VA Health Care: Additional Steps Needed to Strengthen Beneficiary Travel Program Management and Oversight
Published: 2013-07-15T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: VHA's Beneficiary Travel Program is designed to encourage eligible veterans to seek medical care by reducing travel costs to medical appointments. Veterans are eligible to receive reimbursement for some travel expenses, such as mileage, through the program that is administered by VA medical centers. In February 2013, the VA Office of Inspector General identified issues with inadequate management and oversight. VHA has identified the program as susceptible to significant improper payments and has estimated $71 million in improper payments for fiscal year 2012.
GAO was asked to examine VHA's Beneficiary Travel Program. In this report, GAO examined recent efforts VHA has developed or implemented to improve the program. GAO reviewed documents and interviewed VHA officials about these efforts; and determined whether VHA applied the appropriate internal controls. GAO also reviewed documents and interviewed officials from six VA medical centers, which vary on the basis of fiscal year 2012 mileage reimbursement spending, geographic location, and other factors.
section_title: What GAO Found
paragraphs: The Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) has developed efforts to improve the Beneficiary Travel Program, but lack of internal controls may impede their effectiveness. Specifically, VHA has developed multiple efforts to improve the management and oversight of its process for reimbursing veterans' travel expenses for medical appointments, as well as the timeliness and accuracy of payments, including the following:
Dashboard . Web-based software that determines a veteran's eligibility for travel reimbursement, the amount of any deductibles, and the number of miles from the veteran's residence to the closest VA medical facility. The software is designed to enable VA medical center staff to quickly and consistently calculate veterans' mileage reimbursement.
Beneficiary Travel Analytics Tool . Tool that provides each medical center with reports identifying questionable veteran reimbursement patterns, such as frequently changing addresses on reimbursement claims, which may be done to inappropriately increase travel reimbursement amounts. The reports are intended to help medical centers define and implement facility-level internal controls to reduce improper payments.
Electronic Funds Transfer (EFT) . Process to transfer travel reimbursement funds electronically into veterans' bank accounts. This effort implements a Department of the Treasury requirement for federal agencies to convert cash payments to electronic funds payments, and aims to improve efficiency, increase oversight, and reduce the amount of cash on hand.
These efforts are expected to increase the consistency of how the program is administered by medical centers. However, GAO found that internal controls were lacking for some of the efforts, including the following:
Monitoring Compliance . VHA has not developed a plan to ensure medical centers' compliance with the efforts or existing policies. For example, although medical centers are required to use the Dashboard, VHA officials told us they do not have a plan in place to ensure that each medical center is using this new software.
Evaluating Performance Indicators . VHA has not developed a plan for evaluating VHA-wide performance indicators for at least one of its efforts, the Beneficiary Travel Analytics Tool.
Providing Effective Communication . VHA did not provide a communication plan for sharing information on EFT with medical centers and veterans in a timely manner.
Without necessary internal controls in place, VHA cannot ensure that its new efforts will meet its goals, such as improved management and oversight, or that the Beneficiary Travel Program, which has seen spending more than double in the past 5 years--approaching $1 billion annually--is operating effectively.
section_title: What GAO Recommends
paragraphs: GAO recommends that VA identify and apply internal controls in its efforts to improve management and oversight of the Beneficiary Travel Program, including ensuring compliance with the Dashboard, evaluating performance indicators for the Beneficiary Travel Analytics Tool, and providing effective communication tools to medical centers for EFT. VA generally agreed with GAO's conclusions and concurred with the recommendation.

section_title: Letter
paragraphs: The Department of Veterans Affairs’ (VA) Veterans Health Administration  (VHA) Beneficiary Travel Program is designed to encourage eligible  veterans to seek needed medical care by reducing travel costs to medical  appointments. Veterans are eligible to receive reimbursement for some  travel expenses associated with medical appointments, such as mileage,  if they meet certain criteria, generally related to whether they have a  service-connected disability or low income level.
