VA is required to provide certain health care benefits—including home  care, hospital care, nursing home care, outpatient care, preventive care,  habilitative and rehabilitative care, case management, and respite care— for spina bifida beneficiaries. However, VHA has conducted limited  outreach with key stakeholder groups that have a relationship with  potentially eligible individuals who are not already enrolled. VHA Provides Information and Updates to Enrolled Spina Bifida Beneficiaries on Covered Health Care Services

VHA provides information on the available health care benefits to  beneficiaries who are enrolled in its spina bifida program using three  primary methods: (1) the initial mailing of information upon program  enrollment, (2) the program website, and (3) contact with beneficiaries  regarding updates to covered services. VHA Has Conducted Limited Outreach with Key Stakeholders regarding Spina Bifida Benefits

VHA has conducted limited outreach with key stakeholder organizations,  and representatives of these organizations told us that this has  contributed to lack of awareness among some individuals who may be  eligible to receive health care benefits under the spina bifida program. Administrative and clinical review. Total Spina Bifida Claims Payments and Number of Claims Paid Have Increased from Fiscal Years 2009 through 2013, with Outpatient Services Making Up the Majority of Claims

From fiscal years 2009 through 2013, total payments for spina bifida  claims increased by 43 percent—from about $19.4 million to about   $27.8 million. VHA officials told us they attribute the growth in the spina bifida program  to an increasing number of claims and payments in the years following  the 2008 legislative expansion of health care coverage under the  program, as well as increasing health care costs for beneficiaries as they  age and their health care needs become more varied and complex. In fiscal years 2009 through 2013, the percentages of paid and denied  claims remained steady, with paid claims representing about 90 percent  of all claims submitted each fiscal year. VHA Primarily Uses Claims Audits to Oversee Its Spina Bifida Claims Process, but Does Not Have Written Guidance for Audit Follow-up

VHA conducts annual audits of spina bifida program claims, and VHA  officials told us these audits and associated audit follow-up activities are   Auditors from the  the primary means of oversight for the claims process.VHA CBOPC’s Department of Audits & Internal Controls conduct audits of  the spina bifida claims process annually. Auditors then complete a report that documents the audit’s findings,  including corrective actions and recommendations. There is currently no written guidance on how CBOPC staff are to  document the status of audit follow-up activities—corrective actions and  recommendations outlined in audit reports—to ensure their completion. In addition, without written guidance for audit follow-up activities related to  the spina bifida claims process, VHA cannot be assured that these  activities have been successfully completed or that the corrective actions  and recommendations outlined in audit reports have been appropriately  implemented. Recommendations for Executive Action

To improve awareness of the spina bifida program’s health care benefits  among potentially eligible individuals and to help them obtain the benefits  to which they may be entitled, we recommend that the Acting Secretary of  Veterans Affairs direct the Acting Under Secretary for Health to conduct  outreach with key stakeholder groups regarding the program and its  benefits.
Why GAO Did This Study

VA provides health care benefits to children diagnosed with spina bifida—a birth defect that can cause physical and neurological issues—born to Vietnam and certain other veterans. Legislation requires the provision of certain health care benefits—including home care, hospital care, outpatient care, and case management—for spina bifida beneficiaries. VHA administers the Spina Bifida Health Care Program for enrolled beneficiaries by processing and paying claims for covered services from private sector providers.
GAO was asked to evaluate VHA's administration of spina bifida health care benefits. In this report, GAO examined for the spina bifida program: (1) the extent to which VHA conducts outreach about available benefits, (2) what is known about health care claims that have been processed, and (3) what, if any, oversight, VHA conducts of the claims process. GAO reviewed the spina bifida program handbook and claims audit reports, analyzed data on submitted, paid, and denied claims from fiscal years 2009 through 2013, and interviewed VHA officials and representatives from key stakeholder organizations.

What GAO Found

The Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) provides information and updates on covered health care services to beneficiaries enrolled in its spina bifida program, but has conducted limited outreach with key stakeholder organizations. VHA provides information on health care benefits to enrolled beneficiaries through the program website, for example. However, VHA has conducted limited outreach with key stakeholder organizations—such as the Spina Bifida Association—that have relationships with individuals who are potentially eligible for the spina bifida program and its benefits but are not enrolled. Representatives of these organizations told GAO this has contributed to lack of awareness of eligibility and available benefits. Without this outreach, VHA may miss important opportunities to help potentially eligible individuals obtain health care benefits to which they may be entitled.
For the spina bifida program, both total claims payments, as well as the total number of claims paid, increased by more than 40 percent from fiscal year 2009 through fiscal year 2013. VHA officials attributed the increase to a 2008 legislative expansion of health care coverage under the program, and growing health care costs for beneficiaries as they age. During this 5-year period, paid claims represented about 90 percent of all claims submitted each fiscal year.
VHA primarily uses claims audits to oversee its spina bifida claims process. Auditors review a sample of claims and prepare a report with the audit's findings and any necessary follow-up activities. However, VHA does not have written guidance on how staff are to document the status of these follow-up activities to ensure their completion. Without such written guidance, VHA cannot be assured that these activities have been successfully completed or that any recommendations outlined in audit reports have been appropriately implemented.

What GAO Recommends

GAO recommends that VA conduct outreach with key stakeholder groups regarding the spina bifida program and its benefits, and develop written guidance for completing and documenting the status of follow-up activities related to claims audits. VA concurred with GAO's recommendations.