Report No. 09-01110-81 February 4, 2010

VA Office of Inspector General 

Washington, DC 20420 

Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Review of Inappropriate Copayment 

Billing for Treatment Related to 

Military Sexual Trauma 
 

 

 

To Report Suspected Wrongdoing in VA Programs and Operations 

Telephone: 1-800-488-8244 between 8:30AM and 4PM Eastern Time,

 Monday through Friday, excluding Federal holidays

 E-Mail: vaoighotline@va.gov 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

Contents 

Page 

Executive Summary ..............................................................................................i

Introduction .......................................................................................................... 1 

Purpose ........................................................................................................................... 1

Background .................................................................................................................... 1

Scope and Methodology ................................................................................................ 8

Results and Conclusions .................................................................................. 10 

Issue 1: Demographics and Characteristics of Patients Who Sought Military Sexual 

Trauma Designated Care at VHA Facilities in Fiscal Year 2009 .......................... 10 

Issue 2: Copayment Billing for Military Sexual Trauma Designated Care at Austin 

Outpatient Clinic in 2008 ....................................................................................... 11

Issue 3: Copayment Billing for Military Sexual Trauma Designated Care at Central 

Texas Veterans Health Care System from October 1, 2006, to June 1, 2009 ........ 12 

Conclusions .................................................................................................................. 14 

Recommendations ........................................................................................................ 15 

Appendixes

A. OIG Referral Memorandum ................................................................................... 16

B. Central Texas Veterans Health Care System Director’s Response ........................ 18

C. Acting Under Secretary for Health Comments ...................................................... 19 

D. VISN Director’s Comments ................................................................................... 22 

E. Central Texas Veterans Health Care System Director’s Comments ...................... 23 

F. OIG Contact and Staff Acknowledgments ............................................................. 26 

G. Report Distribution................................................................................................. 27 

VA Office of Inspector General 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

Executive Summary 

Introduction 

At the request of Senate Veterans’ Affairs Committee Chairman Daniel K. Akaka, the 

VA Office of Inspector General (OIG) investigated allegations of charging veterans for 

treatment as a result of military sexual trauma (MST) at the Austin Outpatient Clinic, 

which is part of Central Texas Veterans Health Care System (CTVHCS). The OIG 

referred the allegations to the Director of CTVHCS for investigation and response. 

Concerned with the information provided in the response from CTVHCS, the OIG 

decided to conduct a VA-wide evaluation of copayment billing practices for care 

rendered for MST-related conditions. 

Results 

Based on the Veterans Health Administration’s (VHA’s) fiscal year (FY) 2009 Medical 

SAS Outpatient data file (generated on October 20, 2009), 5,340,754 patients sought 

outpatient care for a total number of 92,892,834 encounters in FY 2009. Among the 

5,340,754 patients, 65,264 (1.2 percent) received at least one outpatient care encounter 

for MST-related conditions at VHA facilities during FY 2009. Sixty percent of the 

patients who sought at least one outpatient care encounter for MST-related conditions in 

FY 2009 were woman veterans. We found that use of the clinic stop code specifically 

designated for MST-related care is inconsistently implemented at VHA medical facilities. 

As a result, MST treatment data are not readily accessible across the VA system based on 

the clinic stop code. 

We conducted a pilot review for information gathering. Based on the pilot review’s 

results, we concluded that a VA-wide evaluation of inappropriate copayment billing 

practices was not warranted and confined our evaluation to CTVHCS. 

It appears that suppressing the copayment trigger for MST-related service in the 

Integrated Billing Package works appropriately except possibly in certain instances 

related to timing. The billing system may not automatically cancel copayment charges if 

MST designation takes place after the encounter date. CTVHCS has cancelled all 

erroneous charges and refunded any payments that were received. 

We found that erroneous copayments for MST-related care have resulted from staff 

changing patients’ copayment status from “not required to make a copayment” to 

“copayment required.” When manual edits are made to create a copayment bill, proper 

controls must be in place to ensure that the manual changes consider MST and any other 

conditions that entitle veterans to cost free care. CTVHCS has cancelled all erroneously 

added charges and refunded any payments received. However, it is a concern that 

VA Office of Inspector General i 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

VA Office of Inspector General ii 

manually added copayment billing may exist at other VHA facilities and for other cost 

free care conditions mandated under special authority. 

Recommendations 

We recommended that: 

• The Acting Under Secretary for Health ensure the use and implementation of a 

method specifically designated to track MST-related care at all VHA medical 

facilities so that MST treatment data are readily accessible across the VA system. 

• The Veterans Integrated Service Network (VISN) 17 Director ensure that the 

CTVHCS Director determines whether a delay of more than 1 day between the 

dates of care and note signing creates an erroneous copayment bill and/or 

accounting for MST-related care. 

• The VISN 17 Director ensure that the CTVHCS Director includes in the facility’s 

standard operating procedure the requirement that business staff review for MST 

designation (or for any other conditions that entitle veterans to cost free care or 

medications) prior to adding copayment charges. 

Comments 

The Acting Under Secretary for Health, VISN 17 Director, and CTVHCS Director 

concurred with the findings and recommendations and provided implementation plans. 

(See Appendixes C–D, pages 18–24, for the full text of the comments.) The Acting 

Under Secretary for Health will revise VHA policy to enable tracking of MST-related 

outpatient care. The revised policy will be implemented, and education will be provided. 

The VISN 17 and CTVHCS Directors have filed a work order along with a request to 

have specific copayment charges reviewed. Once the work order is processed and closed, 

they will be able to determine whether corrections need to be made to the Integrated 

Billing Package. Also, the VISN 17 and CTVHCS Directors have instructed CTVHCS 

staff who add copayment charges to review appropriate documentation prior to adding 

charges. Quarterly documentation reviews will be conducted to determine compliance. 

