VA Health Care: Opportunities Exist for Improving Implementation and Oversight of Enrollment Processes for Veterans
Released: 2017-09-05T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: Enrollment is generally the first step veterans take to access VA health care, thus timely and accurate processing of enrollment applications is critical to help ensure eligible veterans obtain needed care.

The Explanatory Statement accompanying the Consolidated Appropriations Act, 2016 included a provision for GAO to examine VA's oversight of patient access to care. This report examines (1) VHA's processes for enrolling veterans for health care benefits and (2) its related oversight. GAO reviewed federal laws, regulations, and VHA policies and procedures. GAO also interviewed officials from HEC and 6 of VHA's 170 VAMCs selected to provide variation in factors such as number of enrollment applications processed and geographic location; reviewed actions to resolve a randomly selected, nongeneralizable sample of pending enrollment applications from these 6 VAMCs; and interviewed HEC and VAMC officials on oversight of enrollment processes.

section_title: What GAO Found
paragraphs: The Department of Veterans Affairs' (VA) Veterans Health Administration's (VHA) implementation and oversight of enrollment processes need improvement to help ensure the timely enrollment of veterans for health care benefits.

VHA frequently did not meet timeliness standards: VHA studies conducted in 2016 revealed that enrollment staff frequently did not process veterans' enrollment applications within the timeliness standard of 5 business days. These issues were found both at VHA's Health Eligibility Center (HEC)—the central enrollment processing center—and at local VA medical centers (VAMC) that also process enrollment applications. In response to an audit recommendation, HEC officials said they have begun prioritizing workload to help meet the timeliness standard. Additionally, the overall time needed to process enrollment applications may increase when staff need to place applications in a pending status, as pending applications require additional information, such as military service information, for staff to make enrollment determinations. However, none of the six VAMCs GAO reviewed had a specific policy for how to resolve pending applications. GAO found that VAMC enrollment staff had not resolved more than half of the pending applications GAO reviewed at these six VAMCs, some of which had been pending for more than 3 months at the time of the review. Although HEC developed new procedures for its enrollment staff to use when resolving pending applications, these procedures were not communicated to VAMCs. Officials from the VAMCs GAO reviewed said that they had not received guidance on these procedures and were confused about whether they would continue to have a role in this process. In the absence of HEC communication with VAMCs, there may be inefficiencies in resolving pending applications. VHA, through HEC, is assessing efforts to improve the timeliness of enrollment application processing and the accuracy of enrollment determinations.

VHA lacks a standardized oversight process and reliable data to monitor enrollment processes system-wide: Although HEC officials said they are responsible for oversight of enrollment processes system-wide, VHA has neither sufficient policies that delineate this role nor procedures that document key oversight activities that should be conducted. For example, policies do not describe the oversight activities HEC should conduct to help ensure the accuracy of enrollment determinations system-wide. Further, VHA does not have reliable data for overseeing the timeliness of processing enrollment applications at VAMCs, which process 90 percent of the applications system-wide. Officials from the six VAMCs in GAO's review and HEC also had varying interpretations of how to measure the timeliness standard. For example, officials from four of the six VAMCs said the standard was met when enrollment staff entered an application into their local system, irrespective of whether an enrollment determination was made. In contrast, HEC officials said the measurement encompasses the time needed to make an enrollment determination, including any time the application was pending. Without reliable data that are consistently measured, VHA cannot accurately oversee the timeliness of application processing system-wide, or assess the extent to which VAMCs face challenges in implementing enrollment processes. To improve oversight, VHA, through HEC, recently implemented an effort to review the accuracy of some enrollment determinations.

section_title: What GAO Recommends
paragraphs: GAO recommends that VHA (1) define the responsibilities of VAMCs in resolving pending enrollment applications; (2) define oversight responsibilities to help ensure timely application processing and accurate enrollment determinations; (3) develop procedures for collecting reliable data system-wide to evaluate the timeliness of application processing; and (4) clarify its 5-day timeliness standard. VA concurred with all of GAO's recommendations and identified actions it is taking to implement them.

section_title: Letter
paragraphs: The Veterans Health Administration (VHA), within the Department of  Veterans Affairs (VA), operates one of the largest health care delivery  systems in the nation. It provides health care to veterans through 170  medical centers and more than 1,000 outpatient facilities. To receive  care, most veterans must be deemed eligible by VHA through an  assessment of military service and financial need, and enrolled in the  VHA health care system. Enrollment is generally the first step veterans  take when accessing VHA care, thus timely and accurate processing of  veterans’ enrollment applications is critical to helping ensure that eligible  veterans obtain needed health care.

Over the past decade, VHA has faced growing demand by veterans for its  health care services—due, in part, to veterans returning from military  operations in Afghanistan and Iraq and the needs of an aging veteran  population—and that trend is expected to continue. The total number of  veterans enrolled in VHA’s health care system rose from 7.9 million in  fiscal year 2006 to almost 9 million in fiscal year 2016.