Concerns have been raised about the program’s efficacy and  management, including VHA’s oversight of VA medical centers that are  responsible for implementing the program at the local level. Specifically,  findings from a recent audit conducted by the VA Office of Inspector  General (OIG) identified problems with the Beneficiary Travel Program,  including inadequate management and oversight, and inaccurate  payments to veterans. Members of Congress also have raised concerns  about the program, particularly regarding veterans’ difficulties receiving  travel reimbursement, including reports of veterans waiting in long lines to  receive cash reimbursement for travel expenses, or facing delays  receiving reimbursement checks by mail. Furthermore, VHA has identified  the Beneficiary Travel Program as a program that is susceptible to  significant improper payments, and has estimated $71 million in improper  payments for fiscal year 2012. Spending for the Beneficiary Travel  Program comes out of individual medical center medical care funds—the  same funds that are used for patient care—and has increased from about  $370 million in fiscal year 2008 to about $860 million in fiscal year 2012.
Congressional requesters expressed interest in obtaining information on  VHA’s Beneficiary Travel Program. In this report, we examine the efforts,  if any, VHA has identified to improve the process for reimbursement of  veterans’ travel expenses to medical appointments within the Beneficiary  Travel Program.
To determine whether VHA has developed efforts to improve the  Beneficiary Travel Program, we asked officials from VHA’s Chief  Business Office and Office of Finance—the offices that have  responsibility for setting policies and procedures related to the Beneficiary  Travel Program—to identify national efforts to improve the program. We  focused on efforts, including policies, processes, and initiatives, that were  developed or implemented from October 2011 to May 2013. For each  effort VHA identified, we reviewed VHA documentation describing its  purpose, development or implementation status, and any issues  encountered in the development and implementation of the effort. We  also collected documentation and interviewed officials from VHA about  any communication VHA provided for veterans about the effort. To  identify local perspectives on any efforts VHA is deploying nationally and  local officials’ experiences with the program generally, we reviewed  documents and interviewed officials from six VA medical centers:   (1) Kansas City VA Medical Center (Mo.); (2) Malcolm Randall VA  Medical Center (Gainesville, Fla.); (3) Minneapolis VA Health Care  System (Minn.); (4) Maine VA Medical Center (Augusta, Maine);   (5) Veterans Health Care System of the Ozarks (Fayetteville, Ark.); and  (6) West Los Angeles VA Medical Center (Calif.). These medical centers  vary in terms of fiscal year 2012 total mileage reimbursement spending;  participation as a pilot or early implementation site for any of VHA’s  efforts to improve its travel reimbursement program; VA region;  rural/urban location; and VA-assigned facility complexity level. We also  interviewed officials from selected veteran service organizations—Blinded  Veterans Association, Disabled American Veterans, and Paralyzed  Veterans of America—to get their perspectives on VHA’s Beneficiary  Travel Program, including challenges veterans may face in seeking  reimbursement, and VHA’s efforts to improve the program. Using  strategic planning and performance measures consistent with the  Government Performance and Results Act and GAO’s related internal  control standards, we determined whether VHA applied appropriate  internal controls in the development and implementation of the efforts.
We conducted this performance audit from December 2012 to July 2013  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: Under authority first provided by Congress in 1940, VA reimburses  eligible veterans for travel expenses associated with medical  appointments through VHA’s Beneficiary Travel Program.travel expenses eligible for reimbursement include mileage, tolls, meals,  and lodging. Through the program, VA may also pay for special mode  transportation—such as ambulances and wheelchair vans.
Veterans are eligible for travel reimbursement if they have 30 percent or  more service-connected disability ratings; are receiving care related to  their service-connected disability if their service-connected disability  rating is less than 30 percent; receive VA pension benefits; have an  annual income below a set annual rate; present clear evidence that they  are unable to defray the cost of travel; or are traveling for compensation  and pension exams. Certain caregivers also may be eligible for travel  reimbursement. Generally, eligible veterans are only reimbursed for  round-trip travel costs associated with scheduled appointments, except in  the case of emergency care.
