VA Spina Bifida Program: Outreach to Key Stakeholders and Written Guidance for Claims Audit Follow-up Activities Needed
Released: 2014-06-23T00:00:00

Letter

Background

SBA officials estimate that, nationally, there are more than 160,000 individuals living with spina bifida. The proportion of those individuals who are children of Vietnam veterans is unknown, due to a lack of data on the prevalence of spina bifida in this population. As of October 2013, there were 1,228 beneficiaries enrolled for coverage under the spina bifida program, ranging from 13 to 50 years of age; the majority of beneficiaries were adults aged 35 through 45.

Spina Bifida Condition and Related Health Care Needs

Spina bifida is a complex congenital disorder that affects multiple body systems. People with spina bifida experience a variety of health problems, including difficulty with lower body mobility, lack of bowel and bladder control, hydrocephalus (a condition in which fluid builds up in the brain), and learning disabilities. As a result, these individuals require care from providers in a variety of specialties, such as orthopedics, urology, neurosurgery, and psychiatry.

Individuals with spina bifida face additional health concerns as they age, including a higher risk for obesity and obesity-related illnesses, depression, early osteoporosis, and pressure ulcers. Many of these health concerns are linked to the diminished mobility that comes with physical disability. In addition to physical disability, adults with spina bifida often face difficulty with executive function. Executive function is defined as a set of mental processes that helps connect past experience with present action, and is used to perform activities such as planning, organizing, strategizing, paying attention to and remembering details, and managing time and space. Difficulty with these mental processes can inhibit the independence of individuals with spina bifida, and their ability to manage their own care. Although studies have found that adults with spina bifida would benefit from access to coordinated care provided in multidisciplinary clinics because of their complex health needs, the availability of such care for adults is extremely limited.

VA’s Spina Bifida Benefits

VA’s Veterans Benefits Administration (VBA) determines eligibility for spina bifida benefits, including both health care and other benefits. Once a beneficiary is deemed eligible for benefits, VBA assigns a disability rating using criteria outlined in regulation, which entitles beneficiaries to monthly monetary payments similar to those provided to disabled veterans, as well as vocational rehabilitation and education services provided through VBA. Regardless of disability rating, beneficiaries are then automatically enrolled for health care benefits in VHA’s spina bifida program, which is operated by VHA’s Chief Business Office for Purchased Care (CBOPC).

VA is required to provide certain health care benefits—including home care, hospital care, nursing home care, outpatient care, preventive care, habilitative and rehabilitative care, case management, and respite care— for spina bifida beneficiaries. Regulations for the spina bifida program provide additional details on covered services and supplies and outline preauthorization requirements for certain services. VHA recently sought to clarify the scope of its authority to provide home care and custodial care services under the spina bifida program.General Counsel issued an opinion confirming that VHA is required to provide coverage for these services, as needed, in the beneficiary’s home or other place of residence (such as a residential group home or assisted- In June 2013, VA’s living facility). As of April 2014, VHA was in the process of drafting a proposed rule incorporating this clarification into regulations.

VHA Informs Enrolled Beneficiaries about Covered Services, but Has Conducted Limited Outreach with Key Stakeholders

VHA provides information and updates on covered health care services to enrolled spina bifida beneficiaries. However, VHA has conducted limited outreach with key stakeholder groups that have a relationship with potentially eligible individuals who are not already enrolled.

VHA Provides Information and Updates to Enrolled Spina Bifida Beneficiaries on Covered Health Care Services

VHA provides information on the available health care benefits to beneficiaries who are enrolled in its spina bifida program using three primary methods: (1) the initial mailing of information upon program enrollment, (2) the program website, and (3) contact with beneficiaries regarding updates to covered services.

Initial contact by mail. After beneficiaries are enrolled in the spina bifida program, VHA’s CBOPC staff mail beneficiaries (1) a program identification card (similar to an insurance card from a and private insurer) that providers can use to bill VHA directly,(2) a copy of the program handbook, which contains information on services covered and services that are generally excluded from coverage, as well as contact information and the website address for the program. VHA officials told us they enroll, on average, about one or two new beneficiaries per month.

Program website. The spina bifida program website includes links to the program handbook, the policy manual—which provides additional details on coverage and exclusions for specific services—and other program documents such as guidance on how to submit claims. VHA officials told us they consider the program website to be the primary means of outreach with beneficiaries.

