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Accuracy of Veteran Copayment Charges' which was released on September 
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United States Government Accountability Office: 
GAO: 

Report to Congressional Requesters: 

August 2011: 

Veterans Health Care: 

Monitoring Is Needed to Determine the Accuracy of Veteran Copayment 
Charges: 

GAO-11-795: 

GAO Highlights: 

Highlights of GAO-11-795, a report to congressional requesters. 

Why GAO Did This Study: 

In fiscal year 2010, the Department of Veterans Affairs’ (VA) Veterans 
Health Administration (VHA) billed veterans millions of medical 
copayment charges totaling more than $1 billon. Witnesses at a 2009 
Subcommittee on Health, House Committee on Veterans’ Affairs, hearing 
raised concerns about inappropriate copayment charges, including some 
associated with veterans’ service-connected conditions. As a result, 
members of the Subcommittee asked GAO to review (1) VHA copayment 
charge accuracy, including error rates and related causes, and (2) VHA 
efforts to monitor copayment charge accuracy. To assess the accuracy 
of VHA’s billed copayment charges, GAO evaluated samples of fiscal 
year 2010 billed and unbilled medical services to determine copayment 
error rates and related causes. GAO also reviewed VHA practices 
related to monitoring the accuracy of copayment charges. 

What GAO Found: 

Of the more than 56 million fiscal year 2010 veteran copayment charges 
billed by VHA, GAO estimates, based on its test of a probability 
sample of copayment charges, that 96 percent (or approximately 54.2 
million) of the copayment charges were accurate and 4 percent (or 
approximately 2.3 million) were inaccurate. GAO’s tests of a separate 
probability sample of the approximately 519 million VHA medical 
services that did not result in copayment charges showed that each of 
those VHA determinations was accurate. These and other estimated 
percentages are based on test results of probability samples and are 
subject to sampling error. Appendix I of this report contains 
additional information on the samples and the 95 percent confidence 
intervals for the estimates contained in this report. 

* Since the errors identified in GAO’s probability sample all involved 
copayment overbilling, GAO estimates that 4 percent of the copayment 
charges involved overbilling of veterans. The errors GAO found were 
due to various factors, including inadequate review of previously 
billed copayment charges following retroactive changes in a veteran’s 
service-connected conditions and the incorrect application of related 
medical reimbursements received from veterans’ third-party insurance. 

* In tests GAO performed on another probability sample to identify 
underbilling errors in the approximately 519 million medical services 
that did not result in copayment charges, GAO found that VHA correctly 
determined that each tested service should not have resulted in a 
copayment charge. As a result, GAO tests showed that VHA accurately 
did not bill copayment charges for these services, which made up more 
than 90 percent of the approximately 576 million medical services 
provided during fiscal year 2010. 

While VHA performed various activities that involved reviewing the 
accuracy of some individual billed copayment charges, these activities 
do not constitute a systematic process for providing VHA-wide 
information on the accuracy and completeness of its copayment charges 
over time. In addition, GAO found that VHA had not established a 
performance measure for the accuracy level it wants to achieve in 
billing copayment charges. Without such a measure, it is not clear how 
the error rates GAO found would compare to error rates that VHA would 
consider acceptable, or if VHA would determine whether corrective 
actions need to be taken to reduce the error rates to lower levels. In 
addition, without a performance measure and periodic, systemwide 
information on the accuracy of its copayment charges, VHA cannot 
monitor changes in error rates and related causes over time. VHA also 
does not have meaningful performance information that it can provide 
to interested stakeholders when questions or concerns are raised 
concerning the accuracy of VHA’s copayment charges billed to veterans. 

What GAO Recommends: 

GAO makes two recommendations to the Secretary of Veterans Affairs to 
(1) establish a copayment accuracy performance measure and 
(2) establish and implement a formal process for periodically 
assessing the accuracy of veteran copayment charges VHA-wide. In 
written comments on a draft of this report, VA agreed with GAO’s 
recommendations. 

View [hyperlink, http://www.gao.gov/products/GAO-11-795] or key 
components. For more information, contact Susan Ragland, at (202) 512-
9095 or raglands@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

Statistical Tests of VHA's Fiscal Year 2010 Copayment Charges Found 
That an Estimated 96 Percent Were Accurate: 

VHA Does Not Monitor Its Systemwide Copayment Error Rate: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Objectives, Scope, and Methodology: 

Appendix II: Enrollment in VA Health Care and Copayment Billing 
Process: 

Appendix III: Comments from the Department of Veterans Affairs: 

Appendix IV: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Fiscal Year 2010 VHA Medical Services: 

Table 2: Number and Amount of Fiscal Year 2010 Copayment Charges by 
Type of Medical Service: 

Table 3: Summary Information on Estimated Error Rates Related to VHA's 
Fiscal Year 2010 Billed Veteran Copayment Charges and Unbilled Medical 
Services: 

Table 4: Fiscal Year 2010 Population of VHA Copayment Charges by Type: 

Table 5: Causes for Identified Errors in Copayment Charges: 

Table 6: Estimated Error Rates for Veterans' Fiscal Year 2010 
Copayment Charges: 

Table 7: Fiscal Year 2010 VHA Medical Services by Type: 

Table 8: Estimated Rates Applicable to Fiscal Year 2010 Medical 
Services That Did Not Result in Veteran Copayment Charges: 

Table 9: Causes for Observed Errors in Case Study Copayment Charges: 

Table 10: VA Health Care Enrollment Priority Groups and Their 
Eligibility Factors: 

Table 11: Fiscal Year 2010 VHA Veteran Medical Services: 

Table 12: General Applicability of Copayment Charges by Priority Group 
and Type of Service: 

Abbreviations: 

CBI: Compliance and Business Integrity: 

CPAC: Consolidated Patient Account Center: 

CPRS: Computerized Patient Record System: 

HEC: Health Eligibility Center: 

MCCF: Medical Care Collections Fund: 

MQAS: Management Quality Assurance Service: 

POWER: Performance and Operations Web-Enabled Reports: 

VA: Department of Veterans Affairs: 

VBA: Veterans Benefits Administration: 

VHA: Veterans Health Administration: 

VistA: Veterans Health Information Services and Technology 
Architecture: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

August 29, 2011: 

Congressional Requesters: 

The Department of Veterans Affairs (VA) provides health care to 
eligible veterans through 21 health care networks, each composed of 
multiple medical facilities, in the Veterans Health Administration 
(VHA). VHA is authorized by law to bill certain veterans for 
copayments for some medical services that are unrelated to conditions 
that VA has determined to be a result of their military service. 
[Footnote 1] Medical services provided by VHA include inpatient and 
outpatient services, prescription medication, home health care, and 
extended care services, including nursing home and respite care. 
Representatives of veterans service organizations[Footnote 2] 
testified at a congressional hearing[Footnote 3] about their concerns 
that veterans were being billed for inappropriate copayment charges, 
including copayments billed for medical services linked to their 
service-connected conditions and injuries and multiple copayment 
charges billed for the same medical treatment. In light of these 
concerns, you asked us to review VHA's billing practices. This report 
addresses (1) the accuracy rate of VHA's copayment charges, including 
causes and rates of any over-and underbilling errors and (2) whether 
VHA had systems and processes in place to adequately monitor the 
accuracy of copayment charges billed to veterans. 

In assessing the accuracy of VHA's fiscal year 2010 copayment charges 
(the most recent fiscal year for which the information was available), 
we first gained an understanding of VHA copayment billing practices by 
reviewing information on VHA's systems and processes related to 
determining which medical services should result in veteran copayment 
charges and then for billing applicable copayment charges. In 
conducting our work on copayment accuracy, including understanding VHA 
activities related to assessing the accuracy of copayment charges, we 
reviewed policies and procedures related to VHA's copayment billing 
process and veterans' eligibility for medical care and copayment 
billing. In addition, we performed a walk-through of the billing 
process at a VHA medical center and discussed billing and monitoring 
policies and practices with VHA officials and staff. 

To determine the accuracy and completeness of VHA's copayment charges, 
including rates and causes of errors, we selected probability samples 
from two populations of VHA medical services provided to veterans--one 
from medical services that resulted in veteran copayment charges and 
the other from those medical services that did not result in copayment 
charges. For each sampled medical service, we reviewed relevant 
supporting documentation from VHA and from the Veterans Benefits 
Administration (VBA), which included information regarding the 
veterans' service-connected conditions. From this review, we 
determined whether a veteran should have been billed a copayment 
charge for the underlying medical service and, if so, whether the 
billed copayment charge amount was correct or, if not, whether the 
copayment charge was an over-or underbilling error. For each error 
identified, we determined the causes.[Footnote 4] In addition, for 
three types of medical services--inpatient, extended care, and fee 
basis services--that were not selected in our sample because they 
infrequently result in copayment charges, we selected and tested three 
nongeneralizable probability samples of a limited number of copayment 
charges as case studies to gain some insight into the types and causes 
of any errors that we identified in copayment charges arising from 
these services. Finally, to determine whether VHA has systems and 
processes in place to adequately monitor the accuracy of billed 
veteran copayment charges, we obtained and reviewed available 
information on VHA practices related to monitoring the accuracy of 
billed veteran copayment charges. 

