choice Program referrals, according 

to VAMC managers and staff. Officials from one selected VAMC 

estimated that their community care staff (which included about 30 

employees) was answering approximately 10,000 calls per month, 

and another VAMC had hired a full-time staff person just to answer 

telephone calls.

• Workload associated with re-authorizing veterans’ care. VAMC 

and TPA staff also told us they faced a lengthy administrative process 

to re-authorize care if veterans’ Choice Program authorizations 

expired before veterans received care or if veterans needed services 

that were outside the scope of their original authorizations. The TPAs 

referred to these as “secondary authorization requests” or “requests 

for additional services.” Without these re-authorizations, veterans’ 
Page 48 GAO-18-281 Veterans Choice Program

care from community providers could be delayed or interrupted.61

VAMC and TPA staff had to process a high volume of these requests 

for two main reasons. First, the Choice Program originally had a 60-

day limit on episodes of care, which meant that all appointments 

within the episode of care had to be completed within 60 days of the 

initial date of service. Even if the veteran needed care that could 

routinely be expected to outlast this 60-day time frame (such as 

maternity care or cancer treatment), community providers and the 

TPAs would still have to request additional referrals from the VAMCs 

to authorize the remaining care. Second, TPAs would have to request 

additional referrals if an episode of Choice Program care was already 

in progress and the veteran needed services that were not specifically 

authorized in the VAMC’s original referral. According to some VAMC 

managers and staff, this generated significant workload for the 

VAMCs. Officials from one of the selected VAMCs said it had to hire a 

full-time nurse just to process secondary authorization requests.

• Manual post-appointment follow-up processes. According to 

VAMC managers and staff we interviewed, the manual processes 

used for post-appointment follow-up also added to delays for veterans 

seeking care through the Choice Program. After an episode of care is 

complete—whether services are delivered at a VHA medical facility or 

in the community—VHA’s policy requires VAMC staff to document 

that care was provided and make the results of encounters available 

to VHA clinicians by entering medical records or other clinical 

information into the veteran’s VA electronic health record.62 When 

medical records from the community provider became available, 

VAMC staff had to retrieve copies from the TPAs’ portals and scan 

them into veterans’ VA electronic health records. (See appendix V for 

an illustration of this process.) VAMC staff described this as a very 

time-consuming process because it could take months for claims or 

medical records from Choice Program appointments to appear in the 

TPAs’ portals. At the time of our interviews in the summer of 2016, 

managers from two of the VAMCs in our sample said they each had 

backlogs of more than 6,000 Choice Program and other community 

care consults to complete. These backlogs adversely affected 

veterans’ access to Choice Program care because the time VAMC 

 

61The high volume of re-authorizations also indirectly affected the timeliness of other 

veterans’ access to Choice Program care because it diverted VAMC and TPA staffs’ 

attention from processing other veterans’ referrals and scheduling appointments. 

62See Veterans Health Administration, Consult Processes and Procedures, VHA Directive 

1232(1) (Aug. 24, 2016, as amended on Sept. 23, 2016).
Page 49 GAO-18-281 Veterans Choice Program

staff spent attempting to complete some veterans’ consults could not 

be spent on preparing other veterans’ Choice Program referrals.

Over the course of the Choice Program’s implementation, VA and VHA 

took multiple actions to address administrative burden, including the 

following. Opportunities exist to improve or build on these actions as VA 

moves forward with the consolidated community care program it plans to 

implement.

• Implementation of a web-based tool to automate Choice Program 

referral preparation. In early 2016, to improve the process of 

gathering information from veterans’ VA electronic health records to 

prepare Choice Program referrals, staff from two VAMCs developed a 

web-based tool—called the “referral documentation” (REFDOC) tool. 

According to VHA documentation, the REFDOC tool automates the 

process of gathering necessary information and assembling it in a 

standardized format for veterans’ Choice Program referrals. 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, which helped reduce the administrative burden 

associated with preparing referrals. However, VHA’s nationwide 

dissemination of the tool to all of the VAMCs was slowed by 

limitations of VA’s information technology systems. As of November 

2016 (about 9 months after the tool was created), it had only been 

implemented at 18 of VHA’s 170 VAMCs. VHA gradually made the 

tool available at the remaining VAMCs between November 2016 and 

May 2017.

• Standardized episodes of care. In April 2017, VHA approved 

standardized episodes of care—or “bundles” of clinically necessary 

medical services and procedures—that are to be authorized whenever 

veterans are referred to community providers for specified types of 

care. This was intended to help address administrative burden 

associated with clinical review processes and improve veterans’ 

access to care. To start, VHA approved standardized episodes of care 

for 15 different types of care, including physical therapy, maternity 

care, and optometry. VA and VHA documentation indicate that they 

intend to roll out additional standardized episodes of care over time 

and continue using them once VA transitions to the consolidated 

community care program it is planning to implement.

• Acquisition of a secure e-mail system and a mechanism for TPAs 

and community providers to remotely access veterans’ VA 

electronic health records. VA recently established two different care 

coordination tools that were intended to make the process of providing 
Page 50 GAO-18-281 Veterans Choice Program

veterans’ medical records to Choice Program and other VA 

community care providers more efficient.

• Secure e-mail system. In the spring of 2017, VA acquired software 

that allows VAMC managers and staff to e-mail encrypted files 

containing veterans’ medical records to the TPAs and community 

providers. Only the intended recipient can decrypt and respond to 

messages containing the files. According to VHA documentation, 

this secure e-mail system was intended to improve the efficiency 

of coordinating veterans’ Choice Program care and address 

potential security risks associated with printing paper copies of 

veterans’ medical records and sending them to the TPAs or 

community providers via fax or U.S. mail.

• Remote access to veterans’ VA electronic health records. In May 

2017, VHA began offering a secure, web-based application called 

the Community Viewer as a tool for community providers 

nationwide to have access to assigned veterans’ VA electronic 

health records. Like the secure e-mail system, this tool is intended 

to improve the efficiency of coordinating veterans’ Choice 

Program care.

However, VHA’s ability to seamlessly coordinate care with community 

providers remains limited—even with the secure e-mail system and the 

Community Viewer—because these tools only facilitate a one-way 

transfer of the information needed to coordinate the care veterans receive 

at VHA medical facilities and in the community. For the purposes of care 

coordination, it is important that information sharing among all participants 

concerned with a veteran’s Choice Program or other VA community 

care—including VHA clinicians, the TPAs, community providers, and the 

veteran—is as seamless as possible. According to the federal internal 

control standard for information and communication, agencies should 

internally and externally communicate the necessary information to 

achieve their objectives.63 While the secure e-mail system and 

Community Viewer tool provide an interim solution for VAMCs to transfer 

information from veterans’ VA electronic health records to the TPAs and 

community providers, they do not provide a means by which VAMCs or 

veterans can (1) view step-by-step progress in scheduling appointments, 

or (2) electronically receive the clinical results of Choice Program or other

VA community care encounters. Building such a capability into the future 

consolidated community care program that VA plans to implement would 

 

63GAO-14-704G. 
Page 51 GAO-18-281 Veterans Choice Program

allow VHA to improve the care coordination processes that exist in the 

Choice Program.

• Pilot programs for VAMC staff to schedule Choice Program 

appointments. In July 2016 and October 2016, VHA began 

implementing pilot projects, whereby staff at two VAMCs took over 

from the TPAs the responsibility of scheduling veterans’ Choice 

Program appointments. 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.64 According to VHA officials, this had 

the potential to improve veterans’ access to care by improving the 

efficiency of the Choice Program appointment scheduling process.