We and others have expressed concerns about VA’s inability to  effectively provide and oversee timely access to health care, which, in  some cases, reportedly has resulted in harm to veterans. For example,  in 2016, we reported that not all newly enrolled veterans received timely  medical appointments. In 2015, VA’s Office of Inspector General  reported that VHA had mismanaged aspects of its enrollment processes,  and that, as of September 30, 2014, nearly 870,000 veterans’  applications for enrollment were “pending;” that is, no enrollment  determination had been reached for them. Based on serious concerns  about VA’s management and oversight of its health care system, we  concluded that VA health care was a high-risk area and, in 2015, added it  to GAO’s High-Risk List. We expressed continued concerns about VA  health care in our 2017 high-risk update.

The Explanatory Statement accompanying the Consolidated  Appropriations Act, 2016 included a provision for us to examine VA’s  oversight of patient access to care. This report examines the extent to  which VHA  1.  has implemented processes for enrolling veterans for health care  2.  oversees processes for enrolling veterans for health care benefits.

To examine the extent to which VHA has implemented processes for  enrolling veterans for health care benefits, we reviewed relevant federal  laws and regulations, and VHA policies and procedures. We interviewed  officials from VHA’s Member Services, including those from its Health  Eligibility Center (HEC), about how they process veterans’ enrollment  applications, including determining eligibility, and from its Compliance and  Internal Control Program Office. Additionally, we reviewed local policies  and procedures for processing enrollment applications, and interviewed  officials responsible for processing enrollment applications at 6 of the 170  local VA medical centers (VAMC) across the United States. These  VAMCs were (1) New Mexico VA Health Care System (Albuquerque,  New Mexico); (2) Charles George VAMC (Asheville, North Carolina); (3)  Battle Creek VAMC (Battle Creek, Michigan); (4) North Florida/South  Georgia Veterans Health System (Gainesville and Lake City, Florida); (5)  Providence VAMC (Providence, Rhode Island); and (6) San Francisco VA  Health Care System (San Francisco, California). We selected the 6  VAMCs for variation in factors such as the number of enrollment  applications processed in fiscal year 2015, number of enrollment  applications in a pending status, facility complexity, geographic location,  and involvement in VHA enrollment pilots.

Although in 2015 VA’s Office of Inspector General identified limitations in  using HEC data for assessing performance of enrollment processing,  based on our discussions with HEC officials, we determined that HEC  data on the number of enrollment applications processed and pending  were sufficiently reliable for our use in selecting individual VAMCs for  review to address our reporting objectives. We also interviewed officials  from 3 additional VAMCs participating in one of VHA’s enrollment pilots to  discuss any lessons learned or enhancements they identified based on  their participation in the pilots. These VAMCs were (1) VA North Texas  Health Care System (Dallas, Texas); (2) Captain James A. Lovell Federal  Health Care Center (North Chicago, Illinois); and (3) South Texas  Veterans Health Care System (San Antonio, Texas).

Further, for each of the six VAMCs included in our overall review of  enrollment processing, we requested a list of veterans whose enrollment  applications were placed in a pending status between October 1, 2016,  and January 6, 2017, and remained pending as of January 6, 2017.  From these lists we selected 60 veterans—a random, nongeneralizable  sample of 10 veterans from each of the six VAMCs. For each of the 60  applications, we sent VAMC officials a questionnaire to obtain information  on any actions taken to resolve the pending status. Based on the  officials’ responses to our questionnaires, and follow-up interviews in  March and April 2017, we determined for each of the applications whether  an enrollment determination was reached, and if so, the amount of time it  took to resolve the pending status. We also identified reasons why any  applications remained in a pending status.

To examine the extent to which VHA oversees enrollment processes, we  reviewed relevant documents, including national VHA and available local  VAMC enrollment policies and procedures from the VAMCs in our review.  We also reviewed previously issued external and internal audits of  enrollment processes conducted by VA’s Office of Inspector General and internal VHA auditors. Additionally, we interviewed officials from HEC, the  six VAMCs in our review, and the six Veterans Integrated Service  Networks (VISN) responsible for overseeing these VAMCs about their  oversight efforts. We identified and examined the key mechanisms,  including reports and data, officials told us they use to monitor the status  of enrollment applications, and whether applications are processed in  accordance with VHA timeliness standards. We also asked officials  whether, based on their oversight, they had identified deficiencies or  made any changes to their enrollment processes.

We evaluated VHA’s implementation of its enrollment processes, and its  key mechanisms for overseeing its enrollment processes against federal  internal control standards related to control activities, control environment,  and information and communication.

We conducted this performance audit from August 2016 through  September 2017 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: The Veterans’ Health Care Eligibility Reform Act of 1996 required that VA  establish an enrollment system to help manage its health care delivery  system. VHA’s HEC is the business owner of the Enrollment System— the official system of record for verifying veterans’ eligibility for health care  benefits and maintaining enrollment information.