The implementation plans are acceptable, and we will follow up until all actions are 

complete. 

 (original signed by:)

JOHN D. DAIGH, JR., M.D. 

Assistant Inspector General for 

Healthcare Inspections 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

Introduction 

Purpose 

The VA Office of Inspector General (OIG) received a request from Senate Veterans’ 

Affairs Committee Chairman Daniel K. Akaka to investigate allegations of charging 

veterans for treatment as a result of military sexual trauma (MST) at the Austin 

Outpatient Clinic (OPC), which is part of Central Texas Veterans Health Care System 

(CTVHCS). In accordance with VA Directive 0701, Office of Inspector General Hotline 

Complaint Referrals, January 15, 2009, the OIG referred the allegations to the Director of 

CTVHCS for investigation and response (Appendix A). 

Concerned with the information provided in the response from CTVHCS (Appendix B), 

the OIG decided to conduct a VA-wide evaluation of copayment billing practices for care 

rendered for MST-related conditions. The purpose of this review was to assess the extent 

of inappropriate copayment charges for treating MST. 

Background 

Basic Eligibility for VA Health Care Benefits. 

Service members are eligible for some VA health care benefits if they served on active 

duty in the uniformed services for the minimum amount of time specified by law and 

were discharged or released under conditions other than dishonorable. Reservists and 

National Guard members also qualify for VA health care benefits if they were called to 

active duty (other than for training only) by a Federal order and completed the full period 

for which they were called to duty. 

In order to be eligible, veterans who enlisted after September 7, 1980, or who entered 

active duty after October 16, 1981, must have served 24 continuous months or the full 

period for which they were called to active duty. This minimum duty requirement may 

not apply to veterans discharged for hardship, early out, or a disability incurred or 

aggravated in the line of duty (Department of Veterans Affairs; Federal Benefits for 

Veterans, Dependents and Survivors; 2009 Edition). 

VA Health Care Enrollment and Priority Groups. 

The Veterans’ Health Care Eligibility Reform Act of 1996 (Public Law 104-262) requires 

VA to establish and operate a system of annual patient enrollment and created seven 

priority groups for managing demand within available resources. The Department of 

Veterans Affairs Health Care Programs Enhancement Act of 2001 (Public Law 107-135) 

subsequently expanded the seven priority groups to eight with Priority Group 8 having 

the lowest priority. 

VA Office of Inspector General 1 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

VA Office of Inspector General 2 

In general, veterans are required to apply for enrollment into the VA health care system 

to receive care (Department of Veterans Affairs; Federal Benefits for Veterans, 

Dependents and Survivors; 2009 Edition). 

Veterans do not have to be enrolled if they: 

• Have a service-connected (SC) disability of 50 percent or more;1

• Seek care for a disability the military determined was incurred or aggravated in the 

line of duty—but which VA has not yet rated—within 12 months of discharge; 

• Seek care for a SC disability only; or 

• Seek registry examinations (Ionizing Radiation, Agent Orange, Gulf 

War/Operation Iraqi Freedom, and Depleted Uranium). 

Unenrolled veterans will be automatically enrolled by VA the first time they seek VA 

care. During enrollment, each veteran is assigned to one of the following eight priority 

groups: 

Priority Group 1: 

• Veterans with SC disabilities rated 50 percent or more, or 

• Veterans determined by VA to be unemployable due to SC conditions. 

Priority Group 2: 

• Veterans with SC disabilities rated 30 or 40 percent. 

Priority Group 3: 

• Veterans with SC disabilities rated 10 or 20 percent; 

• Veterans who are former prisoners of war (POWs) or were awarded a Purple 

Heart medal; 

• Veterans awarded special eligibility for disabilities incurred in treatment or 

participation in a VA vocational rehabilitation program; or 

• Veterans whose discharge was for a disability incurred or aggravated in the 

line of duty. 

Priority Group 4: 

• Veterans receiving aid and attendance or housebound benefits, or 

• Veterans who were determined by VA to be catastrophically disabled. 

Priority Group 5: 

• Veterans receiving VA pension benefits; 

• Veterans who are eligible for Medicaid programs; or

 

1

VA assigns disability ratings to compensate veterans for physical or mental conditions incurred or aggravated 

during military service. These ratings are assigned in increments of 10, ranging from zero to 100 percent. 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

• Non-SC veterans and non-compensable, zero percent SC veterans whose gross 

annual household income and net worth are below the established VA means 

test thresholds. 

Priority Group 6: 

• Veterans of World War I or the Mexican Border War; 

• Veterans seeking care solely for conditions associated with exposure to toxins 

or environmental hazards while in service; 

• Veterans with zero percent SC disabilities who are receiving disability 

compensation benefits; or 

• Veterans who served in a theater of combat operations after November 11, 

1998, as follows: 

o Veterans discharged/released from active duty on or after January 28, 

2003, who were enrolled as of January 28, 2008, and veterans who 

apply for enrollment after January 28, 2008, for 5 years post discharge. 

o Veterans discharged/released from active duty before January 28, 2003, 

who applied for enrollment after January 28, 2008, or who apply by 

January 27, 2011. 

Priority Group 7: 

• Veterans with income and/or net worth above the VA national income 

threshold but below the geographic income threshold who agree to pay 

copayments. 

Priority Group 8: 

• Veterans with income and/or net worth above the VA national income 

threshold and the geographic income threshold who agree to pay copayments. 

Copayment Requirement for VA Health Care and Medication. 

VA provides cost free care and medication for the treatment of SC conditions and to 

veterans with SC disabilities rated 50 percent or more, former POWs, and VA pensioners. 