Since the program’s inception, Congress has made several modifications,  including adjusting eligibility requirements, types of travel expenses  covered, deductible costs, and mileage reimbursement rates. For  example, in fiscal years 2008 and 2009, Congress directed VA to  increase its mileage reimbursement rate from 11 cents per mile to   28.5 cents per mile and then to 41.5 cents per mile. Committee reports  accompanying VA’s fiscal years 2008 and 2009 Medical Services  appropriations indicated that the committees identified specific amounts  to fund these rate increases.
subsections: section_title: Program Spending
paragraphs: Spending for the Beneficiary Travel Program increased from about   $370 million in fiscal year 2008 to about $860 million in fiscal year 2012,  with mileage reimbursement accounting for an increased proportion of the  spending in this same period. (See fig. 1.) According to VHA officials, the  increase in spending was primarily due to the increased number of  veterans claiming mileage reimbursement, a rise in the average number  of claims per veteran, and higher mileage reimbursement rates. For  example, according to VHA, the number of veterans claiming mileage  reimbursement increased from about 450,000 in fiscal year 2008 to about  1,450,000 in fiscal year 2012.
VHA’s Chief Business Office is responsible for establishing policies and  providing guidance to medical centers for the Beneficiary Travel Program.  These policies describe, for example, the eligibility requirements and the  types of travel expenses that are reimbursable. VHA’s Office of Finance  is responsible for establishing national policies for the processing of  payments for reimbursement and financial quality assurance. Veterans  Integrated Service Networks (VISN) have no specific oversight  responsibilities for the Beneficiary Travel Program beyond the general  responsibility of ensuring compliance with VHA’s policies at the medical  centers within their region.handled at the local medical center level.
Administration of the program is largely  VHA’s policies outline requirements for the Beneficiary Travel Program’s  reimbursement process, and can be summarized into the following three  broad steps:
Veteran applies for travel reimbursement: VHA policies stipulate  that veterans must apply for reimbursement within 30 calendar days  of the travel. Veterans must provide information on the travel costs  incurred to the medical center responsible for the care.
Medical center reviews eligibility and determines reimbursement  amount: After the veteran applies for reimbursement, VHA requires  medical centers to assess the veteran’s eligibility for reimbursement,determine distance traveled, and apply appropriate deductibles. For  example, VHA policies stipulate that except under certain  circumstances, veterans are reimbursed for mileage between their  place of residence and the nearest VA facility where the care could be  provided.
Medical center reimburses veteran: After eligibility has been verified  and reimbursement amounts determined, medical centers reimburse  veterans those amounts.
Medical centers also have local procedures for managing the program.  (See app. I for examples of procedures used by some of the medical  centers included in our review.)
In February 2013, the VA OIG released a report summarizing findings  from its audit of VHA’s Beneficiary Travel Program. The audit revealed  problems such as inadequate management and oversight, and inaccurate  payment amounts. Specifically, the VA OIG reported that it did not have  reasonable assurance that Beneficiary Travel Program costs were  accurate or were being paid only to eligible veterans. The VA OIG report  found that from January 2010 through March 2011 VA paid $89 million  more in beneficiary travel reimbursements than facilities approved,  including $42.5 million in unexplained payments. On the basis of its  findings, the VA OIG recommended that VHA establish and implement  procedures to strengthen authorization, payment, and oversight controls  for the program. VHA concurred with the OIG’s findings and  recommendations and reported that it would, among other things, be  implementing several initiatives to address the findings.
