VA Health Care: Further Action Needed to Address Weaknesses in Management and Oversight of Non-VA Medical Care
Released: 2014-06-18T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: Due to serious and longstanding problems with the timely scheduling of veterans' appointments in VA facilities, VA recently announced that it will allow additional veterans to be treated through its Non-VA Medical Care Program.

This testimony is based on two GAO reports and addresses the extent to which (1) VA collects reliable information on wait times and cost-effectiveness of the Non-VA Medical Care Program; (2) VA facilities comply with Millennium Act claims processing requirements and VA oversees claims processing activities; and (3) VA educates veterans about eligibility for Millennium Act emergency care and communicates with non-VA providers. For both reports, GAO reviewed relevant requirements and visited 10 VA facilities. For its report on the oversight and management of the Non-VA Medical Care Program, GAO reviewed non-VA medical care spending and utilization data from fiscal year 2008 through fiscal year 2012. For its report on the Millennium Act emergency care benefit, GAO reviewed 128 denied Millennium Act claims to determine the accuracy of processing decisions.

GAO made numerous recommendations to VA in the two prior reports related to improving (1) data on wait times and cost-effectiveness for non-VA medical care; (2) compliance with claims processing requirements; and (3) veterans' knowledge of non-VA medical care eligibility. VA agreed with these recommendations but has yet to fully implement them.

section_title: What GAO Found
paragraphs: GAO's May 2013 report on the oversight and management of the Non-VA Medical Care Program found that the Department of Veterans Affairs (VA) does not collect data on wait times veterans face in obtaining care from non-VA providers. The lack of data on wait times limits VA's efforts to effectively oversee the Non-VA Medical Care Program because it is not possible for VA to determine if veterans who receive care from non-VA providers are receiving that care sooner than they would in VA facilities. In addition, GAO found that VA cannot assess the cost-effectiveness of non-VA medical care because it cannot analyze data on all services and charges for an episode of care, which is a combined total of all care provided to a veteran during a single office visit or inpatient stay. As a result, VA cannot determine whether delivering care through non-VA providers is more cost-effective than augmenting its own capacity in areas with high utilization of non-VA medical care.

GAO's March 2014 report found patterns of noncompliance with applicable requirements for processing emergency care claims covered under the Veterans Millennium Health Care and Benefits Act (Millennium Act) at each of the four VA facilities visited. This led to the inappropriate denial of some claims and the failure to notify veterans that their claims had been denied at these facilities. The Millennium Act authorizes VA to cover emergency care for conditions not related to veterans' service-connected disabilities when veterans who have no other health plan coverage receive care at non-VA providers and meet other specified criteria. Specifically, GAO determined that about 20 percent of the 128 claims it reviewed had been denied inappropriately, and almost 65 percent of the reviewed claims lacked documentation showing that the veterans were informed their claims were denied and explained their appeal rights. As a result of GAO's review, the VA facilities reconsidered and paid 25 claims that they initially had inappropriately denied. GAO also found that there is significant risk that these patterns of noncompliance will continue because VA's existing oversight mechanisms do not focus on whether VA facilities appropriately approve or deny non-VA medical care claims or fail to notify veterans that their claims have been denied.

GAO also reported in March 2014 that gaps exist in veterans' knowledge about eligibility criteria for Millennium Act emergency care, and communication weaknesses exist between VA and non-VA providers. Specifically, GAO found that veterans' lack of understanding about their emergency care benefits under the Millennium Act presents risks for potentially negative effects on veterans' health because they may forgo treatment at non-VA providers, and on veterans' finances because they may assume VA will pay for care in situations that do not meet VA criteria. Despite VA's efforts to improve communications, some non-VA providers reported instances in which VA facilities' claims processing staff were unresponsive to their questions about submitted claims.

section_title: Letter
paragraphs: I am pleased to be here today to discuss our work on the Department of  Veterans Affairs’ (VA) delivery of care through its Non-VA Medical Care  Program. The majority of veterans enrolled in the VA health care system  receive care in VA-operated medical facilities, such as VA medical  centers and community-based outpatient clinics. However, VA is  authorized to obtain health care services from non-VA providers to help  ensure that veterans are provided timely and accessible care. For  example, VA may utilize non-VA medical care when a VA facility is unable  to provide certain specialty care services, such as cardiology or  orthopedics, or when a veteran would have to travel long distances to  obtain care at a VA medical facility. Non-VA providers treat veterans in  non-VA facilities, such as physicians’ offices or hospitals in the  community. Non-VA providers are commonly paid by VA using a fee-for- service arrangement. In fiscal year 2013, VA spent about $4.8 billion on  non-VA medical care for more than 1 million veterans, which accounted  for about 11.6 percent of VA’s total medical services budget for that year.