We conducted this performance audit from February 2010 through August 
2011 in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives.[Footnote 5] 

Background: 

VHA Health Care Eligibility and Enrollment: 

To obtain VHA health care, most veterans submit an application by mail 
or online to VHA's Health Eligibility Center (HEC) in Atlanta or in 
person at a local VHA medical center. Generally, the nature and extent 
of an individual veteran's service-connected medical conditions are 
established through VBA.[Footnote 6] HEC processes applications and 
assigns veterans to one of eight priority groups based on their 
service-connected disabilities; special treatment authorities, such as 
exposure to Agent Orange or ionizing radiation; and income level. 
Whether VHA charges a veteran a copayment for medical services it 
provides is determined, in part, by the veteran's priority group. For 
example, veterans in priority group 1 are not required to pay any 
copayments, and veterans in priority groups 7 and 8 are generally 
required to pay copayments for all types of medical services. See 
appendix II for additional details on the enrollment and eligibility 
process, including priority groups and requirements for copayments. 

When VHA is notified by VBA of a change in a veteran's service- 
connected conditions or disability rating, VHA is responsible for 
reevaluating the veteran's priority group status and reviewing the 
veteran's account to determine whether any copayment charges that were 
assessed after the effective date of the VBA award should be canceled 
or refunded, if applicable, or whether any copayments should be 
charged. 

Medical Service and Copayment Billing: 

Veterans' health records are stored in the Computerized Patient Record 
System (CPRS) application of the Veterans Health Information Services 
and Technology Architecture (VistA) system. CPRS includes information 
on veterans' rated service-connected conditions and special treatment 
authorities. When a veteran receives a VHA-provided medical service, 
the provider identifies in CPRS whether the service provided was 
related to the veteran's service-connected conditions or provided 
under a special treatment authority. 

When medical services provided to a veteran are not otherwise 
precluded from copayment billing, VistA automatically establishes a 
copayment charge to the veteran's account. VistA prevents copayment 
charges to a veteran when: 

* a provider indicates in CPRS that the medical service provided was 
related to a veteran's service-connected conditions or special 
authority; 

* the medical service provided is one that is exempt from copayments 
for all veterans, such as preventive screenings, immunizations, and 
some laboratory services; and: 

* a veteran receives more than one medical service in a single day. 
[Footnote 7] 

If a veteran has third-party medical insurance, VistA puts the 
copayment charge placed on the veteran's account on hold for up to 90 
days to allow time for VHA to process a claim for reimbursement from 
the third-party insurer. To the extent that VHA receives third-party 
reimbursement attributable to the medical service that resulted in a 
copayment being charged to a veteran's account, VHA's policy is to 
apply the insurance reimbursement to reduce or eliminate the related 
pending copayment charge. The third-party insurance offset process is 
a manual process that is to be performed, according to VHA policy, on 
a daily basis by local medical center staff. 

See appendix II for additional details on the copayment billing 
process. 

Fiscal Year 2010 Medical Services and Copayment Charges: 

According to fiscal year 2010 VA information, VHA provided 
approximately 576 million medical services to over 5.6 million 
veterans through VHA's 21 health care networks composed of 153 medical 
centers, 768 outpatient clinics, and 134 nursing homes located in all 
50 states, the District of Columbia, and territories including Puerto 
Rico and the Virgin Islands. When VHA facilities are not capable of 
furnishing economical hospital care or medical services because of 
geographic inaccessibility or are not capable of furnishing the care 
or services required, VHA may authorize and pay a non-VHA provider to 
provide certain veterans hospital care and medical services. When 
authorized, VHA identified these as fee basis services. Table 1 shows 
the types, number, and percentage of medical services provided by 
type--outpatient, prescription, inpatient, extended care, and fee 
basis. 

Table 1: Fiscal Year 2010 VHA Medical Services: 

Medical service type: Outpatient; 
Number of services: 407,858,000; 
Percentage of services: 70.83%. 

Medical service type: Prescription; 
Number of services: 136,036,000; 
Percentage of services: 23.63%. 

Medical service type: Inpatient; 
Number of services: 7,703,000; 
Percentage of services: 1.34%. 

Medical service type: Extended care; 
Number of services: 707,000; 
Percentage of services: 0.12%. 

Medical service type: Fee basis; 
Number of services: 23,494,000; 
Percentage of services: 4.08%. 

Medical service type: Total; 
Number of services: 575,798,000; 
Percentage of services: 100.00%. 

Source: GAO analysis of VHA data. 

[End of table] 

VA is also authorized, by statute to bill certain veterans for medical 
service copayments (38 U.S.C. § 1710, 1710B, 1722A), and, if 
applicable, their third-party medical insurance when the medical 
services VHA provides are not related to the veteran's service- 
connected medical conditions or associated with special treatment 
authorities (38 U.S.C. § 1729). These collections supplement VA's 
appropriations and are used to fund VHA medical services to veterans. 

When VHA provides medical services that are not associated with a 
veteran's service-connected conditions or special treatment 
authorities and the veteran has third-party medical insurance, VHA is 
authorized by statute (38 U.S.C. § 1729) to pursue insurance 
reimbursement to the extent available under the veteran's coverage 
from the veteran's third-party insurance. Veterans who owe copayment 
charges for medical services for non-service-connected conditions or 
for conditions not related to special treatment authorities must be 
allowed to benefit from their third-party insurance to satisfy their 
VHA obligations. Therefore, VHA is required to apply any insurance 
reimbursement it receives from a veteran's third-party insurance to 
the related copayment charge to reduce or eliminate the copayment 
charge owed by the veteran. 

VHA billed veterans for over 56.5 million copayment charges totaling 
over $1 billion in fiscal year 2010. These copayment charges were 
related to approximately 9.8 percent of the total of approximately 576 
million VHA medical services provided. Individual veteran copayment 
amounts in fiscal year 2010 ranged from a low of $5 for some extended 
care services to a high of $1,100 for the first 90 days of an 
inpatient hospital stay. Most billed copayment charges (88 percent) 
were for prescription medications, for which the copayment charge is 
generally $8 or $9 for up to a 30-day supply of medication. Table 2 
shows the number, amounts, and related percentages associated with the 
copayment charges billed to veterans in fiscal year 2010 by type of 
service. 

Table 2: Number and Amount of Fiscal Year 2010 Copayment Charges by 
Type of Medical Service: 

Medical service type: Prescription; 
Total number of copayment charges: 49,852,000; 
Percentage of individual copayment charge types: 88.22%; 
Value of billed copayment charges: $824,504,000; 
Percentage of billed copayment charge value: 78.02%. 

Medical service type: Outpatient; 
Total number of copayment charges: 6,325,000; 
Percentage of individual copayment charge types: 11.19%; 
Value of billed copayment charges: $173,698,000; 
Percentage of billed copayment charge value: 16.44%. 

Medical service type: Inpatient; 
Total number of copayment charges: 125,000; 
Percentage of individual copayment charge types: 0.22%; 
Value of billed copayment charges: $47,255,000; 
Percentage of billed copayment charge value: 4.47%. 

Medical service type: Extended care; 
Total number of copayment charges: 12,000; 
Percentage of individual copayment charge types: 0.02%; 
Value of billed copayment charges: $4,653,000; 
Percentage of billed copayment charge value: 0.44%. 

Medical service type: Fee basis; 
Total number of copayment charges: 196,000; 
Percentage of individual copayment charge types: 0.35%; 
Value of billed copayment charges: $6,742,000; 
Percentage of billed copayment charge value: 0.64%. 

Medical service type: Total; 
Total number of copayment charges: 56,510,000; 
Percentage of individual copayment charge types: 100.00%; 
Value of billed copayment charges: $1,056,852,000; 
Percentage of billed copayment charge value: 100.00%. 

Source: GAO analysis of VHA data. 

Note: Percentages may not add to 100 because of rounding. 

[End of table] 

Statistical Tests of VHA's Fiscal Year 2010 Copayment Charges Found 
That an Estimated 96 Percent Were Accurate: 

Based on our tests of a probability sample of billed copayment 
charges, we estimate that 96 percent of VHA's fiscal year 2010 
copayment charges were accurate and 4 percent were inaccurate or 
erroneous.[Footnote 8] We selected a probability sample of 100 fiscal 
year 2010 copayment charges billed to veterans, which included only 
prescription and outpatient services,[Footnote 9] and found 4 
erroneous copayment charges, each of which resulted in an overbilling 
to a veteran. Based on these test results, we estimate that of VHA's 
56.5 million fiscal year 2010 copayment charges, approximately 54.2 
million (96 percent) were accurate and approximately 2.3 million (4 
percent) were inaccurate.[Footnote 10] In addition, none of the four 
copayment errors we found involved underbilling of veterans.[Footnote 
11] 

In fiscal year 2010, more than 90 percent of VHA's medical services 
did not result in billed copayment charges. To assess the completeness 
of the billed copayment charge population and the extent of possible 
underbilling errors associated with those medical services, we also 
selected a second probability sample of 100 unbilled medical services 
to assess whether VHA had correctly determined that each of the tested 
medical services should not have been billed. We did so because 
incorrect "no bill" determinations by VHA would represent underbilling 
inaccuracies associated with VHA's fiscal year 2010 copayment charges. 
Our tests of 100 unbilled medical services found that VHA correctly 
determined that each of the medical services should not have resulted 
in a veteran copayment charge--a 100 percent accuracy rate for this 
probability sample. As a result, we are 95 percent confident that for 
fiscal year 2010, VHA's rate of error in the population of unbilled 
medical services associated with incorrectly determining that medical 
services should not have resulted in a copayment charge was between 0 
percent and 3 percent.[Footnote 12] (See table 3.) 

