Alleged Nonacceptance of VA Authorizations by Community Care Providers, Fayetteville, North Carolina

Report Information

Issue Date
Report Number
17-05228-279
VISN
State
North Carolina
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Audits and Evaluations
Report Type
Audit
Recommendations
6
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted this audit to determine whether community care providers associated with the Fayetteville, North Carolina, VA Medical Center (VAMC) stopped accepting Non-VA Care (NVC) and Veterans Choice Program (Choice) authorizations. In July 2017, the OIG received an allegation that two orthopedic community providers stopped accepting VA patients because claims were not paid timely. The OIG substantiated the allegation and determined that at least 15 community providers stopped accepting VA patients from January 2015 through July 2017 primarily because claims were not being paid timely and there was difficulty resolving unpaid claims. The VA’s Office of Community Care is responsible for paying NVC claims. The network’s third-party administrator, Health Net, is responsible for paying Choice claims. The OIG determined community providers who stopped accepting NVC authorizations waited, on average, about 46 days for their claims to be processed in 2017. The OIG also found provider frustration over unpaid Choice claims stemming from Health Net’s clearinghouse automatically rejecting some claims and not notifying providers. Fewer community providers affected the ability to schedule patients for dermatology, neurosurgery, orthopedic, and urology services in the community. Also, VA paid about $156,000 in interest on delayed payments. If there is no improvement in the timeliness of payments, and if VA staff do not effectively address community provider medical claim inquires, additional providers may stop accepting VA patients, presenting a risk of increased wait times and travel distances. The OIG made six recommendations including ensuring community care provider participation is monitored at the local level, dedicating staff needed to process medical claims, ensuring staff are not inaccurately rejecting claims and notifying providers when claims are rejected, implementing controls to ensure the timely resolution of medical claim inquiries, and overseeing procedures to ensure the resolution of medical claim inquiries.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Executive in Charge, Office of the Under Secretary for Health, ensure community care provider participation is effectively monitored at the local level to mitigate the risk of unidentified gaps in specialty care coverage.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Executive in Charge, Office of the Under Secretary for Health, ensure the Veterans Integrated Service Network 6 Claims Adjudication and Reimbursement office identify and dedicate the appropriate number of staff needed to timely process Non-VA Care medical claims.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Executive in Charge, Office of the Under Secretary for Health, ensure the Veterans Integrated Service Network 6 Claims Adjudication and Reimbursement office implements specific controls to ensure staff are not inaccurately rejecting Non-VA care claims, or rejecting claims for the wrong reasons.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Executive in Charge, Office of the Under Secretary for Health, implement controls to ensure VA staff timely resolve medical claim inquiries from community providers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Executive in Charge, Office of the Under Secretary for Health, implement oversight procedures to ensure community care contractors effectively notify community providers when they reject their claims.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Executive in Charge, Office of the Under Secretary for Health, implement oversight procedures to ensure community care contractors effectively resolve medical claim inquiries from community providers.