Veterans Health Care: VA Needs to Address Challenges as It Implements the Veterans Community Care Program
Released: 2019-04-10T00:00:00

Letter

Background

The Veterans Access, Choice, and Accountability Act of 2014 provided up to $10 billion in funding for veterans to obtain health care services from community providers through the Choice Program when veterans faced long wait times, lengthy travel distances, or other challenges accessing care at VA medical facilities. The temporary authority and funding for the Choice Program was separate from other previously existing programs through which VA has the option to purchase care from community providers. Legislation enacted in April, August, and December of 2017 and June 2018 extended the Choice Program and provided an additional $9.4 billion for the Veterans Choice Fund. Authority for the Choice Program will sunset on June 6, 2019.

Responsibilities of the Choice Program’s Third Party Administrators

In October 2014, VA modified its existing contracts with two contractors— referred to as third party administrators (TPA)—that were administering another VA community care program to add certain administrative responsibilities associated with the Choice Program. For the Choice Program, each of the two TPAs—Health Net and TriWest—was responsible for managing networks of community providers who deliver care in a specific multi-state region. Specifically, the TPAs were responsible for establishing networks of community providers, scheduling appointments with community providers for eligible veterans, and paying community providers for their services. Health Net’s contract for administering the Choice Program ended on September 30, 2018, with TriWest continuing to administer the Choice Program in its region and the region previously administered by HealthNet until the program ends.

Process for Choice Program Appointment Scheduling

Through policies and standard operating procedures for VA medical facilities and contracts with the TPAs, VA established processes for referring and scheduling appointments through the Choice Program: one process for time-eligible veterans and another for distance-eligible veterans. Table 1 provides an overview of the appointment scheduling process that applies when a veteran is referred to the Choice Program because the veteran is time-eligible—that is, the next available medical appointment with a VA clinician is more than 30 days from the veteran’s preferred date or, in the absence of such a date, the date the veteran’s physician determines he or she should be seen.

When veterans reside more than 40 miles from a VA medical facility or meet other travel-related criteria, VA uses the appointment scheduling process it developed for distance-eligible veterans. The process for distance-eligible veterans differs from that for time-eligible veterans in that VA medical facilities do not prepare a referral and send it to the TPA.

Instead, distance-eligible veterans contact the TPA directly to request Choice Program care.

Choice Program Claim Processing and Payment

VA’s Choice Program TPA processes claims it receives from community providers for the care they deliver to veterans and pays providers for approved claims. Figure 1 provides an overview of the steps the TPA follows for processing claims and paying community providers.

To be reimbursed for its payments to providers, the TPA in turn submits electronic invoices—or requests for payment—to VA. The TPA generates an invoice for every claim it receives from community providers and pays. VA reviews the TPA’s invoices and either approves or rejects them. Invoices may be rejected, for example, if care provided was not authorized. Approved invoices are paid, whereas rejected invoices are returned to the TPA. Under the Prompt Payment Act, VA is required to pay its TPAs within 30 days of receipt of a clean Choice Program invoice.

VA’s Planned Veterans Community Care Program

The VA MISSION Act of 2018, among other things, requires VA to establish a permanent community care program no later than 1 year after passage of the Act (June 6, 2019) and authorizes VA to utilize a TPA for claims processing. VA refers to the consolidated program as the VCCP. In December 2016, prior to enactment of the VA MISSION Act of 2018, VA issued a request for proposals for contractors to help administer the VCCP. The VCCP will be similar to the current Choice Program in certain respects. For example, under the VCCP, TPAs will be responsible for establishing regional networks of community providers and processing and paying those providers’ claims. However, unlike the Choice Program, under the VCCP, VA is planning to have medical facilities—not the TPAs—generally be responsible for scheduling veterans’ appointments with community providers. VA awarded contracts for administering the VCCP in three of six regions on December 28, 2018. As of April 3, 2019, VA had not yet awarded contracts for the remaining three regions.