The results of these two VAMC scheduling pilots are particularly 

relevant, given that VA’s RFP, as amended, for its planned 

consolidated community care program indicates that VAMCs—rather 

than TPAs—will carry out community care appointment scheduling, 

unless VA exercises a contract option for the TPAs to provide such 

services for VAMCs that request them.65 However, while VHA officials 

told us that while they have taken some steps to begin evaluating the 

effectiveness of the pilots in improving appointment scheduling, these 

efforts have not been completed. The lack of an evaluation of the two 

VAMC scheduling pilots is inconsistent with the federal internal control 

standard for risk assessment, which stipulates that an agency should 

identify, analyze, and respond to risks related to achieving defined 

objectives. In addition, the federal internal control standard for 

monitoring calls for ongoing monitoring to assess the effectiveness of 

management strategies, make needed corrections if shortcomings are 

identified, and determine if corrective actions are achieving desired 

outcomes.66 Without evaluating the results of the scheduling pilots at 

the Alaska and Fargo VA Health Care Systems, VA lacks assurance 

that VAMC staff have the potential to schedule veterans’ community 

 

64As part of the pilot process, the TPAs send authorizations to community providers after 

receiving notification that the VAMCs have scheduled appointments and before 

appointments occur. 

65A May 26, 2017 amendment to VA’s December 2016 RFP gave VA the option of 

contracting with the TPAs to carry out the appointment scheduling process for VAMCs that 

request these services. 

66GAO-14-704G. 
Page 52 GAO-18-281 Veterans Choice Program

care appointments in a more timely manner than TPA staff otherwise 

would schedule them. Furthermore, VA is missing an opportunity to 

inform its planning and decisions for scheduling under its planned 

consolidated community care program.

TPA officials and managers and staff from the six selected VAMCs 

frequently discussed staffing- and communication-related factors that 

adversely affected the timeliness of veterans’ Choice Program care. 

During the course of our review, they cited the following factors that 

delayed VAMCs’ processing of veterans’ referrals and TPAs’ scheduling 

of appointments:

• Staff vacancies and turnover. TPA officials and managers and staff 

at selected VAMCs said that VAMCs and TPAs were initially 

understaffed as Choice Program implementation began.

• VAMCs. Managers at the six selected VAMCs told us that after 

implementing the Choice Program, they hired additional 

community care staff, with one of them increasing its community 

care staffing level almost five-fold by July 2016. Some VAMC 

managers told us in 2016 and again in 2017 that they still 

struggled with staff retention and vacancies—among both 

managers and staff. Five of the VAMCs said they relied on 

overtime for their existing staff to keep up with the Choice 

Program workload. According to community care managers from 

four of the selected VAMCs, it takes about 6 months to recruit, 

hire, and train new community care staff, and this process could 

take more time if the VAMC’s human resources office is also 

understaffed, which was the case for at least one of the six 

VAMCs.67 That VAMC had not had a permanent community care 

manager for more than 2 years as of July 2017—which covered 

the majority of the Choice Program’s original 3-year 

implementation.68

 

67In 2016, we issued a report on VHA’s human capital challenges. Among other things, we 

found that VAMCs’ human resources capacity is limited, which has affected their ability to 

recruit and retain VAMC staff who help deliver important services to veterans (such as 

staff who process referrals for VA community care). See GAO, Veterans Health 

Administration: Management Attention is Needed to Address Systemic, Long-standing 

Human Capital Challenges, GAO-17-30 (Washington, D.C.: Dec. 23, 2016).

68This VAMC’s leadership temporarily detailed two different managers from other areas of 

the VAMC to serve in the role of community care manager.

Inadequate Staffing and 

Ad Hoc Communication 

Contributed to Choice 

Program Access Delays, 

and Actions Taken Have 

Been Focused on the 

Staffing Concerns
Page 53 GAO-18-281 Veterans Choice Program

• TPAs. Officials from both TPAs also told us that they initially 

underestimated the workload associated with scheduling Choice 

Program appointments, and they brought on additional staff, 

including sub-contractors, to better manage their workloads as 

utilization of the program increased. One TPA opened eight 

operations centers in addition to the two it already had when the 

Choice Program was initially implemented.69

• Ineffective mechanisms for VAMCs to resolve problems. VAMC 

managers and staff we interviewed also said they lacked useful 

mechanisms and points-of-contact when they needed to resolve 

issues and problems they were having with referral and appointment 

scheduling processes. VHA established a web-based Choice Program 

“issue tracker” system for VAMCs to report problems to VHA’s Office 

of Community Care. However, staff at four of the selected VAMCs told 

us they rarely used the tracker and some had stopped using the 

tracker altogether because it took too long for VHA’s Office of 

Community Care or the TPAs to respond and resolve the issues (if 

they responded at all), and they did not see the value in taking the 

time to report them via this mechanism. Managers at one of the 

VAMCs also told us about a phone line that their TPA had established 

to escalate and resolve urgent issues, but the TPA told the VAMC 

only to use it for emergencies. 

• VHA’s untimely communication of Choice Program policy and 

process changes. According to managers and staff at the six 

selected VAMCs, VA and VHA have issued numerous contract 

modifications and policy changes with little advanced notice 

throughout the Choice Program’s implementation. According to these 

VAMC managers and staff, the untimely communication of changes 

created confusion at the VAMC level that affected veterans’ access to 

Choice Program care. We reviewed documentation showing that from 

October 2014 (when it modified the TPAs’ contracts to add 

responsibilities related to Choice Program administration) until July 

2017, VA modified each TPA’s contract about 40 times. Many of these 

contract modifications—along with other legislative and regulatory 

changes that VA implemented during this period—changed VAMC or 

TPA processes related to Choice Program referrals and appointment 

scheduling. Many of the VAMC managers and staff we interviewed 

said they struggled to keep up with the contract modifications and 

 

69Operations centers are where TPA employees who are responsible for opting veterans 

in to the Choice Program, scheduling veterans’ appointments, and answering customer 

service calls from veterans and community providers work. 
Page 54 GAO-18-281 Veterans Choice Program

policy changes, that VHA’s Office of Community Care did not always 

leave adequate time to prepare for them, and they felt they were 

never really able to become proficient at new processes before 

additional changes occurred. This meant that training sometimes 

happened after the contract modifications or VHA policy changes had 

already gone into effect. For example, managers and staff at three of 

the selected VAMCs told us that they were not informed in advance 

about a June 2016 contract modification that required the TPAs to 

return Choice Program authorizations to VAMCs if they failed to 

schedule appointments within required time frames.70 This contract 

modification had the potential to significantly increase VAMCs’ 

workloads, because they would have to arrange veterans’ care 

through other means once the authorizations were returned. 

According to individuals at two of these three VAMCs, they first heard 

about this change from TPA staff, rather than from VHA.

VHA took the following two actions intended to help address staffingrelated factors that adversely affected the timeliness of veterans’ Choice 

Program care.

• Staffing tool for VAMCs to estimate needs. In the spring of 2017, 

VHA developed a tool that is intended to help VAMCs project their 

staffing needs for the consolidated community care program VA plans 

to implement. VHA used workload data and site visit observations to 

develop the tool. Among the six selected VAMC managers we 

interviewed, impressions about the reasonableness of the staffing 

estimates generated by the community care staffing tool were mixed. 

For example, managers at two of the VAMCs said that the tool likely 

underestimated the number of staff they would need to handle 

referrals and appointment scheduling once VA transitions to the 

consolidated community care program. In contrast, managers from 

two other VAMCs thought that the tool’s staffing estimates seemed 

about right.71

 

70In June 2016, VA modified its contracts with the TPAs to require the TPAs to return 

Choice Program authorizations when the TPAs do not meet contractual standards related 

to the timeliness with which they (1) review and accept referrals and (2) schedule 

appointments after veterans have opted into the program. Previously, the TPAs only had 

to return referrals if veterans had not opted in 10 days after the TPA sent a letter; there 

was no requirement for the TPAs to accept referrals within a certain time frame or to 

return authorizations if the TPAs had not scheduled appointments within required time 

frames after veterans opted in.

