Report Summary

Title: Non VA Emergency Care Claims Inappropriately Denied and Rejected
Report Number: 18-00469-150 Download
Report
Issue Date: 8/6/2019
City/State:
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Audits and Evaluations
Report Type: Audit
Release Type: Unrestricted
Summary:

In response to a congressional request, the VA Office of Inspector General (OIG) conducted this audit to determine whether processors of non-VA emergency care claims inappropriately denied or rejected the claims, and, if so, whether the cause was pressure to meet production standards.

The OIG conducted an accuracy review of claims for emergency medical care obtained outside VA and found that 31 percent of denied or rejected non-VA emergency care claims—with an estimated billed amount of $716 million—were inappropriately processed from April 1 through September 30, 2017, creating the risk of undue financial burden to an estimated 60,800 veterans.

The review revealed that some of those denied and rejected claims should have been approved. The OIG estimated from its sample that about 17,400 veterans—with related bills totaling approximately $53.3 million—were negatively affected.

The remaining processing errors still created a risk that the claimants did not receive complete and accurate information regarding why their claim was not approved, and therefore could not effectively respond with necessary information to obtain claim approval and payment.

The OIG concluded there was a significant risk that some of the errors identified in this audit resulted from pressure to meet production targets, insufficient quality assurance of claims processing accuracy, and incentives associated with meeting production targets.

The OIG made 11 recommendations to improve the accuracy of non-VA emergency claims processing that included addressing the culture of prioritizing claims productivity over accuracy, improving performance evaluation standards and review processes, tying incentives to all performance standards rather than just production quantity, reevaluating inappropriately processed claims, and improving internal and external communication about claim status.