Additionally, VHA has identified the Beneficiary Travel Program as being  susceptible to significant improper payments. The Improper Payments  Elimination and Recovery Act of 2010 (IPERA) requires agencies with  programs identified as being susceptible to significant improper payments  to estimate the annual amount of improper payments for each program  and publish these estimates and corresponding corrective actions in an  annual report; VA includes this information in its annual Performance  and Accountability Report. For VA’s 2012 Performance and Accountability  Report, VHA estimated that the Beneficiary Travel Program had   $71 million in improper payments. IPERA also requires federal  agencies’ inspectors general to annually determine whether their  respective agencies are in compliance with IPERA requirements and to  report on their determinations. In March 2013, the VA OIG reported  limitations in VHA’s methodology for estimating improper payments for  the Beneficiary Travel Program and other programs but noted that this  was not a matter of noncompliance with IPERA requirements.
section_title: VHA Has Developed Efforts to Improve the Beneficiary Travel Program, but Lack of Internal Controls May Impede Their Effectiveness
paragraphs: VHA has developed multiple efforts to improve the management and  oversight of its process for reimbursing veterans’ travel expenses for  medical appointments. However, lack of internal controls for some efforts  may hinder VHA’s ability to improve the process.
subsections: section_title: VHA Has Developed Efforts That Aim to Improve the Management and Oversight of the Beneficiary Travel Program
paragraphs: VHA has developed multiple efforts to improve the management and  oversight of the Beneficiary Travel Program, as well as the timeliness and  accuracy of payments. (See table 1.) These efforts—many of which  medical centers are or will be required to implement—are expected to  increase the consistency of how the program is administered. For  example, the Dashboard, a Web-based software, provides a standardized  process that medical centers are required to use to determine a veteran’s  eligibility for travel reimbursement, the amount of any deductibles, and the  number of miles from the veteran’s residence to the closest VA medical  facility where care could be provided.
The efforts are in various stages of development and implementation,  with some being fully implemented in all medical centers, while others are  in earlier stages. For some of the efforts, VHA has utilized a pilot process  in a small number of medical centers to help identify and resolve potential  problems before releasing the efforts VHA-wide to all medical centers.  For example, in the fall of 2012, VHA piloted the Electronic Funds  Transfer (EFT) effort—a process for transferring travel reimbursement  funds electronically into veterans’ bank accounts—in medical centers in 2  of the 21 VISNs. The EFT effort—along with VHA’s Debit Card effort, a  VHA-wide card that veterans can use to receive travel reimbursement  electronically—implements a Department of the Treasury requirement for  federal agencies to convert cash payments to electronic funds payments  by March 1, 2013. VHA has requested and received an extension from  the Department of the Treasury on the implementation of electronic funds  payments to allow VHA to simultaneously implement both the EFT and  Debit Card efforts. VHA anticipates VHA-wide implementation of both  efforts by December 31, 2013.
Some of VHA’s efforts to improve the Beneficiary Travel Program have  been developed in response to OIG and IPERA report findings as  corrective actions to improve monitoring and oversight of the program and  to decrease improper payments. One such effort is the Facility Audit  Tool—a tool used to audit facilities’ past travel reimbursement  transactions and operations through a more standardized process.  Currently this tool is being used by VHA’s Office of Finance to annually  audit programs identified as susceptible to improper payments under  IPERA. VHA officials told us that this tool may ultimately be used by  VISNs to audit their facilities’ past travel reimbursement transactions and  operations, but did not have a time frame for its VHA-wide  implementation.
Officials from the six medical centers we interviewed told us the new  efforts that have been implemented generally improved or would improve  some aspects of the Beneficiary Travel Program. For example, medical  center officials reported that the implementation of the Dashboard had  increased staff efficiency by decreasing the time needed to determine a  veteran’s eligibility, as well as increased the accuracy of payments, in line  with VHA’s goals for this program. In addition, officials said EFT would  help improve oversight over the payment process. Compared to the  process of paying veterans in cash, EFT provides an opportunity for the  medical center staff—in this case the fiscal office staff—to review and  audit travel payments before a reimbursement is issued to the veteran.  Officials said these reviews could help medical centers reduce improper  payments, and that EFT also improves security at medical centers  because less cash is on hand for reimbursements.
