VA Health Care: Actions Needed to Improve Administration and Oversight of Veterans' Millennium Act Emergency Care Benefit
Highlights
What GAO Found
The Veterans Millennium Health Care and Benefits Act (Millennium Act) authorizes the Department of Veterans Affairs (VA) to cover emergency care for conditions not related to veterans' service-connected disabilities when veterans who have no other health plan coverage receive care at non-VA providers. However, GAO identified a number of instances where VA staff who processed claims did not comply with applicable requirements of the Millennium Act, its implementing regulations, or VA policies when they denied the claims. Specifically, at the four VA facilities included in this review, GAO found 66 instances of noncompliance among the 128 denied claims reviewed, which led some claims to be inappropriately denied. VA facilities subsequently reconsidered and paid 25 of these claims. GAO also found that VA facilities may not be notifying veterans as required that their Millennium Act claims have been denied. Eighty-three claims out of 128 that GAO reviewed lacked documentation that the veteran was notified of the denial or of his or her appeal rights. These findings suggest that veterans whose claims have been inappropriately denied may have been held financially liable for emergency care that VA should have covered, and they may not be aware of their rights to appeal these denials.
GAO also found that, as a result of weaknesses in VA's oversight of Millennium Act claims, VA facilities are at risk for inappropriately denying such claims. For example, agency oversight activities do not focus on compliance with all applicable requirements but rather on the timeliness of claims processing. In addition, VA has limited assurance that deficiencies relating to Millennium Act claims processing identified during reviews are corrected because it only conducts limited follow-up with VA facilities. Moreover, VA does not collect adequate data for monitoring the appropriateness of Millennium Act claim denials. This lack of data hinders VA's ability to track patterns as to why Millennium Act claims are denied and identify areas where communications with veterans and non-VA providers about Millennium Act emergency care benefits could be improved.
VA has used various methods to educate veterans about their Millennium Act eligibility; however, VA officials, non-VA providers, and representatives of veterans service organizations told GAO that veterans still lack knowledge about their eligibility. For example, VA officials reported that because some veterans were uninformed about their eligibility, these veterans may have delayed or avoided seeking treatment at local non-VA providers, choosing instead to go to a less accessible VA facility. Because VA does not require facilities to conduct evaluations of veterans' understanding of Millennium Act eligibility, it lacks information needed to address potential gaps in veterans' knowledge about these benefits. Also, the non-VA providers GAO interviewed cited communication challenges with VA regarding Millennium Act claims, such as not having a specific point of contact at VA for directing specific questions and raising concerns, and a lack of VA responsiveness when issues are raised. Despite VA's efforts to improve communications with non-VA providers after a 2011 customer service survey revealed significant issues, these challenges persisted at the facilities GAO visited.
Why GAO Did This Study
VA spent an estimated $418 million on Millennium Act emergency care claims in fiscal year 2012 and projects spending will increase to $580 million by fiscal year 2015. GAO was asked to review VA's administration of the emergency care benefit under the act. This report examines the extent to which (1) selected VA facilities complied with applicable requirements, in particular when denying claims; (2) VA's oversight activities ensure that Millennium Act claims are not inappropriately denied; and (3) veterans understand the Act's emergency care benefit and how VA communicates with non-VA providers about Millennium Act claims.
To do this work, GAO reviewed 4 VA facilities out of 142 based on variations in Millennium Act spending levels and geographic location. GAO also reviewed VA documents—including 128 denied Millennium Act claims from these four facilities—and interviewed officials from VA, non-VA providers, and veterans service organizations. These results cannot be generalized across VA but provide insights.
