Veterans Community Care Program: VA Should Improve Its Ability to Identify Ineligible Health Care Providers

GAO-22-105831 Published: Mar 30, 2022. Publicly Released: Mar 30, 2022.
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Fast Facts

The VA allows eligible veterans to receive care from community providers when they face challenges accessing care at VA medical facilities. The VA is still responsible for ensuring that these community providers are qualified and competent.

We testified that VA may have mistakenly allowed ineligible providers to participate in this program. For example, we found 1,600 potentially ineligible providers in VA's system—including some who had revoked or suspended medical licenses.

We recommended improving controls and standard operating procedures to exclude ineligible providers from the community care program; VA agreed with our recommendations.

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Highlights

What GAO Found

GAO found vulnerabilities in the controls used by the Veterans Health Administration (VHA) and its contractors to identify health care providers who are not eligible to participate in the Veterans Community Care Program (VCCP), resulting in the inclusion of potentially ineligible providers.

Examples of Requirements of and Restrictions on Veterans Community Care Program Provider Eligibility

Examples of Requirements of and Restrictions on Veterans Community Care Program Provider Eligibility

Of over 800,000 providers assessed, GAO identified approximately 1,600 VCCP providers who were ineligible to work with the federal government, were reported as deceased, or had revoked or suspended medical licenses. For example, GAO identified a provider eligible for referrals in the VHA system but whose medical license had been revoked in 2019. Licensing documents stated that the provider posed a clear and immediate danger to public health and safety.

VHA and its contractors had controls in place to identify such providers. However, the existing controls missed some providers who could have been identified with enhanced controls and more consistent implementation of standard operating procedures. For example, GAO found that VHA did not perform some automated checks on a monthly basis as required by the agency's standard operating procedures.

GAO also identified weaknesses in oversight of provider address data. Some VCCP providers used commercial mail receiving addresses, such as a United Parcel Service (UPS) store, as their only service address. Such addresses could be disguised as business addresses by individuals intending to commit fraud. VHA has not assessed the fraud risk that invalid address data pose to the program.

While the number of potentially ineligible providers GAO identified represents a relatively small fraction of the providers in its analysis, these vulnerabilities put veterans at risk of receiving care from unqualified providers. Additionally, VHA is at risk of fraudulent activity, as some of the providers GAO identified had previous convictions of health-care fraud.

Why GAO Did This Study

Eligible veterans may receive care from community providers through Department of Veterans Affairs' (VA) VCCP when veterans face challenges accessing care at VA medical facilities. VA is responsible for ensuring VCCP providers are qualified and competent to provide safe care to veterans based on the eligibility requirements and restrictions.

This testimony summarizes GAO's December 2021 report on VCCP provider eligibility controls. For that report, GAO interviewed knowledgeable officials and reviewed VHA and contractor standard operating procedures, policies, and guidance. To identify potentially ineligible providers, GAO compared data from VHA's Office of Community Care to data sources related to actions that may exclude providers from participating in the VCCP.

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Recommendations

In December 2021, GAO made ten recommendations to VA, including that VA enhance existing controls, consistently implement controls as described in standard operating procedures, and assess the fraud risk of invalid provider address data. While VA reported taking initial steps toward addressing some of these recommendations, the recommendations are not yet implemented. GAO maintains that all ten recommendations should be implemented to help ensure that veterans receive care from qualified providers through this program.

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