Report Summary

Title: VHA Risks Overpaying Community Care Providers for Evaluation and Management Services
Report Number: 21-01807-251 Download
Issue Date: 12/8/2021
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Audits and Evaluations
Report Type: Review
Release Type: Unrestricted

The OIG conducted this review to determine the risk of the Veterans Health Administration (VHA) improperly paying community care providers for evaluation and management services not supported by medical documentation.

The review team found that some providers are billing VA at a significantly higher rate for high-level evaluation and management services than their peers in the same specialty. The team determined that in fiscal year (FY) 2020, more than 37,900 non-VA providers billed and were paid for significantly more high-level evaluation and management codes than were all providers in that specialty on average. These non-VA providers received about $39.1 million (13 percent) of the approximately $303.6 million paid for all non-VA evaluation and management services.

Additionally, some providers billed separately for evaluation and management services during periods when the global surgery package was in effect. This package is supposed to cover all surgery-related services for a set period. The review team identified more than 45,600 providers who were paid about $37.8 million in FY 2020 for these evaluation and management services.

Improper payments were not easy to detect because VHA staff did not retrospectively audit medical documentation as required. Additionally, the OIG found no evidence that VHA or contractors trained non VA providers on documenting evaluation and management services, similar to how VA providers are trained. The OIG determined VHA risked overpaying for evaluation and management services by about $19.9 million in FY 2020.

The OIG made two recommendations to the under secretary for health related to (1) reviewing medical documentation for evaluation and management services billed by non-VA providers and then developing processes to act on the results of those reviews; and (2) ensuring non-VA providers receive current and future continuing education materials on proper medical documentation for evaluation and management services.

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