Phone or mail contact to provide updates on covered services. VHA has recently shared changes to its spina bifida program with beneficiaries through telephone calls, and VHA officials told us they plan to share updates made between handbook printings through mailings to beneficiaries. Specifically, beginning in November 2013, VHA’s call center placed phone calls to enrolled spina bifida beneficiaries to gauge their interest in obtaining case management services.March 2014, the call center successfully made contact with 579 beneficiaries (47 percent of those enrolled) and 129 of them expressed interest in obtaining case management services.

According to VHA, as of In addition to asking about case management services, VHA officials told us that during these calls, they also provided clarification that the program covers home care and custodial care services. After the program regulations are updated to reflect the June 2013 opinion from VA’s General Counsel regarding coverage of these services, the program handbook will be updated and mailed out to enrolled beneficiaries, according to VHA officials.

Officials told us that they also plan to follow up with a letter in May 2014 to provide clarification on the program’s coverage for home care and custodial care services, as well as case management.

VHA Has Conducted Limited Outreach with Key Stakeholders regarding Spina Bifida Benefits

VHA has conducted limited outreach with key stakeholder organizations, and representatives of these organizations told us that this has contributed to lack of awareness among some individuals who may be eligible to receive health care benefits under the spina bifida program. VHA’s outreach with stakeholder organizations has been limited primarily to providing materials on the program to veteran service organizations for distribution at conferences. For example, VHA officials told us they provided materials for conferences held by four different veteran service organizations in the summer of 2013. However, VHA has not conducted outreach with VVA and SBA—the two key stakeholder organizations that we contacted—in recent years. Specifically, representatives from VVA— an organization that represents veterans who served in Vietnam and advocates on their behalf regarding a variety of issues, including health care—told us that VHA has not reached out to them regarding its spina bifida program, and has not provided them any materials regarding available health care benefits to distribute to their membership. VHA officials told us that they have met with VVA officials to explain updates to covered services, but stated that their outreach efforts with stakeholder organizations are driven by requests from the organizations, and they were not certain if VVA had requested further outreach. VHA’s most recent coordination with SBA—an organization with direct contact with individuals with spina bifida, their families, and the providers who treat them—was in 2009. VHA officials told us that they coordinated with SBA that year by staffing a resource education booth at SBA’s annual conference. VHA officials also told us that limits on travel spending have prevented them from attending or participating in the conference in recent years.

Limited outreach with key stakeholder organizations has contributed to the lack of awareness about available health care benefits among some individuals who may be eligible to enroll in the spina bifida program, according to representatives from these organizations. Specifically, representatives from VVA told us that through VVA’s Agent Orange Education Campaign they identified new individuals who were potentially eligible for VHA’s spina bifida program and its benefits, but were not aware of them.regularly contacted by individuals who have questions about VHA’s spina bifida program benefits and do not know where to go for more information. Although SBA includes information on its website about VHA’s spina bifida program benefits, when we reviewed this page in April 2014, we found that it contained outdated information.

In addition, representatives from SBA told us they are Federal internal control standards state that agency management should ensure there are adequate means of communicating with, and obtaining information from, external stakeholders that may have a significant impact on the agency achieving its goals.of the spina bifida program is to provide for the special needs of Vietnam and certain other veterans’ birth children who have been diagnosed with spina bifida. Key stakeholder organizations are well-positioned to provide information to these individuals on available benefits because of their established relationships with veterans and individuals with spina bifida and their health care providers. However, VHA has not leveraged these organizations’ relationships with potentially eligible individuals to further VHA’s goal of providing for the special needs of beneficiaries with spina bifida.

According to VHA officials, the goal Representatives from both VVA and SBA stated that they would be willing to coordinate with VHA on efforts that could improve awareness and understanding of VHA’s spina bifida program. For example, VVA officials told us that they could help VHA promote the health care benefits available through the spina bifida program, including providing information on the benefits through their weekly emails to subscribers. VVA officials also suggested that outreach with providers or provider organizations would be beneficial because it would increase awareness of the connection between military service and certain health issues, such as spina bifida, among individuals who are the “first line” in interacting with patients. Similarly, according to an SBA representative, SBA could facilitate the connection between VHA and health care providers who serve individuals with spina bifida. These providers could help identify spina bifida patients who have a Vietnam-era veteran parent, and provide those individuals with information about VHA’s health care benefits for which they may be eligible.