Generally, all veterans enrolled in the VA health care system would be able to qualify for care through the VCCP when (1) VA does not offer the care or service required by the veteran; (2) the veteran resides in a state without a full-service VA medical facility; (3) the veteran would have been eligible under the 40-mile criterion of the Choice Program before June 6, 2018; (4) VA cannot provide the veteran with care and services that comply with its designated access standards; or (5) the veteran and the veteran’s referring clinician agree that it is in the best interest of the veteran to receive care in the community. In January 2019, VA proposed new access standards for the VCCP based on average drive times and wait times:

For primary care, mental health, and non-institutional extended care services, VA is proposing a 30-minute average drive time standard.

For specialty care, VA is proposing a 60-minute average drive time standard.

VA is proposing appointment wait-time standards of 20 days for primary care, mental health care, and non-institutional extended care services, and 28 days for specialty care from the date of request with certain exceptions.

Eligible veterans who cannot access care within those standards would be able to choose between eligible community providers and care at a VA medical facility. VA expects to issue the final regulation establishing access standards for the VCCP by June 2019.

VA Needs to Address Various Factors That Adversely Affected Veterans’ Access to Care through the Choice Program to Help Ensure Timely Care under the VCCP

In June 2018, we reported that numerous factors adversely affected veterans’ timely access to care through the Choice Program and could affect implementation of the VCCP. These factors included the following: (1) administrative burden caused by complexities of VA’s referral and appointment scheduling processes; (2) poor communication between VA and its medical facilities; and (3) inadequacies in the networks of community providers established by the TPAs, including an insufficient number, mix, or geographic distribution of community providers. VA has taken steps to help address these factors; however, not all access factors have been fully addressed. For example, to help address administrative burden and improve the process of coordinating veterans’ Choice Program care, VA established a secure e-mail system and a mechanism for TPAs and community providers to remotely access veterans’ VA electronic health records. However, these mechanisms only facilitate a one-way transfer of necessary information. They do not provide a means by which VA medical facilities or veterans can view the TPAs’ step-by-step progress in scheduling appointments or electronically receive medical documentation associated with Choice Program appointments.

We made five recommendations to VA to address the factors that adversely affected veterans’ access to Choice Program care. VA agreed or agreed in principle with all five recommendations. Our recommendations and the steps, if any, VA has taken in response to these recommendations are described in table 2.

VA Needs Complete and Reliable Data to Effectively Monitor Veterans’ Access to Care under the VCCP

In June 2018, we reported that VA cannot systematically monitor the timeliness of veterans’ access to Choice Program care because it lacks complete, reliable data to do so. VA will need to address these data limitations in order to effectively monitor the care delivered to veterans through the VCCP. The data limitations we identified included the following:

A lack of data on the timeliness of accepting referrals and opting veterans in to the program. We found that the data VA uses to monitor the timeliness of Choice Program appointments do not capture the time it takes VA medical facilities to prepare veterans’ referrals and send them to the TPAs, nor do they capture the time spent by the TPAs in accepting VA medical facilities’ referrals and opting veterans in to the Choice Program. VA had implemented an interim solution to monitor overall wait times that relies on VA medical facility staff consistently and accurately entering unique identification numbers on VA clinicians’ requests for care and on Choice Program referrals, a process that is prone to error.

Inaccuracy of clinically indicated dates. We found that clinically indicated dates (used to measure the timeliness of care) are sometimes changed by VA medical facility staff before they send Choice Program referrals to the TPAs, which could mask veterans’ true wait times. We found that VA medical facility staff entered later clinically indicated dates on referrals for about 23 percent of the 196 authorizations we reviewed. It is unclear if VA medical facility staff mistakenly entered incorrect dates manually, or if they inappropriately entered later dates when the VA medical facility was delayed in contacting the veteran, compiling relevant clinical information, and sending the referral to the TPA.

