From the U.S. Government Accountability Office, www.gao.gov

Transcript for: Veterans' Health Care Physician Credentials

Description: Audio interview by GAO staff with Elizabeth Curda,
Director, Health Care

Related GAO Work: GAO-16-795: Veterans' Health Care: Improved Oversight
of Community Care Physicians' Credentials Needed

Released: September 2016


[Background music]

[ Narrator: ] Welcome to GAO's Watchdog Report, your source for news and
information from the U.S. Government Accountability Office. It's
September 2016. In addition to the healthcare services that the
Veteran's Health Administration directly provides, VHA purchases care
from outside physicians to help ensure that veterans have timely and
accessible health care. Two programs that facilitate these services,
Choice, and Patient-Centered Community Care, are operated by contractors
and require their physicians to hold certain credentials reflecting
their qualifications. A team led by Elizabeth Curda, a director in GAO's
Health Care team, recently looked at VHA's role in overseeing the
processes that ensure a physician's compliance with these credential
requirements. Jacques Arsenault sat down with Elizabeth to talk about
what they found.

[ Jacques Arsenault: ] The Veteran's Health Administration contracts out
some health care services so it can provide more timely service to
veterans, but it seems like we're not sure whether all these healthcare
providers have the necessary credentials. Can you tell me about what
your team found?

[ Elizabeth Curda: ] Yes, sure Jacques. I think the key there is that
'we're not sure' part. We looked at a sample of 100 credentialing files
for the both contractors that operate the two programs through which
community care is provided. And in doing so, we found that there were,
on the one hand in one program the files looked pretty good and the
credentials had been checked and everything looked square. On the other
program, the Choice Act Program, we did find some deficiencies in the
credentialing review process.

[ Jacques Arsenault: ] So then backing up a little bit, can you explain
how these contracts work?

[ Elizabeth Curda: ] VHA contracts with two large networks of providers,
TriWest and Health Net and the contract calls for them to assemble a
network of providers who can provide care in the community. And as part
of that responsibility, before a veteran sees one of these physicians in
their networks, the contractors are to initially verify that these
physicians have the correct credentials to serve patients and are
qualified to do so.

[ Jacques Arsenault: ] So that they have an MD or if they're supposed to
have a specialty, that they have all the [inaudible].

[ Elizabeth Curda: ] The necessary licenses that are unrestricted, that
there's a lack of sanctions against them, that they have malpractice
insurance--things like that.

[ Jacques Arsenault: ] Okay. And so it sounds like in one program, that
seems to be happening, and in the other one, they're not necessarily
going through that. Did you find any cases where the physicians don't
actually have the credentials, or is it more of an uncertainty issue?

[ Elizabeth Curda: ] A little bit of both. So for example, there's
basically two types of things that the contractors are responsible for
doing when they do credentialing. The first is a timing issue. They have
to ensure that the verification occurs before a patient sees the doctor.
And then subsequently on an annual basis, they are supposed to re-verify
the credentials. So from a timing perspective with the Choice Act
Program, we found that the contractors were not consistently doing what
they needed to do on time. So in one case, we found that a physician
whose credentials had not been verified prior to treating patients and
the verification was done only after we had identified the physician for
our sample. So the contractors didn't know that the physician had the
right credentials or not. In that case it turned out that they did. In
another case, we found little evidence that the contractors were doing
the re-verification they were supposed to be doing. And we also found
problems with documentation. The contractors are supposed to document
their reviews of the credentials in terms of both who did the
credentialing, the date it was done, the source of the information they
were supposed to look at--primary documents. And we found that the
contractors were generally not re-verifying.

[ Jacques Arsenault: ] And that re-verification, so that's important to
make sure that credentials don't expire?

[ Elizabeth Curda: ] Don't expire, right. Because things can happen in
the meantime and things can change. And I'll give you an example of
that. We found with the documentation, that one of the contractors had
not initially verified six physicians' certifications to prescribe
controlled substances, which is one of the requirements. And that
together, these physicians had treated at least 15 patients beforehand.

[ Jacques Arsenault: ] So it sounds like there are some problems. Can
you tell me what is VHA's role here in oversight and making sure that
this is happening the way it should be?

[ Elizabeth Curda: ] Well, I should say that after we conducted our
review, the contractors did go back and fix the problems that we
identified with our sample. And they also went back and reviewed their
policies and procedures to address some of the problems that resulted in
these issues that we found. So at the end, we were fairly confident that
they had plans in place to provide the corrective actions. The bigger
issue for us was the VHA oversight of the contractors. There is a
provision of the contract for VHA to provide oversight, have access to
information for that purpose. We found that VHA was doing some selective
monitoring of the credentials of the providers and they had done one
audit of one of the contractors, however, they were not doing any
ongoing or sort of in-depth evaluation of the contractor's processes to
find out what the root causes were of the problems that they were
identifying. And in fact, VHA was identifying physicians who lacked the
proper credentials in their own monitoring.

[ Jacques Arsenault: ] So then, can you talk about the recommendations
that GAO's making in this report?

[ Elizabeth Curda: ] Sure. Our main recommendation is to VHA that they
develop a strategy for how they will oversee these programs going
forward to ensure that the processes are being conducted the way they're
supposed to be.

[ Jacques Arsenault: ] And finally then, what would you say is the
bottom line of this report?

[ Elizabeth Curda: ] I think the bottom line is that veterans, whether
they are seeking care at a VHA facility or through a contract in the
private sector, they need some assurance that the doctors that they're
seeing have the proper credentials. So I think going forward the VHA,
they have plans to consolidate their various community care programs
into one program. Our recommendation provides a real opportunity for
them to re-visit their oversight strategy for how they will do
credentialing in the future.

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