To enroll for health care benefits, veterans submit an application to either  HEC or a VAMC. Application information includes demographic, military  service, financial, and insurance information. A veteran may apply  online, by mail, by fax, by phone, or in person. Once a veteran submits an  application, there are three key steps for processing the application:  intake of application, verification of eligibility, and enrollment  determination. There may be an additional processing step—resolving a  pending application—if enrollment staff need additional information to  determine eligibility. According to VHA policy, staff are required to  process applications within 5 business days of receipt. Figure 1  provides an overview of the enrollment process, as of June 2017.

Intake of application. If a veteran applies in person, or faxes or mails an  application to a VAMC, local enrollment staff enter the application  information into the VAMC’s Veterans Health Information Systems and  Technology Architecture (VistA) system. If a veteran applies in person,  by phone, or faxes or mails an application to HEC, HEC enrollment staff  enter application information into the Enrollment System. A veteran may  also apply online, and the application information is directly transmitted  into the Enrollment System. Historically, VAMCs have received more  than 90 percent of enrollment applications for processing.

Verification of eligibility. After the intake of an application, VAMC and  HEC staff attempt to verify whether veterans meet eligibility requirements  based on their military service and, if applicable, financial information.  VAMC staff attempt to verify military service by reviewing supporting  documentation provided by veterans (e.g., military discharge or  separation papers). If veterans do not provide any documentation of  military service, staff will try to verify this information through military  service databases. For application information that HEC staff have  entered into the Enrollment System or for those applications that have  been submitted online with information transmitted directly to the  Enrollment System, the system assesses eligibility based on the  information entered. Both VistA and the Enrollment System automatically  assess whether a veteran’s self-reported income meets VHA income  thresholds for eligibility, as applicable. VAMC staff are required to  ensure that application information is accurately entered into VistA.  Application information that is entered into local VistA systems is  transmitted nightly into the Enrollment System.

Enrollment determination. The Enrollment System makes all enrollment  determinations, including those for applications processed at VAMCs.  Specifically, the Enrollment System determines whether veterans are  enrolled, rejected, or ineligible for health care benefits. Veterans who  are enrolled or rejected are placed in a category based on type of  eligibility—called a priority group—established to manage the provision of  care. For example, priority group 1 consists of veterans who are rated  50 percent or greater based on service-connected disabilities. Priority  group 5 consists of veterans who are eligible because their incomes are  at or below VHA’s eligibility thresholds; and priority group 8g consists of  non-service connected veterans whose incomes are above the  thresholds, and thus are rejected for health care benefits. HEC sends a  letter and a personalized handbook to each veteran once it has made an  enrollment determination with the decision and a description of benefits, if  applicable.

Resolving pending applications. If VAMC or HEC enrollment staff  cannot verify veterans’ eligibility for making an enrollment determination,  the application is categorized as pending. To resolve a pending  application, VAMC or HEC staff are to contact the veteran to obtain the missing information (e.g., military service or financial information). VAMC  and HEC staff share responsibility for resolving pending applications. For  instance, HEC staff may send a pending application for VAMC staff to  help process. VAMC staff may also contact HEC staff for assistance in  collecting missing information because, for example, according to  officials, HEC has greater access to military service databases.

section_title: VHA’s Implementation of Enrollment Processes Has Hindered the Timely and Accurate Enrollment of Veterans, and VHA Is Assessing Efforts to Improve These Processes
paragraphs: VHA enrollment staff, both from HEC and VAMCs, frequently did not  process enrollment applications in accordance with VHA’s timeliness  standards and made incorrect enrollment determinations. VHA, through  HEC, is assessing efforts to improve its enrollment processes.
subsections: section_title: VHA Frequently Did Not Meet Timeliness Standards for Processing Enrollment Applications
paragraphs: Prior studies show that VHA enrollment staff, whether from HEC or  VAMCs, frequently did not process enrollment applications within 5  business days in accordance with VHA timeliness standards. Specifically,  a June 2016 VHA audit found that HEC staff did not process 143 of 253  applications reviewed (57 percent) within VHA’s timeliness standard.  The audit found that this occurred, in part, because HEC enrollment staff  were not prioritizing workload to focus on processing applications that  were approaching the timeliness standard. In response to an audit  recommendation, HEC officials said they have begun prioritizing workload  to help meet the timeliness standard.

A VHA Chief Business Office analysis showed that VAMCs also did not  consistently process online applications within 5 business days.  According to the analysis, only 35 percent of online applications were  processed by VAMCs within 5 business days in fiscal year 2012 and 65  percent through the first 7 months of fiscal year 2016. VAMC officials we  contacted said because there is no mechanism for veterans to provide  supporting military service records, such as discharge papers, with their  online applications, VAMC staff need to obtain the information by  querying available military service databases or following up with the  veterans, which may cause delays in processing. Several VAMC officials  said that HEC should implement automated controls that do not allow  veterans to submit online applications without attaching supporting  documents that include information needed for making enrollment  determinations.

