Almost a third of the claims denied or rejected by the Veterans Affairs Department for emergency care delivered at non-VA hospitals were inappropriately processed, leading to wrongful claim denials that put veterans at risk for unnecessary medical bills, an audit by the VA's Office of Inspector General found.
The 31% of non-VA emergency care claims inappropriately denied or rejected represented $716 million in claims from 60,800 veterans, according to an OIG report on the audit findings published Tuesday.
Of those denied or rejected claims, $53.3 million submitted for reimbursement by 17,400 veterans should have been approved, the OIG report stated. Processing errors also left veterans without the information needed to appeal denied or rejected claims.
The OIG said the errors stemmed from a culture at the VA that pressured staff to process claims quickly without focusing on making accurate claims decisions.
"Inappropriately denied or rejected non-VA emergency care claims present a risk of substantial, undue financial burden on veterans," the report said.
According to the report, veterans who seek emergency care at non-VA facilities may file for reimbursement of those emergency care costs. If claims are denied because there is no basis for payment or rejected because the claim requires additional or corrected information, non-VA facilities can bill veterans for some or all of the emergency care costs.
The OIG audit, conducted following requests from lawmakers, included emergency care claims submitted from April 1 to Sept. 30, 2017. It found that the Claims Adjudication and Reimbursement Directorate staff in the VA's Office of Community Care, which processes the claims, prioritized the number of claims processed over the accuracy of claims decisions while it tried to reduce a growing backlog of unprocessed claims.
The claims processors, also called voucher examiners, received a "work-production credit" when they denied or rejected a claim but not when they researched the claim and then suspended it for clinical review, according to the report. They were also given incentives to meet production targets with overtime and telework privileges.
"Interviews and survey responses showed that some voucher examiners were verbally directed or encouraged to deny non-VA emergency claims to meet production standards," the report said. "Additionally, some examiners who had not been directly encouraged to reject or deny claims responded that they still felt the CAR (Claims Adjudication and Reimbursement Directorate) culture created 'systemic pressure to favor speed over accuracy.'"
Meanwhile, the VA didn't have a standardized practice to review claims processors' accuracy. Several leadership changes since 2017 ensured that problems continued, the OIG said.