1.) For each VA clinical contract, the CO responsible for the contract  designates a contracting officers’ representative (COR) at the VA facility  to help develop the clinical contract and monitor the contract provider’s  performance once the provider begins work. 3.) Significant Weaknesses Exist in VA’s Monitoring and Oversight of Non-VA Medical Care

		VA Lacks Critical Data on Wait Times and Cost- Effectiveness of Non-VA Medical Care

As our recent work has found, critical data limitations related to the wait  times veterans face in obtaining care from non-VA providers and the cost- effectiveness of such services hinder VA’s efforts to oversee the Non-VA  Medical Care Program in an effective manner. VA does not collect data on how long veterans must wait to be seen by  non-VA providers. VA Cannot Analyze the Cost-Effectiveness of Non- VA Medical Care

Our recent work found that limitations in the way VA collects non-VA  medical care data did not allow the Department to analyze the cost- effectiveness of non-VA medical care provided to veterans. As we  reported in May 2013, 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   For example, we reported that during an office visit to  or inpatient stay.an orthopedic surgeon for a joint replacement evaluation, an X-ray of the  affected joint may be ordered, the veteran may be given a blood test, and  the veteran may receive a physical evaluation from the orthopedic  surgeon. Without cost-effectiveness data, we concluded that 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. As a result, this recommendation remains unimplemented. VA Lacks Automated Processes for Monitoring Non-VA Medical Care Claims Processing and Has Limited Oversight Mechanisms for Validating VA Facility Actions

Our recent reports have found that crucial limitations exist in VA’s  monitoring and oversight of non-VA medical care claims processing. Specifically, VA does not have automated systems to help VA facility- based claims processing staff determine whether a non-VA medical care  claim is eligible for payment or notifying veterans that their claims have   In addition, VA’s oversight mechanisms—including field  been denied.assistance visits to VA facilities processing non-VA medical care claims  and audits of VA facilities’ claims determinations—are limited due to  weaknesses in their execution. As we reported in March 2014, we found that there were no automated  processes for determining whether a claim for non-VA medical care  meets criteria for payment or ensuring that veterans are notified when a  claim is denied.and diligence of VA facility-based claims processing staff reviewing each  claim and their adherence to VA policies. For example, we found nine instances where a veteran’s claim  was denied under VA’s emergency care authority for non-service  connected conditions, but should have been paid under VA’s  preauthorized non-VA medical care authority because a VA clinician had   Instead these processes rely largely on the judgment  referred the veteran to the non-VA provider. Significant Limitations Exist in VA’s Monitoring and Oversight of Clinical Contracts and Contractors

		Contract Monitoring Is Limited by Heavy COR Workloads and Inadequate Training

As we reported in October 2013, we found that CORs cited two  challenges that may compromise VA’s monitoring of contractors’  performance—the heavy workload associated with the COR position and  the lack of adequate training for CORs. Many of these CORs’  primary positions require them to manage staff, maintain budgets, and  oversee other clinical providers. Specifically, CORs for 8 of the 12  contracts reported that the demands of their primary positions had at  times prevented them from fully monitoring contract providers’  performance. In addition, CORs for 6 of these 12 contracts stated that  they could not complete certain elements of their COR responsibilities— such as adequately monitoring contract costs—due to limited time and  resources. Relating to training, CORs from the four VA facilities we visited noted  weaknesses in VA’s COR training courses and our own analysis of these  courses confirmed these limitations. The primary  examples used in the course did not include a discussion of clinical  contracts at VA and instead walked students through the contracting  process using examples such as replacing carpet and making a large  computer equipment purchase. Included little information on monitoring responsibilities. In October 2013, we recommended that VA modify its COR training to  ensure it includes examples and discussion of how to develop and  monitor service contracts—including contracts for the provision of clinical  care in VA facilities. VA’s Oversight of VA Facility Clinical Contract Monitoring Is Limited

Our recent work has also found that VA has not established a robust  method for overseeing the monitoring of clinical contractors by COs and  CORs throughout its health care system. While VA has made progress in implementing this recommendation by  completing 45 more reviews of COR files in fiscal year 2014 than in fiscal  year 2013, these reviews were still only conducted in 5 of the 21 network  contracting offices.
Why GAO Did This Study