71The other two VAMCs did not comment on the reasonableness of the staffing estimates

generated by the staffing tool. 
Page 55 GAO-18-281 Veterans Choice Program

• Co-locating TPA staff at selected VAMCs to assist with 

resolution of problems. To help facilitate problem resolution 

between VAMCs and the TPAs as they work to schedule veterans’ 

Choice Program appointments, VA modified the TPAs’ contracts in 

November 2015 to allow for TPA staff to be co-located at selected 

VAMCs. VHA officials expected that one potential benefit of colocating TPA staff would be that fewer veterans’ Choice Program 

referrals would be returned to VAMCs because of missing clinical 

information because TPA staff could help resolve such problems 

locally before the TPA returned referrals. As of May 2017, TPA staff 

were working at 70 of VHA’s 170 VAMCs—or about 40 percent of all 

VAMCs. Similar care coordination arrangements may exist under the 

consolidated community care program VA is planning to implement, if 

VA exercises a contract option for the TPAs to provide such services 

at VAMCs that request them.

However, the communication-related factors that VHA and TPA officials 

identified as affecting the timeliness of veterans’ Choice Program care 

remain. VHA relied on ad hoc communications such as memoranda, fact 

sheets, e-mails, national conference calls, and occasional web-based 

trainings to communicate policy and process changes to VAMCs 

throughout the Choice Program’s implementation. Our interviews with 

VAMC managers and staff suggest that these were not the most effective 

methods of communication because messages about key changes 

sometimes lacked sufficient detail or failed to reach the VAMC staff 

responsible for implementing them in a timely manner. According to the 

federal internal control standard for control activities, agencies should 

implement control activities through their policies and procedures, which 

document the responsibilities of managers and staff who are responsible 

for implementing a program.72 Among other things, this may include 

management reviewing and updating policies and day-to-day procedures 

in a timely manner after a significant change in the program has occurred. 

VHA has no comprehensive policy directive or operations manual for the 

Choice Program, and its broader policy directive for VA community care 

 

72GAO-14-704G. 
Page 56 GAO-18-281 Veterans Choice Program

programs has not been updated since January 2013.73 As a result, VAMC 

staff have operated in an environment that is frequently changing with no 

definitive reference source or sources of up-to-date policy and processes 

to consult, such as a comprehensive policy directive or operations 

manual. Instead, VAMC staff have had to keep track of the Choice 

Program’s policy and process changes through VHA’s various ad hoc 

communications. This poses a risk to VHA, as it increases the likelihood 

that VAMCs will implement new policies and processes inconsistently. In 

addition, there is risk that VAMC managers and staff will not always be 

aware of the most current policies and processes. Unless a 

comprehensive policy directive or operations manual is created, those 

risks could remain for the consolidated community care program VA is 

planning to establish.

According to VAMC managers and TPA officials we interviewed, the 

TPAs’ inadequate networks of community providers affected both the 

timeliness with which veterans received Choice Program care and the 

extent to which veterans were able to access community providers 

located close to their homes. In September 2015, about 11 months after 

the Choice Program was implemented, VA contracting officials sent 

corrective action letters to both TPAs, citing network adequacy (i.e., the 

number, mix and geographic distribution of network providers) as a 

concern. TPA officials we interviewed acknowledged that their networks 

initially were not adequate to meet demand for Choice Program care. 

From the TPAs’ perspective, the brief transition period before the Choice 

Program began operations in November 2014 was not enough time to 

strengthen the community provider networks they had previously 

established under PC3, another VHA community care program.

Furthermore, the TPAs told us that VA had not provided them with 

sufficient data on the expected demand for Choice Program care—by 

clinical specialty and zip code—prior to or after the Choice Program’s 

implementation.

 

73In October 2016 (nearly 2 years after the Choice Program was implemented), VHA 

issued a policy directive for the Choice Program, but it was not comprehensive because it 

lacked certain information that those responsible for administering the program would 

need to know. For example, it did not specify any time frames within which VAMC staff 

must complete key steps of the Choice Program referral process, such as the number of 

days after receiving a consult within which the VAMC’s community care staff must confirm 

that the veteran is eligible for the Choice Program and to begin contacting the veteran to 

offer a referral to the program. See Veterans Health Administration, Veterans Choice 

Program, VHA Directive 1700 (Oct. 25, 2016).

Inadequate Provider 

Networks Affected Timely 

Access, but VHA Plans to 

Improve Available 

Information Related to 

Provider Capacity and 

Veteran Demand for 

Future TPAs
Page 57 GAO-18-281 Veterans Choice Program

The overall number of community providers participating in the TPAs’ 

Choice Program networks nationwide grew dramatically over the following 

year—from almost 39,000 providers in September 2015 to more than 

161,000 providers as of September 2016. However, at the time of our 

review, managers at five of the six selected VAMCs told us that they still 

observed TPA network inadequacies that impeded veterans’ access to 

Choice Program care. Similarly, managers at three VAMCs in our sample 

said that key community providers—including large academic medical 

centers—have refused to join the TPAs’ networks or dropped out of the 

networks after joining them, often because the TPAs had not paid them in 

a timely manner for the services they provided. 

Establishing adequate networks of Choice Program providers in rural 

areas has been particularly difficult. Officials at two of the three of the 

rural VAMCs in our sample pointed to general health care workforce 

shortages in rural areas as one cause for the TPAs’ network 

inadequacy—a challenge that is not limited to the Choice Program or 

VA’s health care system. According to a December 2015 analysis by VHA 

researchers, the majority of network providers in two of the three VISNs 

examined were located within 40 miles of VAMCs, leaving large 

geographic areas of these VISNs (particularly rural areas) outside the 40-

mile radius with few network providers.74 For example, only 3.8 percent of 

primary care providers and 3.2 percent of behavioral health providers in 

VISN 20 (which covers Alaska, Idaho, Oregon, and Washington) were 

located more than 40 miles from VAMCs within that VISN. While the 

areas lacking network providers generally have fewer veterans relative to

other areas within these VISNs, the analysis by VHA researchers 

suggests that veterans living in these areas are likely to have difficulty 

accessing Choice Program network providers that are located closer to 

their homes than the nearest VAMC, which is over 40 miles away.

VA and VHA have tried to address network inadequacy that existed under 

the Choice Program and either have taken or plan to take additional 

actions to address this issue for the community care program VA plans to 

implement, including the following.

 

74Evan Carey, Paula Langner, and Michael Ho, VACA Spatial Evaluation: Quantitative 

Results, a report prepared for the Department of Veterans Affairs, Veterans Health 

Administration, Dec. 28, 2015. The analysis examined the distribution of network providers 

participating in the Choice Program in VISN 10, which covers Ohio, Indiana, and 

Michigan; VISN 19, which covers Colorado, Montana, Oklahoma, Utah, and Wyoming; 

and VISN 20, which covers Alaska, Idaho, Oregon, and Washington.
Page 58 GAO-18-281 Veterans Choice Program

• Establishment of Choice Program provider agreement process.

To help address inadequacies in the TPAs’ provider networks and 

improve veterans’ access to care under the Choice Program, VHA 

established the Choice Program provider agreement process in 

February 2016. This process allowed VAMCs to establish agreements 

with community providers, schedule veterans’ appointments, and 

reimburse the providers directly (using Choice Program funds) when 

the TPAs failed to schedule veterans’ appointments for reasons 

relating to network inadequacy, among others.75 Originally, the 

VAMCs were required to send veterans’ referrals to the TPAs and 

wait for them to be returned before they could proceed with arranging 

care through a Choice Program provider agreement. While this 

process had the potential to increase the availability of providers for 

the Choice Program, it did not immediately improve the timeliness of 

veterans’ Choice Program care because veterans still had to wait for 

as long as it took the VAMCs to send their referrals to the TPAs and 

for TPAs to return them before the VAMCs could proceed with 

arranging care through Choice Program provider agreements. 