Additionally, the overall time needed to process enrollment applications  may increase when staff need to place applications in a pending status. In  its September 2015 report, VA’s Office of Inspector General found that,  as of September 2014, the Enrollment System contained nearly 870,000  pending applications, many of which had been pending for more than 5  years. According to the report, 72 percent of those applications were  pending because additional financial information was needed from  veterans. In response to the report, in 2016, HEC and VAMCs undertook  outreach efforts, such as attempting to contact all veterans with pending  applications via phone and letters. According to HEC officials, as of May  2017, they were able to resolve about 30 percent of the applications  (about 255,000 applications). This included enrolling approximately  88,000 veterans, as well as removing from pending status applications for  which HEC officials said veterans were no longer living. HEC officials and  VAMC staff in our review said they experienced problems resolving  pending applications because they were generally several years old and  lacked accurate contact information. HEC officials stated they would  continue to work on resolving them, but if staff cannot obtain the  information within 365 days, the applications’ status will change from  pending to closed at that time.

Based on our discussions with enrollment staff, we found that none of the  VAMCs in our review had a specific policy or procedure for how to resolve  pending applications. Officials indicated that they had not received any  national procedure or guidance from VHA, nor had they developed local  procedures. According to federal internal control standards, management  should design control activities, such as policies and procedures, to  achieve objectives and respond to risk. In the absence of a standard  procedure for VAMCs to use to resolve pending applications, veterans  are at risk for experiencing unnecessary delays while waiting for their  applications to be processed.

For the six VAMCs in our review, we found that, as of March and April  2017, VAMC enrollment staff had not resolved 31 (55 percent) of the 56  pending applications included in our random, nongeneralizable sample of  pending applications. (See table 1.) Specifically we found that for 22 (71  percent) of the 31 unresolved applications there was no evidence that  VAMC enrollment staff had attempted to contact the veterans to obtain  missing military service or financial information, and that 18 of these 22  applications had been in a pending status for 3 months or longer at the  time of our review. VAMC officials told us they were not aware that some  of the unresolved were in a pending status prior to our review. For the  remaining 9 applications, we found VAMC enrollment staff attempted to  contact the veterans, but were unable to resolve the application, for  example, due to the lack of response from the veteran or lack of valid  contact information. These 9 applications had been in a pending status  between 2 and 5 months at the time of our review.

For the 25 applications that enrollment staff resolved, we found that staff  enrolled the veterans for 19, and for the other 6, staff determined the  veterans were ineligible or rejected for enrollment. We also found the time  it took staff to make an enrollment determination varied widely—ranging  from 3 to 119 days. (See table 2.)

Officials from five of the six VAMCs told us that based on our review they  recognized the need to improve their processes. For example, officials  from two VAMCs indicated that they were going to develop a standard  operating procedure for identifying pending applications, following up with  veterans to obtain missing information, and documenting actions such as  the dates that enrollment staff called veterans or mailed letters to resolve  outstanding issues.

section_title: VHA Frequently Made Incorrect Enrollment Determinations
paragraphs: VHA’s Compliance and Internal Control Program Office conducted two  audits (in April and August 2016), which found that VHA enrollment staff,  including those from HEC and VAMCs, frequently made incorrect  enrollment determinations. In some cases, veterans were rejected for  health care benefits when those veterans should have been enrolled, and  in other cases veterans were enrolled when they were ineligible for  benefits, according to these audits. Specifically, VHA’s audits found the  following:  HEC had a 12 percent error rate. The April 2016 audit found that HEC  enrollment staff made incorrect determinations for 31 of 253 randomly  selected applications. The audit found that these errors included a  combination of incorrect enrollment and rejection determinations, and the  most frequent errors—in 15 of the 31 cases—related to enrollment staff  enrolling or rejecting veterans for health care benefits without sufficient  documentation, such as proof of military service. Audit findings indicated  these applications should have been assigned a pending status.

VAMCs had a 27 percent error rate. The August 2016 audit found that  VAMC enrollment staff made incorrect determinations for 101 of 381  randomly selected applications. Similar to the audit of HEC, the audit of  VAMCs found that errors included a combination of incorrect enrollment  and rejection determinations. For example, the audit of VAMCs identified  15 applications for which enrollment staff incorrectly rejected the veterans  for health care benefits. According to the audit, VAMC staff should have  either enrolled the veterans because they had provided adequate  documentation needed to verify their eligibility, or categorized the  applications as pending until adequate documentation was obtained such  as proof of military service needed to verify eligibility.

In addition to the two audits, VHA’s Compliance and Internal Control  Program Office conducted an informal review that found for a sample of  357 phone applications, enrollment staff made incorrect enrollment  determinations for 87 (24 percent ). The most frequent errors again  related to staff enrolling or rejecting veterans for health care benefits  without sufficient documentation, such as proof of military service. In  these instances, the applications should have been assigned a pending  status, according to the review. Although documentation on the audits  and the informal review did not provide information on specific causes of  the errors, officials responsible for conducting the audits indicated that the  incorrect enrollment determinations were the result of human error.

section_title: VHA Is Assessing Efforts to Improve Its Enrollment Processes
paragraphs: Through its HEC, VHA is assessing efforts to improve the timeliness of  enrollment application processing and the accuracy of enrollment  determinations. Specifically, HEC officials established the National  Enrollment Improvement, an initiative which includes two efforts to  centralize or standardize key aspects of enrollment processes.

