Report Summary

Title: Lack of Adequate Controls for Choice Payments Processed through the Plexis Claims Manager System
Report Number: 19-00226-245 Download
Report
Issue Date: 9/30/2020
City/State:
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Audits and Evaluations
Report Type: Audit
Release Type: Unrestricted
Summary:

The OIG examined whether the VA Office of Community Care accurately reimbursed third-party administrators under the Veterans Choice Program for payments made to community healthcare providers for services to veterans during the audit period. This is the third OIG report on healthcare claims payments under the Choice program. It focuses on claims processed through the Plexis Claims Manager system that were paid from February 21, 2017, through December 31, 2018.

The audit team found that the Office of Community Care reimbursed third-party administrators at rates higher than what was typical for the same or similar medical services in a given geographic area. The office could have saved approximately $132.1 million during the period audited if it reimbursed third-party administrators at verifiable usual and customary rates, as required by the governing contract.

Additionally, the Office of Community Care did not fully implement prior OIG recommendations to develop effective payment and internal control processes for the Choice program. As a result, the office made about $73 million in overpayments to Choice third-party administrators for medical services provided under the program. These errors were made because the appropriate payment rate was not used. The OIG will continue to monitor all recommendations.

The OIG made eight recommendations to the Office of Community Care in this report to prevent and address payment errors under current and future contracts (as the Choice program has ended and other community care programs continue).