Veterans Health Care: Actions Needed to Improve the Foreign Medical Program
Fast Facts
Veterans with service-related disabilities living or traveling abroad may use health care benefits through the Department of Veterans Affairs' Foreign Medical Program.
The program has had trouble reimbursing some veterans and doctors. For example, despite a federal law calling for electronic payments, the program sends paper checks—sometimes resulting in lost or delayed payments. VA began transitioning to an electronic payment system, but it's unclear when it will be complete.
VA also authorized hiring additional staff to speed up the reimbursement process, but many of those positions remain vacant.
Our recommendations address this, and more.
Highlights
What GAO Found
The Department of Veterans Affairs (VA) is responsible for providing benefits to veterans. Within VA, the Veterans Health Administration (VHA) provides health care benefits to eligible veterans with service-connected disabilities living or traveling abroad through its Foreign Medical Program. In fiscal year 2024, VHA data show the program paid $128.3 million in reimbursements to 8,024 veterans or their providers, representing a 263 percent increase in reimbursements since fiscal year 2018. In fiscal year 2024, the program reported processing 37 percent of claims within 45 days; its goal is to process 90 percent within that time.
Foreign Medical Program Reimbursements, Fiscal Years 2018 through 2024
The Foreign Medical Program makes reimbursements using paper checks, despite a federal law generally calling for electronic payments. Reliance on paper checks has resulted in challenges, including delayed or lost checks, according to officials. VA has begun a transition to an electronic payment method, but when or how the transition will occur is unclear. Implementing the new method will help ensure the timeliness and security of reimbursements.
VHA increased its authorized staffing in August 2023 from 25 to 38 positions for the Foreign Medical Program to help meet its timeliness goal. However, 14 positions remained vacant in 2024 due to various reasons, including a VHA zero-growth hiring policy, according to officials. VHA has taken some steps to help with hiring, such as allowing positions to be remote, but has not otherwise identified and evaluated staffing strategies. Evaluating and implementing such strategies could help the program address its staffing challenges and process claims in a timely manner.
VA has not comprehensively assessed fraud risks in the program in line with selected leading practices, despite evidence of potential fraud. This included VA suspending providers in 2024 due to their alleged involvement in a long-term fraud scheme. VHA developed two documents to outline efforts for fraud, waste, and abuse activities within VHA. However, VA has not implemented selected leading practices outlined in GAO's Fraud Risk Framework. These include assigning an entity to lead and regularly assess fraud risks. Implementing such practices will help VA better prevent, detect, and respond to fraud.
Why GAO Did This Study
Thousands of veterans live in or travel to foreign countries each year. For qualifying medical expenses incurred abroad, veterans, or the providers that deliver services, may submit claims to VHA's Foreign Medical Program for reimbursement.
The Consolidated Appropriations Act, 2023, includes a provision for GAO to review the VHA Foreign Medical Program. This report addresses available data on program claims, VHA processes for reimbursing claims, program staffing, and the extent to which fraud risk management activities for the program are consistent with selected leading practices.
GAO reviewed data on claims processed for fiscal years 2018 through 2024 and relevant program policies and documentation; assessed the program's processes against criteria, such as human capital management key practices and GAO's Fraud Risk Framework; and interviewed agency officials, veterans who use the program, and five veterans service organizations. GAO conducted interviews with veterans in person and obtained written responses via email.
Recommendations
GAO is making nine recommendations to VHA, including that it finalize and prioritize implementation of the steps to transition to electronic funds transfers, evaluate and implement strategies to help mitigate staffing challenges, and follow leading practices for addressing the elements for assessing fraud risks. VA concurred with the recommendations and identified steps VHA plans to take to implement them.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Veterans Health Administration | The Under Secretary for Health should, in coordination with the Foreign Medical Program, develop and implement a modernization plan for the program's legacy claims processing system, including milestones, a description of the work necessary, and details on the disposition of the legacy system. (Recommendation 1) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
|
| Veterans Health Administration | The Under Secretary for Health should, in coordination with the Foreign Medical Program, finalize the necessary steps to transition to electronic funds transfers and immediately prioritize their implementation in coordination with the Department of the Treasury, as appropriate. (Recommendation 2) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
|
| Veterans Health Administration | The Under Secretary for Health should, in coordination with the Foreign Medical Program, evaluate and implement as appropriate strategies to help mitigate staffing challenges that affect the Foreign Medical Program. (Recommendation 3) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
|
| Veterans Health Administration | The Under Secretary for Health should, in coordination with the Foreign Medical Program, designate a dedicated entity for managing the process of assessing fraud risks to the program, consistent with leading practices. This entity should have, among other things, clearly defined and documented responsibilities, and authority for managing fraud risk assessment for the program. (Recommendation 4) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
|
| Veterans Health Administration | The Under Secretary for Health should, in coordination with the Foreign Medical Program, regularly identify inherent fraud risks in the program and coordinate with external stakeholders, such as the Department of the Treasury, as appropriate. (Recommendation 5) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
|
| Veterans Health Administration | The Under Secretary for Health should, in coordination with the Foreign Medical Program, assess the likelihood and impact of inherent fraud risks in the program. (Recommendation 6) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
|
| Veterans Health Administration | The Under Secretary for Health should, in coordination with the Foreign Medical Program, determine a fraud risk tolerance for the program. (Recommendation 7) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
|
| Veterans Health Administration | The Under Secretary for Health should, in coordination with the Foreign Medical Program, examine the suitability of existing fraud controls and prioritize residual fraud risks in the program. (Recommendation 8) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
|
| Veterans Health Administration | The Under Secretary for Health should, in coordination with the Foreign Medical Program, document a fraud risk profile for the program. (Recommendation 9) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
|