Recommendations
GAO recommends that VA take a number of actions, including steps to ensure facilities comply with applicable requirements, notify veterans of denials, improve oversight of claims processing, and collect better data on denials and veterans' understanding of eligibility for Millennium Act coverage. VA agreed with the recommendations and described its plans to implement them. However, as described in the report, GAO believes that some of VA's proposed actions do not fully address the issues identified.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
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| Department of Veterans Affairs | To address VA facilities' compliance with applicable requirements for processing non-VA provider emergency care claims, the Secretary of Veterans Affairs should direct the Under Secretary for Health to implement measures to ensure that all VA facilities comply with VA's policy requirement that incoming claims be date-stamped and scanned into FBCS on the date of receipt. |
In March and November 2014, VA reiterated the importance of promptly date-stamping and scanning claims for non-VA care through written communications to Veterans Integrated Service Networks (VISN) and VA facilities, national teleconferences for VISNs and VA facilities, and a virtual training for staff who process claims. The department also added questions to its field assistance visit checklist to monitor VA facilities' compliance with the scanning and date-stamping requirements. In November 2015, VA began requiring supervisors at VA facilities to certify that their staff was scanning incoming claims and medical records daily, and in February 2016, VA began regular monitoring of facility scanning activities using a standard report that displays the number of pages scanned each day at each facility.
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| Department of Veterans Affairs | To address VA facilities' compliance with applicable requirements for processing non-VA provider emergency care claims, the Secretary of Veterans Affairs should direct the Under Secretary for Health to clarify policies and guidance for processing Millennium Act claims to specify that clinicians determine whether emergent care is related to a veteran's service-connected disability before other Millennium Act criteria are applied to claims, and implement measures to ensure that all VA facilities comply with this policy. |
Existing VA policies relating to the processing of emergency care claims state that Millennium Act emergency care criteria should not be applied to claims until after a clinician has determined that the care was unrelated to the veteran's service-connected disability. In 2014, VA clarified this requirement by taking the following steps to help ensure that only clinical reviewers make determinations about whether emergency care was related to a veteran's service-connected disability: (1) VA published an article in its biweekly bulletin for staff who process claims, to communicate the steps that should be taken to route incoming claims that may be related to veterans' service-connected disabilities to clinicians for review; (2) VA reiterated this guidance through two national conference calls for managers and staff responsible for claims processing; and (3) VA added questions to its field assistance visit checklist relating to whether clinicians are making determinations about whether emergency care was related to veterans' service-connected disabilities. As a result, VA has reduced the risk of inappropriately applying Millennium Act criteria to emergency care claims that are related to veterans' service-connected disabilities.
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| Department of Veterans Affairs | To address VA facilities' compliance with applicable requirements for processing non-VA provider emergency care claims, the Secretary of Veterans Affairs should direct the Under Secretary for Health to clarify the policy for processing Millennium Act claims to communicate the importance of promptly verifying that claims have been sent to the correct VA facility, and implement measures to ensure that all VA facilities comply with this policy. |
In 2014, VA updated its written policies and communicated through written materials and national teleconferences for Veterans Integrated Service Networks (VISN) and VA facilities the importance of promptly verifying that Millennium Act claims have been sent to the correct VA facility. VA facilities are now required to forward misrouted Millennium Act claims to the appropriate facility within three business days. The receiving VA facility is required to date stamp the claim on the date of receipt and use that date as the start date for determining claims processing timeliness.
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| Department of Veterans Affairs | To address VA facilities' compliance with applicable requirements for processing non-VA provider emergency care claims, the Secretary of Veterans Affairs should direct the Under Secretary for Health to revise VA policy for processing Millennium Act claims to require that VA fee basis staff who process the claims use the VSSC Find User search to make determinations about veterans' enrollment and use of VA services. |
In June 2016, VA updated its policy for processing Millennium Act claims to require that VA fee basis staff who process the claims use the VSSC Find User search to make determinations about veterans' enrollment and use of VA services. This helped reduce the risk that veterans' Millennium Act claims will be inappropriately denied based on whether they were enrolled in the VA health care system and whether they had received VA care in the 24 months prior to the episode of emergent care.