According to the policies and contractual requirements that were in 

effect at the time, it could have taken up to 40 calendar days after a 

VHA clinician first identified the veteran’s need for care until the TPA 

returned the referral and the VAMC could proceed with arranging care 

through a Choice Program provider agreement. However, in March 

2017, VHA updated the Choice Program provider agreement process 

so that—if the TPAs were returning a high volume of a VAMC’s 

referrals for one or more types of care—the VAMC could seek 

approval from its VISN and VHA’s Office of Community Care to 

bypass the TPA and proceed directly to arranging that type of care 

through Choice Program provider agreements. This had the potential 

to improve the timeliness of veterans’ access to Choice Program care 

because it eliminated the steps of sending referrals to the TPAs and 

waiting for them to be returned.

 

75Specifically, VAMCs could proceed with arranging care through the Choice Program 

provider agreement process if the TPAs returned veterans’ referrals for any of these 

reasons, among others: (1) the TPA had no network provider available for the service VA 

requested; (2) the veteran requested a specific community provider that was not part of 

the TPA’s network; (3) the TPA failed to complete the steps of the appointment scheduling 

process within the time frames that were outlined in its contract; (4) the TPA was unable to 

reach the veteran via telephone or letter when attempting to schedule the appointment; 

and (5) the TPA did not schedule the appointment on a day and time that was convenient 

for the veteran. In addition, VAMCs were permitted to arrange care through the Choice 

Program provider agreement process (and pay for it using Choice Program funds) when 

the veteran needed services that were not covered under the TPAs’ contracts, such as 

dental and home health services. 
Page 59 GAO-18-281 Veterans Choice Program

• Improving quality of information given to future TPAs. To help 

inform the recruitment of network providers for the consolidated 

community care program VA plans to establish, VA plans to provide 

future TPAs more robust data than they provided the current TPAs at 

the start of the Choice Program. In particular, VA’s RFP for the 

consolidated community care program, as amended, indicates that VA 

will provide (1) zip-code-level data on the number of authorizations 

that were issued in fiscal year 2015 for specific types of care (e.g., 

chemotherapy and obstetrics) and (2) VAMC-level data on the clinical 

specialties with the greatest wait times for appointments at VAMCs. 

These local-level data could help TPAs estimate the number of 

network providers of various specialties they will need to recruit in 

specific localities if awarded a contract for the consolidated 

community care program that VA is planning to implement.

• Performing market assessments. In preparation for the 

consolidated community care program VA plans to establish, VA and 

VHA officials are planning to conduct market assessments in 96 

markets nationwide. Through these market assessments, officials told 

us, VA will (1) examine the clinical capacity that currently exists within 

VHA medical facilities and among community providers, (2) assess 

veterans’ current and future demand for health care services, and (3) 

develop long-term plans for ensuring that veterans will have access to 

high-quality health care services—whether they receive care from 

VHA clinicians or from community providers. According to VHA 

officials, the market assessments will help inform network provider 

recruitment efforts for the consolidated community care program VA is 

planning to implement. In addition, VHA officials told us that the 

market assessments will help VISN- and VAMC-level leaders make 

more informed, strategic decisions about whether it is more efficient to 

maintain or build capacity for delivering particular types of care within 

VHA medical facilities, or if they should routinely purchase certain 

types of care in the community. In November 2017, VHA officials told 

us that they expect to begin conducting the market assessments early 

in calendar year 2018, and the officials estimate that it will take about 

18 months to complete assessments for all 96 markets.

The Choice Program is approaching the end of its life, and with plans to 

consolidate it with VA’s other community care programs, opportunities to 

improve the program are diminishing. Congress created the Choice 

Program in 2014 in response to longstanding challenges in veterans’ 

access to care delivered within VHA medical facilities. However, we found 

numerous operational and oversight weaknesses with VHA’s 

management of scheduling veterans’ medical appointments through the 

Conclusions
Page 60 GAO-18-281 Veterans Choice Program

Choice Program. While it may not be feasible for VA and VHA to 

implement corrective actions to address all of our findings before the 

Choice Program ends, it is imperative that VA incorporate lessons 

learned from the Choice Program when it implements the consolidated 

community care program it has planned.

First, we found VHA’s process for scheduling appointments for veterans 

through the Choice Program was not consistent with statutory 

requirements. The Choice Act requires veterans to receive care no more 

than 30 days from the date an appointment is deemed clinically 

appropriate or from the date the veteran prefers to receive care; however, 

we found that veterans could potentially wait up to 70 calendar days to 

receive routine care through the Choice Program. In effect, we found that 

in 2016, some veterans’ actual wait times far exceeded 30 days. Although 

VA has made some relevant contract modifications and issued guidance 

to address Choice Program wait times, VHA has not adjusted the Choice 

Program’s appointment scheduling process or established timeliness 

standards for all steps of the process. In addition, VHA’s monitoring of 

access to Choice Program care has been limited by incomplete and 

unreliable data. In particular, the data VHA uses preclude it from 

accurately identifying the number of days that occur within each phase of 

the process, from initial referral to the actual appointment. Furthermore, a 

lack of controls has allowed for inappropriate changes to be made in 

veterans’ clinically indicated dates and routine versus urgent care 

categorizations, affecting VA’s ability to monitor whether veterans are 

receiving Choice Program care in a timely manner. The lack of reliable 

data and performance measures also hinders VHA’s ability to oversee the 

program and identify problems and corrective actions. Further, we found 

that VHA is missing out on opportunities to enhance its design of the 

planned consolidated community care program. For example, VHA has 

not fully evaluated its pilot programs for scheduling appointments nor 

developed tools such as a mechanism that would allow the seamless 

sharing of information between VHA and the TPAs. Lastly, we found that 

VHA often relied on inefficient, ad hoc methods of sharing information 

(such as memoranda, fact sheets and emails), which often failed to reach

the VAMC managers and staff responsible for implementing the program.

After the Choice Program ends, VA anticipates that veterans will continue 

to receive care from non-VHA providers under the consolidated 

community care program that it is planning to implement. VA’s and VHA’s 

design of the future program can benefit from the lessons learned under 

the Choice Program. Ignoring these lessons learned and the challenges 

that have arisen under the Choice Program as VA and VHA design the
Page 61 GAO-18-281 Veterans Choice Program

future consolidated program would only increase VA’s risk for not being 

able to ensure that all veterans will receive timely access to care in the 

community.

To ensure that VA and VHA incorporate lessons learned from the Choice 

Program as they develop and implement a consolidated VA community 

care program, we are making the following 10 recommendations:

• The Under Secretary for Health should establish an achievable waittime goal for the consolidated community care program that VA plans 

to implement that will permit VHA to monitor whether veterans are 

receiving VA community care within time frames that are comparable 

to the amount of time they would otherwise wait to receive care at 

VHA medical facilities. (Recommendation 1)

• The Under Secretary for Health should design an appointment 

scheduling process for the consolidated community care program that 

VA plans to implement that sets forth time frames within which (1) 

veterans’ referrals must be processed, (2) veterans’ appointments 

must be scheduled, and (3) veterans’ appointments must occur, which 

are consistent with the wait-time goal VHA has established for the 

program. (Recommendation 2)

• The Under Secretary for Health should establish a mechanism that 

will allow VHA to systematically monitor the average number of days it 

takes for VAMCs to prepare referrals, for VAMCs or TPAs to schedule 

veterans’ appointments, and for veterans’ appointments to occur, 

under the consolidated community care program that VA plans to 

implement. (Recommendation 3)

• The Under Secretary for Health should implement a mechanism to 

prevent veterans’ clinically indicated dates from being modified by 

individuals other than VHA clinicians when veterans are referred to 

the consolidated community care program that VA plans to 

implement. (Recommendation 4)

• The Under Secretary for Health should implement a mechanism to 

separate clinically urgent referrals and authorizations from those for 

which the VAMC or the TPA has decided to expedite appointment 

scheduling for administrative reasons. (Recommendation 5)

• The Under Secretary for Health should (1) establish oversight 

mechanisms to ensure that VHA is collecting reliable data on the 

reasons that VAMC or TPA staff are unsuccessful in scheduling 

veterans’ appointments through the consolidated community care 

Recommendations for 

Executive Action
Page 62 GAO-18-281 Veterans Choice Program

program VA plans to implement, and (2) demonstrate that it has 

corrected any identified deficiencies. (Recommendation 6)

• The Secretary of Veterans Affairs should ensure that the contracts for 

the consolidated community care program VA plans to implement 

include performance metrics that will allow VHA to monitor average 

driving times between veterans’ homes and the practice locations of 

community providers that participate in the TPAs’ networks. 

