Report Summary

Title: Overtime Use in the Office of Community Care to Process Non-VA Care Claims Not Effectively Monitored
Report Number: 18-06292-117 Download
Issue Date: 6/23/2020
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Audits and Evaluations
Report Type: Audit
Release Type: Unrestricted

VA’s Office of Community Care (OCC) intended to use overtime to reduce a backlog of non-VA care claims. This backlog had been increasing since at least October 2016. The VA Office of Inspector General (OIG) examined how the overtime was used, the effect on claims backlog reduction, and whether claims processors and nurses abused overtime.

The OIG found neither OCC nor its Payment Operations and Management (POM) directorate established a policy requiring employees to use overtime exclusively to process those claims or detailed appropriate uses for overtime. Officials did not implement controls to ensure employees used overtime primarily to reduce the claims backlog.

A data review of a sample of 45 POM employees found the employees were paid an estimated $11.6 million for overtime hours for which there was no evidence of claims-related activity in the Fee Basis Claims System in fiscal years 2017 and 2018, representing almost half of the total overtime paid. Significantly, 16 of the 45 employees each received more than $10,000 in overtime for hours during which there was no claims-related activity. The audit team referred those cases to the OIG’s Office of Investigations.

There must be effective controls in place to monitor use of overtime. The OIG found that during the scope of this audit, such controls did not exist or were ineffective. Supervisors also did not effectively manage productivity during overtime hours, creating a high risk for fraud and abuse.

The OIG recommended the under secretary for health review overtime activities for certain POM employees to determine whether disciplinary or other corrective action is warranted, ensure supervisors have the tools to effectively monitor overtime productivity to reduce the risk of abuse, clarify nurse productivity standards and requirements, and implement controls on the appropriate use of overtime.