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| Department of Veterans Affairs | To address VA facilities' compliance with applicable requirements for processing non-VA provider emergency care claims, the Secretary of Veterans Affairs should direct the Under Secretary for Health to establish a VA policy regarding processing Millennium Act claims to require VA facilities to assist the veteran in determining whether a claim is eligible for coverage by auto insurance or another third party before denying the claim; and ensure that the standard letters sent to veterans whose claims are denied because of third-party liability, in this case auto insurance coverage, more clearly communicate that the denial could be overturned if the veteran can prove that auto insurance did not fully cover the claim. |
In February 2014, VA reiterated the policy related to auto insurance and third party coverage through a national conference call for managers and staff responsible for claims processing. In April 2014, VA updated its procedure guide for Millennium Act claims processing to more clearly communicate its policy on assisting the veteran in determining whether there is auto insurance or third party coverage before denying an emergency care claim. In December 2016, VA revised its standard letter for veterans whose claims are denied because of auto insurance or third-party liability to more clearly communicate that VA can reconsider the denial if the veteran forwards proof that auto insurance did not fully cover his or her claim.
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| Department of Veterans Affairs | To better ensure that veterans are notified of Millennium Act emergency care claim denials, the Secretary of Veterans Affairs should direct the Under Secretary for Health to require fee basis supervisors at each VA facility to develop mechanisms for verifying that veteran denial letters are printed and mailed. |
To raise awareness of the importance of verifying that veteran denial letters are printed and mailed, VA printed an article in its April 2014 bi-weekly bulletin for staff and made an announcement during its July 2014 bi-monthly call for VISN Business Implementation Managers. In December 2016, VA collected information from each VISN about its process for verifying that denial letters for Millennium Act claims are printed and mailed to veterans. For example, supervisors in several locations said they monitor FBCS queues of pending letters on a daily basis and visually observe that denial letters are printed and mailed to veterans.
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| Department of Veterans Affairs | To improve oversight of Millennium Act claims processing by increasing the focus on determining whether claims are inappropriately denied and ensuring that deficiencies are corrected, the Secretary of Veterans Affairs should direct the Under Secretary for Health to revise the scope of field assistance visits to include an assessment of whether fee basis staff are making appropriate decisions about whether Millennium Act claims meet administrative and clinical criteria for payment. |
VA discontinued its field assistance visit program in October 2014. However, VA has since taken other actions that meet the intent of this recommendation. First, in November 2016, VA's Office of Community Care conducted its own audit of 578 Millennium Act claims that were approved or denied between March and May of 2016. They found that about 20 percent of the claims were approved or denied inappropriately or considered under the incorrect payment authority. Second, VA developed templates to help standardize the administrative and clinical review process for Millennium Act claims. These tools help ensure that staff reviewing claims are--among other things--(1) applying administrative and clinical eligibility criteria for emergency care claims in the correct order, (2) using appropriate tools to determine veterans' enrollment and use of VA services, and (3) using all available resources to determine whether veterans have other health insurance or third party coverage. VA required non-VA care staff at all facilities to begin using these templates in December 2016, and in February 2017, the Office of Community Care began collecting data from the facilities to monitor the extent to which they have been using the template when adjudicating Millennium Act claims.
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| Department of Veterans Affairs | To improve oversight of Millennium Act claims processing by increasing the focus on determining whether claims are inappropriately denied and ensuring that deficiencies are corrected, the Secretary of Veterans Affairs should direct the Under Secretary for Health to require VA facilities to systematically audit the appropriateness of Millennium Act claim approvals and denials by taking actions such as revising VA Central Office's internal controls procedure guide for fee basis managers or by establishing performance measures related to the appropriateness of claim approval or denial decisions for fee basis staff. |
While VA did not take either of the actions we suggested (i.e., revising its internal controls procedure guide for fee basis managers or establishing performance measures related to the appropriateness of approval or denial decisions), VA has taken other actions that meet the intent of this recommendation. First, in November 2016, VA's Office of Community Care conducted its own audit of 578 Millennium Act claims that were approved or denied between March and May of 2016. They found that about 20 percent of the claims were approved or denied inappropriately or considered under the incorrect payment authority. Second, VA developed templates to help standardize the administrative and clinical review process for Millennium Act claims. These tools help ensure that staff reviewing claims are--among other things--(1) applying administrative and clinical eligibility criteria for emergency care claims in the correct order, (2) using appropriate tools to determine veterans' enrollment and use of VA services, and (3) using all available resources to determine whether veterans have other health insurance or third party coverage. VA required non-VA care staff at all facilities to begin using these templates in December 2016, and in February 2017, the Office of Community Care began collecting data from the facilities to monitor the extent to which they have been using the template when adjudicating Millennium Act claims.