One effort involves VAMCs’ processing of applications using the  Enrollment System rather than VistA. To examine potential options, HEC  implemented two pilots in 2016:

Pilot 1— implemented May through August 2016, required enrollment  staff at three VAMCs to process all applications by entering  information directly into the Enrollment System. VAMC enrollment  staff participating in this pilot told us they encountered challenges,  including not being able to log into the Enrollment System, and  frequently had to revert to processing many applications in VistA. In  total, the VAMCs processed 239 applications using the Enrollment  System, which did not provide HEC sufficient data for determining the  pilot’s effectiveness, according to the officials responsible for  implementing the pilot.

Pilot 2—a case study implemented over 2 weeks in December 2016,  required enrollment staff at six VAMCs to enter application information  for veterans applying in person into an online application for direct  transmittal to the Enrollment System. According to officials, a goal of  the pilot was to test the automatic verification of military service  information against databases to reduce human intervention in  verifying eligibility, thereby improving the timeliness and accuracy of  enrollment determinations. Similar to the first pilot, technology issues  precluded effective processing. For example, automated verification  was not consistently successful, and most applications processed (65  of 86) required manual intervention to reach an enrollment  determination. In addition, officials said the online application did not  always capture information needed to make an enrollment  determination.

HEC officials told us they did not obtain sufficient information from the  pilots to make a decision on which option would replace VAMCs use of  VistA for processing applications. As such, HEC officials told us they are  planning to conduct a third pilot to further test the option of having VAMCs  enter application information directly into the Enrollment System. Officials  said they do not have a definitive implementation plan or timeline for  conducting this pilot.

A second effort under the National Enrollment Improvement involves  standardizing the process of resolving pending applications. HEC  developed procedures for HEC enrollment staff to use when resolving  pending applications. Specifically, when a veteran’s application is placed  in a pending status, staff are to send the veteran a letter that includes  information about why the application is pending; the information HEC  needs to make an enrollment determination; and instructions for providing  the information to HEC. Additionally, staff are instructed to make phone  calls at pre-determined time intervals—8 days, 30 days, 90 days, 180  days, and 310 days after an application becomes pending—in an attempt  to contact the veteran to obtain missing information. HEC enrollment staff  are also required to document each phone call attempt and the results. If  staff are able to obtain the information within 1 year of informing a veteran  about an application’s pending status, that information is documented,  and staff make an enrollment determination. If, after 365 days, staff  cannot obtain the information needed to make an enrollment  determination, the application status would be changed from pending to  closed in the Enrollment System.

Although HEC has developed standardized procedures for the resolution  of pending applications by HEC staff, it has not communicated these  procedures to VAMC enrollment staff. Officials from the six VAMCs in our  review indicated they were not aware of HEC’s plans to standardize this  process, nor had they been asked to provide input or feedback on some  of the challenges they have experienced. Furthermore, VAMC officials  told us that they had not received any guidance regarding the new  procedures and were confused about whether they would continue to  have a role in this process. HEC’s new procedures do not specify whether  VAMCs have a continued role in resolving pending applications and  whether the procedures apply to VAMCs, although HEC officials told us  that VAMCs would continue to be involved.

According to federal internal control standards for information and  communication, management should internally communicate the  necessary information to achieve the agency’s objectives.  Communicating quality information down and across reporting lines  enables personnel to perform key roles in achieving objectives,  addressing risks, and supporting the internal control system. In the  absence of HEC coordination and communication with VAMCs about its  effort to standardize the process for resolving pending applications,  including the role VAMCs will have, there may be duplication of efforts  between HEC and VAMC enrollment staff, which could lead to  inefficiencies.

section_title: VHA’s Limited Oversight Impedes Its Ability to Ensure Timely and Accurate Enrollment of Veterans
paragraphs: VHA lacks a standardized process for system-wide oversight of  enrollment processes to ensure applications are processed in a timely  manner and enrollment determinations are accurate. Further, VHA,  through HEC, lacks reliable data to oversee timely processing of  applications across VAMCs. HEC has recently implemented an effort to  review the accuracy of some enrollment determinations, specifically those  for which veterans were found to be ineligible or rejected for health care  benefits.
subsections: section_title: VHA Lacks a Standardized Process for System-Wide Oversight of Enrollment Processes
paragraphs: VHA has not sufficiently defined through policies or procedures a  standardized oversight process that describes and delineates the roles  and responsibilities of HEC and VISNs—the networks that manage and  oversee VAMCs in their geographic area—in monitoring and evaluating  the efficiency and effectiveness of enrollment processes. Although HEC  officials said they are responsible for oversight of enrollment processes  system-wide and VHA policy generally states that HEC is responsible for  performing a second-level review of all enrollment determinations,  policies and procedures do not document the key oversight activities that  should be conducted, how often they should be done, or the data that  should be assessed for ensuring timely and accurate enrollment  processes system-wide. Additionally, although HEC officials said VISNs  should be overseeing VAMCs’ enrollment processes within their  networks, we found that VHA’s policies do not describe these oversight  role and responsibilities.