VA also provides cost free care and medication for veterans under special authorities (for 

example, medications for conditions that place the veterans in Priority Group 6) and for 

the treatment for MST-related conditions. 

Other veterans must make copayments in order to receive VA health care and/or 

medications (Department of Veterans Affairs; Federal Benefits for Veterans, Dependents 

and Survivors; 2009 Edition). Specifically, 

 

VA Office of Inspector General 3 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

Inpatient Care: 

• Copayment for Priority Group 7 and certain other veterans is 20 percent or 

$213.60 for the first 90 days of inpatient hospital care during any 365-day period. 

For each additional 90 days, the copayment is $106.80. In addition, there is a 

$2 per diem charge. 

• Copayment for Priority Group 8 and certain other veterans is $1,068 for the first 

90 days of care during any 365-day period. For each additional 90 days, the 

copayment is $534. In addition, there is a $10 per diem charge. 

Outpatient Care: 

The copayment is $15 for a primary care visit and $50 for some specialized care. 

Copayments are exempted for outpatient visits solely for preventive screening and/or 

immunizations; laboratory, flat film radiology, electrocardiograms, and hospice care; and 

publicly announced VA health fairs. 

Medication: 

Medication copayments do not apply to the following groups of veterans: 

• Veterans with a SC disability of 50 percent or more; 

• Veterans receiving medication for SC conditions; 

• Veterans whose annual income does not exceed the maximum annual rate of the 

VA pension; 

• Veterans enrolled in Priority Group 6 who receive medication under their special 

authority; 

• Veterans receiving medication for conditions related to MST; 

• Certain veterans receiving medication for treatment of cancer of the head or neck; 

• Veterans receiving medication for a VA-approved research project; or 

• Former POWs. 

For other veterans whose conditions are not SC, the copayment is $8 for each 30-day or 

less supply of medication provided by VA. For veterans enrolled in Priority Groups 2 

through 6, the maximum copayment for medications in calendar year 2009 was $960. 

Extended Care: 

The copayment amount is based on each veteran’s financial situation and is determined 

upon application for extended care services. Copayments range from $0 to $97 a day. 

VA Office of Inspector General 4 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

Military Sexual Trauma. 

VA refers to MST as the experiences of sexual harassment and/or sexual assault that 

occurred while the veteran was in the military. Both males and females can experience 

MST. The perpetrator can be of the same or of the opposite gender. Like other types of 

trauma, MST can negatively impact a person’s mental and physical health, even many 

years later.

The Veterans Health Care Act of 1992 (Public Law 102-585) was signed into law after a 

series of hearings on women veterans’ issues by the Senate Veterans’ Affairs Committee 

in July 1992. The Veterans Health Care Act of 1992 authorized VA to provide outreach 

and establish MST counseling and treatment programs for women veterans who 

experienced incidents of sexual trauma while on active duty. The Veterans Health Care 

Extension Act of 1994 (Public Law 103-452) authorized VA to provide MST counseling 

and treatment to men as well as women. The Veterans Millennium Health Care Act 

(Public Law 106-117) expanded the focus on MST programs to include outreach and 

extended VA’s authority to provide MST programs until December 2004. The Veterans 

Health Program Improvement Act of 2004 (Public Law 108-422) extended VA’s 

authority permanently and extended MST counseling and related treatment to veterans 

whose MST occurred while serving on active duty or active duty for training (as defined 

under Title 38 United States Code §101(22)) if service was in the National Guard or 

Reserves. 

Following the passage of these public laws, Veterans Health Administration (VHA) 

Directive 2005-015, Military Sexual Trauma Counseling, March 25, 2005, mandated 

universal screening of all enrolled veterans for a history of MST and mandated that each 

VA medical facility appoint an MST Coordinator to oversee the screening and treatment 

referral process. The directive recommended the use of clinic stop code 524 so that 

collection of MST treatment data is accessible and consistent across the VA system. Stop 

codes are identifiers used in VHA’s managerial cost accounting system, the Decision 

Support System (DSS), to indicate the primary clinical group providing the services. 

DSS is a congressionally-mandated resource management tool. Implementation began 

throughout VHA in 1994. 

VA provides free, confidential counseling and treatment for veterans’ mental and 

physical health conditions resulting from MST that occurred while serving on active duty 

or active duty for training if service was in the National Guard or Reserves. Veterans do 

not need to have reported the incident(s) when they happened or have other 

documentation that they occurred. Appropriate services are provided for any injury, 

illness, or psychological condition resulting from MST. Veterans do not need to be SC 

and may be able to receive this benefit even if they are not otherwise eligible for VA 

health care benefits. Although veterans receiving MST-related counseling and treatment 

are not billed for inpatient, outpatient, or medication copayments, applicable copayments 

may be charged for services not related to MST or for other non-SC conditions. 

VA Office of Inspector General 5 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

Designation of Military Sexual Trauma Related Care. 

According to the VA Automated Service Connected Designation Technical Manual of 

September 2007, the SC designation has been automated for outpatient encounters within 

the Patient Care Encounter and Scheduling packages. The automation of SC designation 

utilizes the mapped International Classification of Diseases, Clinical Modification, 

9th Revision (ICD-CM-9) with rated disability codes at the time the provider actually 

picks the ICD-9 code for the encounter. When a provider chooses the ICD-9 diagnosis 

code for the encounter, the software will automatically determine if the diagnosis is 

related to the veteran’s established SC conditions to make the proper SC or non-SC 

designation for that encounter. These encounters are then displayed for editing 

incorrectly designated encounters. 