VA uses both the Non-VA Medical Care Program and clinical contracts to augment its delivery of care to veterans. GAO has previously highlighted weaknesses in the monitoring and oversight of both non-VA medical care and clinical contracts that remain unresolved.
This testimony is based on three GAO reports issued in 2013 and 2014 and addresses the extent to which VA monitors and oversees its (1) Non-VA Medical Care Program and (2) clinical contracts and contracted non-VA providers working in VA facilities. For all three reports, GAO reviewed relevant requirements and visited a total of 14 VA facilities. For its May 2013 report on the oversight and management of the Non-VA Medical Care Program, GAO reviewed non-VA medical care data from fiscal year 2008 through fiscal year 2012. For its October 2013 report on clinical contract monitoring and oversight, GAO administered a data collection instrument to CORs and reviewed 12 selected clinical contracts. For its March 2014 report on non-VA emergency medical care for veterans' non-service connected conditions, GAO reviewed 128 denied claims.

What GAO Found

GAO's recent work has found significant weaknesses in the Department of Veterans Affairs' (VA) monitoring and oversight of its Non-VA Medical Care Program. Through this program, care is provided to veterans by non-VA providers in non-VA facilities. As GAO reported in May 2013, VA did not collect data on wait times veterans face in obtaining care from non-VA providers. Having data on wait times for veterans referred to non-VA providers would help VA better determine if veterans are receiving comparable access to non-VA providers and VA-based providers. In addition, GAO found that VA was unable to analyze non-VA medical care data on all services and charges for an episode of care, which is the combined total of all care provided to a veteran during a single office visit or inpatient stay. As a result, VA cannot ensure that non-VA providers are billing VA appropriately for care or determine whether delivering care through non-VA providers is more cost-effective than augmenting its own capacity in areas of high utilization of non-VA medical care. Moreover, in March 2014 GAO reported that crucial limitations existed in VA's monitoring and oversight of non-VA medical care claims processing. Specifically, VA lacked automated processes for (1) determining whether claims met VA's criteria for payment and (2) notifying veterans when their claims were denied. Instead, these processes relied largely on the judgment and diligence of VA facility-based claims processing staff. For example, GAO found several non-VA medical care claims that were inappropriately denied because VA facility-based claims processing staff processed the claims under the wrong payment authority. Moreover, GAO found that VA's oversight was lacking in key aspects of the claims review process, a factor that allowed inappropriate denials and notification issues to persist.
GAO's recent work has also found significant limitations in VA's monitoring and oversight of clinical contracts and contractors—a method VA uses to bring non-VA providers into VA facilities. As GAO reported in October 2013, contracting officer's representatives' (COR) heavy workloads and inadequate training compromised VA's monitoring of contractor performance. CORs are responsible for monitoring the work of non-VA providers working in VA facilities under a contract once the contract is in place. CORs for 8 of the 12 contracts GAO reviewed in depth reported that the demands of their primary positions at the VA facility have at times prevented them from fully monitoring contract providers' performance. Six of these CORs stated that they could not complete certain elements of their COR responsibilities—such as adequately monitoring contract costs—due to limited time and resources. Robust VA oversight would better ensure that the contract providers deliver high quality care to veterans and fulfill the responsibilities of their contracts. In addition, CORs from the four VA facilities GAO visited noted weaknesses in VA's COR training and GAO's analysis confirmed these limitations. Specifically, GAO found this training focused on teaching CORs to develop contracts that purchase goods and not clinical services. The primary examples in this course included discussions of the contracting process for replacing carpet and making a large computer purchase. In addition, COR training included little information on how CORs should engage in post-award monitoring of clinical contractors.

What GAO Recommends

GAO made 22 recommendations to VA in its prior three reports related to improving (1) data on wait times and cost-effectiveness of non-VA medical care; (2) VA's oversight and monitoring of claims processing; and (3) VA's monitoring of clinical contractors. VA agreed with these recommendations, and has taken action on some, but has yet to fully implement many of them.