Officials from the six VISNs in our review reported different perspectives  about their role in overseeing enrollment processes, and as a result,  oversight activities were limited and varied across these VISNs. For  example, officials from two of the VISNs in our review considered VISNs  to have no role in the oversight of enrollment processes, and primarily  provided information from HEC to the VAMCs within their networks. In  contrast, an official from another VISN did consider VISNs to have an  oversight responsibility, and that VISN is planning to develop a standard  set of report requirements for VAMCs within the network to use so that  the VISN would have consistent information to use for monitoring VAMCs’  enrollment processes.

According to federal internal control standards for a control environment,  an agency should establish an organizational structure and assign  responsibility for achieving its objectives. An oversight structure would  help fulfill responsibilities set forth by applicable laws and regulations, and  relevant government guidance. Without defining a standardized process  for oversight, HEC—VHA’s entity responsible for enrollment—may be  unable to determine what oversight, if any, is being conducted system- wide and may not have key information about deficiencies in processing  enrollment applications. Thus, HEC is limited in its ability to effectively  develop systematic solutions and ensure enrollment processes are  efficient and resulting in accurate enrollment determinations. HEC officials  said they recognized the need to improve the oversight of enrollment  processes, and a goal under the National Enrollment Improvement is for  HEC to have 100 percent accountability and oversight of applications— those processed both at HEC and at the VAMCs.

section_title: VHA Lacks Complete and Reliable Data to Oversee the Timeliness of Processing Enrollment Applications System-Wide
paragraphs: VHA—through HEC—does not have complete and reliable data for  overseeing the timeliness of processing enrollment applications system- wide. HEC has data about processing timeliness for the applications that  it receives. HEC officials said it lacks similar data for those applications  received by the VAMCs—which comprised about 90 percent of the  applications received system-wide in fiscal year 2016. HEC officials said  they are able to monitor processing timeliness for the applications they  receive because enrollment staff log the dates of the applications  received into a workload tool and track monthly the processing timeliness  and application status, such as the percent of applications that remained  pending. In contrast, applications received by VAMCs are entered into  local VistA systems that do not capture information on the date the  application was received, which precludes accurate measurement of the  timeliness of application processing. Although VistA captures the date  enrollment staff entered the application information into the system, this  date may not yield an accurate start date to measure timeliness of  processing, specifically for applications received by mail or fax, because  there is no assurance the information was entered when the application  was received, according to HEC officials and VAMC staff. For example,  officials from one VAMC in our review said if mailed or faxed applications  are missing military service or financial information, staff do not enter the  information into VistA until all the required information is obtained.

Absent the information in VistA needed to track and monitor their  performance in processing enrollment applications, three of the six  VAMCs in our review developed Excel spreadsheets to collect this  information. These spreadsheets tracked the dates when applications  were received, as well as the enrollment determination made for each.  However, such Excel spreadsheets were developed and maintained  solely at the discretion of individual VAMCs in our review.

HEC and VAMCs in our review also have varying interpretations of how to  measure whether VHA’s 5 business day timeliness standard has been  met. VHA policy states the starting point for measuring adherence with its  timeliness standard is the date the application was submitted online by  the veteran, time-stamped when received by VAMCs or HEC, or the date  the veteran came in person to apply. However, the policy does not  define the end point for measuring the amount of time elapsed and does  not specify whether the processing time includes the time applications are  pending due to missing information. HEC officials told us the end point is  the date of an enrollment determination, and measurement of timeliness  should include any time the application was pending. Officials from four of  the six VAMCs in our review, in contrast, said they considered the  timeliness standard met when an application was entered into the system,  irrespective of whether an enrollment determination was made or whether  the application was pending.

According to federal internal control standards for information and  communication, management should use quality information to achieve  the entity’s objectives. Management obtains relevant data from relevant  internal and external sources in a timely manner based on identified  information requirements. Relevant data collected have a logical  connection with identified information requirements, and management  evaluates the sources of data for reliability. Without a central repository of  reliable data about enrollment processes and a clearly defined  measurement of the processing standard, VHA cannot reliably and  consistently oversee processing timeliness of enrollment applications,  assess the extent to which VAMCs face challenges in meeting the  standard, and make appropriate decisions to improve processes system- wide.

HEC officials acknowledged their lack of adequate information to monitor  timeliness of application processing system-wide and told us they plan to  develop the capacity to collect this information. Under the National  Enrollment Improvement, HEC officials identified several steps for  collecting standardized and centralized data for conducting oversight,  including (1) eliminating VAMCs use of VistA for processing enrollment  applications and solely using the Enrollment System, which is able to  capture application receipt dates, (2) developing standardized procedures  for capturing in the Enrollment System the date a mailed application was  received, and (3) developing a series of reporting metrics for assessing  the timeliness of processing applications across different modes.

