Audit of Selected VHA Non-Institutional Purchased Home Care Services

We assessed whether the Veterans Health Administration (VHA) effectively managed non-institutional purchased home care services to ensure eligible veterans receive entitled services. We audited these services because of their expected growth, budgeted to increase to $798 million in FY 2013. VHA's Non-Institutional Care program allows veterans to receive VA and contractor-provided services in the least restrictive environment possible. Under purchased home care, contract agencies provide veterans with home health aide or other skilled care services in their homes. We estimated VHA’s waiting lists did not include at least 49,000 veterans who had purchased home care needs in FY 2012. We projected that 114 VA medical facilities limited access to purchased home care services through the use of more restrictive eligibility criteria than VHA policy required, applying nonstandard review processes, and relying on inaccurate and nonstandard eligibility information. We found VA facilities added requirements to limit veterans’ access and did not always use required waiting lists to track eligible veterans. This occurred because VA medical facility officials limited the costs of services paid through fee service, relied on inaccurate eligibility information for skilled care services, and redirected funds towards higher priorities. VHA redistributed $76 million, VA medical facilities spent $99 million less than VA had budgeted for these services, and VHA did not meet its target to increase the average daily census for these services in FY 2012. VA medical facilities’ staff also did not identify 31 ineligible agencies and properly manage 19 high-risk agencies, who were providing care to these veterans. Fee staff did not always verify billings before paying for services, resulting in $67,000 in improper payments. Without actions to strengthen controls, VHA could pay ineligible agencies about $893.5 million and make just over $13.2 million in improper payments over the next 5 years. We recommended the Under Secretary for Health standardize the application of eligibility reviews and criteria and strengthen controls to ensure eligible patients receive purchased home care services. We also recommended that VHA adequately review and monitor agencies and properly document and use orders verify payments. The Under Secretary for Health concurred with our recommendations and provided responsive action plans, but had concerns about our sampling methodology and statistical analysis.