There are two main non-VA medical care delivery methods— preauthorized care and emergency care—that are approved using two  different processes. The first, preauthorized care, is approved in advance  by VA facility officials. VA may authorize veterans to seek care from non- VA providers for a number of reasons, including when (1) wait times for  appointments at VA facilities exceed VA standards; (2) the distance  veterans must travel to VA facilities is impractical for the veteran; and   (3) VA facilities do not offer the medical services the veteran needs.  Preauthorized care accounts for the majority of spending and utilization  (about 60 percent of spending and about 88 percent of utilization) for the  Non-VA Medical Care Program. The second, emergency care, is not  typically approved in advance by VA facility officials and has certain  criteria that must be met in order for VA to approve reimbursement for the  non-VA provider.

In response to serious and longstanding problems regarding the timely  scheduling of veterans’ appointments in VA facilities that have been  highlighted in recent congressional oversight hearings, VA has  announced its intention to allow additional veterans to be treated through  its Non-VA Medical Care Program. With this likely increase in the  utilization of non-VA medical care, it is not only important to ensure that  veterans will obtain timely treatment from non-VA providers, but also to  ensure that non-VA medical care is a reliable and cost-effective means  for VA to deliver services. Today, I will address the extent to which (1) VA  collects reliable information on wait times and cost-effectiveness of the  Non-VA Medical Care Program; (2) VA facilities comply with claims  processing requirements for emergency care provided under the  Veterans Millennium Health Care and Benefits Act (Millennium Act), and  the extent to which VA oversees facilities’ claims processing activities;  and (3) VA educates veterans about eligibility for Millennium Act  emergency care and communicates with non-VA providers about claims  processing.

My statement is based on the key findings of two GAO reports that  identified weaknesses in VA’s management and oversight of its Non-VA  Medical Care Program: a March 2014 report entitled VA Health Care:  Actions Needed to Improve Administration and Oversight of Veterans’  Millennium Act Emergency Care Benefit, and a May 2013 report entitled  VA Health Care: Management and Oversight of Fee Basis Care Need  Improvement. For the March 2014 report, which focused on VA’s administration and oversight of Millennium Act emergency care delivered  to veterans by non-VA providers, we reviewed the law, its implementing  regulations, and applicable VA policies and guidance to identify  applicable requirements for processing these claims. We then visited four  VA facilities that were selected on the basis of fiscal year 2012 spending  totals and geographic location and reviewed VA documents—including  128 Millennium Act emergency care claims that these four facilities had  denied in fiscal year 2012. We also interviewed officials from VA, non-VA  providers, and veterans service organizations. For the May 2013 report,  which focused on VA’s management and oversight of non-VA medical  care spending and utilization, we reviewed relevant laws and regulations,  VA policies, and spending and utilization data on non-VA medical care  from fiscal years 2008 through 2012. We also interviewed VA officials and  examined the non-VA medical care operations at six selected VA facilities  that varied in size, services offered, and geographic location. The results  of both of these studies cannot be generalized to all VA facilities, but they  illustrate the serious weaknesses in various aspects of the Non-VA  Medical Care Program. We have made numerous recommendations to  VA in these previous reports, and VA has concurred with all of them. We  are not making any new recommendations at this time. In June 2014, in  preparation for this statement, we met with VA officials to discuss the  status of VA’s implementation of action plans to address the  recommendations included in these two reports.