Table 3: Summary Information on Estimated Error Rates Related to VHA's 
Fiscal Year 2010 Billed Veteran Copayment Charges and Unbilled Medical 
Services: 

Sampled population: Billed copayment charges; 
Type of possible error: Copayment charge--overbilling; 
Number of errors: 4; 
Estimated error rate percentage: 4%; 
Ninety-five percent confidence: Lower limit percentage: 1.1%; 
Ninety-five percent confidence: Upper limit percentage: 9.9%; 
Size of applicable population: 56.5 million copayment charges. 

Sampled population: Billed copayment charges; 
Type of possible error: Copayment charge--underbilling; 
Number of errors: 0; 
Estimated error rate percentage: 0%; 
Ninety-five percent confidence: Lower limit percentage: 0%; 
Ninety-five percent confidence: Upper limit percentage: 3%; 
Size of applicable population: 56.5 million copayment charges. 

Sampled population: Unbilled medical services; 
Type of possible error: Failed to bill a valid copayment charge; 
Number of errors: 0; 
Estimated error rate percentage: 0%; 
Ninety-five percent confidence: Lower limit percentage: 0%; 
Ninety-five percent confidence: Upper limit percentage: 3%; 
Size of applicable population: 519.3 million[A] unbilled medical 
services. 

Source: GAO test results from a VHA-wide probability sample of billed 
copayment charges to veterans and a second VHA-wide probability sample 
of unbilled medical services. 

[A] Population is estimated using fiscal year 2010 medical services 
and copayment charges prepared in fiscal year 2010. 

[End of table] 

Nature and Causes of Copayment Billing Errors Vary: 

With respect to erroneous copayment charges and our estimated error 
rate of 4 percent, we found that each of the four copayment errors 
occurred in overbilling to a veteran because: 

* the veteran was billed for an incorrect amount, 

* the charge should have been reversed or offset, or: 

* if paid, the amount should have been refunded to the veteran. 

Also, three of the four errors we found had not been identified by VHA 
prior to our selection of the copayment charges for testing. For the 
fourth error, VHA learned about the error when the veteran notified 
VHA after receiving a monthly statement containing the wrong copayment 
charge amount. 

The four overbilling errors we found resulted from three causes. For 
one of the errors, the copayment should not have been billed to the 
veteran because, prior to billing the veteran, VHA had received 
sufficient third-party insurance reimbursement to offset the copayment 
and eliminate any amount owed by the veteran. Two of the errors 
involved copayment charges that were paid by the veterans but were not 
later refunded by VHA as would have been correct following VBA 
decisions that resulted in a retroactive change to the veterans' 
priority group status. VBA had informed VHA that it had retroactively 
awarded the veterans either an additional service-connected condition 
or increased a veteran's disability rating, which led VHA to change 
the two veterans' priority groups. With a (retroactive) change in 
priority group back to an effective date prior to the medical service 
that led to the copayment charge we tested, each of the veterans was 
no longer responsible for the copayment charge they had paid. Once VHA 
revised the veterans' priority group status in response to VBA's 
retroactive decisions, the veterans were due refunds for the two paid 
copayment charges we tested. VHA had been aware of VBA's retroactive 
award decisions for at least 4 months prior to our identification of 
the copayments as errors; however, VHA had not determined that the 
veterans were due refunds for the tested copayment charges. Following 
our test-related inquiries, VHA officials provided us with 
documentation that refunds to the veterans had been approved by VHA. 
The fourth copayment error resulted when VHA incorrectly billed a 
veteran a copayment amount for a 90-day prescription, instead of the 
smaller copayment amount that was due for the 30-day prescription 
supply the veteran received. After the veteran inquired about the 
erroneous charge, VHA corrected it on the veteran's subsequent monthly 
statement. 

Case Study Tests Found Copayment Errors: 

Three types of VHA medical services--inpatient, extended care, and fee 
basis services--together represented less than 1 percent of VHA's 
fiscal year 2010 copayment charge population.[Footnote 13] Therefore, 
to provide some limited insight into copayments related to these 
infrequently billed services, we tested--as case studies--three small 
probability samples consisting of 10 each for inpatient, extended 
care, and fee basis services.[Footnote 14] 

We found four inaccurate copayment charges--two errors each associated 
with inpatient and extended care services. Three of the four copayment 
errors represented overbilling (two extended care services and one 
inpatient service) and the other represented an underbilling error 
(one inpatient service). In each case, VHA had not identified the 
copayment errors we found prior to our selecting the copayment charges 
for testing. Two of the three overbilling errors we found in our case 
study tests involved VHA's incorrect application of the veterans' 
third-party insurance reimbursement to offset the veterans' copayment 
charges. The third overbilling error occurred when VHA billed the 
veteran for a second copayment charge in the same day, which generally 
is not permitted under VHA's policy. The one underbilling error 
occurred when VHA incorrectly billed a veteran a lower copayment 
amount based on the 2009 copayment rate instead of the higher 2010 
copayment rate that was applicable at the time medical service was 
provided. 

Our case study test results are not generalizable to the larger 
populations of medical services from which the samples were drawn. 
However, they may provide some limited insight into copayment errors 
affecting these infrequently billed types of medical services. 
Copayment errors identified in both the probability sample and the 
case study test work mostly involved overbillings, including errors 
resulting from VHA's incorrect handling of third-party insurance 
reimbursements. The case study errors we found do not affect our 
estimate of VHA's overall error rate for fiscal year 2010 copayment 
charges. 

VHA's processes for determining copayment charges for many of the 
copayments we tested resulting from inpatient, extended care, and fee 
basis services are more complicated and generally require greater VHA 
staff involvement and review compared with the processes for 
determining the copayment charges associated with the more routine 
outpatient and prescription services. This difference in complexity 
may help explain why we found four copayment errors--two each in two 
of the three small probability samples we tested in our case studies. 

Veteran-Specific Data Issues Could Affect Other Copayment-Related 
Billing Decisions: 

In conducting our tests of the accuracy of VHA's copayment charges and 
"no bill" decisions,[Footnote 15] we compared relevant veteran- 
specific data maintained by VBA and VHA's HEC and local medical 
centers to determine whether the VHA data were consistent and correct. 
The relevant data we compared included each veteran's recorded service-
connected conditions, degree of disability, and priority group status. 
[Footnote 16] These data are key to correctly determining whether a 
medical service should be billed to a veteran as a copayment charge 
and, if so, the correct amount of the copayment. Of the 200 medical 
services we tested, we found that the key data for 197 veterans were 
consistently and correctly recorded by VBA and VHA's HEC and local 
medical centers. We found two instances where specific elements of 
veteran data were not consistently recorded in VHA records and one 
instance in which the recorded data were incorrect. After following up 
with VHA on these instances, VHA corrected the data. While these data 
recording errors did not cause the particular copayment-related charge 
or "no bill" decision we tested to be inaccurate, they could have 
affected other VHA copayment-related decisions for these veterans. 

In one of the two data inconsistencies we found, HEC and the local VHA 
medical center's records had the veteran's combined service-connected 
condition percentage lower than what VBA had established, which 
resulted in the veteran being assigned to an incorrect priority group. 
As a result, if the veteran had been provided certain other medical 
services, the data inconsistency could have caused the veteran to be 
incorrectly charged a copayment. VHA officials said that the cause for 
the incorrect data related to the data transfer from VBA to VHA's HEC 
and local medical centers. According to VHA, the data transfer issue 
and the incorrect data have since been corrected. In the other data 
inconsistency instance, the disability rating recorded in HEC's and 
the medical center's records were inconsistent, resulting in the 
medical center having the veteran in an incorrect priority group. 
According to VHA, the data error was due to problems during 
registration at the medical center, which have since been resolved. 
The third data error involved a local medical center's records having 
an incorrect priority group for a veteran. The medical center had not 
received the information needed to update the veteran's financial 
assessment (also known as a means test), which was necessary to keep 
the veteran in a priority group that would have made him exempt from 
paying certain copayments. After our follow-up inquiries, VHA 
confirmed that at the time the medical service was provided, the 
veteran's recorded priority group was incorrect, and the center has 
since received the information necessary to update the financial 
assessment, and the veteran's recorded priority group is now correct. 

VHA Does Not Monitor Its Systemwide Copayment Error Rates: 

While various activities performed by VHA staff involve examining or 
reviewing the accuracy of some individual veteran copayment charges, 
we found that those activities do not provide VHA with systematic VHA-
wide information on the accuracy of copayment charges needed to 
effectively monitor--over time--the rates of and causes for copayment 
errors. We also found that VHA has not established a performance 
measure or goal for the level of accuracy it wants to achieve for the 
copayment charges it bills to veterans. As a result, it was not clear 
how the copayment charge error rates we observed in our probability 
samples would compare to rates of error VHA would consider acceptable 
or whether corrective action needs to be taken to reduce the error 
rates to lower levels. In addition, without procedures to periodically 
assess the accuracy and completeness of its copayment charges, VHA 
does not have the information needed to determine whether changes in 
its accuracy rates are occurring over time. 

