Resolving pending applications. VHA’s Implementation of Enrollment Processes Has Hindered the Timely and Accurate Enrollment of Veterans, and VHA Is Assessing Efforts to Improve These Processes

VHA enrollment staff, both from HEC and VAMCs, frequently did not  process enrollment applications in accordance with VHA’s timeliness  standards and made incorrect enrollment determinations. VHA Frequently Did Not Meet Timeliness Standards for Processing Enrollment Applications

Prior studies show that VHA enrollment staff, whether from HEC or  VAMCs, frequently did not process enrollment applications within 5  business days in accordance with VHA timeliness standards. In response to an audit  recommendation, HEC officials said they have begun prioritizing workload  to help meet the timeliness standard. Additionally, the overall time needed to process enrollment applications  may increase when staff need to place applications in a pending status. Based on our discussions with enrollment staff, we found that none of the  VAMCs in our review had a specific policy or procedure for how to resolve  pending applications. For the six VAMCs in our review, we found that, as of March and April  2017, VAMC enrollment staff had not resolved 31 (55 percent) of the 56  pending applications included in our random, nongeneralizable sample of  pending applications. These 9 applications had been in a pending status  between 2 and 5 months at the time of our review. HEC  developed procedures for HEC enrollment staff to use when resolving  pending applications. Furthermore, VAMC officials  told us that they had not received any guidance regarding the new  procedures and were confused about whether they would continue to  have a role in this process. HEC has recently implemented an effort to  review the accuracy of some enrollment determinations, specifically those  for which veterans were found to be ineligible or rejected for health care  benefits. VHA Lacks a Standardized Process for System-Wide Oversight of Enrollment Processes

VHA has not sufficiently defined through policies or procedures a  standardized oversight process that describes and delineates the roles  and responsibilities of HEC and VISNs—the networks that manage and  oversee VAMCs in their geographic area—in monitoring and evaluating  the efficiency and effectiveness of enrollment processes. Although HEC  officials said they are responsible for oversight of enrollment processes  system-wide and VHA policy generally states that HEC is responsible for  performing a second-level review of all enrollment determinations,  policies and procedures do not document the key oversight activities that  should be conducted, how often they should be done, or the data that  should be assessed for ensuring timely and accurate enrollment  processes system-wide. HEC officials  said they recognized the need to improve the oversight of enrollment  processes, and a goal under the National Enrollment Improvement is for  HEC to have 100 percent accountability and oversight of applications— those processed both at HEC and at the VAMCs. VHA Lacks Complete and Reliable Data to Oversee the Timeliness of Processing Enrollment Applications System-Wide

VHA—through HEC—does not have complete and reliable data for  overseeing the timeliness of processing enrollment applications system- wide. Officials from four of  the six VAMCs in our review, in contrast, said they considered the  timeliness standard met when an application was entered into the system,  irrespective of whether an enrollment determination was made or whether  the application was pending. Without a central repository of  reliable data about enrollment processes and a clearly defined  measurement of the processing standard, VHA cannot reliably and  consistently oversee processing timeliness of enrollment applications,  assess the extent to which VAMCs face challenges in meeting the  standard, and make appropriate decisions to improve processes system- wide. First, VHA—through  HEC—has recently implemented an effort to review the accuracy of  enrollment determinations for which veterans were found to be ineligible  or rejected for health care benefits. Conclusions

Timely and accurate processing of veterans’ enrollment applications is  critical to ensuring that eligible veterans obtain needed health care. Additionally, limitations in VHA’s oversight further impede its ability to  ensure the timeliness of application processing and the accuracy of  enrollment determinations system-wide. Clarify its 5-day timeliness standard for processing enrollment  applications, including whether it covers the total time needed to make  an enrollment determination and the time applications are pending,  and ensure the clarification is communicated system-wide. In its  written comments, VA concurred with all four of the report’s  recommendations, and identified actions it is taking to implement them.
Why GAO Did This Study