The work this statement is based on was conducted in accordance with  generally accepted government accounting standards. Those standards  require that we plan and perform the audit to obtain sufficient, appropriate  evidence to provide a reasonable basis for our findings and conclusions  based on our audit objectives. We believe that the evidence obtained  provides a reasonable basis for our findings and conclusions based on  our audit objectives. The reports cited provide additional information on  our scope and methodology.
subsections: section_title: Background
subsections: section_title: Types of Non-VA Medical Care
paragraphs: When veterans obtain care from non-VA providers, the non-VA providers  submit claims to VA for payment. See table 1 for a description of the  types of non-VA medical care claims processed by VA.

section_title: Preauthorization Process for Non-VA Medical Care
paragraphs: Preauthorizing non-VA medical care involves a multistep process  conducted by the VA facility that regularly serves a veteran. The  preauthorization process is initiated by a VA provider who submits a  request for non-VA medical care to the VA facility’s non-VA medical care  unit, which is an administrative department within each VA facility that  processes VA providers’ non-VA medical care requests and verifies that  non-VA medical care is necessary. Once approved by the VA facility’s  Chief of Staff or his or her designee, the veteran is notified of the approval  and can choose any non-VA provider willing to accept VA payment at  predetermined rates. (See fig. 1.)

section_title: Criteria for VA Coverage of Emergency Care from Non-VA Providers
paragraphs: For claims that are emergent in nature and therefore would not have gone  through the traditional VA preauthorization process, VA is authorized to  pay claims for emergency care from non-VA providers under certain  conditions, which vary depending on whether the care was related to the  veteran’s service-connected disability.

If a non-VA emergency care claim is related to a veteran’s service- connected disability, the following criteria must be met in order for the  services to be paid for by VA.

First, the non-VA emergency care must have been rendered to treat  one of the following: (a) a veteran’s service-connected disability; (b) a  condition that is associated with and aggravating the veteran’s  service-connected disability; (c) any condition for a veteran who has  been rated by VA as permanently and totally disabled due to a  service-connected disability; or (d) any condition for a veteran  participating in a vocational rehabilitation program who needs care to  participate in a course of training.

Second, the non-VA emergency care must also meet all of these  the claim must be filed within 2 years of the date the care or  services were rendered;  the services were rendered in a medical emergency, as  determined using the prudent layperson standard; a VA or other federal facility was not feasibly available to provide  the needed care, and an attempt to use either would not have  been considered reasonable; and  the services were needed before the veteran was stable enough  to be transferred to a VA or other federal facility and before the VA  or other federal facility agreed to accept the transfer.

If a claim for non-VA emergency care is not related to a veteran’s service- connected disability, there are different criteria that must be met in order  for the services to be paid for by VA. The Millennium Act, which was  enacted in 1999, provides a safety net for veterans when they do not  have other insurance and need emergency care that is not related to a  service-connected disability. Specifically, all of the following criteria must  be met for VA to cover Millennium Act claims:

The claim is not payable under the payment authority for emergency  care related to service-connected disabilities.

The claim must be filed within 90 days of the latest of the following:  the date of discharge, date of death, or date that the veteran  exhausted, without success, action to obtain payment or  reimbursement from a third party.

The veteran must be enrolled in the VA health care system and have  received treatment from a VA clinician within 24 months of the  emergency care episode.

The veteran must be financially liable to the non-VA provider of  emergency care.

The veteran can have no entitlement to care under a health plan contract (such as Medicare or a private health insurance plan).

The veteran can have no other contractual or legal recourse against a  third party that would in whole extinguish his or her liability to the non- VA provider.

The services must be rendered in a hospital emergency department  or a similar facility providing emergency care to the public.

The services must be rendered in a medical emergency as  determined using the prudent layperson standard.

A VA or other federal facility was not feasibly available to provide the  needed care, and an attempt to use either would not have been  considered reasonable by a prudent layperson.

The services were rendered before the veteran was stable enough to  be transferred to a VA or other federal facility and before the VA or  other federal facility agreed to accept the transfer.

section_title: Process for Paying Non- VA Medical Care Claims
paragraphs: Regardless of whether a veteran’s non-VA medical care was  preauthorized or the result of an emergency, the steps for processing  payments to non-VA providers are the same. Specifically, the non-VA  provider submits a claim to either a Veterans Integrated Service Network  (VISN) or a VA facility for payment following the veteran’s treatment. In  some VISNs, claims processing activities are centralized in a VISN-level  department that is responsible for reviewing claims from non-VA  providers, obtaining copies of medical records for veterans’ non-VA  medical care, and approving payment to non-VA providers. In other  VISNs, these claims-processing activities are decentralized and are the  responsibility of individual VA facilities. After VA facility or VISN officials  review the claims for accuracy, non-VA providers are reimbursed by VA.  (See fig. 2.)