Figure 1. Screen for medication order. The provider needs to designate if the medication order is 

related to MST (or related to other conditions that entitle veterans to cost free care) before he or 

she can sign the order. 

VA Office of Inspector General 6 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

Designation of MST encounters, however, requires care providers to check the 

corresponding MST box before they can sign the notes. This same process also applies to 

all medication orders. Figure 1 gives an example of the screen display for a medication 

order. The provider needs to designate if the medication order is related to MST (or 

related to other conditions that entitle veterans to cost free care) by resolving the question 

marks to suppress or not suppress the copayment billing charges before he or she can sign 

the order. 

Because one prescription order may include multiple medications, some of which may 

not be for MST-related treatment, each medication needs to be designated individually as 

MST related or not. 

Central Texas Veterans Health Care System. 

CTVHCS is one of the three health care systems in the VA Heart of Texas Health Care 

Network (Veterans Integrated Service Network (VISN) 17). The other two systems in 

VISN 17 are South Texas Veterans Health Care System and VA North Texas Health Care 

System (http://www.heartoftexas.va.gov/. Last accessed on November 15, 2009). 

CTVHCS serves over 230,000 veterans from 39 counties in central Texas. It covers 

35,243 square miles and eight congressional districts. CTVHCS consists of two main 

medical centers located in Temple and Waco; an outpatient clinic located in Austin; and 

four community based outpatient clinics located in Brownwood, College Station, Cedar 

Park, and Palestine (http://www.centraltexas.va.gov/about/index.asp. Last accessed on 

November 15, 2009). CTVHCS offers treatment for MST on an outpatient basis for both 

male and female veterans. MST treatment is available at the Austin, Temple, and 

Waco facilities (http://www.centraltexas.va.gov/services/index.asp. Last accessed on 

November 15, 2009). 

Alleged Inappropriate Billing for Military Sexual Trauma Care at the Austin 

Outpatient Clinic.

Senate Veterans’ Affairs Committee Chairman Daniel K. Akaka received allegations that 

veterans at CTVHCS’s Austin OPC were charged for treatment that was related to MST. 

In accordance with VA Directive 0701, Office of Inspector General Hotline Complaint 

Referrals, January 15, 2009, the OIG referred the allegations to the Director of CTVHCS 

for investigation and response (Appendix A). 

The CTVHCS Director’s response indicated that the Austin OPC treated 250 veterans for 

MST in calendar year 2008 and that 86 rendered services flagged as related to MST were 

billed, including 91 prescriptions and six visits (Appendix B). Concerned with the 

information provided in the response, the OIG decided to conduct this review to assess 

the extent of inappropriate copayment charges for treating MST. 

VA Office of Inspector General 7 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

Scope and Methodology 

We reviewed applicable regulations, policies, procedures, and guidelines. VHA’s fiscal 

year (FY) 2009 Medical SAS Outpatient data file (generated on October 20, 2009) was 

used to describe VA MST patient demographics and characteristics. 

Veterans who seek care for MST may or may not be associated with SC disabilities. 

Veterans receive cost free counseling and treatment (including medication) for mental 

and physical health conditions related to experiences of MST even though they may not 

otherwise be eligible for VA health care. For veterans with less than 50 percent SC 

disabilities and high income, copayment may be required for counseling and treatment of 

conditions that are not SC. Although veterans receiving MST-related counseling and 

treatment are not billed for inpatient, outpatient, or medication copayments, applicable 

copayments may be charged for services not related to MST and for non-SC conditions. 

In order to suppress the copayment trigger in the VA billing system—the Integrated 

Billing Package (IB)—for MST-related counseling, encounters, and medications, the 

provider needs to check the MST box to designate that the service provided is MST 

related. 

Staff then review the patient visit information, make necessary edits, and release them for 

first party (copayment) and/or third party (reimbursable health insurance) billing where 

appropriate. We limited our review to copayment only. 

Logically, only MST patients who meet copayment requirements and who have not 

reached their applicable maximum copayment may be mistakenly billed for MST-related 

services. Patients who do not meet copayment requirements (for example, 50 percent or 

more SC or low income) are automatically suppressed for billing for any treatment. We 

thus limited our review to only patients who met copayment requirements, were billed for 

care, and had been diagnosed with MST. 

Furthermore, inappropriate copayment billing for MST-related treatment may occur if: 

1. The suppressing copayment trigger for MST-related service in the IB is not set up 

appropriately, and/or 

2. MST designated service encounters were inappropriately edited for billing. 

Situation 1 would reflect a system-wide issue. 

We conducted a pilot review for information gathering. We first requested from 

CTVHCS the 2008 Austin OPC MST data that were originally used in the Director’s 

response letter to the OIG inquiry. The pilot review focused on only those MST patients 

who met copayment requirements and were billed copayments for care designated as 

MST related. 

VA Office of Inspector General 8 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

Based on the pilot evaluation results, we concluded that a VA system-wide evaluation of 

inappropriate copayment billing practices was not warranted. Thus, we confined our 

evaluation to CTVHCS. 

We then requested and analyzed CTVHCS copayment data that covered all Central Texas 

MST patients who met copayment requirements and for whom at least one copayment 

bill was generated by the IB for outpatient visits from October 1, 2006 to June 1, 2009. 

Medical record reviews were conducted when necessary to verify pertinent information. 

We conducted the inspection in accordance with Quality Standards for Inspections

published by the President’s Council on Integrity and Efficiency. 

VA Office of Inspector General 9 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

Results and Conclusions 

Issue 1: Demographics and Characteristics of Patients Who 

Sought Military Sexual Trauma Designated Care at VHA 

Facilities in Fiscal Year 2009 

According to VHA’s FY 2009 Medical SAS Outpatient data file (generated on 

October 20, 2009), 5,340,754 patients sought outpatient care for a total number of 

92,892,834 encounters in FY 2009. 