(Recommendation 7)

• The Secretary of Veterans Affairs should establish a system for the 

consolidated community care program VA plans to implement to help 

facilitate seamless, efficient information sharing among VAMCs, VHA 

clinicians, TPAs, community providers, and veterans. Specifically, this 

system should allow all of these entities to electronically exchange 

information for the purposes of care coordination. (Recommendation 

8)

• The Under Secretary for Health should conduct a comprehensive 

evaluation of the outcomes of the two appointment scheduling pilots it 

established at the Alaska and Fargo VA Health Care Systems (where 

VAMC staff, rather than TPA staff, are responsible for scheduling 

veterans’ Choice Program appointments), which should include a 

comparison of the timeliness with which VAMC staff and TPA staff 

completed each step of the Choice Program appointment scheduling 

process, as well as the overall timeliness with which veterans 

received appointments. (Recommendation 9)

• The Under Secretary for Health should issue a comprehensive policy 

directive and operations manual for the consolidated community care 

program VA plans to implement and ensure that these documents are 

reviewed and updated in a timely manner after any significant 

changes to the program occur. (Recommendation 10)

VA provided written comments on a draft of this report, which are

reprinted in Appendix VII. In its comments, VA concurred with 8 of our 10 

recommendations and described its plans for implementing them. VA 

stated that VHA’s Office of Community Care will work collaboratively with 

other VA and VHA offices to evaluate modifications to the current waittime goals and measurement processes so that wait times for VA 

community care can be compared to wait times for care delivered at VHA 

medical facilities. 

VA did not concur with our recommendation to implement a mechanism 

to separate clinically urgent referrals and authorizations from those that 

are designated as urgent for administrative reasons. VA stated that 

Agency Comments 

and Our Evaluation
Page 63 GAO-18-281 Veterans Choice Program

because VAMC staff (rather than TPA staff) will be responsible for 

scheduling veterans’ appointments under the consolidated community 

care program it plans to implement, there would no longer be a need to 

separate clinically urgent referrals from those that need to be 

administratively expedited. However, we maintain that our 

recommendation is warranted. In particular, we found that VA’s data did 

not always accurately reflect the timeliness of urgent care because both 

VAMC and TPA staff inappropriately re-categorized some routine care 

referrals and authorizations as urgent ones for reasons unrelated to the 

veterans’ health conditions. Regardless of whether VAMC staff or TPA 

staff are responsible for appointment scheduling, VA will need to ensure 

that it uses reliable data to monitor the extent to which veterans receive 

urgent care within required time frames. Without a means of separating 

clinically urgent referrals and authorizations from ones for which the 

scheduling process must be administratively expedited, VA’s data on the 

timeliness of urgent care will continue to be unreliable. 

VA agreed in principle with our recommendation to issue a 

comprehensive policy directive and operations manual, but stated in its 

comments that it would wait to determine whether a comprehensive policy 

directive is needed until after the consolidated community care program 

has been fully implemented and any interim implementation challenges 

have been resolved. However, when implementing a new program, it is 

important that agencies establish the program’s structure, responsibilities, 

and authorities at the beginning to help ensure that the new program’s 

objectives are met. Relying on outdated policies and unreliable 

communication methods increases VA’s risk of encountering foreseeable

challenges. Without issuing a comprehensive policy directive and 

operations manual before the start of the new program, VA risks 

experiencing untimely communication issues similar to those that affected 

veterans’ access to care throughout the Choice Program’s 

implementation. A comprehensive policy directive and operations manual 

that could be updated as changes occur would give VAMCs a definitive 

source of real-time, up-to-date information and reduce the likelihood that 

VAMCs will implement new policies and processes inconsistently under 

the future program.
Page 64 GAO-18-281 Veterans Choice Program

We are sending copies of this report to the Secretary of Veterans Affairs, 

the Under Secretary for Health, appropriate congressional committees, 

and other interested parties. This report is also available at no charge on 

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

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

Sharon M. Silas at (202) 512-7114 or silass@gao.gov or A. Nicole 

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

Offices of Congressional Relations and Public Affairs are on the last page 

of this report. GAO staff who made major contributions to this report are 

listed in appendix VIII.

Sharon M. Silas

Acting Director, Health Care

A. Nicole Clowers

Managing Director, Health Care
Page 65 GAO-18-281 Veterans Choice Program

List of Addressees

The Honorable Johnny Isakson

Chairman

The Honorable Jon Tester

Ranking Member

Committee on Veterans’ Affairs

United States Senate

The Honorable John Boozman

Chairman

The Honorable Brian Schatz

Ranking Member

Subcommittee on Military Construction, 

Veterans Affairs, and Related Agencies

Committee on Appropriations

United States Senate

The Honorable Phil Roe

Chairman

The Honorable Tim Walz

Ranking Member

Committee on Veterans’ Affairs

House of Representatives

The Honorable John Carter

Chairman

The Honorable Debbie Wasserman Schultz

Ranking Member

Subcommittee on Military Construction, 

Veterans Affairs, and Related Agencies

Committee on Appropriations

House of Representatives
Page 66 GAO-18-281 Veterans Choice Program

List of Addressees Continued

The Honorable Richard Blumenthal

United States Senate

The Honorable Mike Enzi

United States Senate

The Honorable John McCain

United States Senate

The Honorable Evan Jenkins

House of Representatives
Appendix I: Scope and Methodology for 

Examining Choice Program Wait Times and the 

Data VHA Uses to Monitor Access

Page 67 GAO-18-281 Veterans Choice Program

To examine selected veterans’ actual wait times to receive routine care 

and urgent care through the Choice Program and the information VHA 

uses to monitor access to care under the program, we took five key steps. 

We (1) analyzed Choice Program appointment wait times for selected 

veterans using a sample of 196 Choice Program authorizations for routine 

and urgent care; (2) reviewed VHA’s analysis of Choice Program 

appointment wait times for a sample of about 5,000 Choice Program 

authorizations; (3) reviewed data VHA uses to monitor the timeliness of 

Choice Program care and reasons that the TPAs have returned Choice 

Program referrals without making appointments; (4) interviewed VA, VHA, 

and TPA officials; and (5) reviewed federal internal control standards, as 

follows.

1. Our analysis of Choice Program wait times for a sample of 196 

authorizations. To analyze the timeliness of Choice Program 

appointment scheduling and completion for a sample of veterans, we 

selected six VAMCs and a random, non-generalizable sample of 196 

authorizations for veterans who were referred to the Choice Program 

by those six VAMCs between January 2016 and April 2016.1 We 

judgmentally selected the six VAMCs to include variation in 

geographic location, with three VAMCs that serve rural veteran 

populations and three VAMCs that serve urban veteran populations. 

In addition, three of the VAMCs were served by Health Net, and three 

were served by TriWest. (See table 5.)

 

1

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

we began our review. We did not assess whether these authorizations met the Choice 

Act’s eligibility requirements. We selected our sample and conducted our analysis based 

on contract requirements that were in effect as of April 2016. Certain contract 

requirements were later modified.