In reviewing VHA's copayment billing process and the extent to which 
VHA systematically monitors its copayment charges for accuracy, we 
identified various activities that generally involved reviewing or 
checking the accuracy of some individual copayment charges; however, 
those activities are performed for reasons other than a systematic VHA-
wide assessment of the accuracy of billed copayment charges and do not 
provide sufficient information for systemwide monitoring. 

* Responding to veteran inquiries. VHA responds to veteran-related 
questions or inquiries concerning specific copayment charges. In doing 
so, VHA may evaluate some individual copayment charges and determine 
whether they were accurate. However, VHA does not systematically track 
and analyze the results of these individual reviews, including whether 
the copayment charges were accurate or inaccurate and, if applicable, 
the cause of any inaccuracies. 

* Revenue reviews. Staff from VA's Management Quality Assurance 
Service's (MQAS) Health Care Financial Assurance Division may evaluate 
specific veteran copayment bills on a limited, ad hoc basis as part of 
the recurring reviews of VA revenue activities at selected individual 
medical centers. During these reviews, MQAS officials said they devote 
most of their resources to evaluating third-party insurance 
collections, as they make up the majority of the Medical Care 
Collections Fund (MCCF).[Footnote 17] These revenue reviews are 
focused on third-party insurance recoveries and in only some instances 
may involve reviewing the accuracy of individual veteran copayment 
charges. 

* Local compliance programs. Individual medical centers and 
Consolidated Patient Account Centers (CPAC) have decentralized 
compliance programs that include varied processes and procedures 
related to reviewing some individual copayment charges. The scope and 
results of these compliance reviews may involve reviewing copayment- 
related charges but do not routinely include a systematic assessment 
of a probability sample of copayment charge accuracy. In addition, the 
results of any reviews of copayment charge accuracy at medical centers 
and CPAC locations are not consolidated and reported to VHA management. 

* Targeted reviews of certain copayment charges. VHA instituted a 
policy in October 2006,[Footnote 18] in response to a VA Inspector 
General report,[Footnote 19] requiring VHA's Compliance and Business 
Integrity (CBI) Office to identify delinquent copayment debts for 
certain veterans whose accounts were being referred to debt 
collection. VHA facilities were required to review the accounts to 
help ensure that the referrals were not based on inaccurate copayment 
charges. Initially, the policy required the VHA facilities to report 
to the CBI Office the results of their targeted reviews until the 
error rate in the applicable copayment charges went below 10 percent 
for two consecutive quarters. As a result of a sustained decrease in 
the related billing error rate, in October 2009, the CBI Office 
stopped collecting national monitoring results from VHA facilities, 
and in March 2010, VHA rescinded the requirements for facilities to 
report the results of their quarterly reviews to the CBI Office. 
[Footnote 20] However, VHA facilities are still responsible for 
conducting the reviews. 

As noted, these activities are conducted for specific reasons and are 
not intended to provide VHA with systematic VHA-wide information on 
the accuracy and completeness of copayment charges needed to 
effectively monitor--over time--the rates of and causes for copayment 
errors. Also, having meaningful performance information to provide to 
stakeholders, including veterans organizations and Congress, could be 
useful in cases where questions regarding the accuracy and 
completeness of copayment charges are raised. 

Conclusions: 

Our tests of a probability sample of VHA copayment charges found 
copayment errors which we estimate to be 4 percent or approximately 
2.3 million of VHA's 56.5 million fiscal year 2010 copayment charges. 
However, because VHA does not have established acceptable or tolerable 
error rates for copayment charges, the extent to which the error rates 
we observed would compare to levels of performance that VHA would 
consider acceptable is unclear. We believe that it is important for 
VHA to establish a performance measure for the copayment accuracy rate 
it wants to achieve in billing copayment charges to veterans and, once 
it is established, to periodically assess--on a systematic basis--the 
accuracy and completeness of its copayment charges. With such 
information, VHA would be able to make informed decisions concerning 
the rates and causes of erroneous copayment charges, including whether 
any actions are needed to lower its overall error rate. Such periodic 
assessments could be integrated into VHA's existing quality assurance 
monitoring efforts and provide meaningful management information on 
various aspects of its copayment billing systems and processes, 
including whether key veteran data were consistently and correctly 
recorded in VHA records and systems. Further, having meaningful 
performance information regarding copayment accuracy to provide to 
stakeholders, including veterans organizations and Congress, could 
assist VA in responding to any questions concerning the accuracy and 
completeness of copayment charges. 

Recommendations for Executive Action: 

To provide VHA with the information needed to adequately monitor the 
accuracy of copayment charges VHA-wide and to assess and respond to 
the causes of copayment errors, the Secretary of Veterans Affairs 
should direct VHA to take the following two actions: 

* establish an accuracy performance measure or goal for copayment 
charges billed to veterans and: 

* establish and implement a formal process for periodically assessing--
VHA-wide--the accuracy of veteran copayment charges and taking 
corrective actions as necessary. 

Agency Comments and Our Evaluation: 

In its written comments, VA generally agreed with our conclusions and 
agreed with our recommendations. It also provided an overview of 
planned actions, starting in fiscal year 2012, including plans to 
establish an initial national performance measure for copayment charge 
accuracy and implement a periodic assessment of billed copayment 
accuracy. As VA implements these plans, it will be important for these 
actions to provide the information needed to monitor VHA-wide 
copayment accuracy and completeness and to assess and respond to the 
causes of copayment errors. Such plans, if fully and effectively 
implemented in accord with our conclusions and recommendations, should 
respond to the conditions we found. We also incorporated VA's 
technical comments where appropriate. VA's comments are reprinted in 
appendix III. 

As agreed with your offices, unless you publicly announce the contents 
of this report earlier, we plan no further distribution until 30 days 
from the report date. At that time, we will send copies to the 
Secretary of Veterans Affairs, appropriate congressional committees, 
and other interested parties. The report will also be available at no 
charge on the GAO website at [hyperlink, http://www.gao.gov]. 

If you or your staffs have any questions about this report, please 
contact me at (202) 512-9095 or raglands@gao.gov. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. Major contributors to this report are 
listed in appendix IV. 

Signed by: 

Susan Ragland: 
Director, Financial Management and Assurance: 

List of Requesters: 

The Honorable Michael H. Michaud: 
Ranking Member: 
Subcommittee on Health: 
Committee on Veterans Affairs: 
House of Representatives: 

The Honorable Gus M. Bilirakis: 
House of Representatives: 

The Honorable Corrine Brown: 
House of Representatives: 

The Honorable Vern Buchanan: 
House of Representatives: 

The Honorable Jerry McNerney: 
House of Representatives: 

The Honorable Cliff Stearns: 
House of Representatives: 

[End of section] 

Appendix I: Objectives, Scope, and Methodology: 

Pursuant to a request from members of the Subcommittee on Health, 
House Committee on Veterans' Affairs, we reviewed the Veterans Health 
Administration's (VHA) copayment billing practices to determine (1) 
the accuracy rate for VHA copayment charges, including causes for any 
under-and overbilling errors, and (2) whether VHA had systems and 
processes in place to adequately monitor the accuracy of copayment 
charges billed to veterans. 

Assessment of VHA Copayment Charge Accuracy: 

To determine the accuracy rate and any causes for under-and 
overbilling errors, we used as our criteria applicable law and VHA 
policy. To gain an understanding of VHA's policies, procedures, 
systems, and processes related to copayment billing practices, we 
performed walk-throughs of applicable processes with appropriate VHA 
staff at a medical center. We reviewed and discussed with agency 
officials and staff applicable processes related to VHA's copayment 
billing practices. We also interviewed Veterans Benefits 
Administration (VBA) officials and staff about VBA decisions related 
to veterans' service-connected conditions and disability ratings and 
the transfer of that information to VHA. In addition, to assess the 
reliability of data and information used in this report, we reviewed 
Department of Veterans Affairs' (VA) procedures for ensuring the 
reliability of data and information generated by key VHA systems used 
in the copayment billing process, including VHA's Veterans Health 
Information Systems and Technology Architecture (VistA), Performance 
and Operations Web-Enabled Reports (POWER), and Prescription Benefits 
Management systems. We determined that the data and information 
generated from key VHA systems used in the copayment billing process 
were sufficiently reliable for the purposes of our testing. 

Probability Sample of VHA Copayment Charges: 

To determine the accuracy of the copayment amount billed to veterans, 
we selected a simple probability sample of 100 copayment charges from 
the population of approximately 56.5 million fiscal year 2010 
copayment charges in POWER[Footnote 21]. This sample was designed to 
estimate the error rates in the population, if errors were found in 
the sample, or to conclude with 95 percent confidence that the 
population error rate is less than 3 percent, if no errors were found 
in the sample. The population consisted of five broad types: (1) 
prescription, (2) outpatient, (3) inpatient, (4) extended care, and 
(5) fee basis (see table 4). 

Table 4: Fiscal Year 2010 Population of VHA Copayment Charges by Type: 

Type of charge: Prescription; 
Number of charges in population: 49,851,878; 
Number of charges as percentage of total: 88.22%. 

Type of charge: Outpatient; 
Number of charges in population: 6,324,632; 
Number of charges as percentage of total: 11.19%. 

Type of charge: Inpatient; 
Number of charges in population: 125,250; 
Number of charges as percentage of total: 0.22%. 

Type of charge: Extended care; 
Number of charges in population: 11,938; 
Number of charges as percentage of total: 0.02%. 

