	Background

		VA Community Care Programs

PC3 and Choice are among several VA community care programs, each  of which has varying eligibility requirements and types of services  offered. As stated in VHA’s  December 2015 guidance, Choice allows eligible veterans to obtain  health care services from community providers if the veteran meets any  of the following criteria:  the next available medical appointment with a VA provider is more  than 30 days from the veteran’s preferred date or the date the  veteran’s physician determines he or she should be seen;  the veteran lives more than 40 miles driving distance from the nearest  VHA medical facility with a full-time primary care physician;  the veteran needs to travel by air, boat, or ferry to the VHA medical  facility that is closest to his or her home;  the veteran faces an unusual or excessive burden in traveling to a  VHA medical facility based on geographic challenges, environmental  factors, or a medical condition;  the veteran’s specific health care needs, including the nature and  frequency of care needed, warrants participation in the program; or  the veteran lives in a state or territory without a full-service VHA  medical facility. VHA began entering into  Choice provider agreements in February 2016. VA Contractors Complied with Requirements for Verifying Selected PC3 Physicians’ Credentials, but their Verification of Choice Physicians’ Credentials was Deficient

		VA Contractors Complied with Contract Requirements for Verifying Selected PC3 Physicians’ Credentials

We found that both Health Net and TriWest complied with contractual  requirements to verify PC3 physicians’ credentials and maintain  documentation for our selected sample. We reviewed the credentials files for 50 PC3 physicians and found that  Health Net always conducted credentials verification consistent with its  policies and procedures, and TriWest almost always did so. VA Contractors’ Verification of Selected Choice Physicians’ Credentials was Deficient

We identified deficiencies in both Health Net’s and TriWest’s verification  of credentials for the 50 selected Choice physicians we reviewed. We  found that the contractors did not always verify the credentials of Choice  physicians in a timely manner and often could not produce documentation  to demonstrate that verification occurred. Similarly, TriWest provided insufficient documentation for us to  determine whether it verified most of the selected Choice physicians’  credentials. VHA Lacked a Comprehensive Strategy for Overseeing Contractors Responsible for Verifying the Credentials of PC3 and Choice Physicians

We found that VHA lacked a comprehensive strategy for overseeing  Health Net’s and TriWest’s compliance with contract requirements for  verifying the credentials of PC3 and Choice physicians. VA’s contracts  with Health Net and TriWest include a section referred to as the quality  assurance surveillance plan (QASP), which specifies that VHA will review  the contractors’ credentialing periodically to determine whether the  contractors are in full compliance with the terms of the contract. In  addition, federal internal control standards call for monitoring, and  corresponding guidance suggests an agency consider having a strategy  to ensure that monitoring is effective. However, we found that VHA’s  monitoring is primarily limited to independent reviews of physicians’  credentials using primary source databases, rather than oversight of the  contractors’ verification processes through review of documentation. VHA  has conducted only one evaluation of the contractors’ documentation of  verifying physicians’ credentials. Additionally, VHA officials provided  conflicting information about the scope, frequency, and interpretation of  the results of the oversight they do conduct. For example,  VHA officials responsible for conducting the reviews were including both  PC3 and Choice physicians in the monthly samples. VHA Did Not Require Its Staff to Verify Licenses and Lacked Specific Plans for Oversight of VHA Choice Provider Agreements

		VHA Did Not Require Its Staff to Verify Choice Physicians’ Licenses under Choice Provider Agreements

Under VHA Choice provider agreements, staff at VHA medical facilities  are not required to verify physicians’ licenses. Federal internal control standards state that management  should define risk tolerances and identify potential risk factors, such as  the opportunity for fraud due to the absence of controls. Without conducting  oversight, VHA cannot ensure that staff at each of its medical facilities are  verifying Choice physicians’ credentials consistent with the requirements  of the program. However, VHA’s existing oversight  approach is insufficient to ensure that Health Net and TriWest are  verifying credentials according to contractual requirements, or that VHA’s  own staff are reviewing qualifications as appropriate under the recently  implemented VHA Choice provider agreements. VHA’s oversight of its  contractors generally does not include the review of credentials file  documentation, and VHA has conducted only one evaluation of the  contractors’ documentation of verifying credentials and has no  documented plans for additional reviews in the future. Recommendations for Executive Action