To process all claims for non-VA medical care, VA facilities use software  called the Fee Basis Claims System (FBCS). FBCS is primarily a  system that helps VA facilities administer payments to non-VA providers,  as opposed to a system that automatically applies relevant criteria and  determines whether claims are eligible for payment. As a result, VA relies  on staff in the VISNs and VA facilities that process claims, such as  administrative clerks and clinicians (typically nurses), to make decisions  about which payment authority applies to the claim and which claims  meet the criteria for VA payment.

section_title: Notifying Veterans and Non-VA Providers of Denials of Claims for Non- VA Medical Care
paragraphs: If VA denies payment for a claim for non-VA medical care, the  Department must provide written notice to the veteran and the claimant  (usually, the non-VA provider) regarding the reason for the denial and  inform them of their rights to request a reconsideration or to formally  appeal the denial. If a veteran or non-VA provider has questions about a  denied claim, claims should be reconsidered by a supervisor at the same  VISN or VA facility that denied the claim. If the denial decision is upheld,  the veteran or non-VA provider has the right to file an appeal through the  Board of Veterans’ Appeals.

section_title: VA Lacks Critical Data on Wait Times and Cost-Effectiveness of Non-VA Medical Care
paragraphs: Critical data limitations related to the wait times veterans face in obtaining  care from non-VA providers and the cost-effectiveness of such services  limit VA’s efforts to oversee the Non-VA Medical Care Program in an  effective manner. Most notably, VA does not collect data on how long  veterans must wait to be seen by non-VA providers. We previously  reported that the amount of time veterans wait for appointments in VA  facilities influenced VA’s utilization of non-VA medical care. For example,  in our May 2013 report, VA officials from all six facilities we reviewed  reported that they routinely referred veterans to non-VA providers to help  ensure that veterans receive timely care and their facilities meet  performance goals for wait times for VA facility-based care.from one of these VA facilities explained that veterans needing treatment  in several specialties—including audiology, cardiology, and  ophthalmology—were referred to non-VA providers for this reason.

In fiscal year 2012, VA performance goals for wait times for care in VA  facilities called for veterans’ primary care appointments to be completed  within 7 days of their desired appointment date and veterans’ specialty  care appointments to be scheduled within 14 days of their desired  appointment date. However, since VA did not track wait times for non-VA  providers, little was known about how often veterans’ wait times for non- VA medical care appointments exceeded VA facility-based appointment  wait time goals. Officials from one VA facility we reviewed explained that  non-VA providers in their community also faced capacity limitations and  may not be able to schedule appointments for veterans any sooner than  the VA facility.

Limitations in the way VA collects non-VA medical care data also did not  allow the Department to analyze the cost-effectiveness of non-VA medical  care provided to veterans. In our May 2013 report, we found that VA  lacked a data system to group medical care delivered by non-VA  providers by episode of care—a combined total of all care provided to a  veteran during a single office visit or inpatient stay. For example, during  an office visit to an orthopedic surgeon for a joint replacement evaluation,  an X-ray for the affected joint may be ordered, the veteran may be given  a blood test, and the veteran may receive a physical evaluation from the  orthopedic surgeon. The non-VA provider would submit a claim to VA for  the office visit, and separate claims would be submitted by the radiologist  that X-rayed the affected joint and the lab that performed the veteran’s  blood test. However, VA’s non-VA medical care data system was not able  to link the charges for these three treatments together. We found that this  left VA without data for comparing the total non-VA medical care costs for  various types of services with the VA facility-based alternative.

Without cost-effectiveness data, VA is unable to efficiently compare VA  and non-VA options for delivering care in areas with high utilization and  spending for non-VA medical care. Two VA facilities we reviewed had  undertaken such assessments, despite the limitations of current data.  Officials at one facility reported that they expanded their operating room  capacity to reduce their reliance on non-VA surgical services, saving an  estimated $18 million annually in non-VA medical care costs. Similarly,  officials from the second facility reported that they were able to reduce  their reliance on non-VA medical care by hiring additional VA staff and  purchasing additional equipment to perform pulmonary function tests, an  effort that reduced related non-VA medical care costs by about $112,000  between fiscal years 2010 and 2012. The lack of non-VA medical care  data available on an episode of care basis also prevents VA from  efficiently assessing the appropriateness of non-VA provider  reimbursement. Specifically, VA officials cannot conduct retrospective  reviews of VA facilities’ claims to determine if the appropriate rate was  applied for the care provided by non-VA providers.