Type of charge: Fee basis; 
Number of charges in population: 196,340; 
Number of charges as percentage of total: 0.35%. 

Type of charge: Total; 
Number of charges in population: 56,510,038; 
Number of charges as percentage of total: 100.00%. 

Source: GAO analysis of VHA data. 

[End of table] 

To assess the reliability of population data used to select the 
sample, we (1) reviewed related documentation, (2) reviewed internal 
and external reports related to the systems, and (3) interviewed 
knowledgeable VHA officials. We also, as part of our testing of 
unbilled medical services, determined that for the purposes of our 
testing, the population of fiscal year 2010 copayment charges was 
materially complete. Based on our data reliability analysis, we 
determined that the population data, obtained from POWER, were 
sufficiently reliable for the purposes of our testing. For each 
sampled item, we obtained applicable information and supporting 
documentation from VHA and VBA and determined whether a veteran's 
copayment charge was accurate in accordance with VHA's established 
policies, procedures, systems, and guidance. For each inaccurate 
copayment charge, we determined the cause and provided VHA with an 
explanation of the error, the related cause, and any other relevant 
information. Table 5 contains a detailed breakout of the causes of the 
errors in copayment charges.[Footnote 22] 

Table 5: Causes for Identified Errors in Copayment Charges: 

Causes of identified errors: Incorrect application of third-party 
insurance offset; 
Number of errors: 1. 

Causes of identified errors: Unprocessed refund following retroactive 
adjudication; 
Number of errors: 2. 

Causes of identified errors: Incorrect charge amount; 
Number of errors: 1. 

Causes of identified errors: Total; 
Number of errors: 4. 

Source: GAO analysis. 

[End of table] 

There were limitations because of the nature of the testing we 
performed. We did not: 

* test the medical determinations (i.e., diagnosis and whether the 
service was related to a veteran's service-connected conditions or 
special treatment authority) of the medical service provider 
(including the pharmacist, doctor, nurse, or other medical staff); 

* test the determinations made as a result of the adjudication process 
at VBA to determine the veteran's service-connected conditions and 
related disability rating percentages; 

* test the determination made by VHA on whether to bill a third-party 
insurer for the medical service or the third-party insurer's 
determination to pay, including the amount of that payment; and: 

* confirm through outside sources (including contacting applicable 
veterans) the accuracy or completeness of veteran-specific information 
relied on by VHA as part of its decision to bill tested copayment 
charges. 

In table 6, we present our statistical results as (1) our projection 
of the estimated error overall and (2) the 95 percent, two-sided 
confidence intervals for the projections.[Footnote 23] 

Table 6: Estimated Error Rates for Veterans' Fiscal Year 2010 
Copayment Charges: 

Test results: Percentage estimate; 
VHA-wide accuracy rate: 96%; 
VHA-wide error rate: 4%. 

Test results: Ninety-five percent, two-sided confidence interval; 
VHA-wide accuracy rate: 90.1% - 98.9%; 
VHA-wide error rate: 1.1% - 9.9%. 

Test results: Estimated copayment charges in fiscal year 2010 (two- 
sided); 
VHA-wide accuracy rate: 50.9 million - 55.9 million; 
VHA-wide error rate: 622,000 - 5.61 million. 

Source: GAO analysis. 

[End of table] 

Probability Sample of Unbilled Medical Services: 

To (1) assess the completeness of the population of fiscal year 2010 
copayment charges billed to veterans and (2) determine the accuracy of 
VHA's decisions not to bill veterans copayments for medical services 
provided in fiscal year 2010, we selected for review a probability 
sample of 100 unbilled medical services from the population of VHA's 
approximately 576 million fiscal year 2010 medical services. 

Our sampling frame for this sample was developed by combining 
databases from three VHA data warehouses (the National Patient Care 
database, Purchased Care Data warehouse, and Pharmacy Data warehouse), 
which totaled approximately 576 million medical services provided in 
fiscal year 2010. VHA's databases do not separately identify or track 
unbilled services, so this set of databases contained both billed and 
unbilled fiscal year 2010 medical services. The population of medical 
services consisted of five broad types: (1) prescription, (2) 
outpatient, (3) inpatient, (4) extended care, and (5) fee basis (see 
table 7). 

Table 7: Fiscal Year 2010 VHA Medical Services by Type: 

Medical service: Outpatient; 
Number of services: 407,857,973; 
Percentage of services: 70.83%. 

Medical service: Prescription; 
Number of services: 136,035,517; 
Percentage of services: 23.63%. 

Medical service: Inpatient; 
Number of services: 7,702,514; 
Percentage of services: 1.34%. 

Medical service: Extended care; 
Number of services: 707,388; 
Percentage of services: 0.12%. 

Medical service: Fee basis; 
Number of services: 23,494,198; 
Percentage of services: 4.08%. 

Medical service: Total; 
Number of services: 575,797,590; 
Percentage of services: 100.00%. 

Source: GAO analysis of VHA data. 

[End of table] 

Because the VHA-provided population of all medical services from which 
we selected our sample included services that resulted in copayment 
charges, we initially selected a larger probability sample of 150 
medical services. After checking billing records, we excluded any 
sampled medical services that resulted in a copayment charge. From the 
remaining medical services, we selected the first 100 as our 
probability sample of unbilled medical services. 

This sample was designed to test for a 3 percent tolerable error rate 
so that if we found no billing errors in the sample, we would be able 
to conclude with 95 percent confidence that (1) the population of 
fiscal year 2010 unbilled medical services did not include a material 
number (more than 3 percent) of medical services that should have been 
billed as copayment charges and (2) the population of billed fiscal 
year 2010 copayment charges was materially complete for the purposes 
of our tests. If errors were found, this sample could be used to 
estimate the rate of copayment underbilling errors associated with 
incorrect VHA determinations not to bill medical services in this 
population. 

To assess the reliability of population data used to select this 
sample for testing, we (1) reviewed related documentation, (2) 
reviewed any internal or external reports related to the systems, and 
(3) interviewed knowledgeable VHA officials. Based on our data 
reliability analysis, we determined that the population data were 
sufficiently reliable for the purposes of our testing. For each of the 
unbilled medical services we tested, we obtained applicable 
information and supporting documentation from VHA and VBA to determine 
whether VHA correctly determined that the 100 tested fiscal year 2010 
medical services should not have resulted in copayment charges, in 
accordance with VHA's established policies, procedures, systems, and 
guidance. 

There were limitations because of the nature of the testing we 
performed. We did not: 

* test the medical determinations (i.e., diagnosis and whether the 
service was related to a veteran's service-connected conditions or 
special treatment authority) of the medical service provider 
(including the pharmacist, doctor, nurse, or other medical staff); 

* test the determinations made as a result of the adjudication process 
at VBA to determine the veteran's service-connected conditions and 
related disability rating percentages; 

* test VHA's ability to record all of the medical services in the 
medical center-level VistA system, or VHA's ability to transfer all 
the medical services to the appropriate data warehouse; and: 

* confirm through outside sources (including contacting applicable 
veterans) the accuracy or completeness of veteran-specific information 
relied on by VHA as part of its decision to not bill for tested 
medical services. 

In table 8, we present our statistical results as (1) our projection 
of the estimated error overall and (2) the 95 percent, two-sided 
confidence intervals for the projections. 

Table 8: Estimated Rates Applicable to Fiscal Year 2010 Medical 
Services That Did Not Result in Veteran Copayment Charges: 

Test results: Percentage estimate; 
VHA-wide accuracy rate: 100%; 
VHA-wide error rate: 0%. 

Test results: Ninety-five percent, two-sided confidence interval; 
VHA-wide accuracy rate: 97% - 100%; 
VHA-wide error rate: 0% - 3%. 

Test results: Estimated medical services in fiscal 2010 (two-sided)[A]; 
VHA-wide accuracy rate: 503.7 million - 519.3 million; 
VHA-wide error rate: 0 - 15.6 million. 

Source: GAO analysis. 

[A] Population is estimated using fiscal year 2010 medical services 
and copayment charges prepared in fiscal year 2010. 

[End of table] 

Case Studies of VHA Copayment Charges: 

In addition to our statistical samples of copayment charges and 
unbilled medical services, we tested--as case studies--three small, 
nongeneralizable samples consisting of 10 copayment charges each from 
inpatient, extended care, and fee basis services.[Footnote 24] These 
three types of medical services combined represented less than 1 
percent of the VHA-wide fiscal year 2010 copayment population. Results 
from our nongeneralizable case study samples cannot be used to make 
inferences about any population; consequently, results obtained from 
these cases are specific to the particular cases selected. We 
conducted this testing to provide limited insight into possible errors 
in copayments billed for these types of medical services. For each 
case study, we obtained applicable information and supporting 
documentation from VHA and VBA and determined whether a veteran's 
copayment charge was accurate in accordance with VHA's established 
policies, procedures, systems, and guidance. For each inaccurate case 
study copayment charge, we determined the cause and provided VHA with 
an explanation of the error, the related cause, and any other relevant 
information. Table 9 contains a breakout of the results of the testing 
of the case studies. 

Table 9: Causes for Observed Errors in Case Study Copayment Charges: 

Causes for observed errors: Incorrect application of third-party 
insurance offset; 
Inpatient: 1; 
Extended care: 1; 
Fee basis: 0; 
Total: 2. 