Table 1 shows that 65,264 (1.2 percent of 5,340,754) patients received at least one 

outpatient care encounter for MST-related conditions at VHA facilities during FY 2009. 

A total of 754 (1.2 percent of 65,264) MST patients had all their outpatient episodes 

designated as MST related (data not shown). Austin OPC treated 454 MST patients, and 

one of them had all outpatient care designated as MST related (data not shown). 

Austin OPC treated a higher percentage of female MST patients (72 percent) than VHA 

as a whole (60 percent). At all VHA facilities, female MST patients were more likely to 

have had at least one of their designated MST episodes of care also designated as SC than 

their male counterparts (62.8 percent for females versus 51.1 percent for males). This is 

in contrast to Austin OPC where females were less likely (59.0 percent for females versus 

63.2 percent for males) to have had at least one of their designated MST episodes of care 

also designated as SC. Overall, female MST patients were younger than male MST 

patients (male patient median age was 57 for all of VHA versus 54 for those at Austin 

OPC) with half of them age 47 or under at the time of their first outpatient episode of care 

for MST-related conditions in FY 2009. 

Table 1. Demographics of patients who sought MST designated care at VHA facilities in FY 2009.  

 All VHA Facilities Austin OPC 

[65,264] [454] 

Female Male Female Male 

Number of MST patients (percent) 38,895 (59.6%) 26,369 (40.4%) 329 (72.5%) 125 (27.5%)

Number of patients with any MST visit also 

 marked as service-connected visit 24,436 (62.8%) 13,483 (51.1%) 194 (59.0%) 79 (63.2%) 

Median age (years) at time of first MST 

 visit in FY 2009 47 57 47 54 

Number of patients with any MST visit 

 recorded at clinic stop code 524 376 (0.97%) 129 (0.49%) 0 0 

VHA Directive 2005-015, Military Sexual Trauma Counseling, March 25, 2005, 

recommended the use of clinic stop code 524 specifically for MST-related care. VHA 

Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics,

VA Office of Inspector General 10 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

September 11, 2008, repeated the same recommendation. However, the recommendation 

has not been fully implemented after 4 years as evidenced by the meager use of the 

524 code for care designated for MST-related conditions (Table 1). As a result, MST 

treatment data are not readily accessible across the VA system. For example, in the 

absence of the indicator for MST-designated care in the VHA FY 2009 Medical SAS 

Inpatient data file, inpatient treatment data for MST-related conditions are not readily 

accessible because of inconsistent use of the specific MST clinic stop code. 

Issue 2: Copayment Billing for Military Sexual Trauma 

Designated Care at Austin Outpatient Clinic in 2008 

The Austin OPC billing data file includes all claims for copayment and reimbursable 

health insurance for clinic visits and/or disbursed medication for all MST patients treated 

there in 2008. These charges may or may not relate to treatment for MST conditions (as 

designated by checked MST boxes) because these MST patients met copayment 

requirements for care rendered for non-SC conditions. There were a total of 97 MST 

patients (39 percent of the 250 MST patients reported in the VISN Director’s response 

letter) with at least one bill generated by the IB for copayment or for third party 

reimbursement. For these 97 patients, the total number of generated claims was 2,132. 

The number of claims among individuals varied from 1 to 161. 

After receiving the OIG’s referral letter, VISN staff generated the data file and reviewed 

the claims in an attempt to determine whether patients were billed inappropriately for 

MST-related care. According to their review, claims for care provided to 17 patients 

were considered MST related. According to the Director’s response letter (Appendix B), 

the claims billed included 91 prescriptions and six visits. To ensure no inappropriate 

billings, these charges were cancelled and any payments received were refunded to the 

patients. 

The primary goal of our pilot evaluation concerned whether the IB trigger for suppressing 

copayment for MST-related services was set up appropriately. Thus, we asked VISN 

staff to further investigate the Austin claim bills. We focused on reviewing each 

copayment billed for MST designated treatment as MST patients might have received 

care for their non-SC conditions that were unrelated to MST. 

Based on further investigation, it was determined that all copayment charges for 16 out of 

the 17 patients were in fact billed correctly for non-MST designated services. One 

copayment charge for one MST-related visit was billed in error. In this case, the clinic 

appointment was checked out with an unsigned provider note, which resulted in the visit 

not being designated as related to MST. Thus, the IB created the charge for the visit on 

the appointment date. When the provider signed the note 1 week later, the encounter was 

marked as related to MST; however, the patient had already been billed for the 

copayment. 

VA Office of Inspector General 11 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

Based on the pilot evaluation results, we abandoned the original plan of conducting a VA 

system-wide review and limited our review to CTVHCS instead. 

Issue 3: Copayment Billing for Military Sexual Trauma 

Designated Care at Central Texas Veterans Health Care 

System from October 1, 2006, to June 1, 2009 

CTVHCS data included all generated bills for outpatient encounter copayments for MST 

patients who met copayment requirements from October 1, 2006 to June 1, 2009. The 

data contained 158 charges from 62 MST patients (Figure 2). The number of encounters 

for each individual varied from 1 to 22. The majority (82 percent = 51/62) of the patients 

had none of their visits designated for MST-related conditions. 

Sixteen (10 percent) out of the 158 encounters from 11 patients were designated as 

related to MST conditions and had a charge generated by the IB for copayment. This 

included the patient who was erroneously billed for the MST-related encounter 

copayment in 2008 at the Austin OPC. 