To help VA address these concerns, we made two recommendations in  our May 2013 report that directed VA to (1) analyze the amount of time  veterans wait to see non-VA providers and apply the same wait time  goals to non-VA medical care that have been used to assess VA facility- based wait times, and (2) establish a mechanism for analyzing the  episode of care costs for non-VA medical care. VA concurred with these  recommendations. In June 2014, we discussed VA’s progress in  implementing these recommendations with VA officials. These officials  indicated that the Department anticipated being able to track some wait  time information for veterans seen by non-VA providers that VA contracts  with under its new Patient Centered Community Care (PCCC) initiative in  the near term. However, wait time information for all non-VA medical  care will not be readily available until VA completes a redesign of its  claims processing system, which is expected to occur in fiscal year 2016.  With respect to establishing a mechanism to analyze the episode of care  costs for non-VA medical care, VA officials explained that they are in the  process of fully implementing this recommendation by (1) improving  existing data systems to systematically audit claims that include billing  codes typically included in bundled payments while the claims are in a  pre-payment status and to require VA facilities to review these claims  prior to payment, and by (2) making improvements to its Non-VA Medical  Care Program data that would allow all non-VA medical care data to be  analyzed on an episode of care basis. However, VA officials did not  provide a time frame for when all non-VA medical care would be routinely  analyzed by episode of care.

section_title: Selected VA Facilities Failed to Comply with Applicable Millennium Act Claims Processing Requirements, and Weaknesses Were Identified in VA’s Oversight of Claims Processing Activities
paragraphs: In March 2014, we reported that four VA facilities we visited had patterns  of noncompliance with VA claims processing requirements, which led to  the inappropriate denial of some Millennium Act emergency care claims  and the failure to notify some veterans that their claims had been  denied. We also found that VA’s existing oversight mechanisms for non- VA medical care claims processing were not sufficiently focused on  whether VA facilities were inappropriately approving or denying claims.
subsections: section_title: Selected VA Facilities Frequently Did Not Comply with Claims Processing Requirements, Which Led to the Inappropriate Denial of Claims
paragraphs: For our March 2014 report, we examined a sample of 128 Millennium Act  emergency care claims that the four VA facilities we visited had denied in  fiscal year 2012 and found 66 instances of noncompliance with VA policy  requirements. We determined that about 20 percent of the claims we  examined had been denied inappropriately, and almost 65 percent of the  claims we examined lacked documentation showing that the veteran was  notified that their claim was denied. As a result of our review, these four  VA facilities reconsidered and paid 25 claims that they had  inappropriately denied.

We found that there are no automated processes for determining whether  a claim for non-VA medical care meets criteria for payment or ensuring  that veterans are notified when a claim is denied; instead these  processes rely on the judgment of VA staff reviewing each claim and  adherence to VA policies. There are a number of steps in the claims  review process that were susceptible to errors that could lead to  inappropriate denials of non-VA medical care claims. For example, we  found nine instances where VA staff incorrectly determined that non-VA  medical care was not preauthorized when, in fact, a VA clinician had  referred the veteran to the non-VA provider.that VA must notify veterans in writing about denied claims and their  appeal rights. However, we found that one facility we visited could not  produce documentation of veteran notification for any of the 30 denied  claims we reviewed. We concluded that when veterans are not informed  that their claims for non-VA medical care have been denied, and VA has  inappropriately denied the claims, then veterans could become financially  liable for care that VA should have covered. Under such circumstances,  veterans’ credit ratings may be negatively affected, and they may face  personal financial hardships if they are unable to pay the bills they receive  from non-VA providers.

In addition, VA policy states  These findings from our March 2014 report raise concerns about  compliance with claims processing requirements at other VA facilities  nationwide. To help VA address these concerns, we made six  recommendations aimed at improving VA’s processing of non-VA medical  care claims, specifically Millennium Act emergency care claims. These  recommendations directed the Department to establish or clarify its  policies or take other actions to improve VA facilities’ compliance with  existing policy requirements. VA concurred with these six  recommendations. Based on discussions with VA officials in June 2014 to  obtain information about the status of their planned actions for  implementing these recommendations, we believe that VA is making  progress on the implementation of three of the six recommendations.  However, VA needs to take additional steps to revise its policies on  claims processing roles and responsibilities in order to address our  remaining three recommendations.