Causes for observed errors: Incorrect charge amount error; 
Inpatient: 1; 
Extended care: 0; 
Fee basis: 0; 
Total: 1. 

Causes for observed errors: Invalid copayment charge; 
Inpatient: 0; 
Extended care: 1; 
Fee basis: 0; 
Total: 1. 

Causes for observed errors: Total; 
Inpatient: 2; 
Extended care: 2; 
Fee basis: 0; 
Total: 4. 

Source: GAO analysis. 

[End of table] 

VHA Monitoring of Copayment Accuracy: 

To determine whether VHA had systems and processes in place to 
adequately monitor the accuracy of copayment charges, we identified 
relevant policies, procedures, systems, practices, and related 
documentation, whether at a national, regional, or local level, 
related to VHA's efforts to monitor copayment accuracy. We reviewed 
the documentation provided to determine whether it contributed to VHA 
periodically assessing the accuracy of copayment charges and taking 
appropriate action to address the underlying causes when errors or 
inaccuracies are found. We also interviewed knowledgeable staff and 
officials from VHA and VA's Office of Inspector General. 

We conducted this performance audit from February 2010 through August 
2011 in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives. 

[End of section] 

Appendix II: Enrollment in VA Health Care and Copayment Billing 
Process: 

As part of our review of the accuracy of Veterans Health 
Administration (VHA) copayment charges, we gained an understanding of 
key aspects of veteran eligibility and enrollment for veteran health 
services, veteran medical services and related copayment charges, and 
copayment billing and adjustments. 

Veteran Eligibility and Enrollment: 

Veterans are eligible for Department of Veterans Affairs (VA) health 
care benefits based on their period of and separation from military 
service under any condition other than a dishonorable separation. To 
obtain VHA medical services, most veterans must take action to enroll 
in the VHA health care system. To initiate their enrollment, veterans 
submit a completed enrollment application (VA Form 10-10EZ) either by 
mail or online to VHA's Health Eligibility Center (HEC) in Atlanta for 
review and processing, or veterans may visit a local VHA medical 
center or facility where they can receive assistance in completing the 
enrollment form. 

HEC establishes a veteran's enrollment status (priority group), which 
is primarily affected by decisions made by the Veterans Benefits 
Administration (VBA), which establishes and administers a variety of 
nonhealth benefits and services for veterans. VBA is responsible for 
determining a veteran's service-connected conditions and, to the 
extent applicable, a veteran's disability rating. In doing so, VBA 
adjudicates veteran claims by determining whether a veteran's illness 
or injury was incurred in or aggravated by the veteran's military 
service (i.e., a service-connected condition). Once awarded to a 
veteran, a service-connected condition is considered a "rated" service-
connected condition. Additional service-connected conditions may also 
result in a change to a veteran's disability rating. VBA sends the 
veteran a notification letter informing him or her of the award 
decision, including the additional service-connected condition, 
applicable changes in disability rating, and the effective date of the 
award determination. Information on VBA award decisions is also 
automatically transmitted to HEC. VBA may grant additional service-
connected conditions and change disability ratings retroactively by 
establishing an effective date that precedes the date VBA makes the 
determination. 

Based on a veteran's service, including rated service-connected 
conditions, applicable disability rating, special treatment 
authorities, and other enrollment information such as the results of a 
financial assessment (called a means test), HEC assigns veterans to 
one of eight enrollment priority groups. Special treatment authorities 
include care provided pursuant to 38 U.S.C. § 1710(e), and 
implementing regulations at 38 C.F.R. §§ 17.36 (a)(3) and 17.36 
(b)(6), which authorizes treatment for disorders that may be 
associated with a Vietnam-era veteran's exposure to herbicide 
(including Agent Orange); certain diseases deemed to be related to 
exposure to radiation; disorders that may be related to service in the 
Southwest Asia theater of operation during the Persian Gulf War; 
illnesses that may be related to services in a qualifying combat 
theater; and disorders that may be related to participation in certain 
biological and chemical warfare testing, including Project SHAD 
(Shipboard Hazard and Defense Project). Veterans covered by section 
1710(e) are enrolled in priority group 6. Generally speaking, the more 
service-connected conditions, higher disability rating, and special 
treatment authorities that apply to a veteran, the less likely a 
veteran will be subject to copayment charges. Table 10 shows the eight 
priority groups and their eligibility factors. 

Table 10: VA Health Care Enrollment Priority Groups and Their 
Eligibility Factors: 

Priority group: 1; 
Eligibility factors: 
* Veterans with service-connected disabilities rated 50 percent or 
more disabling; 
* Veterans determined by VA to be unemployable because of service-
connected conditions. 

Priority group: 2; 
Eligibility factors: 
* Veterans with service-connected disabilities rated 30 percent or 40 
percent disabling. 

Priority group: 3; 
Eligibility factors: 
* Veterans who are former prisoners of war; 
* Veterans awarded the Purple Heart; 
* Veterans whose discharge was for a disability that was incurred or 
aggravated in the line of duty; 
* Veterans with service-connected disabilities rated 10 percent or 20 
percent disabling; 
* Veterans awarded special eligibility classification under 38 U.S.C. 
§ 1151, "benefits for individuals disabled by treatment or vocational 
rehabilitation"; 
* Veterans awarded the Medal of Honor. 

Priority group: 4; 
Eligibility factors: 
* Veterans who are receiving aid and attendance or housebound benefits; 
* Veterans who have been determined by VA to be catastrophically 
disabled. 

Priority group: 5; 
Eligibility factors: 
* Non-service-connected veterans and noncompensable service-connected 
veterans rated 0 percent disabled whose annual incomes, net worth, or 
both are below the established VA means test thresholds; 
* Veterans receiving VA pension benefits; 
* Veterans eligible for Medicaid benefits. 

Priority group: 6; 
Eligibility factors: 
* World War I veterans; 
* Compensable 0 percent service-connected veterans; 
* Veterans exposed to ionizing radiation during atmospheric testing or 
during the occupation of Hiroshima and Nagasaki; 
* Project 112/SHAD participants (Shipboard Hazard and Defense Project); 
* Veterans exposed to the defoliant Agent Orange while serving in the 
Republic of Vietnam from 1962 through 1975; 

* Veterans of the Persian Gulf War who served from August 2, 1990 
through November 11, 1998; 
* Veterans who served in a theater of combat operations after November 
11, 1998, as follows: 
- Currently enrolled veterans and new enrollees who were discharged 
from active duty on or after January 23, 2003, are eligible for the 
enhanced benefits for 5 years post discharge; 
- Veterans discharged from active duty before January 23, 2003, who 
apply for enrollment on or after January 28, 2008, are eligible for 
this enhanced enrollment benefit through January 27, 2011. 

Priority group: 7; 
Eligibility factors: Veterans with income above the VA national income 
threshold and below the geographic income threshold who agree to pay 
copayment charges. 

Priority group: 8; 
Eligibility factors: Veterans with income above the VA national income 
threshold and the geographic income threshold who agree to pay 
copayment charges. 

Source: VHA. 

[End of table] 

Medical Services and Copayment Charges: 

Medical services provided by VHA include inpatient and outpatient 
services, prescription medication, and extended services. When VHA 
facilities are not capable of furnishing economical hospital care or 
medical services because of geographic inaccessibility or are not 
capable of furnishing the care or services required, VHA may authorize 
and pay a non-VHA provider to provide certain veterans hospital care 
and medical services. When authorized, VHA identifies these as fee 
basis services. 

VHA's clinical and health records system--the Computerized Patient 
Record System--contains, among other things, information on veterans' 
rated service-connected conditions and special treatment authorities. 
When a veteran receives medical services, the provider indicates in 
the system whether the service provided was related to a veteran's 
service-connected conditions or special authorities, which affects 
whether a copayment will be charged to the veteran. 

According to VHA, almost 95 percent of the approximately 576 million 
medical services provided to veterans in fiscal year 2010 consisted of 
outpatient services (70.8 percent) and prescription services (23.6 
percent). (See table 11.) 

Table 11: Fiscal Year 2010 VHA Veteran Medical Services: 

Medical service type: Outpatient; 
Number of services: 407,858,000; 
Percentage of services: 70.83%. 

Medical service type: Prescription; 
Number of services: 136,036,000; 
Percentage of services: 23.63%. 

Medical service type: Inpatient; 
Number of services: 7,703,000; 
Percentage of services: 1.34%. 

Medical service type: Extended care; 
Number of services: 707,000; 
Percentage of services: 0.12%. 

Medical service type: Fee basis; 
Number of services: 23,494,000; 
Percentage of services: 4.08%. 

Medical service type: Total; 
Number of services: 575,798,000; 
Percentage of services: 100.00%. 

Source: GAO analysis of VHA data. 

[End of table] 

Outpatient services. There are three copayment tiers or categories 
that apply to outpatient services-no copayment, basic $15 copayment, 
and specialty $50 copayment. For example, an outpatient visit for 
immunizations or preventive screenings is included in the no copayment 
tier. A basic (nonspecialty) outpatient service, which includes 
primary care visits for diagnosis and management of acute and chronic 
conditions, has a $15 copayment. A specialty outpatient service, which 
requires a referral, includes cardiology services and radiology 
services, such as magnetic resonance imagery, has a $50 copayment. If 
the medical service, which might otherwise have an applicable 
copayment, is determined to be related to a veteran's service-
connected condition or special treatment authority, then no copayment 
charge would be due. Generally, only veterans in priority groups 7 and 
8 are charged for applicable outpatient copayments. Further, when a 
veteran in priority group 7 or 8 receives more than one outpatient 
service in a single day, only one copayment--the highest applicable 
amount--is to be charged to the veteran for that day. 