Ten (62.5 percent) of the 16 billed MST-related encounters were automatically generated 

by the IB at the time the patients checked out—prior to providers signing their notes—so 

that the 10 encounters were not designated as MST related. Later on the same days, 

when five encounters were designated as MST related once providers signed their notes, 

the IB package (correctly) automatically cancelled these charges. The other five 

encounters (including the 2008 Austin OPC case) had the same situation as the Austin 

case—the providers’ notes were signed after the dates of the patients’ visits. 

The other six copayments were manually added as a result of an Income Verification 

Match review, which changed the patients’ status from “not required to make a 

copayment” to “copayment required.” These charges were added by staff without any 

review for an MST designation. All erroneous charges have been cancelled, and any 

payments received were refunded to the patients. Staff have been instructed to review for 

MST designation prior to adding charges. 

It appears that the IB would automatically cancel copayment bills generated when 

services not designated as MST related were changed to MST related later on the same 

day as the encounter. For example, if an encounter was checked out when the service 

was not designated as MST related but the service was re-designated as MST related later 

on that same date, the copayment bill would be automatically cancelled by the IB. 

However, if the designation was modified after the check out date, there were instances 

when the copayment was not automatically cancelled by the IB. This resulted in 

erroneous copayment bills for MST-related care. 

 

VA Office of Inspector General 12 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

VA Office of Inspector General 13 

Figure 2. Erroneous copayment billing for MST designated encounters: ALL MST patients treated 

at CTVHCS who met VA copayment requirement and were billed at least once from 

October 1, 2006 to June 1, 2009. 

158 Encounter Copayment Bills

62 Patients

∙ 39 Patients had 1 Encounter

∙ 15 Patients had 2‐4 Encounters

∙ 5 Patients had 5‐7 Encounters

∙ 3 Patients had 13 or More Encounters

26 Encounter Copayment Bills

11 MST Patients With at Least One Visit

Designated as MST

∙ 8 Patients had 1 Encounter

∙ 1 Patient had 2 Encounters

∙ 1 Patient had 3 Encounters

∙ 1 Patient had 13 Encounters

16 Encounters Designated as MST

11 Patients

∙ 9 Patients had 1 Encounter

∙ 1 Patient had 2 Encounters

∙ 1 Patient had 5 Encounters

5 Encounters

Cancelled on the Same Day

as the Patient's Encounter

5 Encounters

Health Care Provider's Note

was Signed After Patient's

Encounter Day

6 Encounters

Added by Staff Through

Income Verificiation Match
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

Conclusions 

1. The recommended use of the clinic stop code specifically designated for MST-related 

care by VHA Directive 2005-015, Military Sexual Trauma Counseling, March 25, 2005, 

and VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers 

and Clinics, September 11, 2008, is inconsistently implemented at VHA medical 

facilities. As a result, MST treatment data are not readily accessible across the VA 

system. 

2. It appears that suppressing the copayment trigger for MST-related service in the 

Integrated Billing Package works appropriately except possibly for instances of timing 

issues between appointment check out and change of “related to MST” designation. It 

seems that the billing system may not automatically cancel copayment charges if MST 

designation takes place after the encounter date. VHA must determine whether this 

condition which permits erroneous bills to be issued exists. 

CTVHCS has cancelled all erroneous charges and refunded any payments that were 

received to the patients. 

3. Erroneous copayments for MST-related care have resulted from staff changing 

patients’ copayment status from “not required to make a copayment” to “copayment 

required.” When manual edits are made to create a copayment bill, proper controls must 

be in place to ensure that the manual changes consider MST and any other conditions that 

entitle veterans to cost free care. 

CTVHCS has cancelled all erroneously added charges and refunded any payments 

received to the patients. It also has educated staff on the process for reviewing for MST 

status prior to adding charges. 

It is a concern that manually added copayment billing may exist at other VHA facilities 

and for other cost free care conditions mandated under special authority. 

VA Office of Inspector General 14 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

VA Office of Inspector General 15 

Recommendations

Recommendation 1: We recommended that the Acting Under Secretary for Health 

ensure the use and implementation of a method specifically designated to track 

MST-related care at all VHA medical facilities so that MST treatment data are readily 

accessible across the VA system. 

Recommendation 2: We recommended that the VISN 17 Director ensure that the 

Director for Central Texas Veterans Health Care System determine, by a review of source 

code for the Integrated Billing Package or other appropriate approach, whether a delay of 

more than 1 day between the dates of care and note signing creates an erroneous 

copayment bill and/or accounting for MST-related care. 

Recommendation 3: We recommended that the VISN 17 Director ensure that the 

Director for Central Texas Veterans Health Care System include in the facility’s standard 

operating procedure the requirement that business staff review for MST designation (or 

for any other conditions that entitle veterans to cost free care or medications) prior to 

adding copayment charges.
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

Appendix A 

OIG Referral Memorandum to Central Texas Veterans Health Care System 

Department of 

Veterans Affairs Memorandum

Date: February 3, 2009 

From: Congressional Relations Officer (50B) 

Subj: Hotline Case Number 2009-1110-CR-40 

To: Director, Central Texas VA Health Care System 

OFFICE OF INSPECTOR GENERAL REFERRAL 

1. Response Due Date: March 20, 2009 

2. The allegations described in the attachments were reported to the Office of 

Inspector General and are referred to your office for review in accordance with VA 

Directive 0701, dated March 5, 2003. 

3. Please determine the merit of each complaint or allegation. Your response 

should include the OIG control number above and describe how the allegations were 

reviewed, whether they were substantiated, what corrective action you have taken to 

address any substantiated allegation(s), and when you initiated or completed that 

action. Please provide the documentation that supports your finding on each 

allegation. You should also include a point of contact and a telephone number or 

e-mail address in case we have follow-up questions. You should make every effort 

to protect the identity of the complainant during your review. 