section_title: Weaknesses Found in VA’s Oversight of Non-VA Medical Care Claims Processing
paragraphs: One of VA’s primary methods for monitoring its facilities’ compliance with  applicable requirements for processing non-VA medical care claims is  field assistance visits. In fiscal year 2013, VA conducted these visits at 30  out of 140 VA facilities that processed non-VA medical care claims.  These 30 facilities were selected for review by VA based on their claims  processing timeliness. However, we reported in March 2014 that the  criteria VA used to select facilities for review may not direct VA to the  facilities most in need of a field assistance visit because VA does not take  into account the accuracy of claims processing activity. Moreover, we  found that the checklist VA uses for its field assistance visits does not  examine all practices that could lead VA facilities to inappropriately deny  claims. Further, VA does not hold facilities accountable for correcting  deficiencies identified during these visits, and it does not validate facilities’  self-reported corrections to address field assistance visit deficiencies.  According to VA officials, these visits are meant to be consultative in  nature and assist facilities in improving their non-VA medical care claims  processing. However, we found weaknesses in VA’s reliance on facilities’  self-reported actions when we reviewed the Department’s fiscal year  2012 and 2013 field assistance visit data and found unresolved problems  in fiscal year 2013 that originated in fiscal year 2012.

Further, VA implemented automated processes for auditing approved  non-VA medical care claims to ensure that VA facilities apply the correct  payment rates and no duplicate versions of the claims were previously  paid. However, VA has no systematic process for auditing claims to  ensure that they were appropriately approved or denied. VA officials  stated that they recommend, but do not require, that managers of non-VA  medical care claims processing units at VA facilities audit samples of  processed claims—including both approved and denied claims—to  determine whether staff processed claims appropriately. However, we  found that VA does not know how many facilities conduct such audits,  and none of the four VA facilities we visited reported conducting such  audits.

In our March 2014 report, we concluded that ensuring VA facilities correct  deficiencies identified during field assistance visits and conduct  systematic audits of the accuracy of claims processing decisions would  provide necessary transparency and stability to the Non-VA Medical Care  Program. To help VA address these issues, we made three  recommendations aimed at revising the scope of the field assistance  visits, ensuring deficiencies identified during these visits are corrected,  and instituting systematic audits of the appropriateness of claims  processing decisions. VA concurred with these recommendations and  detailed its plans to address them. In June 2014, VA officials detailed the  Department’s progress implementing these recommendations. However,  we do not believe the Department’s actions have sufficiently addressed  these recommendations. To fully implement these three  recommendations, VA needs to ensure field assistance visits include a  review of a sample of processed claims in order to determine whether  staff are complying with applicable requirements for claims processing  and needs to establish systematic audits of claims processing decisions,  among other things.

section_title: Veterans Lack Knowledge about Millennium Act Emergency Care Eligibility, and Selected Non-VA Providers Have Reported Communication Challenges with VA
paragraphs: In March 2014, we found that despite VA’s communication efforts with  veterans and non-VA providers, knowledge gaps exist for veterans about  eligibility for Millennium Act emergency care, and communication  weaknesses exist between VA and non-VA providers.
subsections: section_title: Veterans Lack Knowledge about Eligibility for Coverage of Millennium Act Emergency Care
paragraphs: In March 2014, we reported that veterans may still be unaware of the  criteria that must be met in order for VA to pay claims for non-VA medical  care; specifically, Millennium Act emergency care. VA primarily educates  veterans about their eligibility for non-VA medical care through patient  orientation sessions and written materials, such as the Veteran Health  Benefits Handbook. However, VA patient benefits and enrollment officials  at two of the four VA facilities we visited said that patient orientation  sessions were generally not well-attended. Also, written materials we  reviewed did not always provide a complete listing of all criteria that must  be met for Millennium Act emergency care claims to be covered, which  may create confusion about whether veterans should seek treatment from  a VA facility or a non-VA provider in the event of an emergency. VA  officials said that the primary intent of the written materials was to  communicate the importance of promptly seeking care and to discourage  veterans from delaying care by bypassing non-VA providers in the event  of an emergency. However, some VA officials acknowledged that they  were aware of specific recent cases where veterans delayed or avoided  seeking treatment at non-VA providers to go to a VA facility instead. For  example, one VA official explained that a veteran experiencing chest pains  drove over 100 miles to a VA facility rather than going to the nearest  emergency department;  two VA officials said the wife of a veteran who had gunshot wounds  drove him to a VA facility about 30 miles away, bypassing a number of  non-VA emergency departments; and another VA official explained that a veteran experiencing chest pains  died during a weekend as he waited to seek care until the local VA  community-based outpatient clinic opened on Monday.