Enrollment is generally the first step veterans take to access VA health care, thus timely and accurate processing of enrollment applications is critical to help ensure eligible veterans obtain needed care.
The Explanatory Statement accompanying the Consolidated Appropriations Act, 2016 included a provision for GAO to examine VA's oversight of patient access to care. This report examines (1) VHA's processes for enrolling veterans for health care benefits and (2) its related oversight. GAO reviewed federal laws, regulations, and VHA policies and procedures. GAO also interviewed officials from HEC and 6 of VHA's 170 VAMCs selected to provide variation in factors such as number of enrollment applications processed and geographic location; reviewed actions to resolve a randomly selected, nongeneralizable sample of pending enrollment applications from these 6 VAMCs; and interviewed HEC and VAMC officials on oversight of enrollment processes.

What GAO Found

The Department of Veterans Affairs' (VA) Veterans Health Administration's (VHA) implementation and oversight of enrollment processes need improvement to help ensure the timely enrollment of veterans for health care benefits.
VHA frequently did not meet timeliness standards: VHA studies conducted in 2016 revealed that enrollment staff frequently did not process veterans' enrollment applications within the timeliness standard of 5 business days. These issues were found both at VHA's Health Eligibility Center (HEC)—the central enrollment processing center—and at local VA medical centers (VAMC) that also process enrollment applications. In response to an audit recommendation, HEC officials said they have begun prioritizing workload to help meet the timeliness standard. Additionally, the overall time needed to process enrollment applications may increase when staff need to place applications in a pending status, as pending applications require additional information, such as military service information, for staff to make enrollment determinations. However, none of the six VAMCs GAO reviewed had a specific policy for how to resolve pending applications. GAO found that VAMC enrollment staff had not resolved more than half of the pending applications GAO reviewed at these six VAMCs, some of which had been pending for more than 3 months at the time of the review. Although HEC developed new procedures for its enrollment staff to use when resolving pending applications, these procedures were not communicated to VAMCs. Officials from the VAMCs GAO reviewed said that they had not received guidance on these procedures and were confused about whether they would continue to have a role in this process. In the absence of HEC communication with VAMCs, there may be inefficiencies in resolving pending applications. VHA, through HEC, is assessing efforts to improve the timeliness of enrollment application processing and the accuracy of enrollment determinations.
VHA lacks a standardized oversight process and reliable data to monitor enrollment processes system-wide: Although HEC officials said they are responsible for oversight of enrollment processes system-wide, VHA has neither sufficient policies that delineate this role nor procedures that document key oversight activities that should be conducted. For example, policies do not describe the oversight activities HEC should conduct to help ensure the accuracy of enrollment determinations system-wide. Further, VHA does not have reliable data for overseeing the timeliness of processing enrollment applications at VAMCs, which process 90 percent of the applications system-wide. Officials from the six VAMCs in GAO's review and HEC also had varying interpretations of how to measure the timeliness standard. For example, officials from four of the six VAMCs said the standard was met when enrollment staff entered an application into their local system, irrespective of whether an enrollment determination was made. In contrast, HEC officials said the measurement encompasses the time needed to make an enrollment determination, including any time the application was pending. Without reliable data that are consistently measured, VHA cannot accurately oversee the timeliness of application processing system-wide, or assess the extent to which VAMCs face challenges in implementing enrollment processes. To improve oversight, VHA, through HEC, recently implemented an effort to review the accuracy of some enrollment determinations.

What GAO Recommends

GAO recommends that VHA (1) define the responsibilities of VAMCs in resolving pending enrollment applications; (2) define oversight responsibilities to help ensure timely application processing and accurate enrollment determinations; (3) develop procedures for collecting reliable data system-wide to evaluate the timeliness of application processing; and (4) clarify its 5-day timeliness standard. VA concurred with all of GAO's recommendations and identified actions it is taking to implement them.