Although medical center officials provided positive feedback on some of  the efforts, they also identified implementation challenges. For example,  medical center officials reported difficulty tracking EFT reimbursements,  and that staff members had received many calls from veterans who were  confused by only limited information transmitted with the EFT direct  deposits. In addition, when veterans claimed reimbursements for multiple  appointments, they did not know which appointment was associated with  which electronic reimbursement payment, or which reimbursements were  still pending. According to medical center officials, investigating pending  reimbursements is time consuming and takes time away from staff  members’ reimbursement-processing responsibilities. Medical center  officials also said the lack of information transmitted with the payments  hinders acceptance of the EFT process in general, as veterans do not  have complete confidence that their reimbursements are timely and  accurate.
section_title: Lack of Internal Controls for Some Efforts May Hinder VHA’s Ability to Improve the Beneficiary Travel Program
paragraphs: In our review of VHA’s efforts to improve the Beneficiary Travel Program,  we found that internal controls were lacking for some of the efforts. The  implementation of internal controls is important for ensuring efforts  achieve intended outcomes and minimizing operational problems. Without  these internal controls in place, VHA cannot ensure that the efforts will  meet its goals, such as improved management and oversight.
Plan for Evaluating Performance Indicators. VHA has not developed a  plan for evaluating VHA-wide performance indicators for at least one of its  efforts, the Beneficiary Travel Analytics Tool (Data Mining Tool), as would  be consistent with internal control standards. According to established  internal control standards, efforts to improve performance and efficiency  should include the evaluation of appropriate performance indicators of the  effort to gauge progress and inform decision making in resolving any  problems. The Web-based Beneficiary Travel Analytics Tool,  implemented March 31, 2013, generates travel reimbursement pattern  reports—reports identifying questionable veteran reimbursement patterns  that may indicate improper payments, such as frequently changing  addresses on reimbursement claims, which may be done to  inappropriately increase travel reimbursement amounts. According to  VHA officials, medical centers are expected to use the reports generated  by the tool to diagnose any problems in their own travel reimbursement  processes and to implement appropriate corrective actions. VHA expects  medical centers to submit documentation to VHA’s Chief Business Office  on any resulting corrective actions they have taken. Officials told us that  they expect to review the corrective actions; however, as of May 14,  2013, they did not have a documented plan for evaluating travel  reimbursement pattern data collected for all medical centers on an  aggregated (VHA-wide) basis.
An appropriate evaluation plan consistent with internal controls would  include documentation of the frequency of performance indicator  evaluations, and an analysis plan for assessing either all, or a portion of,  the travel reimbursement pattern data. Officials acknowledged the need  to fully develop a plan to ensure that potential weaknesses are identified  so that needed program improvements may be made. A plan for  evaluating the data on a VHA-wide basis is necessary to ensure that the  power of the Beneficiary Travel Analytics Tool is more fully realized.
Timely Guidance. VHA has not provided timely guidance to medical  centers on its new EFT effort, as would be consistent with internal control  standards. According to these standards, reliable and timely program  information should be provided to management and others to ensure that  responsibilities are being carried out and VHA goals are being met.  Specifically, despite being aware of the March 1, 2013, Department of the  Treasury deadline for implementation of EFT in December 2010, VHA did  not provide guidance to medical centers on how to implement the effort  until February 22, 2013. Had the guidance been provided earlier, it would  have provided timely, key information to medical centers on the  implementation of EFT, including the process that medical centers should  be using to enroll veterans; the procedures for veterans to request a  waiver from an electronic payment when they have an immediate need  for a cash payment; and VHA’s contingency plan for the travel  reimbursement process due to its delay in providing policies for  implementing EFT VHA-wide. By delaying the issuance of the guidance,  VHA failed to ensure that all medical centers were provided with  consistent and timely guidance, which, according to medical center  officials we spoke with, led to frustration for medical centers, as well as  confusion for veterans. For example, most medical centers in our review  already had developed their own local procedures for enrolling veterans  into EFT and processing payments before VHA’s EFT pilot began;  officials from some of the medical centers in our review expressed  frustration that they would have to revise some of these processes when  the VHA-wide effort was eventually implemented.