VHA Uses an Automated System Augmented by Administrative and Clinical Reviews to Process Spina Bifida Claims

VHA uses an automated system, augmented by administrative and clinical reviews, to process spina bifida claims. The claims process begins when a provider or beneficiary submits an electronic or paper claim to VHA. Upon receipt, the claim’s information is to be entered into an automated claims processing system maintained by VHA’s CBOPC.necessary, staff members conduct administrative or clinical reviews before denial or payment decisions are made. VHA also has a process for reconsideration of denied claims.

Automated claims processing. CBOPC’s automated claims processing system uses business rules to compare the information in the claim against the spina bifida program’s policies and regulations for eligibility and covered services. For example, VHA officials told us the system checks the date of service against the date the beneficiary was determined to be eligible for the spina bifida program.

Administrative and clinical review. If the automated system cannot complete the processing of a claim because it detects an error or needs additional documentation or approval to continue with processing, VHA officials told us a CBOPC staff member conducts an administrative or clinical review. In an administrative review, a staff member examines a claim to ensure that required documentation (e.g., required preauthorization for mental health services) has been received. In a clinical review, the claim is reviewed by a clinical nurse reviewer to ensure that medical documentation included is sufficient for processing the claim.example, a clinical nurse reviewer could examine documentation included with a claim for specialized durable medical equipment to ensure it is sufficient to support the request, and request additional documentation if necessary.

Payment or denial. Once the automated system has completed its checks, and any needed administrative or clinical reviews are completed, the claim is either routed for payment or it is denied. For a denied claim, the automated system or reviewer assigns a denial reason code to the claim, which provides a brief description of the cause of the denial (e.g., missing documentation or the service billed was not a covered service). This information is included in the explanation of benefits document mailed to the provider and beneficiary.

Resubmission or request for reconsideration. A provider or beneficiary who disagrees with the amount of payment or the decision to deny the claim can resubmit the claim for reprocessing, or submit a request for reconsideration of the claim to CBOPC within 1 year of the original decision. Resubmission of claims for reprocessing is separate from the claims reconsideration process. A resubmitted claim must include the original explanation of benefits and any other relevant documentation or corrections for consideration, and resubmitted claims are sent through the claims processing system as new claims. VHA officials told us that requests for reconsideration are processed outside of the automated claims processing system, and are reviewed by CBOPC staff with consultation from clinical nurse reviewers as needed. A request for reconsideration that is subsequently denied can be submitted for a second review within 90 days. Each claim’s explanation of benefits document provides contact information for CBOPC and the mailing address for requests for reconsideration.

VHA updates the business rules used by its automated claims processing system in accordance with changes to the applicable laws and regulations that govern coverage of specific services. VHA officials told us that these updates are not made until the rulemaking process is complete and applicable rules have been published in the Federal Register, a process that can take years. In the interim, officials said affected claims— such as those for home care services provided in an assisted-living facility, which VHA recently clarified as covered—would be processed manually to ensure they are not incorrectly denied by the automated system.

Total Spina Bifida Claims Payments and Number of Claims Paid Have Increased from Fiscal Years 2009 through 2013, with Outpatient Services Making Up the Majority of Claims

From fiscal years 2009 through 2013, total payments for spina bifida claims increased by 43 percent—from about $19.4 million to about $27.8 million. (See table 1.) The number of beneficiaries who had claims paid increased by 10 percent, from 803 to 883, and the number of paid claims increased by 45 percent, from 58,560 to 84,702.

VHA officials told us they attribute the growth in the spina bifida program to an increasing number of claims and payments in the years following the 2008 legislative expansion of health care coverage under the program, as well as increasing health care costs for beneficiaries as they age and their health care needs become more varied and complex. Officials told us that, in the future, they expect spending on health care services to continue to increase due to new services being offered, such as custodial care. However, they do not expect significant increases in the number of beneficiaries because there are few new children with spina bifida born to Vietnam-era veterans and currently proposed expansions of coverage to new eligibility groups are not likely to add significantly to program enrollment.

In fiscal years 2009 through 2013, the percentages of paid and denied claims remained steady, with paid claims representing about 90 percent of all claims submitted each fiscal year. For example, out of 95,149 claims submitted in fiscal year 2013, 84,702 (89 percent) were paid. (See fig. 1.)

About two-thirds of the total number of paid claims in each year from fiscal years 2009 through 2013 were for outpatient services, the largest of the six categories tracked by VHA. For example, in fiscal year 2013, 63 percent of the total number of paid claims were for outpatient services. (See fig. 2.) Outpatient services represented nearly 50 percent of total payments made that year. In contrast, inpatient claims represented less than 1 percent of the total number of paid claims in fiscal year 2013, but 31 percent of total claims payments that fiscal year.