Appendix I: Scope and Methodology for 

Examining Choice Program Wait Times and 

the Data VHA Uses to Monitor Access 
Appendix I: Scope and Methodology for 

Examining Choice Program Wait Times and the 

Data VHA Uses to Monitor Access

Page 68 GAO-18-281 Veterans Choice Program

Table 5: Department of Veterans Affairs (VA) Medical Centers (VAMC) GAO Selected for Its 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 – 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-18-281

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 selected—a 

universe of about 55,000 authorizations. From these 55,000 

authorizations, we randomly selected:

• 55 routine care authorizations (about 10 authorizations per VAMC) 

for which the TPAs scheduled appointments for veterans,

• 53 urgent care authorizations (about 10 authorizations per VAMC) 

for which the TPAs scheduled appointments for veterans, and

• 88 routine and urgent care authorizations (about 15 authorizations 

per VAMC) that the TPAs returned to VA without scheduling 

appointments for any one of the following three reasons—(1) VA 

requested the authorization be returned, (2) VA data were missing 
Appendix I: Scope and Methodology for 

Examining Choice Program Wait Times and the 

Data VHA Uses to Monitor Access

Page 69 GAO-18-281 Veterans Choice Program

from the referral, and (3) the veteran declined or did not want 

Choice Program care.2

For all 196 Choice Program authorizations in our sample, we 

manually 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.3 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 VHA medical facility—and how long it took to 

receive that care. Determining whether veterans in our sample 

experienced clinical harm or adverse clinical outcomes because of 

delays in the VAMCs’ or TPAs’ processing of their referrals and 

authorizations was outside the scope of our review.

We selected our sample of 55 routine care and 53 urgent care 

authorizations for which the TPAs succeeded in scheduling 

appointments 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.4 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 and 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 

 

2

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. 

3

In this report, “days” refers to calendar days, unless otherwise indicated.

4

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 provide care within 2 business days after veterans opt in to the Choice Program. 
Appendix I: Scope and Methodology for 

Examining Choice Program Wait Times and the 

Data VHA Uses to Monitor Access

Page 70 GAO-18-281 Veterans Choice Program

reach the veterans for them to opt in to the program).5 We omitted this 

phase of the appointment scheduling process when calculating the 

timeliness of appointment completion for the 55 routine care 

authorizations and 53 urgent care authorizations in our sample. 

Rather than reporting veterans’ overall wait times for these 

authorizations, we report the average number of calendar days that 

elapsed (1) while VAMCs were preparing veterans’ Choice Program 

referrals, (2) while the TPAs were attempting to reach veterans for 

them to opt in to the program, and (3) while veterans waited to attend 

their appointments after the TPAs succeeded in scheduling them. 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.

2. VHA’s analysis of Choice Program wait times for a sample of 

about 5,000 authorizations. We obtained from VHA’s Office of 

Community Care the results of a nationwide analysis of Choice 

Program appointment timeliness it conducted in February 2017. 

Specifically, VHA directed its VAMCs to manually review veterans’ 

health records and TPA documentation and report observations for a 

non-generalizable sample of about 5,000 randomly selected Choice 

Program authorizations that were created between July and 

September of 2016.6 The sample was limited to authorizations for 

Choice Program appointments that had been scheduled for timeeligible veterans who needed four types of specialty care—

mammography, gastroenterology, cardiology, and neurology. 

According to VHA officials, they limited their analysis to these four 

types of care because delayed treatment for any of these specialties 

 

5

As we discuss in this report, 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.

6

The VAMCs were directed to report to VHA the dates on which key steps of the Choice 

Program appointment scheduling process occurred for each authorization—such as the 

date the veteran’s need for care was identified, the date the VAMC sent the veteran’s 

Choice Program referral to the TPA, the date the TPA succeeded in scheduling an 

appointment, and the date on which the scheduled appointment was to occur.
Appendix I: Scope and Methodology for 

Examining Choice Program Wait Times and the 

Data VHA Uses to Monitor Access

Page 71 GAO-18-281 Veterans Choice Program

could cause adverse health outcomes for patients. To assess the 

reliability of VHA’s data, we manually reviewed the results of its 

analysis and interviewed knowledgeable agency officials about 

potential outliers. We concluded that VHA’s data were sufficiently 

reliable for the purposes of our reporting objective. The results of 

VHA’s analysis cannot be generalized beyond the sample of Choice 

Program authorizations that it reviewed.

3. VHA data on timeliness of Choice Program appointments and the 

reasons TPAs return referrals without making appointments. To 

evaluate the information VHA uses to monitor access to care under 

the Choice Program, we reviewed data that VHA collects to monitor 

the timeliness with which the TPAs schedule appointments and the 

timeliness with which appointments occur after the TPAs have 

scheduled them. We also reviewed and tested the reliability of VHA 

data on the reasons the TPAs have returned Choice Program 

referrals to VAMCs without scheduling appointments, which may offer 

insights about access to care (e.g., the percentage of referrals that 

are returned due to a lack of providers in the TPAs’ networks).

4. Interviews with officials. We interviewed VA, VHA, and TPA officials 

responsible for administering the Choice Program contracts and 

overseeing implementation of the program. We interviewed these 

officials to gain an understanding of the processes they followed and 

the information they used to monitor veterans’ access to Choice 

Program care.

5. Federal internal control standards. We examined the results of our 

and VHA’s analyses and the information VHA uses to monitor 

veterans’ access to care under the program in the context of federal 

standards for internal control for (1) information and communication 

and (2) monitoring.7 The internal control standard for information and 

communication relates to management’s ability to use quality 

information to achieve the entity’s objectives. The internal control 

standard for monitoring relates to establishing activities to monitor the 

quality of performance over time and evaluating the results.

 

7

GAO, Standards for Internal Control in the Federal Government, GAO-14-704G 

(Washington, D.C.: Sept. 2014).
Appendix II: Process for Veterans to Obtain 

Department of Veterans Affairs (VA) Choice 

Program Care if They Are Time-Eligiblea

Page 72 GAO-18-281 Veterans Choice Program

Figure 5: Process for Veterans to Obtain Department of Veterans Affairs (VA) Choice Program Care if They Are Time-Eligiblea

a

VHA uses the time-eligible appointment scheduling process when the services needed are not 

available at a VHA medical facility or are not available within allowable wait times.

b

If the veteran does not respond to the letter within 14 calendar days, a notification is sent to the 

veteran’s VA clinician so that they can determine if additional action should be taken.

Appendix II: Process for Veterans to Obtain 

Department of Veterans Affairs (VA) Choice 

Program Care if They Are Time-Eligiblea
Appendix III: Process for Veterans to Obtain 

Department of Veterans Affairs (VA) Choice 

Program Care if They Are Distance-Eligiblea

Page 73 GAO-18-281 Veterans Choice Program

Figure 6: Process for Veterans to Obtain Department of Veterans Affairs (VA) 

Choice Program Care if They Are Distance-Eligiblea

a

VHA uses the distance-eligible appointment scheduling process when veterans reside more than 40 

miles from a VHA medical facility or meet other travel-related criteria.

Appendix III: Process for Veterans to Obtain 

Department of Veterans Affairs (VA) Choice 

Program Care if They Are Distance-Eligiblea
Appendix IV: Comparison of Processes for 

Arranging Choice Program and Individually 

Authorized Community Care

Page 74 GAO-18-281 Veterans Choice Program

Figure 7: Comparison of Processes for Arranging Choice Program and Individually 

Authorized Department of Veterans Affairs (VA) Community Care

a

The Veterans Health Administration (VHA) uses the time-eligible appointment scheduling process 

when the services needed are not available at a VHA medical facility or are not available within 

allowable wait times.

Appendix IV: Comparison of Processes for 

Arranging Choice Program and Individually 

Authorized Community Care
Appendix V: Process for Obtaining the Clinical 

Results of Choice Program Appointments

Page 75 GAO-18-281 Veterans Choice Program

Figure 8: Process for the Department of Veterans Affairs (VA) to Obtain the Clinical 

Results of Veterans’ Choice Program Appointments

Appendix V: Process for Obtaining the 

Clinical Results of Choice Program 

Appointments
Appendix VI: Selected Actions Taken by VA 

and VHA to Address Choice Program Access 

Issues

Page 76 GAO-18-281 Veterans Choice Program

We found 21 actions that the Department of Veterans Affairs (VA) and the 

Veterans Health Administration (VHA) took after the Choice Program’s 

November 2014 implementation that were intended to help address 

issues related to veterans’ access to care. Table 6, below, provides a 

chronological summary of the actions VA and VHA had taken as of 

August 2017 and the issues they were intended to address.