4. When the review is complete, you may send your response by mail [VA OIG 

50B/CG), P.O. Box 50410, Washington, DC 20091–0410] or by fax [202–565–8667]. If 

you send the response by fax, you do not need to mail the original. TO MAINTAIN 

SECURITY, DO NOT USE E-MAIL TO SEND US YOUR RESPONSE.

5. For your information, all or part of your report to the Inspector General may be 

available to the complainant under the Freedom of Information Act. 

6. If you have any questions, please call me (202-461-4527) or Ms. Joanne Moffett 

(202-461-4720). 

 (original signed by:) 

CATHERINE A. GROMEK 

Attachment 

cc: 10B5, VISN 17 

VA Office of Inspector General 16 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

FOR OFFICIAL USE ONLY 

THIS REPORT OF CONTACT IS THE PROPERTY OF THE OFFICE OF INSPECTOR GENERAL 

AND IS FOR OFFICIAL USE ONLY. DISCLOSURE TO UNAUTHORIZED PERSONS IS PROHIBITED.

VA Office of Inspector General 17 

REPORT OF CONTACT 

Date: February 3, 2009 HOTLINE CASE NO.: 2009-1110-CR-40 

ISSUES OR ALLEGATIONS TO BE ADDRESSED: Central Texas Veterans Health 

Care System - Austin Outpatient Clinic 

DETAILS OF ALLEGATIONS OR COMPLAINT: 

The Office of Inspector General received allegations from the Chairman, Senate 

Veterans’ Affairs Committee, that the Austin Outpatient Clinic may be charging 

veterans, specifically, women veterans, for treatment as a result of military sexual 

trauma (MST). As you know, VHA Directive 2005-015 (March 25, 2005) sets out the 

policy that veterans receiving MST-related counseling and treatment are not to be billed 

for inpatient, outpatient, or pharmaceutical copayments. 

Please provide the number of veterans treated for MST during calendar year 2008. 

Please review each veteran’s record to determine whether the veteran was charged for 

treatment or pharmaceuticals related to MST, and whether VA has received any 

payments for such treatment or pharmaceuticals. If a veteran was charged for care 

related to the MST, provide the justification. If the charges were in error, provide the 

OIG with a corrective action plan for these veterans. Also, provide information on what 

you will do to ensure that other community outpatient clinics (CBOCs) attached to the 

Central Texas Veterans Health Care System follow the VHA Directive with regards to 

MST as well as any actions planned to review the records of veterans that sought MST 

care at those CBOCs. 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

Appendix B 

Director, Central Texas Veterans Health Care System, Response to 

OIG Referral Memorandum

VA Office of Inspector General 18 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

Appendix C 

Acting Under Secretary for Health Comments 

VA Office of Inspector General 19 

Department of 

Veterans Affairs Memorandum

Date: December 30, 2009 

From: Acting Under Secretary for Health (10) 

Subject: OIG Draft Report, Healthcare Inspection, Review of 

Inappropriate Copayment Billing for Treatment Related to 

Military Sexual Trauma, Central Texas Veterans Health Care 

System, Temple, Texas

To: Assistant Inspector General for Healthcare Inspections (54) 

1. I have reviewed the draft report and I concur with the recommendations. 

As an organization, VHA strives to ensure that Veterans receive the health 

care that they are entitled to and are not erroneously billed for services. 

Your report suggests that there may be limited situations in which the 

opportunity for inappropriately billing Veterans for treatment related to 

Military Sexual Trauma (MST) exists. I will ensure that VHA conducts a 

review of the circumstances that may lead to inappropriate copayment 

billing for MST-related treatments and make the changes necessary to 

prevent such errors in the future. 

2. Your report also states that VHA is inconsistent in tracking MST-related 

care at medical facilities, and as a result, MST treatment data is not readily 

accessible across the VA system. I agree that we need to improve our 

process for tracking this information consistently throughout the system. 

VHA staff has already recognized that the current policy, which 

recommends the use of a stop code specifically designated for MST-related 

care to track MST treatment data, is not optimal. We are currently in the 

process of revising this policy to recommend use of the encounter-level 

identifier available in the Medical SAS Data sets (the MST check box) to 

track MST-related outpatient care. I believe that the encounter level 

identifier is the most effective means for tracking care because, unlike 

clinic stop codes, this identifier is linked to the Integrated Billing package. 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

The designation of MST-related care in this manner is the best way for 

providers to ensure that patients are not billed for MST-related services. 

By using the encounter-level identifier, information on MST-related 

treatment will be readily accessible across the VA system. 

3. As for the availability of MST treatment data across the VA system, I 

must point out that by using the encounter-level identifier as described 

earlier, the VHA Office of Mental Health Services MST Support Team has 

been effective in making this information readily available. The MST 

Support Team compiles and distributes reports on MST-related care 

throughout VHA annually. 

For example, in FY 2008, the MST Support Team produced the following 

reports: MST Screening; MST-Related Outpatient Care; MST Screening 

and Outpatient Care among Operation Enduring Freedom/Operation Iraqi 

Freedom Veterans; MST-related Screening at VHA Community Based 

Outpatient Clinics (CBOCs); and MST-related Outpatient Care at VHA 

CBOCs. Furthermore, the MST Support Team conducts system-wide 

education on these issues and provides technical support regarding 

MST-related screening and treatment. 

4. Thank you for the opportunity to review the report. Attached is VHA’s 

plan of corrective action for the one recommendation in the report that is 

directed to me for a response. The Director of the Central Texas Veterans 

Health Care System has directly responded to the other two 

recommendations in the report that are specifically provided to him. If you 

have any questions, please contact Margaret Seleski, Director, Management 

Review Service (10B5) at (202) 461-7245. 

