The Veterans Health Administration risks losing the cooperation of community providers because staffing shortages and technology limitations continue to delay claims processing, according to a recent report from the Government Accountability Office.
The report is further evidence of ongoing problems at the department. The VHA has frequently been found to have slow claims processing by the GAO, the VA Office of the Inspector General and the National Academy for Public Administration.
GAO reports from 2014 and 2015 found community providers waiting months or even years to receive payments from the VHA. In fiscal 2015, the department said it processed two-thirds of claims within 30 days, compared to Medicare and Tricare rates of about 99% within 30 days. But the VHA rate is likely actually worse, because the internal statistics do not account for delays in scanning paper claims, according to the most recent GAO report.
Recent increases in use of community care have added to the problem. The number of processed claims at the VHA increased by more than 80% from fiscal year 2012 to 2015.
In October, VHA officials submitted a plan to Congress to consolidate its care in the community programs and included strategies for improving timeliness and accuracy of payment. The plan called for more automation in claims processing, ways for providers to submit more information electronically and the creation of a dedicated customer service staff.
The VHA agreed with the GAO recommendations to set a schedule for implementing the changes and performance goals and interim milestones to evaluate progress.
The agency is “taking the important steps necessary to develop an implementation strategy that will include the design and specific details regarding transitioning, deployment of technologies, resourcing, servicing parameters, accountability and quality controls,” according to the VHA comment.
Last month, Jeff Miller (R-Fla.), chairman of the House Committee on Veterans Affairs introduced legislation that would establish a permanent Veterans Choice Program and drop requirements for receiving medical records before care is approved.
The American Medical Association said in a statement that it supports that provision and other aspects of the bill that could expedite claims processing.
“However, we urge the committee to amend the draft bill to include provisions that require the prompt payment of claims; delayed payment of claims has been one of the main barriers to encouraging physicians and other providers to participate in the program,” the AMA wrote.
GAO observers found that scanning paper claims took an average of two weeks at the 95 VHA claims processing locations, and at one location some piles of claims went untouched for more than a month. This is despite a 2014 GAO recommendation that VHA require all claims to be scanned upon receipt.
Providers told the GAO that the claims process had unnecessary administrative burdens and that VHA staff often failed to respond to questions.
One provider told investigators that the office employed one full-time employee to handle all VHA claims, even though it accounted for about 5% of all claims. Another staffer was able to handle all Medicare claims, which made up about 85%.
Another provider said VHA staff at their processing location would answer questions about only three claims each a day. Staff would have to end a call when they reached a staff member who was over that limit for the day and call back hoping to be connected with a different staff member.
“Based on statements made by community providers that participated in our review, it is critical for the VHA to succeed in achieving its goal of deploying a modernized claims processing system,” the GAO authors wrote.
Claims processing at VHA has many differences from the methods at Medicare and Tricare and several of them have contributed to delays.
VHA requires prior authorization and medical documentation for nearly all community services. But there is no automatic claim adjudication, no web-based provider portal and no dedicated customer service staff. VHA also does not use contractors and cannot accept many document electronically, GAO found.