Alternatively, we found that without knowledge of specific criteria for VA  payment of non-VA medical care, specifically Millennium Act emergency  care, veterans may seek treatment in situations where the Department  cannot pay. For example, veterans may seek care at a non-VA provider  for conditions they believe require immediate attention—such as one for  which they have not been able to obtain timely treatment from a VA  facility. However, VA staff reviewing the claim may decide that the  condition does not meet the prudent layperson standard for emergency  care and deny payment. Veterans that are admitted as inpatients to non- VA providers also may not be aware that they should be transferred to VA  facilities once their conditions have stabilized and a VA facility has  notified the non-VA provider that a bed is available for their care at the VA  facility.

To help VA address concerns about veterans’ lack of knowledge of non- VA medical care—specifically, Millennium Act emergency care—we  recommended in March 2014 that VA take steps to better understand  gaps in veterans’ knowledge regarding eligibility for non-VA coverage by  surveying them about their health care benefits knowledge and using  information from those surveys to tailor the Department’s veteran  education efforts. While VA concurred with this recommendation, in June  2014 VA officials indicated that the Department has decided not to pursue  veteran surveys but instead will promote veteran education by appearing  at conferences and town halls with veterans service organizations and  updating the information on its public website. We remain concerned that,  without surveying veterans directly, VA will not be able to identify specific  veteran knowledge gaps regarding coverage of non-VA medical care or  determine ways to better target VA’s veteran education efforts.

section_title: Non-VA Providers Reported Communication Problems with VA
paragraphs: For our March 2014 report, all four non-VA providers we visited cited  problems in their non-VA medical care claims processing communication  with VA regarding the following issues:

Points-of-contact not designated. Two of the four non-VA providers  said they did not have a specific point-of-contact at their VA facilities  who could answer concerns and issues about claims they had  submitted, which led to problems resolving their issues in a timely  manner.

Delays in claims processing. Billing officials at one non-VA provider  described lengthy delays in the processing of their claims, which in  some cases went on for years.

Lack of responsiveness when trying to transfer veterans and  failure to document discussions about potential transfers.  Officials at one non-VA provider said they had experienced  challenges connecting with the inpatient admissions staff at their local  VA facility, making it difficult for them to transfer veterans to the VA  facility after the veterans were stabilized. According to this provider,  the VA facility did not consistently answer calls during business hours  or weekends. Officials from a non-VA provider also described cases  where they had attempted to transfer stable veterans to the VA  facility, but the VA facility informed them that there were no beds  available. Later, the VA facility denied these claims because VA could  find no record of this contact with the non-VA provider or  authorizations for continued care.

VA officials said they have attempted to improve communications with  non-VA providers. Specifically, they have established a website and  electronic newsletter for non-VA providers in order to disseminate  information about non-VA medical care requirements. In addition, VA  mailed letters to all non-VA providers that had submitted claims during the  previous 2 years to inform them of these online resources. However,  none of the four non-VA providers included in our March 2014 review  recalled receiving the letter that VA mailed. Two non-VA providers were  familiar with the website, but one commented that it lacked some  necessary information and was not useful. None of these four non-VA  providers were aware of VA’s electronic newsletter, and VA officials  acknowledged that a very small percentage of the non-VA providers who  submit claims to VA had signed up for it. While these communications  have not always reached their intended audience, VA is continuing its  efforts to improve communications with non-VA providers. Specifically,  VA has been conducting satisfaction surveys to continue monitoring its  communications with non-VA providers and has been holding training  sessions for VA staff on improving outreach with non-VA providers.

Chairman Miller, Ranking Member Michaud, and Members of the  Committee, this completes my prepared statement. I would be pleased to  respond to any questions that you may have.

section_title: GAO Contact and Staff Acknowledgments
paragraphs: If you or your staffs have any questions about this statement, please  contact me at (202) 512-7114 or williamsonr@gao.gov. Contact points for  our Offices of Congressional Relations and Public Affairs may be found  on the last page of this statement. GAO staff who made key contributions  to this statement include Marcia A. Mann, Assistant Director; Emily Beller;  Cathleen Hamann; Katherine Nicole Laubacher; Alexis C. MacDonald;  and Jennifer Whitworth.

