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Improvements Needed to Reduce Duplicate Payments by VHA and Medicare and Ensure VHA Has Authorized Community Medical Services

Report Information

Issue Date
Report Number
21-03630-250
VISN
State
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Audits and Evaluations
Report Type
Review
Recommendations
3
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted this review to determine whether community care providers are receiving potential duplicate payments for the same healthcare services from VHA and Medicare and to determine whether VHA paid any of these claims without authorization. In this review, the VA OIG collaborated with the Department of Health and Human Services (HHS) OIG—which is currently conducting its own review of duplicate Medicare payments—to better understand duplicate payments and confirm that they had occurred. The VA OIG determined that VHA and Medicare made potential duplicate claim payments for community care services that were authorized by VHA. Because VHA and the Centers for Medicare and Medicaid Services do not share healthcare claims data, neither agency is aware of claims paid by the other agency. Without an interagency system, the risk of duplicate payments is increased, and it may be difficult to determine which agency should pay the claim and which agency can collect overpayments. The OIG made three recommendations to the under secretary for health, including working with the Centers for Medicare and Medicaid Services to establish a data-sharing agreement with VA to limit duplicate claim payments. The OIG also recommended identifying overpayments made for care provided to dual-eligible veterans that were not authorized by VHA and ensure documentation of care is completed or that VA seeks reimbursement for any unauthorized care. Finally, the OIG recommended making sure all nonemergent community care is preauthorized and that documentation for all authorizations is complete and properly stored before services are provided.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Work with the Centers for Medicare and Medicaid Services to establish a data sharing agreement with VA to limit potential duplicate claim payments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Identify overpayments made for care provided to dual eligible veterans that were not authorized by VHA and ensure either documentation of care is completed, or VA seeks reimbursement for any care without prior approval.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Make sure all nonemergent community care is preauthorized and that documentation for all authorizations is complete and properly stored before treatment is provided.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 15,700.00