However, HEC officials told us that they need VHA approval to implement  these actions, and as of June 2017, they did not have a timeline for when  these actions might be implemented to allow them to accurately track and  report on processing timeliness across all modes and VAMCs.

section_title: VHA Has Efforts Underway and Planned to Oversee the Accuracy of All Enrollment Determinations
paragraphs: HEC has efforts underway and planned to oversee the accuracy of  enrollment determinations made system-wide. First, VHA—through  HEC—has recently implemented an effort to review the accuracy of  enrollment determinations for which veterans were found to be ineligible  or rejected for health care benefits. This effort, which began in March  2017, employs a dedicated team of HEC staff to centrally conduct these  secondary reviews daily, according to HEC officials. Prior to this date,  VHA instructed VAMCs to conduct monthly secondary reviews of the  accuracy of these enrollment determinations, and report the results of  these reviews to HEC. However, HEC officials said they conducted an  internal review of a sample of applications that had undergone this  secondary review, and found that 20 to 30 percent still were incorrectly  determined to be ineligible or rejected. Although HEC officials said  VAMCs should continue these secondary reviews, HEC will also conduct  its own independent review of all ineligible or rejected enrollment  determinations. HEC officials said they plan to use the results of the  reviews for quality assurance and training purposes with HEC and VAMC  enrollment staff. Additionally, HEC officials told us they plan to expand  their reviews of the accuracy of enrollment determinations and are  currently assessing how to conduct second level reviews effectively  system-wide. Although VHA policy states that HEC is responsible for  performing a second-level review of all enrollment determinations, HEC  officials said they have not been fully adhering with this requirement  because, primarily, they have been focused on resolving the backlog of  pending applications.

section_title: Conclusions
paragraphs: Timely and accurate processing of veterans’ enrollment applications is  critical to ensuring that eligible veterans obtain needed health care.  Without efficient and effective enrollment processes, veterans may be  delayed in obtaining needed services or incorrectly denied benefits.  VHA’s current enrollment processes are decentralized and fragmented,  with enrollment processing spread across 170 individual VAMCs as well  as VHA’s HEC. The current processes are also prone to delays and  errors, such as enrollment staff frequently not meeting the 5-day  timeliness standard and making incorrect enrollment determinations when  processing veterans’ enrollment applications.

In particular, in some instances veterans may not have provided all the  information HEC or VAMC staff need to process an enrollment application  and the application becomes pending. VAMCs, however, do not have  effective processes for obtaining information needed to resolve pending  applications, which has resulted in veterans experiencing unnecessary  delays waiting for enrollment determinations. Although HEC has  developed new procedures for its staff to resolve pending applications,  the procedures do not delineate whether VAMCs have a continued role in  this process or whether they should be following these new procedures.

A system-wide standard procedure that clarifies the roles and  responsibilities of VAMC enrollment staff in resolving pending applications  may help improve efficiency and help ensure that veterans receive a  timely response when applying for health care benefits.

Additionally, limitations in VHA’s oversight further impede its ability to  ensure the timeliness of application processing and the accuracy of  enrollment determinations system-wide. VHA has not sufficiently defined  roles and responsibilities for HEC and VISNs for conducting oversight of  enrollment processing. Without establishing and clearly communicating  the entity responsible for oversight and the activities that should be  routinely conducted, there are no assurances that oversight is being  conducted system-wide and deficiencies are being addressed  appropriately. Oversight is further challenged by the lack of reliable and  consistent data needed to evaluate timeliness of processing enrollment  applications, and a clearly defined policy to measure processing  timeliness. Due to this lack of data needed for system-wide oversight,  VHA may be unable to determine if all veterans who submit an application  to VAMCs—which handle a majority of the applications system-wide—are  receiving timely enrollment determinations. HEC has efforts planned to  improve its oversight; implementing and assessing these efforts may help  ensure the timeliness and accuracy of enrollment processes, and help  VHA make appropriate system-wide process improvements.

section_title: Recommendations for Executive Action
paragraphs: We recommend that the Secretary of Veterans Affairs direct the Acting  Under Secretary for Health to take the following four actions:  1.  Develop and disseminate a system-wide standard operating  procedure that clearly defines the roles and responsibilities of VAMCs  in resolving pending enrollment applications.  2.  Clearly define oversight roles and responsibilities for HEC, and for  VISNs as appropriate, to help ensure timely processing of applications  and accurate enrollment determinations.  3.  Develop procedures for collecting consistent and reliable data system- wide to track and evaluate timeliness of enrollment processes, and  institute an oversight mechanism to ensure VAMC and HEC  enrollment staff are appropriately following the procedures.  4.  Clarify its 5-day timeliness standard for processing enrollment  applications, including whether it covers the total time needed to make  an enrollment determination and the time applications are pending,  and ensure the clarification is communicated system-wide.

section_title: Agency Comments
paragraphs: We provided VA with a draft of this report for its review and comment. VA  provided written comments, which are reprinted in appendix I. In its  written comments, VA concurred with all four of the report’s  recommendations, and identified actions it is taking to implement them. In  addition, VA provided technical comments which we incorporated as  appropriate.

