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. 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. 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. 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. 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. 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. 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. 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. 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. This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately.

Summary: In June 2018, Congress passed the VA MISSION Act of 2018, which requires VA to establish a permanent community care program. VA plans to consolidate the Choice Program and its other VA community care programs into one community care program—the VCCP. This legislation helps address some of the challenges faced by the Choice Program and VA's other community care programs. VA's implementation of the VCCP can benefit from the lessons learned under the Choice Program. Ignoring these lessons learned increases VA's risk for not being able to ensure that all veterans receive timely access to care in the community and that community providers are reimbursed in a timely manner. This testimony focuses on lessons learned from the Choice Program, including recommendations GAO has made to VA to help ensure (1) veterans' timely access to care under the VCCP (2) effective monitoring of veterans' access to care under the VCCP, and (3) timely payments to community providers under the VCCP. This testimony is based on GAO reports on the Choice Program that were issued in June 2018 and September 2018. The Department of Veterans Affairs' (VA) Veterans Choice Program (Choice Program) allows eligible veterans to obtain health care services from providers not directly employed by VA (community providers). The program is largely managed by third party administrators (TPA), who are responsible for establishing provider networks, scheduling veterans' appointments, and paying providers. GAO has identified the following challenges to the Choice Program that VA needs to address as it implements its new Veterans Community Care Program (VCCP). Factors that adversely affected veterans' timely access to care. GAO found that numerous factors adversely affected veterans' timely access to care through the Choice Program. These factors included (1) administrative burden caused by complexities of 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 intended to help address these factors, however, some have not been fully addressed. In June 2018, GAO made five recommendations to VA, including that VA establish a system that will facilitate care coordination and exchanges of information among VA medical facilities, VA clinicians, TPAs, community providers, and veterans. VA agreed or agreed in principle with all five recommendations, but has not yet implemented them. Unavailable and unreliable data. GAO found that VA cannot systematically monitor the timeliness of veterans' access to Choice Program care because it lacks complete, reliable data to do so. The data limitations GAO identified included a lack of data on the timeliness of accepting referrals and opting veterans in to the program, inaccurate data on clinically indicated dates (which are used to measure the timeliness of care), and unreliable data on the timeliness of urgent care. In June 2018, GAO made five recommendations to VA, including that VA implement mechanisms to allow VA to systematically monitor the amount of time taken to prepare referrals, schedule appointments, and complete appointments. VA agreed with four of the five recommendations, but has not yet implemented them. Untimely payments to community providers. GAO identified three key factors that affected timeliness of payments to community providers under the Choice Program. These factors included (1) VA's untimely payments to TPAs, which in turn extended the length of time TPAs took to pay providers' claims; (2) Choice Program reimbursement requirements, which led to claim denials; and (3) inadequate provider education on filing claims. GAO found that VA has taken actions to address the factors, such as amending certain reimbursement requirements. However, two of these factors have not been fully addressed. In September 2018, GAO made two recommendations to VA, including that VA collect data on and monitor compliance with its requirements pertaining to customer service for community providers. VA agreed with the recommendations, but has not yet implemented them. GAO has made 12 recommendations to VA to improve its management and oversight of the Choice Program and the VCCP. VA generally agreed with all but one of GAO's recommendations. GAO continues to believe that all of the recommendations are warranted. As of April 2019, these recommendations have not been implemented.