Specifically, the TPAs  are responsible for establishing networks of community providers,  scheduling appointments with community providers for eligible veterans,  and paying community providers for their services. The Length of Time Taken by TPAs to Pay Claims from Community Providers Has Varied Widely, and VA’s Monitoring of This Timeliness Has Been Limited

		The Time TPAs Have Taken to Pay Claims Has Varied Widely, and Available Data Do Not Account for Payment Delays Due To Rejected or Denied Claims

From November 2014 through June 2018, VA’s TPAs paid a total of  about 16 million clean claims—which are claims that contain all required  data elements—under the Choice Program, of which TriWest paid about  9.6 million claims and Health Net paid about 6.4 million. Data on the  median number of days VA’s TPAs have taken to pay clean claims each  month show wide variation over the course of the Choice Program—from  7 days to 68 days. Stakeholders Identified Three Key Factors Affecting the Timeliness of Claim Payments to Community Providers under the Choice Program

VA and its TPAs identified three key factors affecting the timeliness of  claim payments to community providers under the Choice Program: (1)  VA’s untimely payments of TPA invoices; (2) Choice Program contractual  requirements related to provider reimbursement; and (3) inadequate  provider education on filing Choice Program claims, as discussed below. According to VA and TPA officials as well as providers we interviewed,  issues related to inadequate provider education may have contributed to  the length of time it has taken the TPAs to pay community providers  under the Choice Program. VA’s Monitoring of Claim Payment Timeliness Has Been Limited under the Choice Program, but VA Plans to Strengthen Monitoring under the Veterans Community Care Program

At the infancy of the Choice Program, November 2014 through March  2016, VA was unable to monitor the timeliness of its TPAs’ payments to  community providers because it did not require the TPAs to provide data  on the length of time taken to pay these claims. Modification of timely filing requirement. However, officials from one of the TPAs and 7 of the 15  providers we interviewed stated that VA medical facilities are not  reviewing and approving SARs in a timely manner. This  in turn increases the likelihood that the community providers’ claims will  be denied. TPAs Have Taken Steps to Improve Provider Education to Help Providers Resolve Claims Processing Issues, but Many Providers Still Report Poor Customer Service

We found that VA and its TPAs have taken steps to educate community  providers in order to help prevent claims processing issues that have  contributed to the length of time TPAs have taken to pay these providers. Furthermore, according to these officials,  VA allows the TPAs to prioritize calls from veterans. Because VA does not enforce the customer service  requirement for providers, VA has not collected data on or monitored the  TPAs’ compliance with these requirements for providers’ calls. Without  collecting data and monitoring customer service requirements for provider  calls, VA does not have information on the extent to which community  providers face challenges when contacting the TPAs about claims  payment issues that could contribute to the amount of time it takes to  successfully file claims and receive reimbursement for services under the  Choice Program. To the extent that these issues make community providers less willing to  continue participating in the Choice Program and the forthcoming  Veterans Community Care Program, they pose a risk to VA’s ability to  successfully implement these programs and ensure veterans’ timely  access to care. (Recommendation 1)
The Undersecretary for Health should collect data and monitor  compliance with the Choice Program contractual requirements pertaining  to customer service for community providers, and take corrective actions  as necessary. In its  written comments, reproduced in appendix I, VA concurred with our two  recommendations and said it is taking steps to address them.
Why GAO Did This Study

Questions have been raised about the lack of timeliness of TPAs' payments to community providers under the Choice Program and how this may affect the willingness of providers to participate in the program as well as in the forthcoming Veterans Community Care Program. You asked GAO to review issues related to the timeliness of TPAs' payments to community providers under the Choice Program.
This report examines, among other things, (1) the length of time TPAs have taken to pay community providers' claims and factors affecting timeliness of payments, and (2) actions taken by VA and the TPAs to reduce the length of time TPAs take to pay community providers for Choice Program claims.
GAO reviewed TPA data on the length of time taken to pay community provider claims from November 2014 through June 2018, the most recent data available at the time of GAO's review. GAO also reviewed documentation, such as the contracts between VA and its TPAs, and interviewed VA and TPA officials. In addition, GAO interviewed a non-generalizable sample of 15 community providers, selected based on their large Choice Program claims volume, to learn about their experiences with payment timeliness.

What GAO Found

The Department of Veterans Affairs' (VA) Veterans Choice Program (Choice Program) was created in 2014 to address problems with veterans' timely access to care at VA medical facilities. The Choice Program allows eligible veterans to obtain health care services from providers not directly employed by VA (community providers), who are then reimbursed for their services through one of the program's two third-party administrators (TPA). GAO's analysis of TPA data available for November 2014 through June 2018 shows that the length of time the TPAs took to pay community providers' clean claims each month varied widely—from 7 days to 68 days. VA and its TPAs identified several key factors affecting timeliness of payments to community providers under the Choice Program, including VA's untimely payments to TPAs, which in turn extended the length of time TPAs took to pay community providers' claims; and inadequate provider education on filing claims.
VA has taken actions to address key factors that have contributed to the length of time TPAs have taken to pay community providers. For example, VA updated its payment system and related processes to pay TPAs more quickly. According to VA data, as of July 2018, VA was paying at least 90 percent of the TPAs' invoices within 7 days. In addition, VA and the TPAs have taken steps to improve provider education to help providers resolve claims processing issues. However, 9 of the 15 providers GAO interviewed said they continue to experience lengthy telephone hold times. According to VA and TPA officials, steps have been taken to improve the customer service offered to community providers. However, VA officials do not collect data on or monitor TPA compliance with customer service requirements—such as calls being answered within 30 seconds or less—for provider calls because they said they are not enforcing the requirements and are allowing TPAs to prioritize calls from veterans. Without collecting data and monitoring compliance, VA does not have information on challenges providers may face when contacting TPAs to resolve payment issues.

What GAO Recommends

GAO is making two recommendations, including that VA should collect data on and monitor compliance with its requirements pertaining to customer service for community providers. VA concurred with GAO's recommendations and described steps it will take to implement them.