We are sending copies of this report to the appropriate congressional  committees, the Secretary of the Department of Veterans Affairs, the  Acting Under Secretary for Health, and other interested parties. In  addition, the report is 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 at draperd@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix II.

section_title: Appendix I: Comments from the Department of Veterans Affairs

section_title: Appendix II: 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;  David Lichtenfeld, Analyst-in-Charge; Joanna Wu Gerhardt; and Joy Kim  made key contributions to this report. Also contributing were Jennie Apter,  Muriel Brown, Jacquelyn Hamilton, and Richard Lipinski.

Fast facts: To receive health care through the Department of Veterans Affairs, veterans must provide various information to prove eligibility.

We found that how VA reviews applications and enrolls veterans can lead to delays and errors. Enrollment staff—spread across VA's central enrollment center and network of 170 medical centers—frequently missed VA's 5-day timeliness standard, and sometimes incorrectly rejected veterans for health care benefits. Some applications we reviewed had been pending for more than 3 months.

Among other things, we recommended VA define the roles of medical centers in resolving pending applications.

Question-summary annotations: questions: question: To what extent did VHA meet timeliness standards?
answer: VHA frequently did not meet timeliness standards: VHA studies conducted in 2016 revealed that enrollment staff frequently did not process veterans' enrollment applications within the timeliness standard of 5 business days.
child_questions: question: At what centers were these issues found?
answer: These issues were found both at VHA's Health Eligibility Center (HEC)—the central enrollment processing center—and at local VA medical centers (VAMC) that also process enrollment applications.

question: How did HEC officials respond to this issue?
answer: In response to an audit recommendation, HEC officials said they have begun prioritizing workload to help meet the timeliness standard.

question: How do differing enrollment applications complicate this issue?
answer: Additionally, the overall time needed to process enrollment applications may increase when staff need to place applications in a pending status, as pending applications require additional information, such as military service information, for staff to make enrollment determinations.
child_questions: question: To what extent did the VAMCs have a policy for resolving pending applications?
answer: However, none of the six VAMCs GAO reviewed had a specific policy for how to resolve pending applications. GAO found that VAMC enrollment staff had not resolved more than half of the pending applications GAO reviewed at these six VAMCs, some of which had been pending for more than 3 months at the time of the review.

question: What describes the relationship between HEC and VAMCs?
answer: Although HEC developed new procedures for its enrollment staff to use when resolving pending applications, these procedures were not communicated to VAMCs.
child_questions: question: What uncertainty has arisen as a result of this lack of communication?
answer: Officials from the VAMCs GAO reviewed said that they had not received guidance on these procedures and were confused about whether they would continue to have a role in this process. In the absence of HEC communication with VAMCs, there may be inefficiencies in resolving pending applications.

question: How is VHA responding to these issues?
answer: VHA, through HEC, is assessing efforts to improve the timeliness of enrollment application processing and the accuracy of enrollment determinations.

questions: question: Why is the VHA unable to monitor system-wide enrollment processes?
answer: VHA lacks a standardized oversight process and reliable data to monitor enrollment processes system-wide: Although HEC officials said they are responsible for oversight of enrollment processes system-wide, VHA has neither sufficient policies that delineate this role nor procedures that document key oversight activities that should be conducted. Further, VHA does not have reliable data for overseeing the timeliness of processing enrollment applications at VAMCs, which process 90 percent of the applications system-wide.
child_questions: question: What is one example of the HEC policy issue?
answer: For example, policies do not describe the oversight activities HEC should conduct to help ensure the accuracy of enrollment determinations system-wide.

question: How uniform were interpretations of the timeliness standard?
answer: Officials from the six VAMCs in GAO's review and HEC also had varying interpretations of how to measure the timeliness standard. For example, officials from four of the six VAMCs said the standard was met when enrollment staff entered an application into their local system, irrespective of whether an enrollment determination was made. In contrast, HEC officials said the measurement encompasses the time needed to make an enrollment determination, including any time the application was pending.

question: Why is reliable data so essential for the VHA?
answer: Without reliable data that are consistently measured, VHA cannot accurately oversee the timeliness of application processing system-wide, or assess the extent to which VAMCs face challenges in implementing enrollment processes.
child_questions: question: How is the VHA hoping to improve this oversight?
answer: To improve oversight, VHA, through HEC, recently implemented an effort to review the accuracy of some enrollment determinations.

questions: question: Why did GAO assess the VA in 2016?
answer: The Explanatory Statement accompanying the Consolidated Appropriations Act, 2016 included a provision for GAO to examine VA's oversight of patient access to care.

question: What two things does GAO's report examine?
answer: This report examines (1) VHA's processes for enrolling veterans for health care benefits and (2) its related oversight.
child_questions: question: In the creation of the report, what did GAO review?
answer: GAO reviewed federal laws, regulations, and VHA policies and procedures.

question: What were the purposes of the interviews the GAO conducted in the creation of this report?
answer: GAO also interviewed officials from HEC and 6 of VHA's 170 VAMCs selected to provide variation in factors such as number of enrollment applications processed and geographic location; reviewed actions to resolve a randomly selected, nongeneralizable sample of pending enrollment applications from these 6 VAMCs; and interviewed HEC and VAMC officials on oversight of enrollment processes.