Table 6: Selected Actions Taken by the Department of Veterans Affairs (VA) and the Veterans Health Administration (VHA) 

between November 2014 and August 2017 to Address Choice Program Access Issues 

Action taken

(implementation time frame)

Description 

of action

Issue(s) that 

action was 

intended to help 

address

1. Updated Choice Program 

eligibility criteria for distanceeligible veterans

(Apr. 2015)

VA published an interim final rule that changed how it determined whether 

veterans were distance-eligible for the Choice Program.a Originally, VA 

used straight-line or geodesic distance to determine whether veterans 

resided more than 40 miles from a VHA medical facility. However, VA later 

changed this standard so that eligibility determinations would instead be 

made on the basis of driving distance, which helped simplify Choice 

Program administrative processes.

☎

2. Established an outbound 

call process

(Sept. – Nov. 2015) 

VA modified the third party administrators’ (TPA) contracts to establish an 

outbound call process. It required that the TPAs contact veterans at least 

three times by telephone after receiving VAMCs’ referrals, to confirm the 

veterans want to opt in to the Choice Program and have the TPA proceed 

with appointment scheduling. Previously, veterans had to contact the TPAs 

on their own and opt in to the Choice Program after VAMCs sent their 

referrals to the TPAs, a confusing process that contributed to delays in 

veterans accessing Choice Program care. 

☎

3. Updated veteran 

eligibility criteria

(Sept. – Dec. 2015)

VA modified the TPAs’ contracts and published an interim final rule, and 

VHA issued guidance to its VAMCs regarding the implementation of 

statutory updates to Choice Program eligibility criteria for veterans. 

Specifically, they allowed all veterans who are enrolled in the VA health 

care system (not just those who were enrolled at the time the Choice Act 

became law) to be eligible to obtain care through the Choice Program, and 

they implemented the “unusual or excessive travel burden” eligibility 

criterion.b These changes had the potential to simplify Choice Program 

administrative processes.

☎

4. Created a standard Choice 

Program referral form

(Oct. – Dec. 2015)

VHA introduced a standard form for VAMCs to use when sending veterans’

Choice Program referrals to the TPAs, and VA modified the TPAs’ 

contracts to account for use of this form. Previously, the TPAs had to wait 

for VA to send them electronic updates to their eligibility files, which did not 

always happen before the TPAs received the VAMCs’ referrals. With the 

standardized form, VAMCs could attest to veterans’ eligibility, which 

removed the step of the TPAs having to verify eligibility through another 

source. 

☎

Appendix VI: Selected Actions Taken by VA 

and VHA to Address Choice Program Access

Issues
Appendix VI: Selected Actions Taken by VA 

and VHA to Address Choice Program Access 

Issues

Page 77 GAO-18-281 Veterans Choice Program

Action taken

(implementation time frame)

Description 

of action

Issue(s) that 

action was 

intended to help 

address

5. Co-located TPA staff 

at selected VAMCs

(Nov. 2015)

VA modified the TPAs’ contracts to allow for TPA staff to be co-located at 

selected VAMCs—an action that VHA officials said could help improve 

communication between VAMC and TPA staff and potentially speed up the 

process of Choice Program appointment scheduling. As of May 2017, 70 

of VHA’s 170 VAMCs had co-located TPA staff. 

✍

6. Expanded standard episode of 

care from 60 days to 1 year

(eff. Dec. 2015 and 

active Jan. 2016)

VA modified the TPAs’ contracts and updated its policies to implement a 

Choice Act amendment that increased the time limit on Choice Program 

episodes of care from 60 days to 1 year.c According to VA and TPA 

officials, this had the potential to significantly reduce TPAs’ and VAMCs’ 

administrative burden associated with re-authorizing care when veterans’ 

Choice Program authorizations expired. 

☎

7. Automated VAMCs’ preparation 

of Choice Program referrals

(Early 2016)

VHA established a web-based tool—called the “referral documentation”

(REFDOC) tool, which automates the process by which VAMC staff 

compile clinical information for veterans’ Choice Program referrals. VHA’s 

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

the process of preparing Choice Program referrals by about 20 minutes 

per referral.

☎

8. Clarified eligibility requirements 

for community providers of 

mental health services

(Feb. 2016)

VA modified the TPAs’ contracts to clarify that mental health providers with 

Masters-level degrees were eligible to participate in the TPAs’ Choice 

Program networks, which had the potential to help address network 

adequacy issues. 

☤

9. Established Choice Provider 

Agreement process

(Feb. 2016 – June 2016)

VHA established a process that allowed VAMCs to use Choice Program 

funds to arrange community care for veterans when the TPAs could not 

arrange such care—either because the services were not covered under 

the Choice Program contracts (e.g., dental and home health services) or 

because the TPAs returned Choice Program authorizations to VAMCs 

without scheduling appointments. In part, this process was intended to 

address network inadequacy, which was causing the TPAs to return 

authorizations to VAMCs. 

☤

10. De-coupled medical 

documentation from payment 

of community providers’ 

Choice Program claims

(Mar. 2016)

VA modified the TPAs’ contracts by relaxing requirements related to the 

amount of time community providers have to return medical records 

associated with an episode of routine care. Previously, the TPAs were not 

allowed to pay community providers’ Choice Program claims until the 

TPAs received medical records from the providers, but the contract 

modification removed this requirement. This action had the potential to 

simplify the TPAs’ post-appointment follow-up processes. It was also 

intended to help address delays in the TPAs’ payments to community 

providers, which had been causing some to drop out of the TPAs’ 

networks. 

☎ ☤
Appendix VI: Selected Actions Taken by VA 

and VHA to Address Choice Program Access 

Issues

Page 78 GAO-18-281 Veterans Choice Program

Action taken

(implementation time frame)

Description 

of action

Issue(s) that 

action was 

intended to help 

address

11. Required TPAs to return 

referrals to VAMCs if 

appointments are not 

scheduled within required 

time frames

(June 2016)

VA modified the TPAs’ contracts to require the TPAs to return Choice 

Program authorizations when the TPAs did not meet contractual standards 

related to the timeliness with which they (1) reviewed and accepted 

referrals and (2) scheduled appointments after veterans opted into the 

program. Previously, the TPAs had to return referrals only if veterans had 

not opted in 10 days after the TPA sent a letter. This contract modification 

had the potential to limit appointment scheduling delays that would be 

attributable to the TPAs. It also had the potential to address network 

adequacy issues, which was a common reason that TPAs were unable to 

meet appointment scheduling timeliness requirements. 

☎ ☤

12. Created two pilot programs 

for VAMC staff to schedule 

Choice Program 

appointments

(July 2016 and Oct. 2016)

VA modified the TPAs’ contracts to establish pilot programs at two VAMCs 

(specifically, the Alaska VA Health Care System and the Fargo VA Health 

Care System), where VAMC staff took over Choice Program appointment 

scheduling responsibilities from the TPAs. In these two locations, VAMC 

staff scheduled veterans’ appointments and sent relevant clinical 

documentation to the Choice Program providers, and the TPAs sent 

authorizations to the Choice Program providers before veterans attended 

their appointments. This had the potential to improve the efficiency of the 

Choice Program appointment scheduling process in the two pilot locations. 

☎

13. Established a real-time, webbased communication tool for 

VAMCs and TPAs

(Aug. 2016 – Jan. 2017) 

VHA implemented a real-time communication tool (specifically, a webbased chat program), which VAMC staff could use to communicate with 

TPA officials about problems that arose with specific Choice Program 

referrals (such as missing clinical information), or patterns of problems that 

emerged with Choice Program referrals. 