Effective Communication. VHA also did not provide a communication  plan for sharing information on EFT with medical centers and veterans in  a timely manner, as would have been consistent with internal control  standards. Specifically, VHA did not share information on EFT with  medical centers to help them inform veterans of the coming changes until  February 22, 2013. VHA officials acknowledged they failed to develop a  communications plan in a timely manner, and agreed that this is  something they should have done to help ensure the success of the  conversion to EFT. By not communicating this information in a timely  manner, VHA did not ensure that medical centers had consistent and  accurate information for informing veterans of the change in payment  options, potentially affecting veterans’ enrollment in EFT and their  satisfaction with the new reimbursement process. Although officials from  some medical centers we spoke with said they have developed their own  materials for communicating with veterans about EFT, having  communication materials come from VHA headquarters would have  carried more weight with veterans and provided more consistency across  all medical centers for this VHA-wide effort.
Plan for Monitoring Compliance. VHA has not developed a plan to  ensure medical centers’ compliance with the efforts or its existing policies,  as would be consistent with internal control standards. For example,  medical centers are required to use the Dashboard, and VHA officials told  us that VHA-wide procedures for using the Dashboard will be included in  the program’s revised Standard Operating Procedures. However, VHA  officials told us they do not have a plan in place to ensure that each  medical center is using this new software. Without knowing whether all  medical centers are using this required software or using it consistently,  VHA cannot ensure that the Dashboard’s goals, including standardizing  the mileage calculations, will be realized.
Furthermore, because medical centers have the flexibility to develop local  procedures for administering the Beneficiary Travel Program, it is  important that VHA monitor local procedures to ensure they are  consistent with VHA policies. For example, one medical center in our  review automatically generates travel reimbursement payments to eligible  veterans after each completed appointment. Thus, instead of applying for  reimbursement after each medical center appointment, eligible veterans  who have a signature on record can simply leave the medical center after  their appointment and receive their reimbursement payment by mail or  direct deposit. Acknowledging that this automatic payment procedure is  different from other medical centers, medical center officials said it has  greatly increased the efficiency of their management of the Beneficiary  Travel Program and has received positive feedback from veterans and  staff. Monitoring compliance with program policies, especially due to  differences in local procedures, is an important internal control for  ensuring that program goals are being met.
Use Information to Improve Efficiency. VHA does not routinely collect  information on medical centers’ local procedures for administering the  Beneficiary Travel Program to identify and share best practices.  According to federal internal control standards, identifying and sharing  best practices is an essential part of ensuring an effective and efficient  use of resources. For example, officials at one of the medical centers we  interviewed said that installing drop boxes at multiple locations around  their facility was a simple and efficient way to make the process more  convenient for veterans, shorten lines at the Beneficiary Travel Office,  and improve staff productivity. Some medical center officials described  sharing best practices on an ad hoc basis with colleagues in other  medical centers, and said that learning from others’ experiences is  valuable to their administration of the Beneficiary Travel Program.  Although VHA officials described one instance of evaluating a software  program for national use that was developed and implemented at one  medical center, they have not regularly solicited information on best  practices; instead, they have relied on medical center and VISN officials  to identify and share information. A more systematic identification and  sharing of best practices would enhance medical centers’ access to the  same information in order to minimize problems and maximize  efficiencies within the Beneficiary Travel Program.
section_title: Conclusions
paragraphs: For more than 70 years, VHA’s Beneficiary Travel Program has  reimbursed eligible veterans for travel expenses associated with medical  appointments. In the past 5 years, spending under the program has more  than doubled, from about $370 million in fiscal year 2008 to about   $860 million in fiscal year 2012. This increase is of particular note, as  travel reimbursements come out of the same VA medical center funds  used for patient care. At the same time spending is increasing, concerns  have been raised about the accuracy of payments and VHA’s  management and oversight of the program.