In our analysis of VHA’s outpatient procedure code data, we determined that home care services, physician visits, physical therapy services, and catheters and other incontinence supplies for spina bifida beneficiaries were commonly reimbursed outpatient services in fiscal year 2013. Studies we reviewed and experts we interviewed confirmed that these services and supplies were consistent with the health care needs of adults with spina bifida.

Home care services. Although the specific health care needs of adults with spina bifida can vary widely based on the severity of their condition, officials from SBA told us that home-based services are important because of the challenges these individuals face with executive functioning and limited mobility. Since many adults with spina bifida rely on wheelchairs and have varying degrees of mobility, traveling to medical appointments can be challenging.

Physician visits. Due to the various health problems associated spina bifida (including musculoskeletal, neurological, and urological health care needs), medical care for adults with spina bifida involves visits to numerous physicians—both for primary and specialty care.

Physical therapy services. A study noted that adults with spina bifida commonly report chronic pain as a result of the body mechanics involved in wheelchair propulsion. Another study noted that physical disability, and the reduced physical activity that results from it, is a risk factor for early onset osteoporosis in adults with spina bifida. Physical therapy services can help alleviate pain and maintain physical functioning for adults with spina bifida.

Catheters and other incontinence supplies. According to SBA officials, a common health care issue for individuals with spina bifida is neurogenic bladder and bowel, in which the nerves in this area of the body do not function properly, leading to ongoing issues with incontinence and urinary tract infections, and potentially renal failure in older populations. Studies we reviewed, as well as SBA’s spina bifida treatment guidelines, noted the need for continence management programs for individuals with spina bifida, including daily intermittent catheterization to improve renal outcomes.

VHA officials told us that a claim is considered denied if all procedure codes included in the claim are denied; if some procedure codes are paid and some are denied, the claim is considered a paid claim. Therefore, the number of denied claims does not reflect all procedure codes that were denied in a given year. service or hospital discharge), or the need for additional documentation.Specifically, in fiscal year 2013, about 90 percent of denied claims were denied for administrative reasons. Few claims were denied because the service was not covered or the beneficiary was ineligible for coverage (less than 3 percent of all denied claims in fiscal year 2013). For example, one denied claim we reviewed was for an eye exam—eye exams and glasses are excluded from coverage per spina bifida program policy. Another denied claim we reviewed was for durable medical equipment. A beneficiary requested payment for a device that, via remote control, could automatically open a door in the home. This claim was denied because VHA does not provide payment for durable medical equipment that is used for housing modification.

Few denied claims were submitted for reconsideration. Of the 136 requests for reconsideration in fiscal years 2009 through 2013, 50 (37 percent) were subsequently paid. Specifically, in fiscal year 2013, there were 35 requests for reconsideration, 15 of which were subsequently paid.

VHA Primarily Uses Claims Audits to Oversee Its Spina Bifida Claims Process, but Does Not Have Written Guidance for Audit Follow-up

VHA conducts annual audits of spina bifida program claims, and VHA officials told us these audits and associated audit follow-up activities are Auditors from the the primary means of oversight for the claims process.VHA CBOPC’s Department of Audits & Internal Controls conduct audits of the spina bifida claims process annually. During the audit, auditors examine a statistically valid sample of paid claims from the previous quarter. The purpose of these audits is to identify whether claims were processed and paid accurately according to spina bifida program policy.

VHA officials told us these audits involve auditors retracing all the steps in the claims approval and payment process to determine whether all claims-related decisions were correct. For example, auditors may review comments from clinical nurse reviewers regarding preauthorization determinations and re-run automated decision-making associated with selected claims through a testing program. Any inaccurate processing identified by the auditors that results in an improper payment (an over- or under-payment on a claim) is recorded as an error and assigned to a category, such as duplicate payments, lack of supporting documentation, or non-compliance with policies and procedures. For example, the fiscal year 2014 audit (of the fourth quarter of fiscal year 2013 claims) had a claims processing accuracy rate—the percentage of claims processed correctly—of 98.4 percent and a proper payment accuracy rate—the percentage of total payments made correctly—of 99.9 percent. Specifically, the audit identified three claims with errors—two claims that should have been denied as duplicates but were not (resulting in overpayments), and one claim where a data entry error resulted in an incorrect payment amount.