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| Department of Veterans Affairs | To improve oversight of Millennium Act claims processing by increasing the focus on determining whether claims are inappropriately denied and ensuring that deficiencies are corrected, the Secretary of Veterans Affairs should direct the Under Secretary for Health to require VA facilities to correct fee basis claims processing deficiencies that are identified through field assistance visits or virtual audits, once they are implemented, and establish a process for validating facilities' self-reported actions taken to address deficiencies. |
In November 2015, VA finalized a new standard operating procedure for field assistance visits. It includes a corrective action plan template that requires VA facilities to submit supporting documentation for actions they have taken to address deficiencies. Before corrective action plans will be considered for closure, VA facilities also must demonstrate improvement on VA's claims processing performance metrics.
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| Department of Veterans Affairs | To improve VA's ability to identify systemwide patterns in denials, areas of noncompliance in VA facilities' processing of Millennium Act claims, and areas where communications for veterans and non-VA providers could be improved, the Secretary of Veterans Affairs should direct the Under Secretary for Health to establish a standard set of Millennium Act denial reasons in FBCS that are specific and aligned with the Millennium Act administrative and clinical criteria, and ensure they are consistently applied across VA facilities. |
In November 2015, VA deployed a technological enhancement that locked down the permissible set of denial reasons in FBCS, and in May 2016, VA established a centralized process by which VA facilities can request changes or updates to the denial reasons. VA facilities can no longer enter their own denial reason verbiage into FBCS, and VA now has a uniform set of Millennium Act denial reasons in FBCS. This will allow VA to better track patterns in the reasons Millennium Act claims are denied and to identify areas where veterans and non-VA providers may benefit from additional education about VA's criteria for covering emergency care.
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| Department of Veterans Affairs | To improve VA's ability to identify systemwide patterns in denials, areas of noncompliance in VA facilities' processing of Millennium Act claims, and areas where communications for veterans and non-VA providers could be improved, the Secretary of Veterans Affairs should direct the Under Secretary for Health to establish a regular reporting mechanism through which VA facilities would provide to VA Central Office data related to the appropriateness of decisions to approve or deny Millennium Act claims. |
VA has taken actions that meet the intent of this recommendation. First, in November 2016, VA's Office of Community Care conducted its own audit of 578 Millennium Act claims that were approved or denied between March and May of 2016. They found that about 20 percent of the claims were approved or denied inappropriately or considered under the incorrect payment authority. Second, VA developed templates to help standardize the administrative and clinical review process for Millennium Act claims. These tools help ensure that staff reviewing claims are--among other things--(1) applying administrative and clinical eligibility criteria for emergency care claims in the correct order, (2) using appropriate tools to determine veterans' enrollment and use of VA services, and (3) using all available resources to determine whether veterans have other health insurance or third party coverage. VA required non-VA care staff at all facilities to begin using these templates in December 2016, and in February 2017, the Office of Community Care began collecting data from the facilities to monitor the extent to which they have been using the template when adjudicating Millennium Act claims.
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| Department of Veterans Affairs | To improve VA's ability to address its strategic plan objective of educating and empowering veterans, the Secretary of Veterans Affairs should direct the Under Secretary for Health to take steps to better understand gaps in veterans' knowledge regarding eligibility for Millennium Act emergency care, such as by conducting veteran surveys of health care benefits knowledge, and using information from those surveys to more effectively tailor the agency's education efforts regarding the Millennium Act benefit. In conducting these surveys, consideration should be given to including a sample of veterans who have had denied Millennium Act claims in order to provide their views and specific details of their experiences. |
In September 2017, VHA completed a survey to assess veterans' knowledge of their Millennium Act emergency care benefits. VHA used the results of the survey (which had about 1,000 respondents) to tailor the agency's efforts regarding the Millennium Act benefit. For example, in February 2018, VHA posted a fact sheet on its emergency care website to provide comprehensive information about its requirements for paying emergency care claims. It also updated its emergency care website to reflect a January 2018 regulatory change related to payment of Millennium Act claims for veterans with other health insurance or third party coverage.
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