In response to these concerns, VHA has taken steps to improve its  process for reimbursing veterans for travel expenses by developing  multiple efforts aimed at enhancing management and oversight of the  program. However, some of the efforts lack key internal controls that  would help VHA better manage and oversee its program. Specifically,  VHA has not developed a plan for evaluating VHA-wide performance  indicators for the Beneficiary Travel Analytics Tool; provided timely  guidance and effective communication tools to medical centers for EFT;  ensured compliance with Dashboard and other efforts; and routinely  collected information on medical centers’ local procedures to identify and  share best practices. Without appropriate management and oversight,  VHA is unable to ensure that its Beneficiary Travel Program—which is on  track to spend nearly $1 billion dollars annually in the next few years—is  operating effectively, including assurances that payments made through  the program are appropriate.
section_title: Recommendation for Executive Action
paragraphs: To improve the management and oversight of the Beneficiary Travel  Program, we recommend that the Secretary of Veterans Affairs direct the  Under Secretary for Health to ensure appropriate internal controls have  been identified and applied in the development and implementation of all  of VHA’s efforts aimed at improving the program, including developing and implementing a plan to evaluate performance  indicators for the Beneficiary Travel Analytics Tool, providing timely guidance and effective communication tools to  medical centers as VHA completes its implementation of EFT, ensuring medical centers’ compliance with Dashboard and other  routinely collecting information to identify and share best practices  across medical centers.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to VA for comment. VA generally  agreed with our conclusions and concurred with our recommendation. VA  identified the activities that VHA would undertake to ensure appropriate  internal controls have been identified and applied related to the four  specific efforts we noted: performance indicators for the Beneficiary  Travel Analytics Tool, guidance and communication to medical centers  regarding EFT, compliance with Dashboard and other improvement  efforts, and identification and sharing of best practices across medical  centers. VA did not directly address ensuring that appropriate internal  controls are identified and applied in the development and implementation  of all efforts aimed at improving the program. We continue to emphasize  the importance of internal controls to the success of VHA's efforts. VA’s  comments are reprinted in appendix II. VA also provided technical  comments, which we have incorporated as appropriate.
We are sending copies of this report to the Secretary of Veterans Affairs  and appropriate congressional committees. In addition, the report will be  available at no charge on the GAO website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or draperd@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff who made key contributions to this report  are listed in appendix III.
section_title: Appendix I: Examples of VA Medical Center Procedures for Administering the Beneficiary Travel Program
paragraphs: Example of medical center procedure  Veteran submits claim for reimbursement at  medical center travel office.
Medical center rationale   Allows medical center to provide same-day claim  review, and in some cases reimbursement.
Veteran puts claim for reimbursement in a  designated drop box.
Helps reduce the lines at the medical center’s  travel office, is more convenient for veterans, and  allows medical center staff more time to review  the claim.
Medical center staff check veteran’s name  against photo identification for each claim  submitted in person.
Helps improve accuracy and reduce improper  payments by ensuring the appropriate person is  reimbursed.
Medical center staff check veteran’s address  and name against information maintained in  VA’s data system for claims not submitted in  person, such as for a veteran using a drop box.
Helps improve accuracy and reduce improper  payments by ensuring correct addresses are  used, and VA has consistent information about  the veteran in its data system.
Reimbursement provided primarily through  cash.  Reimbursement provided primarily through a  check.
Allows for same-day reimbursement.
Limits cash payments, which may shorten  veterans’ time waiting at the medical center’s  travel office, and reduces security and other risks  associated with having large amounts of cash on- hand at medical centers. Also, helps ensure VHA  has valid addresses for veterans for calculating  travel reimbursements, because these addresses  are where the checks are mailed.
Reimbursement provided primarily through  direct deposit or a debit card.
Limits cash payments, which may shorten  veterans’ time waiting at the medical center’s  travel office, and reduces security and other risks  associated with having large amounts of cash on- hand at medical centers. Also, turn-around time  for veterans’ receipt of direct deposit or debit  card reimbursements is generally shorter than for  check reimbursements.
This procedure will change with full implementation of the Electronic Funds Transfer and Debit Card  efforts.
section_title: Appendix II: Comments from the Department of Veterans Affairs
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Janina Austin, Assistant Director;  Jennie Apter; Robin Burke; Kelli Jones; Lisa Motley; and Karin Wallestad  made key contributions to this report.