After the audit is complete, auditors meet with relevant staff to determine the underlying causes of improper payments and other inaccuracies. An audit representative also presents the audit’s findings to an audit review committee, which includes senior CBOPC officials who discuss the root causes of findings and decide on any necessary follow-up activities. Auditors then complete a report that documents the audit’s findings, including corrective actions and recommendations. The audit report’s corrective actions directly address the errors found in the audit. For example, VHA collects overpayments or pays providers for underpayments. Audit report recommendations suggest additional actions such as training or additional resources that should be made available to increase processing accuracy moving forward.

There is currently no written guidance on how CBOPC staff are to document the status of audit follow-up activities—corrective actions and recommendations outlined in audit reports—to ensure their completion. VHA officials told us that, beginning with the fiscal year 2014 audit, staff from CBOPC’s Quality/Corrective Action Program are responsible for overseeing the status of audit follow-up activities, including working with relevant staff responsible for implementing any corrective actions.

According to VHA officials, these staff are responsible for determining the extent of documentation necessary for audit follow-up activities. Officials also stated that these staff store any documentation in non-networked files. This can render audit follow-up documentation inaccessible to other VHA officials who may need it. Further, although staff maintain information on the status of actions taken to implement audit findings and the individuals responsible for implementing them, they do not maintain information on estimated or actual completion dates for audit follow-up activities. There also is no documentation of interactions with staff or interim steps taken to ensure that follow-up activities are completed as planned. For example, officials told us that for one of the identified actions, there would be monthly follow-ups until the action is complete; however, there is no documentation to indicate that this interim follow-up is taking place. According to VHA officials, one reason for the lack of written guidance on completing and documenting audit follow-up activities is that their audit follow-up process is new; they anticipate having written guidance drafted by August 2014.

Federal internal control standards state that internal controls should be documented and all documentation should be properly managed and These standards also maintained, and readily available for examination.state that agencies should have policies and procedures for ensuring that the findings of audits and other reviews are promptly resolved. VHA’s lack of written guidance for audit follow-up activities places VHA at increased risk that these internal control activities may not be performed, may be performed inconsistently, or may not be continued when knowledgeable employees leave. This can lead to unreliable monitoring of the spina bifida claims process, including the inability to ensure that all necessary audit follow-up activities are completed.

Conclusions

The legislation that created VA’s spina bifida benefits charged VHA with serving the needs of a very vulnerable population. Given the lack of data on the prevalence of spina bifida in the children of veterans, and concerns from stakeholder organizations that potentially eligible individuals may not be aware of available benefits under the spina bifida program, stakeholder organizations are uniquely positioned to assist VHA in communicating information on spina bifida benefits. By not conducting outreach with key stakeholders, VHA may be missing important opportunities to increase awareness among potentially eligible individuals, and ultimately to help these individuals obtain the benefits to which they may be entitled.

In addition, without written guidance for audit follow-up activities related to the spina bifida claims process, VHA cannot be assured that these activities have been successfully completed or that the corrective actions and recommendations outlined in audit reports have been appropriately implemented. The lack of written guidance puts VHA at increased risk that these activities may be inconsistently performed—or not performed at all—if there are personnel changes. By developing written guidance for documenting these activities in a manner consistent with federal internal control standards, VHA would have greater assurance that audit follow-up activities are consistently completed, thereby helping to ensure that spina bifida beneficiaries’ health care claims continue to be accurately processed.

Recommendations for Executive Action

To improve awareness of the spina bifida program’s health care benefits among potentially eligible individuals and to help them obtain the benefits to which they may be entitled, we recommend that the Acting Secretary of Veterans Affairs direct the Acting Under Secretary for Health to conduct outreach with key stakeholder groups regarding the program and its benefits.

To help ensure continued accurate claims processing, we recommend that the Acting Secretary of Veterans Affairs direct the Acting Under Secretary for Health to develop written guidance, consistent with federal internal control standards, for completing and documenting the status of follow-up activities for the spina bifida program’s claims audits.

Agency Comments

We provided a draft of this report to VA for comment. In its written comments, reproduced in appendix I, VA generally agreed with our conclusions and concurred with our recommendations. In addition, VA provided information on its plans for implementing each recommendation, with an estimated completion date of December 2014.

We are sending copies of this report to appropriate congressional committees, the Acting Secretary of Veterans Affairs, and other interested parties. In addition, the report will be available at no charge on the GAO Web site 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.

Appendix I: Comments from the Department of Veterans Affairs

Appendix II: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

In addition to the contact named above, Janina Austin, Assistant Director; Jennie F. Apter; George Bogart; Vikki L. Porter; Julie T. Stewart; and Malissa G. Winograd made key contributions to this report.