☎

14. Established qualifications 

for certain types of non-federal 

and non-Medicare participating 

providers to participate in the 

TPAs’ Choice Program 

networks

(Jan. – Feb. 2017)

VA modified the TPAs’ contracts to revise Choice Program eligibility 

requirements for providers of women’s health care services, audiology, 

pediatrics, and optometry. These contract modifications implemented a 

July 2015 statutory change, which allowed these types of providers to 

participate in the TPAs’ Choice Program networks.d Previously, the Choice 

Act limited the TPAs’ networks to providers that either (1) participated in 

the Medicare program or (2) were affiliated with the Department of 

Defense, the Indian Health Service, or federally qualified health centers.e

☤

15. Clarified requirements 

relating to the provision of 

durable medical equipment 

during episodes of Choice 

Program care

(Feb. – Mar. 2017) 

VA modified the TPAs’ contracts to clarify requirements relating to the 

provision of durable medical equipment —specifically, how the TPAs are to 

coordinate with VAMCs to obtain durable medical equipment during 

episodes of routine care, and the extent to which VA will cover durable 

medical equipment (such as crutches, slings, and canes) supplied by 

community providers during episodes of urgent care. This had the potential 

to improve the process of delivering durable medical equipment to 

veterans who need it and streamline discharge processes when veterans 

are leaving inpatient settings of care. 

☎

16. Added tele-mental health 

services to the TPAs’ 

contracts

(Mar. – May 2017)

VA modified the TPAs’ contracts to permit psychologists, psychiatrists, 

licensed clinical social workers, and advanced registered nurse 

practitioners to provide tele-mental health services through the TPAs’ 

networks. This has the potential to improve the availability of network 

providers for veterans who reside in rural locations. 

☤
Appendix VI: Selected Actions Taken by VA 

and VHA to Address Choice Program Access 

Issues

Page 79 GAO-18-281 Veterans Choice Program

Action taken

(implementation time frame)

Description 

of action

Issue(s) that 

action was 

intended to help 

address

17. Acquired a secure e-mail 

system for transmitting 

veterans’ medical records

(Mar. – May 2017)

VA acquired software that allows VAMC managers and staff to e-mail 

encrypted files containing veterans’ medical records to the TPAs and 

Choice Program community providers. Only the intended recipient can 

decrypt and respond to messages containing the files. This action is 

intended to improve the efficiency of coordinating veterans’ Choice 

Program care and address potential security risks associated with printing 

paper copies of veterans’ medical records and sending them to the TPAs 

or community providers via fax or U.S. mail. 

☎

18. Approved standard sets of 

clinical services that are to 

be authorized whenever 

veterans are referred to the 

Choice Program for certain 

types of care

(April 2017)

VHA approved standardized episodes of care—or “bundles” of clinically 

necessary medical services and procedures—that are to be authorized 

whenever veterans are referred to community providers for specified types 

of care. VHA approved standardized episodes of care for 15 different types 

of care, including physical therapy, maternity care, and optometry, and 

planned to roll out additional standardized episodes of care over time. This 

had the potential to simplify the VAMCs’ preparation of veterans’ Choice 

Program referrals and TPAs’ processing of authorizations.

☎

19. Implemented a new law 

that made VA the primary 

coordinator of benefits for 

veterans with other health 

insurance

(Apr. 2017)

VHA implemented an April 19, 2017, law that made VA the primary 

coordinator of benefits when veterans with other health insurance use the 

Choice Program for nonservice-connected care.f

This had the potential to 

simplify VAMCs’, TPAs’, and community providers’ administrative 

processes. Previously, VAMCs had to determine whether the health care 

services the veteran was attempting to access through the Choice 

Program were related to the veteran’s service-connected disability. If they 

were not, community providers had to collect other health insurance 

copayments and bill veterans’ other health insurance prior to seeking 

Choice Program payments from the TPAs. Under the new law, community 

providers will bill only the TPAs, and VA will later bill veterans’ other health 

insurance for nonservice-connected care. 

☎

20. Provided a mechanism for 

community providers to 

have access to veterans’ VA 

electronic health records

(May 2017)

VA developed a secure, web-based application called the Community 

Viewer, which allows community providers to remotely view veterans’ VA 

electronic health records. VAMC staff create usernames and passwords 

for approved community providers, who then have access only to assigned 

veterans’ medical information. The Community Viewer is intended to 

improve the efficiency of care coordination and sharing health information 

between veterans’ VHA clinicians and community providers. 

☎
Appendix VI: Selected Actions Taken by VA 

and VHA to Address Choice Program Access 

Issues

Page 80 GAO-18-281 Veterans Choice Program

Action taken

(implementation time frame)

Description 

of action

Issue(s) that 

action was 

intended to help 

address

21. Provided a tool for VAMCs to 

analyze their future staffing 

needs

(May 2017)

VHA developed a tool that is intended to help VAMCs project their future 

staffing needs. VHA used workload data and site visit observations to 

develop the tool. ✍

Legend: ☎ = administrative burden 

✍ = staffing, feedback mechanisms for VAMCs, and VHA’s communication of policy and process changes

☤ = network inadequacy

Source: GAO analysis of VA and VHA information. | GAO-18-281

a

80 Fed. Reg. 22906 (2015)

b

Pub. L. No. 114-41, § 4005(a), 129 Stat. 443, 464 (2015).

c

Pub. L. No. 114-41, § 4005(c), 129 Stat. 443, 464 (2015).

d

Pub. L. No. 114-41, § 4005(c), 129 Stat. 443, 464 (2015).

e

Pub. L. No. 113-146, § 101(a)(1)(B), 128 Stat. 1754, 1756 (2014).

f

Pub. L. No. 115-26, § 2, 131 Stat. 129 (2017).
Page 81 GAO-18-281 Veterans Choice Program

Appendix VII: Comments from the 

Department of Veteran’s Affairs
Page 82 GAO-18-281 Veterans Choice Program
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Page 88 GAO-18-281 Veterans Choice Program
Page 89 GAO-18-281 Veterans Choice Program
Page 90 GAO-18-281 Veterans Choice Program
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Appendix VIII: GAO Contacts and Staff 

Acknowledgments

Page 93 GAO-18-281 Veterans Choice Program

Sharon M. Silas, (202) 512-7114 or silass@gao.gov

A. Nicole Clowers, (202) 512-7114 or clowersa@gao.gov

In addition to the contact named above, Marcia A. Mann (Assistant 

Director), Alexis C. MacDonald (Analyst-in-Charge), Daniel Powers, and 

Michael Zose made major contributions to this report. Also contributing 

were Muriel Brown, Christine Davis, Helen Desaulniers, Krister Friday, 

Sandra George, Jacquelyn Hamilton, and Vikki Porter.

Appendix VIII: GAO Contacts and Staff 

Acknowledgments

GAO Contacts

Staff 

Acknowledgments
Related GAO Products

Page 94 GAO-18-281 Veterans Choice Program

Veterans’ Health Care: Preliminary Observations on Veterans’ Access to 

Choice Program Care, GAO-17-397T (Washington, D.C.: March 7, 2017).

VA Health Care: Improved Monitoring Needed for Effective Oversight of 

Care for Women Veterans, GAO-17-52 (Washington, D.C.: December 2, 

2016).

VA’S Health Care Budget: In Response to a Projected Funding Gap in 

Fiscal Year 2015, VA Has Made Efforts to Better Manage Future 

Budgets, GAO-16-584 (Washington, D.C.: June 3, 2016).

Veterans’ Health Care: Proper Plan Needed to Modernize System for 

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

2016).

VA Health Care: Actions Needed to Improve Monitoring and Oversight of 

Non-VA and Contract Care. GAO-15-654T (Washington, D.C.: June 1, 

2015).

VA Health Care: Further Action Needed to Address Weaknesses in 

Management and Oversight of Non-VA Medical Care, GAO-14-696T 

(Washington, D.C.: June 18, 2014).

VA Health Care: Actions Needed to Improve Administration and Oversight 

of VA’s Millennium Act Emergency Care Benefit, GAO-14-175 

(Washington, D.C.: March 6, 2014).

VA Health Care: Management and Oversight of Fee Basis Care Need 

Improvement, GAO-13-441 (Washington, D.C.: May 31, 2013).

Related GAO Products

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