Unreliable data on the timeliness of urgent care. We found that VA medical facilities and TPAs do not always categorize Choice Program referrals and authorizations in accordance with the contractual definition for urgent care. According to the contracts, a referral is to be marked as “urgent,” and an appointment is to take place within 2 business days of the TPA accepting it, when a VA clinician has determined that the needed care is (1) essential to evaluate and stabilize the veteran’s condition, and (2) if delayed would likely result in unacceptable morbidity or pain. We reviewed a sample of 53 urgent care authorizations and determined that about 28 percent of the authorizations were originally marked as routine care authorizations but were changed to urgent by VA medical facility or TPA staff, in an effort to administratively expedite appointment scheduling.

We made five recommendations to VA on improving the completeness and accuracy of data on veterans’ wait times for care. VA agreed with four of the five recommendations. Our recommendations and the steps VA has taken in response to these recommendations are described in table 3.

Further Improvements Are Needed to Help Ensure Timely Payments to Community Providers

In September 2018, we reported that three key factors affected timeliness of payments to community providers under the Choice Program and that if unaddressed could affect provider payment timeliness for the VCCP. These factors included the following: (1) VA’s untimely payments to TPAs, which in turn extended the length of time TPAs took to pay community providers’ claims; (2) Choice Program reimbursement requirements, which led to claim denials; and (3) inadequate provider education on filing claims. We reported that VA has taken some actions to address these factors. For example, VA updated its payment system and related processes to pay TPAs more quickly. According to VA data, as of July 2018, VA was paying at least 90 percent of the TPAs’ invoices within 7 days, a significant increase from the 50 percent timely payments VA made to TPAs between November 2014 and September 2016. In addition, VA and the TPAs had taken steps to amend certain reimbursement requirements and improve provider education to help providers resolve claims processing issues.

However, we found that VA has not fully addressed two of these factors. First, with respect to reimbursement requirements, VA does not have complete data allowing it to effectively monitor adherence with its policy for VA medical facilities to perform timely reviews and approvals of secondary authorization requests. Community providers request secondary authorization requests when veterans need health care services that exceed the period or scope of the original authorization. Incomplete data impacted VA’s ability to meet the requirement. When VA medical facilities delay these reviews and approvals, community providers may have to delay care or deliver care that is not authorized, which in turn increases the likelihood that the providers’ claims will be denied and the providers will not be paid. Second, with respect to provider education on filing claims, VA requires the TPAs to establish a customer call center to respond to calls from veterans and non-VA providers. However, VA does not enforce the contractual requirement for responding to calls from community providers and allows the TPAs to prioritize calls from veterans over calls from community providers. Consequently, VA is not collecting data, monitoring, or enforcing compliance with its contractual requirements for the TPAs to provide timely customer service to providers. As a result, VA does not have information on the extent to which community providers face challenges when contacting the TPAs about claims payment issues, which could contribute to the amount of time it takes to receive reimbursement for services.

To address remaining factors that affect provider payment timeliness, we made two recommendations to VA. VA agreed with both recommendations. Our recommendations and the steps VA has taken in response to these recommendations are described in table 4.

In summary, consolidating its existing community care programs into the VCCP and launching this new program in June 2019 is a large and complex undertaking, which comes with many risks and challenges for VA. Heeding the lessons learned from its implementation and management of the Choice Program will better position VA to ensure veterans receive timely access to care under the VCCP and avoid past challenges such as delays in scheduling appointments and untimely payments to community providers. Continued oversight of VA’s implementation of the VCCP will be critical given the scale of change and the associated risks. We stand ready to assist this Committee with this continued oversight.

Chairman Isakson, Ranking Member Tester, and Members of the Committee, this concludes my prepared statement. I would be pleased to respond to any questions you may have.

GAO Contacts and Staff Acknowledgments

If you or your staff members have any questions concerning this testimony, please contact me at (202) 512-7114 or silass@gao.gov. Contact points for our Office of Congressional Relations and Public Affairs may be found on the last page of this statement. Other individuals who made key contributions to this testimony include Marcia Mann (Assistant Director), Michael Zose (Analyst-in-Charge), Jacquelyn Hamilton, Christina Ritchie, Kate Tussey, and Emilie Weisser.

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