 (original signed by:) 

Gerald M. Cross, MD, FAAFP 

Attachment 

VA Office of Inspector General 20 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

VETERANS HEALTH ADMINISTRATION 

Action Plan 

OIG Draft Report, Healthcare Inspection, Review of Inappropriate 

Copayment Billing for Treatment Related to Military Sexual Trauma 

Central Texas Veterans Health Care System, Temple, Texas 

Recommendations/ Status Completion 

Actions Date 

Recommendation 1: We recommended that the Acting Under Secretary 

for Health ensure the use and implementation of a method specifically 

designated to track MST-related care at all VHA medical facilities so that 

MST treatment data are readily accessible across the VA system. 

Concur 

VHA’s Office of Patient Care Services, Office of Mental Health will revise 

VHA Directive 2005-015, Military Sexual Trauma Counseling (issued 

March 25, 2005) and VHA Handbook 1160.01, Uniform Mental Health 

Services in VA Medical Centers and Clinics, (issued September 11, 2008) 

to recommend use of the encounter-level identifier available in the Medical 

SAS Data sets (the MST check box) to track MST-related outpatient care. 

Subsequently, VHA’s Office of the Deputy Under Secretary for Health for 

Operations and Management, in conjunction with VHA’s Office of Patient 

Care Services, will disseminate and ensure implementation of the revised 

policy. VHA’s Office of Mental Health MST Support Team will conduct 

system-wide education to support effective implementation of the revised 

policy. 

In Process 03/31/10 

VA Office of Inspector General 21 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

Appendix D 

VISN Director Comments 

VA Office of Inspector General 22 

Department of 

Veterans Affairs Memorandum

Date: December 17, 2009 

From: Network Director, VA Heart of Texas Health Care Network, 

Arlington, TX (10N17) 

Subject: Review of Inappropriate Copayment Billing for Treatment 

Related to Military Sexual Trauma

To: Acting Under Secretary for Health (10N) 

I have reviewed and concur with the attached response from the Central 

Texas Veterans Health Care System regarding the above referenced health 

care inspection. Thank you. 

 (original signed by:) 

Timothy P. Shea, FACHE 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

Appendix E 

Central Texas Veterans Health Care System Director 

Comments 

VA Office of Inspector General 23 

Department of 

Veterans Affairs Memorandum

Date: December 17, 2009 

From: Director, Central Texas Veterans Health Care System 

Subject: Review of Inappropriate Copayment Billing for Treatment 

Related to Military Sexual Trauma

To: Director, VA Heart of Texas Health Care Network (10N17) 

I concur with the findings and recommendations in the draft report. The 

following corrective actions will be taken in response to the 

recommendations. 

 (original signed by:) 

Thomas C. Smith, III, FACHE 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

Central Texas Veterans Health Care System Director’s Comments 

to Office of Inspector General’s Report 

The following Director’s comments are submitted in response to the 

recommendations in the Office of Inspector General’s report: 

OIG Recommendations

Recommendation 2: We recommended that the VISN 17 Director ensure 

that the Director for Central Texas Veterans Health Care System determine, 

by a review of source code for the Integrated Billing Package or other 

appropriate approach, whether a delay of more than 1 day between the dates 

of care and note signing creates an erroneous copayment bill and/or 

accounting for MST-related care. 

Concur Target Completion Date: Ongoing

During the reviews, instances were identified when copayment charges 

were initially created for a bill that was not annotated as related to MST. 

At a later time, the appointment status was changed to be related to MST. 

In some cases, the Integrated Billing (IB) Package appropriately cancelled 

the copayment charges. In a few, the charges were not automatically 

cancelled as expected. A Remedy Ticket was filed, November 25, 2009, 

with CO IT Ticket # 0000000365558 along with a request that these 

specific copayment charges are reviewed to determine if the appointment 

that appears to be linked to the copayment charges is the correct 

appointment, and if so why the IB package did not automatically cancel 

these charges, when the appointment status was changed. Until the 

Remedy Ticket is processed and closed we are unable to determine and 

correct circumstances surrounding the above recommendations. 

Recommendation 3: We recommended that the VISN 17 Director ensure 

that the Director for Central Texas Veterans Health Care System include in 

the facility’s standard operating procedure the requirement that business 

staff review for MST designation (or for any other conditions that entitle 

veterans to cost free care or medications) prior to adding copayment 

charges. 

Concur Target Completion Date: August 25, 2009 

When the process for manually adding copayment charges was reviewed, it 

was determined that staff were not reviewing the medical documentation to 

VA Office of Inspector General 24 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

VA Office of Inspector General 25 

determine if the visit status was related to MST. All Central Texas 

Veterans Health Care System staff, with access to add copayment charges, 

have been instructed to review the appropriate documentation to identify 

those encounters for MST related care, and exempt from copayments, prior 

to charge creation. The MCCF Coordinator will conduct quarterly 

documentation reviews to determine compliance with revised billing 

guidelines. 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

Appendix F 

OIG Contact and Staff Acknowledgments 

OIG Contact Limin X. Clegg, Ph.D., Director 

Biostatistics, Program Evaluation and Consultation 

202-461-4664 

Acknowledgments Elizabeth A. Bullock 

Patricia Christ 

Nathan McClafferty 

Patrick Smith 

VA Office of Inspector General 26 
Review of Inappropriate Copayment Billing for Treatment Related to Military Sexual Trauma 

Appendix G 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans Integrated Service Network 17 (10N17) 

Director, Central Texas Veterans Health Care System (674/00) 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate: Daniel K. Akaka 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 27