The Office of Community Care’s Oversight of Non-VA Healthcare Claims Processed by Its Contractor

In 2019, a confidential complainant alleged that employees of the contractor Signature Performance incorrectly processed claims for non VA care. The VA Office of Inspector General (OIG) conducted this audit to determine whether contractor employees accurately processed these claims. VA authorizes care from non VA providers based on eligibility requirements, availability of VA care, and the circumstances of individual veterans. VA contracted Signature Performance to help process non-VA medical care claims for such care. If claims are not decided or processed accurately, VA has an increased risk of errors, delays, or rework. Additionally, veterans are at risk of being billed unnecessarily by the community providers. The OIG audit found that inadequate contract terms and VA’s lack of effective oversight contributed to claims processing inconsistencies and errors. VA’s contract with Signature Performance did not include standardized criteria for contractor employees to use when distributing and processing claims. Furthermore, the contract did not require contractor employees to follow VA’s Office of Community Care (OCC) claims-processing guidance. Although the contractor cannot be faulted for acting inconsistently with OCC guidance not required in its contract, the resulting inconsistencies mean VA lacks assurances that proper processes were used. VA also did not have an official quality reporting mechanism in place prior to February 2019. The OIG found 13 percent of the contractor’s claims decisions did not align with OCC guidance, increasing the risk of inaccurately decided claims that could shift the financial burden to veterans. VA agreed that oversight of the contractor’s performance was not robust and stated that it has strengthened its processes. The OIG’s recommendations to the under secretary included providing additional training and guidance, enhancing quality surveillance, and ensuring contract requirements specify that contractor employees must follow OCC’s guidance for processing non-VA care claims.