In order to ensure that veterans receive quality care from qualified  physicians, we recommend that the Secretary of Veterans Affairs direct  the Under Secretary for Health to take the following two actions:
Develop and implement a comprehensive oversight strategy that  includes ongoing monitoring and evaluations of the contractors’  verification of PC3 and Choice physicians’ credentials, as well as VHA  staff’s review of Choice physicians. Assess the risk associated with not verifying Choice physicians’ licenses under VHA Choice provider agreements, and determine whether modifications to VHA’s policy are needed.
Why GAO Did This Study

To help ensure that veterans are provided timely and accessible health care, VHA purchases care from community physicians. Two community care programs, PC3 and Choice, require physicians to hold certain credentials reflecting their qualifications. Congress included a provision in law for GAO to review VHA's processes for, and oversight of, credentials verification for PC3 and Choice physicians. This report examines (1) whether VA contractors comply with contractual requirements for verifying PC3 and Choice physicians' credentials; (2) the extent to which VHA oversees the contractors responsible for verifying the credentials of PC3 and Choice physicians; and (3) VHA's own processes for, and oversight of, verifying Choice physicians' credentials under recently implemented VHA Choice provider agreements. GAO reviewed PC3 and Choice contracts, VHA and contractor policies, and federal internal control standards. GAO reviewed a nongeneralizable sample of 50 PC3 and 50 Choice physician credentials files, selected among five types of care across the nation. GAO also interviewed VHA officials and contractor representatives.

What GAO Found

GAO found that the Department of Veterans Affairs' (VA) contractors—Health Net Federal Services (Health Net) and TriWest Healthcare Alliance (TriWest)—complied with contractual requirements to verify the credentials of physicians under one community care program, but were deficient in doing so under another program. Based on GAO's review of selected physicians, GAO found that the contractors almost always verified and documented the credentials of physicians in the Veterans Health Administration's (VHA) Patient-Centered Community Care (PC3) program consistent with the requirements of the contract. In contrast, the contractors did not always verify credentials of the physicians in the Veterans Choice Program (Choice) in a timely manner; and for many physicians, contractors could not produce documentation to support verification consistent with the requirements of the contract. For example, Health Net did not document verification of six Choice physicians' certification to prescribe controlled substances, and TriWest provided insufficient documentation for GAO to determine whether it verified most of the selected Choice physicians' credentials. Both contractors shared plans to address the identified deficiencies.
VHA lacked a comprehensive strategy for overseeing Health Net's and TriWest's compliance with contract requirements for verifying the credentials of PC3 and Choice physicians. VA's contracts with Health Net and TriWest specify that VHA will review the contractors' credentialing periodically to determine whether the contractors are in full compliance with the terms of the contract. In addition, federal internal control standards call for monitoring, and corresponding guidance suggests that agencies consider having a strategy to ensure that monitoring is effective. However, GAO found that VHA's monitoring is primarily limited to independent reviews of physicians' credentials using primary source databases, rather than oversight of the contractors' processes for verifying physicians' credentials. VHA has evaluated TriWest's documentation of verifying physicians' credentials for PC3 physicians, but not Health Net's, and has not evaluated either contractor for Choice physicians. Additionally, VHA officials provided conflicting information about the scope, frequency, and interpretation of the results of the oversight they do conduct. Without a comprehensive oversight strategy, VHA cannot ensure that Health Net and TriWest are in compliance with the terms of the contract and that veterans are treated by qualified physicians.
In February 2016, VHA began entering into Choice provider agreements with community physicians to provide Choice care to veterans in certain situations. Under these agreements, VHA staff at each medical facility—rather than the contractors—review Choice physicians' credentials. GAO found that VHA did not require its staff to verify licenses submitted by physicians against the issuing source; rather, they review copies of the licenses. Federal internal control standards state that management should identify potential risk factors, such as opportunities for fraud, due to the absence of controls. Without assessing the risk of not verifying physicians' licenses against the issuing source, VHA does not know if a policy change is needed. Furthermore, VHA lacked plans for overseeing staff across each of its medical facilities with the new responsibility of verifying Choice physicians' credentials under the recently implemented VHA Choice provider agreements.

What GAO Recommends

VHA should develop a comprehensive oversight strategy that includes monitoring and evaluations of the contractors' verification of PC3 and Choice physicians' credentials, as well as VHA staff's review of Choice physicians; and assess the risk of not verifying Choice physicians' licenses under VHA Choice provider agreements. VA concurred with these recommendations.