Audit of Non-VA Medical Care Claims for Emergency Transportation

We conducted this audit to determine the accuracy of payments for Veterans Health Administration’s (VHA) non-VA medical care emergency transportation claims. The Non VA Medical Care Program assists veterans who cannot feasibly receive care at a VA medical facility. Inaccurate payments affect VA’s commitment to delivering timely and high quality health care to veterans while controlling costs. VHA’s Non-VA Medical Care Program improperly paid 129 of 353 (37 percent) emergency transportation claims from April 1, 2013, through September 30, 2013. Of the total 353 payments valued at $585,800, the 129 improper payments amounted to $167,600. Non-VA medical care staff made the following improper payments: (1) $19,300 for 27 of 353 claims (8 percent) to vendors that submitted a claim or required documentation untimely; (2) $25,000 for 7 of 353 claims (2 percent) for care provided to ineligible veterans; and (3) $123,300 for 95 of 353 claims (27 percent) for the incorrect amount. These claims were improperly paid because staff did not conduct an adequate review to ensure that all documentation was received prior to processing the claim and did not correctly determine veterans’ eligibility for emergency transportation. Staff also misunderstood the criteria for processing non-service and service-connected emergency transportation claims. As a result, we projected an annual improper payment amount of approximately $11.2 million. Over the next 5 years, we projected improper payments of approximately $56.2 million if claims processing controls are not strengthened. We recommended the Interim Under Secretary of Health implement periodic training and systematic reviews of emergency transportation claims, and instruct the sampled VA medical facilities to initiate recovery of overpayments and reimbursement of underpayments identified in this audit. The Interim Under Secretary for Health concurred with our recommendations and provided responsive action plans. We will follow up on these actions.