Prescription services. Veterans can fill prescriptions for medications 
at a VHA pharmacy or through the mail. Veterans whose prescriptions 
require a copayment are charged either $8 (for veterans in priority 
groups 2 through 6) or $9 (for priority groups 7 and 8)[Footnote 25] 
for supplies of 30 days or less. If authorized, prescriptions may be 
filled for up to a 90-day period at a time with a corresponding 
copayment charge based on a longer number of days. Priority group 1 
veterans do not pay any prescription copayment charges. Veterans in 
priority groups 2 through 6 are subject to applicable copayment 
charges but have an annual cap that limits their total prescription 
copayment charges to $960 per year. Priority group 7 and 8 veterans 
are generally subject to applicable prescription copayments but do not 
have an annual cap. 

Inpatient services. Inpatient stay copayment charges are $1,100 for up 
to the first 90 days of care during a 365-day period and $550 for each 
additional 90 days. In addition to the inpatient stay copayment 
charges, patients are also subject to inpatient per diem charges of 
$10 per day. As with other medical services, no inpatient copayment or 
per diem will be charged if the stay is related to the veteran's 
service-connected conditions or special treatment authority. 
Generally, only veterans in priority groups 7 and 8 are charged 
applicable inpatient copayment and per diem charges. 

Extended care services. Extended care services generally include both 
institutional (inpatient) and noninstitutional (outpatient) services. 
VHA does not charge any copayments for the first 21 days of extended 
care services in any 12-month period. Extended care copayment charges 
are capped at a maximum of $97 per day for institutional nursing home 
or institutional respite care, $5 per day for institutional 
domiciliary care, and $15 per day for noninstitutional adult day 
health care and noninstitutional respite care services. No extended 
care copayments will be charged if the services are related to a 
veteran's service-connected conditions or special treatment 
authorities. Generally, only veterans in priority groups 4 through 8 
may be subject to extended care copayment charges. 

Fee basis care services. VHA may authorize certain veterans to receive 
hospital care and medical services from non-VHA providers. When this 
occurs, VHA refers to these services as fee basis care. Non-VHA 
providers submit bills to VHA for medical services provided to 
veterans. Copayment amounts and requirements related to fee basis 
services are otherwise the same as those for services provided in VHA 
facilities. 

Determining the correct applicable copayment charge depends on many 
factors, including the underlying medical service provided, a 
veteran's applicable service-connected conditions and special 
treatment authorities, priority group, and established copayment 
amount. Table 12 provides general information on whether copayment 
charges may apply to veterans in particular priority groups. 

Table 12: General Applicability of Copayment Charges by Priority Group 
and Type of Service: 

Priority groups: 1; 
Type of medical service: 
Outpatient[A]: No; 
Prescription[B]: No; 
Inpatient[C]: No; 
Extended care[D]: No. 

Priority groups: 2 and 3; 
Type of medical service: 
Outpatient[A]: No; 
Prescription[B]: Yes; 
Inpatient[C]: No; 
Extended care[D]: No. 

Priority groups: 4; 
Type of medical service: 
Outpatient[A]: No; 
Prescription[B]: No; 
Inpatient[C]: No; 
Extended care[D]: Yes. 

Priority groups: 5; 
Type of medical service: 
Outpatient[A]: No; 
Prescription[B]: Yes; 
Inpatient[C]: No; 
Extended care[D]: Yes. 

Priority groups: 6; 
Type of medical service: 
Outpatient[A]: Yes; 
Prescription[B]: Yes; 
Inpatient[C]: Yes; 
Extended care[D]: Yes. 

Priority groups: 7; 
Type of medical service: 
Outpatient[A]: Yes; 
Prescription[B]: Yes; 
Inpatient[C]: Yes; 
Extended care[D]: Yes. 

Priority groups: 8; 
Type of medical service: 
Outpatient[A]: Yes; 
Prescription[B]: Yes; 
Inpatient[C]: Yes; 
Extended care[D]: Yes. 

Source: GAO analysis of VHA data. 

[A] No copayment is due for X-rays, lab tests, and immunizations; a 
$15 copayment is due for primary outpatient care; and $50 copayment is 
due for specialty outpatient care. 

[B] An $8 copayment is due for a 30-day prescription supply for 
veterans in priority groups 2 through 6 who are also subject to a 
calendar year cap of $960; a $9 copayment is due for a 30-day 
prescription supply for veterans in priority groups 7 through 8 who 
are not subject to the annual cap. (Priority groups 7 and 8 were 
subject to the $8 copayment until July 1, 2010, when the $9 amount 
became effective.) 

[C] Veterans in priority groups 6 through 8 may be subject to a $10 
per diem charge and $1,100 copayment charge for the first 90 days of 
an inpatient stay during a year and $550 for each additional 90 days. 

[D] Veterans in priority groups 4 through 8 are subject to applicable 
copayment charges of $5 per day for domiciliary care, $15 per day for 
noninstitutional respite care and adult day health care, and a maximum 
$97 per day for institutional nursing home and respite care. 

[End of table] 

While table 12 reflects the general applicability of copayment charges 
by priority group, some exceptions apply, including the following: 

* Former prisoners of war, who make up part of priority group 3, are 
not subject to any prescription copayment charges. 

* Copayment requirements do not apply to priority group 6 veterans if 
medical service is related to the priority group 6 placement. 

* For priority group 7 veterans, the inpatient stay copayment rate 
($1,100) is reduced by 80 percent. 

* Veterans may be exempted from copayments based on results of the 
financial assessment. 

* Veterans who experience temporary financial difficulties may apply 
to their local VHA facility for hardship waivers to eliminate 
copayments for a defined short-term period or to have VHA waive a 
specified amount of outstanding debt incurred for prior medical 
services. 

Copayment Billing and Adjustments: 

Generally, when a copayment charge is applicable to a medical service, 
the billing system determines whether that medical service should 
result in a copayment amount being charged to a veteran's account 
based on information recorded by the service provider and the 
veteran's specific enrollment information, including priority group 
status. The billing system also tracks all prescription copayment 
charges billed to a veteran at all medical center sites to ensure that 
the annual maximum prescription billing cap is not exceeded. For fee 
basis care, staff at the local VHA facilities who process claims 
submitted by non-VHA providers for reimbursement for the cost of 
medical services provided to veterans outside of VHA medical centers 
also manually establish a veteran copayment charge in the billing 
system if the medical service in question would have resulted in a 
copayment charge had the service been provided in a VHA facility. 

If a veteran has active third-party health insurance, VHA's policy is 
to file a claim with the veteran's third-party insurer seeking 
reimbursement of costs related to medical services covered by the 
veteran's third-party insurance that were not related to a veteran's 
service-connected conditions or special treatment authorities. VHA is 
authorized to pursue reimbursement from third-party insurers 
regardless of whether the services were provided by VHA or non-VHA 
providers. Under this policy, VHA is required to apply any related 
insurance reimbursement received to reduce or eliminate any related 
pending copayment charges due from the veteran. As a result, if a 
veteran has third-party insurance and is subject to a copayment 
charge, the copayment charge is not billed to the veteran on the 
monthly statement for up to 90 days to allow time for VHA to receive 
and apply reimbursement from the veteran's third-party insurer. If the 
reimbursement received does not fully cover or offset the veteran's 
copayment obligation, the veteran is responsible for any balance. 

Unless reimbursement received from a veteran's third-party health 
insurer is applied to eliminate or reduce the pending copayment 
charge, the original copayment charge is released after 90 days, and 
the charge appears on the veteran's subsequent monthly billing 
statement. Applicable third-party insurance reimbursement received 
after the copayment charge is billed to the veteran should still be 
applied to reduce or eliminate a copayment charge if still unpaid, or 
used to provide a refund of the billed amount if the veteran has paid 
the amount. According to VHA procedures, this process, which is known 
as the third-party insurance offset, is manual and is to be performed 
on a daily basis after third-party insurance reimbursement is received 
by local facility staff. 

VHA is expected to adjust copayment charges or issue copayment refunds 
when certain matters related to the billed amount change. When a third-
party insurance reimbursement that would fully offset or reduce a 
billed copayment charge is received, VHA is expected to eliminate or 
reduce the amount billed to the veteran's account, and if the amount 
was previously paid by the veteran, VHA is responsible for initiating 
a refund to the veteran. In addition, when VBA notifies VHA of a new 
retroactively awarded service-connected condition or an increased 
disability rating for a veteran, VHA staff are to review the veteran's 
account to determine whether any previously billed copayment charges 
for services provided after the effective date of the retroactive VBA 
award determination should be canceled (if unpaid) or refunded (if 
paid). 

[End of section] 

Appendix III: Comments from the Department of Veterans Affairs: 

Department of Veterans Affairs: 
Washington DC 20420: 

August 11, 2011: 

Ms. Susan Ragland: 
Director, Financial Management and Assurance: 
U.S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Ms. Ragland: 

The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, "Veterans Health Care: 
Monitoring is Needed to Determine the Accuracy of Veteran Copayment 
Charges" (GAO-11-795), and generally agrees with GAO's conclusions and 
concurs with GAO's recommendations to the Department. 

