The  preauthorization process is initiated by a VA provider who submits a  request for non-VA medical care to the VA facility’s non-VA medical care  unit, which is an administrative department within each VA facility that  processes VA providers’ non-VA medical care requests and verifies that  non-VA medical care is necessary. 1.) Criteria for VA Coverage of Emergency Care from Non-VA Providers

For claims that are emergent in nature and therefore would not have gone  through the traditional VA preauthorization process, VA is authorized to  pay claims for emergency care from non-VA providers under certain  conditions, which vary depending on whether the care was related to the  veteran’s service-connected disability. 2.) VA Lacks Critical Data on Wait Times and Cost-Effectiveness of Non-VA Medical Care

Critical data limitations related to the wait times veterans face in obtaining  care from non-VA providers and the cost-effectiveness of such services  limit VA’s efforts to oversee the Non-VA Medical Care Program in an  effective manner. We previously  reported that the amount of time veterans wait for appointments in VA  facilities influenced VA’s utilization of non-VA medical care. In our May 2013 report, we found that VA  lacked a data system to group medical care delivered by non-VA  providers by episode of care—a combined total of all care provided to a  veteran during a single office visit or inpatient stay. Without cost-effectiveness data, VA is unable to efficiently compare VA  and non-VA options for delivering care in areas with high utilization and  spending for non-VA medical care. With respect to establishing a mechanism to analyze the episode of care  costs for non-VA medical care, VA officials explained that they are in the  process of fully implementing this recommendation by (1) improving  existing data systems to systematically audit claims that include billing  codes typically included in bundled payments while the claims are in a  pre-payment status and to require VA facilities to review these claims  prior to payment, and by (2) making improvements to its Non-VA Medical  Care Program data that would allow all non-VA medical care data to be  analyzed on an episode of care basis. Selected VA Facilities Failed to Comply with Applicable Millennium Act Claims Processing Requirements, and Weaknesses Were Identified in VA’s Oversight of Claims Processing Activities

In March 2014, we reported that four VA facilities we visited had patterns  of noncompliance with VA claims processing requirements, which led to  the inappropriate denial of some Millennium Act emergency care claims  and the failure to notify some veterans that their claims had been  denied. We also found that VA’s existing oversight mechanisms for non- VA medical care claims processing were not sufficiently focused on  whether VA facilities were inappropriately approving or denying claims. We determined that about 20 percent of the claims we  examined had been denied inappropriately, and almost 65 percent of the  claims we examined lacked documentation showing that the veteran was  notified that their claim was denied. As a result of our review, these four  VA facilities reconsidered and paid 25 claims that they had  inappropriately denied. VA concurred with these recommendations and  detailed its plans to address them. Veterans Lack Knowledge about Millennium Act Emergency Care Eligibility, and Selected Non-VA Providers Have Reported Communication Challenges with VA

In March 2014, we found that despite VA’s communication efforts with  veterans and non-VA providers, knowledge gaps exist for veterans about  eligibility for Millennium Act emergency care, and communication  weaknesses exist between VA and non-VA providers. VA primarily educates  veterans about their eligibility for non-VA medical care through patient  orientation sessions and written materials, such as the Veteran Health  Benefits Handbook. Alternatively, we found that without knowledge of specific criteria for VA  payment of non-VA medical care, specifically Millennium Act emergency  care, veterans may seek treatment in situations where the Department  cannot pay. However, VA staff reviewing the claim may decide that the  condition does not meet the prudent layperson standard for emergency  care and deny payment.
Why GAO Did This Study

Due to serious and longstanding problems with the timely scheduling of veterans' appointments in VA facilities, VA recently announced that it will allow additional veterans to be treated through its Non-VA Medical Care Program.
This testimony is based on two GAO reports and addresses the extent to which (1) VA collects reliable information on wait times and cost-effectiveness of the Non-VA Medical Care Program; (2) VA facilities comply with Millennium Act claims processing requirements and VA oversees claims processing activities; and (3) VA educates veterans about eligibility for Millennium Act emergency care and communicates with non-VA providers. For both reports, GAO reviewed relevant requirements and visited 10 VA facilities. For its report on the oversight and management of the Non-VA Medical Care Program, GAO reviewed non-VA medical care spending and utilization data from fiscal year 2008 through fiscal year 2012. For its report on the Millennium Act emergency care benefit, GAO reviewed 128 denied Millennium Act claims to determine the accuracy of processing decisions.
GAO made numerous recommendations to VA in the two prior reports related to improving (1) data on wait times and cost-effectiveness for non-VA medical care; (2) compliance with claims processing requirements; and (3) veterans' knowledge of non-VA medical care eligibility. VA agreed with these recommendations but has yet to fully implement them.

What GAO Found

GAO's May 2013 report on the oversight and management of the Non-VA Medical Care Program found that the Department of Veterans Affairs (VA) does not collect data on wait times veterans face in obtaining care from non-VA providers. The lack of data on wait times limits VA's efforts to effectively oversee the Non-VA Medical Care Program because it is not possible for VA to determine if veterans who receive care from non-VA providers are receiving that care sooner than they would in VA facilities. In addition, GAO found that VA cannot assess the cost-effectiveness of non-VA medical care because it cannot analyze data on all services and charges for an episode of care, which is a combined total of all care provided to a veteran during a single office visit or inpatient stay. As a result, VA cannot determine whether delivering care through non-VA providers is more cost-effective than augmenting its own capacity in areas with high utilization of non-VA medical care.
GAO's March 2014 report found patterns of noncompliance with applicable requirements for processing emergency care claims covered under the Veterans Millennium Health Care and Benefits Act (Millennium Act) at each of the four VA facilities visited. This led to the inappropriate denial of some claims and the failure to notify veterans that their claims had been denied at these facilities. The Millennium Act authorizes 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 and meet other specified criteria. Specifically, GAO determined that about 20 percent of the 128 claims it reviewed had been denied inappropriately, and almost 65 percent of the reviewed claims lacked documentation showing that the veterans were informed their claims were denied and explained their appeal rights. As a result of GAO's review, the VA facilities reconsidered and paid 25 claims that they initially had inappropriately denied. GAO also found that there is significant risk that these patterns of noncompliance will continue because VA's existing oversight mechanisms do not focus on whether VA facilities appropriately approve or deny non-VA medical care claims or fail to notify veterans that their claims have been denied.
GAO also reported in March 2014 that gaps exist in veterans' knowledge about eligibility criteria for Millennium Act emergency care, and communication weaknesses exist between VA and non-VA providers. Specifically, GAO found that veterans' lack of understanding about their emergency care benefits under the Millennium Act presents risks for potentially negative effects on veterans' health because they may forgo treatment at non-VA providers, and on veterans' finances because they may assume VA will pay for care in situations that do not meet VA criteria. Despite VA's efforts to improve communications, some non-VA providers reported instances in which VA facilities' claims processing staff were unresponsive to their questions about submitted claims.