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Question-summary annotations: questions: question: What were GAO's findings on the Non-VA Medical Care Program?
answer: GAO's May 2013 report on the oversight and management of the Non-VA Medical Care Program found that the Department of Veterans Affairs (VA) does not collect data on wait times veterans face in obtaining care from non-VA providers.
child_questions: question: How does this lack of data impact VA?
answer: The lack of data on wait times limits VA's efforts to effectively oversee the Non-VA Medical Care Program because it is not possible for VA to determine if veterans who receive care from non-VA providers are receiving that care sooner than they would in VA facilities.
child_questions: question: How does a lack of data impact VA's ability to assess the cost-effectiveness of its program?
answer: In addition, GAO found that VA cannot assess the cost-effectiveness of non-VA medical care because it cannot analyze data on all services and charges for an episode of care, which is a combined total of all care provided to a veteran during a single office visit or inpatient stay.
child_questions: question: How is this inability to assess cost-effectiveness detrimental to VA?
answer: As a result, VA cannot determine whether delivering care through non-VA providers is more cost-effective than augmenting its own capacity in areas with high utilization of non-VA medical care.

questions: question: What were GAO's findings on the VA facilities visited?
answer: GAO's March 2014 report found patterns of noncompliance with applicable requirements for processing emergency care claims covered under the Veterans Millennium Health Care and Benefits Act (Millennium Act) at each of the four VA facilities visited.
child_questions: question: How did this noncompliance affect claims being processed?
answer: This led to the inappropriate denial of some claims and the failure to notify veterans that their claims had been denied at these facilities.
child_questions: question: What proportion of claims were affected?
answer: Specifically, GAO determined that about 20 percent of the 128 claims it reviewed had been denied inappropriately, and almost 65 percent of the reviewed claims lacked documentation showing that the veterans were informed their claims were denied and explained their appeal rights.

question: Why does GAO believe that this noncompliance will continue?
answer: GAO also found that there is significant risk that these patterns of noncompliance will continue because VA's existing oversight mechanisms do not focus on whether VA facilities appropriately approve or deny non-VA medical care claims or fail to notify veterans that their claims have been denied.

question: What is the purpose of the Millennium Act?
answer: The Millennium Act authorizes VA to cover emergency care for conditions not related to veterans' service-connected disabilities when veterans who have no other health plan coverage receive care at non-VA providers and meet other specified criteria.

question: How did VA react to GAO's review?
answer: As a result of GAO's review, the VA facilities reconsidered and paid 25 claims that they initially had inappropriately denied.

questions: question: What were GAO's findings on VA communication?
answer: GAO also reported in March 2014 that gaps exist in veterans' knowledge about eligibility criteria for Millennium Act emergency care, and communication weaknesses exist between VA and non-VA providers.
child_questions: question: How is veterans' lack of understanding of emergency care benefits potentially detrimental?
answer: Specifically, GAO found that veterans' lack of understanding about their emergency care benefits under the Millennium Act presents risks for potentially negative effects on veterans' health because they may forgo treatment at non-VA providers, and on veterans' finances because they may assume VA will pay for care in situations that do not meet VA criteria.

question: What was the result of VA's efforts to improve communications?
answer: Despite VA's efforts to improve communications, some non-VA providers reported instances in which VA facilities' claims processing staff were unresponsive to their questions about submitted claims.

questions: question: What is the purpose of this testimony?
answer: This testimony is based on two GAO reports and addresses the extent to which (1) VA collects reliable information on wait times and cost-effectiveness of the Non-VA Medical Care Program; (2) VA facilities comply with Millennium Act claims processing requirements and VA oversees claims processing activities; and (3) VA educates veterans about eligibility for Millennium Act emergency care and communicates with non-VA providers.
child_questions: question: How did GAO gather information for the preceding reports?
answer: For both reports, GAO reviewed relevant requirements and visited 10 VA facilities.
child_questions: question: How did information gathering differ between the two reports?
answer: For its report on the oversight and management of the Non-VA Medical Care Program, GAO reviewed non-VA medical care spending and utilization data from fiscal year 2008 through fiscal year 2012. For its report on the Millennium Act emergency care benefit, GAO reviewed 128 denied Millennium Act claims to determine the accuracy of processing decisions.