The enclosure specifically addresses each of GAO's recommendations and 
provides technical comments on the draft report. VA appreciates the 
opportunity to comment on your draft report. 

Sincerely, 

Signed by: 

John R. Gingrich: 
Chief of Staff: 

Enclosure: 

[End of letter] 

Enclosure: 

Department of Veterans Affairs (VA) Comments to Government 
Accountability Office (GAO) Draft Report: 

Veterans Health Care: Monitoring is Needed to Determine the Accuracy of
Veteran Copayment Charges (GA0-11-795): 

GAO recommendation: To provide VHA with the information needed to 
adequately monitor the accuracy of copayment charges VHA-wide and to 
assess and respond to causes for copayment errors, the Secretary of 
Veterans Affairs should direct the Veterans Health Administration to 
take the following two actions: 

Recommendation 1: establish an accuracy performance measure or goal
for copayment charges billed to veterans; 

VA response: Concur. The Veterans Health Administration (VHA) Chief 
Business Office (CBO) and Office of Compliance and Business Integrity 
(CBI) will jointly implement a national performance accuracy measure. 
Based on GAO's findings, CBO will initially apply a 96 percent 
accuracy rate performance standard for copayment charges issued to 
Veterans. This performance standard may be adjusted quarterly to 
ensure improved accuracy in copayment billing for Veterans. CBO will 
take appropriate corrective actions to address any instances of non-
compliance with the new performance standards. The anticipated 
implementation date is March 31, 2012. 

Recommendation 2: establish and implement a formal process for 
periodically assessing—-VHA-wide—-the accuracy of veteran copayment 
charges and taking actions as necessary. 

VA response: Concur. VHA will implement quarterly system-wide 
processes to periodically assess the accuracy of Veteran copayment 
changes and look for any trends. 

VHA's CBO will implement an internal monitor for copayment accuracy. 
For this internal monitoring process, CBO will generate a random 
sample size from copayment billing activity. The sample will include 
first party copayment billing data and any associated third party 
claims. Each Consolidated Patient Account Center (CPAC) Quality
Assurance Department will conduct quarterly reviews using the 
generated sample to monitor copayment charges. The reviews will assess 
each copayment charge for accuracy related to amount, eligibility 
category, and third to first party offset. 

On a quarterly basis, performance results will be published for each 
VHA facility and CPAC on the Performance and Operational Web Enabled 
Reporting (POWER) Web site. CBO will take appropriate corrective 
actions to address any instances of noncompliance with the new 
performance standards. Reviews will begin first quarter fiscal year 
(FY) 2012. 

VHA's CBI will implement an external verification for copayment 
accuracy. CBI recently developed an automated national performance 
metric which identifies potentially inappropriate copayment charges 
issued to Veterans in Priority Groups 1 through 5. On a quarterly 
basis, performance results will be published for each VHA facility and 
CPAC on the CBI Metrics Dashboard. CBI will also provide monthly 
reports of this data to CBO and facilities for local monitoring. CBO 
will take appropriate corrective actions to review Veterans' 
eligibility and copayments, cancel inappropriate copayments, and issue 
refunds to Veterans as appropriate. Reviews will begin first quarter 
FY 2012. 

[End of section] 

Appendix IV: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Susan Ragland, (202) 512-9095 or raglands@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, John J. Reilly, Assistant 
Director; Wilfred Holloway, Assistant Director; Mark Ramage, Assistant 
Director; Sophie Brown; James Healy; Diane Morris; Quang Nguyen; 
Gabrielle Perret; Sabrina Rivera; and Matthew Zaun made key 
contributions to this report. 

[End of section] 

Footnotes: 

[1] 38 U.S.C. §§ 1710, 1710B, and 1722A. 

[2] Veterans service organizations advocate for veterans and assist 
them in obtaining benefits and medical care from VA. The organizations 
include AMVETS, Disabled American Veterans, Paralyzed Veterans of 
America, and the Veterans of Foreign Wars. 

[3] Identifying the Causes of Inappropriate Billing Practices by the 
U.S. Department of Veterans Affairs: Hearing on H.R. 3365 Before the 
H. Subcomm. on Health of the Comm. on Veterans' Affairs, 111thCong. 
(2009). 

[4] Our test of copayment charge accuracy included the accuracy of the 
original copayment charge billed to a veteran's account as well as 
VHA's handling of all subsequent adjustments to the copayment amount 
that occurred or should have occurred as a result of third-party 
insurance recovery related to the medical service or a retroactive 
adjustment or change to a veteran's service-connected conditions and 
applicable special authorities. Special authorities include care 
provided for disorders that may be associated with exposure to 
herbicide (including Agent Orange) or ionizing radiation, among other 
disorders. Copayments originally charged in error but then identified 
by VHA through a systematic review process and corrected in a timely 
manner are considered to be accurate. 

[5] See appendix I for additional details on our scope and methodology. 

[6] VBA determines veterans' service-connected conditions and degree 
of disability caused by those conditions. Once VBA has made these 
determinations, a veteran is entitled to file a claim for additional 
service-connected conditions or for a change in the degree of service- 
connected disability through a formal process known as adjudication. 
VBA automatically sends information regarding awarded service- 
connected conditions, including subsequent changes, to HEC for, among 
other things, HEC's use in determining a veteran's priority group 
status. 

[7] When a veteran receives more than one medical service in a day, 
only one copayment charge--the highest applicable amount--is charged 
to the veteran's account. This exception does not apply to multiple 
prescription services on the same day. 

[8] The estimated error rate in the population is based on observing 
errors in our probability sample of billed copayment charges. Because 
this estimate is based on a probability sample, it is subject to 
sampling error because a different probability sample could have 
produced different results. As a result, we are 95 percent confident 
that fiscal year 2010 charges were inaccurate between 1.1 and 9.9 
percent of the time. See appendix I for additional information on our 
sample and sampling errors. 

[9] Because this probability sample was drawn from the population of 
billed copayment charges for which prescription (88.2 percent) and 
outpatient (11.2 percent) services made up over 99 percent of all 
copayment billed services, our probability sample of copayment charges 
included only prescription-and outpatient-related copayment charges. 

[10] We are 95 percent confident that for fiscal year 2010, the number 
of accurate VHA copayment charges was between 50.9 million and 55.9 
million and the number of inaccurate copayment charges was between 
622,000 and 5.61 million. See appendix I for additional information on 
our sample and sampling errors. 

[11] We are 95 percent confident that for fiscal year 2010, the 
underbilling error rate for VHA's copayment charges was between 0 
percent and 3 percent. Appendix I contains additional information on 
our sample of unbilled services. 

[12] We are 95 percent confident that in fiscal year 2010, for the 
population of unbilled medical services, VHA correctly determined that 
medical services should not result in a copayment charge between 97 
percent and 100 percent of the time. Appendix I contains additional 
information on our sample of unbilled services. 

[13] Because of the relatively high number of prescription and 
outpatient services in the population, the probability sample of 100 
copayment charges we tested did not include any copayment charges 
resulting from these three types of medical services. 

[14] Although the copayment charges we tested as part of our case 
study tests were randomly selected, they represent a nongeneralizable 
sample and were not designed to produce estimates or to be used to 
make inferences about their population. 

[15] For the probability samples we tested for the accuracy of VHA's 
billed copayment charges and VHA's decisions that other medical 
services should not result in a copayment charge, we obtained and 
reviewed VBA and VHA data for 200 veterans--100 for each of the two 
samples. 

[16] For priority group status, we compared data from HEC and the 
medical centers, as they maintain data on a veteran's assigned 
priority group status. 

[17] Collections from copayments, third-party reimbursements, parking 
fees, and other fees are deposited in the MCCF and expended at the 
local medical centers as medical service funds. 

[18] VHA, First Party Co-Payment Monitoring Policy, VHA Handbook 
1030.03 (Oct. 16, 2006). 

[19] VA, Office of Inspector General, Evaluation of Selected Medical 
Care Collections Fund First Party Billings and Collections, Rep. No. 
03-00940-38 (Dec. 1, 2004). 

[20] VHA Notice 2010-03, Rescission of VHA Handbook 1030.03, First- 
Party Co-Payment Monitoring Policy (Mar. 4, 2010) 

[21] With this probability sample, each member of the study population 
had a nonzero probability of being included, and that probability 
could be computed for any member. 

[22] Our test of copayment charge accuracy included the accuracy of 
the original copayment charge billed to a veteran's account as well as 
VHA's handling of all subsequent adjustments to the copayment amount 
that occurred or should have occurred as a result of third-party 
insurance recovery related to the medical service or a retroactive 
adjustment or change to a veteran's service-connected conditions and 
applicable special authorities. Copayments originally charged in 
error, but then identified by VHA through a systematic review process 
and corrected in a timely manner, are considered to be accurate. 

[23] Our 95 percent confidence interval means that if you were to 
determine an estimate for 100 different probability samples, 95 out of 
100 times the confidence interval would include the actual population 
value. In other words, the actual population value is between the 
lower and upper limits of the confidence interval 95 percent of the 
time. 

[24] Although these cases were randomly selected, we do not generalize 
to a larger population because of the small number of cases selected 
in each of the three samples. 

[25] The $9 prescription copayment for priority groups 7 and 8 became 
effective July 1, 2010. 

[End of section] 

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