General Accountability Office


VETERANS’ HEALTH CARE - Preliminary Observations on VHA’s Claims Processing Delays and Efforts to Improve the Timeliness of Payments to Community Providers Read full text in English

2016 report GAO-16-380T

Due to increases in expenditures and utilization of VA care in the community services in recent years, VHA has had difficulty processing claims in a timely manner. In planning to consolidate its existing VA care in the community programs, as required by law, the agency said it will examine strategies for improving the timeliness and accuracy of its payments to community providers.
This statement, which is based on ongoing work, summarizes GAO’s preliminary observations about (1) VHA’s, Medicare’s, and TRICARE’s claims processing timeliness in fiscal year 2015; (2) factors that have impeded VHA’s timeliness in processing claims; (3) community providers’ experiences; and (4) VHA’s recent actions and plans to improve its claims processing and payment timeliness. To conduct its ongoing work, GAO obtained fiscal year 2015 data on the timeliness of VHA’s, Medicare’s, and TRICARE’s claims processing. GAO visited 4 of 95 VHA claims processing locations (selected on the basis of variation in geographic location, performance, and workload); reviewed VHA documents and 156 claims from those 4 locations; and interviewed officials from VHA, Medicare, TRICARE, and selected community providers and state hospital associations. Results from GAO’s analysis are not generalizable to all VHA claims processing locations or community providers. GAO shared the information provided in this statement with VHA, Medicare, and TRICARE officials and incorporated their comments as appropriate. Because this work is ongoing, GAO is not making recommendations at this time.

In the report

- Technology limitation and related staffing shortages have delayed VHA's claim processing. The majority of Medicare and TRICARE claims are submitted electronically and their contractors' claim processing systems are highly automated - agency officials can independently validate the contractors's performance data. In contrast, VHA cannot accept medical documentation electronically. Additionally authorizations for VA care in the community services are not always readily available in FBCS (Fee Basis Claims System) and FBCS cannot automatically adjudicate claims. Finally staffing shortages adversely affect claims processing timeliness.

- Veterans Health Administration's (VHA's) of the Department of Veteran Affairs (VA) claim processing was significantly less timely than Medicare's and TRICARE's in fiscal year 2015. VHA processed about 66% of claims within the agency's required timeframe of 30 days or less in comparison to 99% of claims within 30 or fewer days in the case of Medicare's and TRICARE's claim processing.

In the report

- The policy states that determinations of claims processing timeless should be based upon the date the claim is but its system can only calculate timeliness on the basis of the date the claim is entered into FBCS. FBCS cannot electronically read the dates that are manually stamped on paper so the scan date becomes the date used to calculate claims processing timeliness.

- VHA's data likely overstate its performance.

In the report

- FBCS and VHA's financial management systems do not permit officials to efficiently monitor the avaiability of funds for VA care in the community services. Monitoring the use of funds - at national level - has remained largely a manual process due to limitation of FBCS and the use of separate systems to track obligations and expenditures.

- Payments on some VA care in the community claims are delayed when VHA does not have funds available to pay them. Payments for 5 of the 156 claims were delayed because funds were unavailable, resulting in payment delays that ranged from 1 to 215 days.

In the report

- The increase in workload contributed to poor staff morale, attrition and staff shortages. Number of claims for VA care in the community processed by VHA increased from 9.3 million in fiscal year 2012 to 13.3 million in 2014 and 16.9 million in 2015. Here were about 300 vacancies among the estimated 2.000 auhtorized positions for claims processing staff.

- Staffing shortages adversly affect processing timeliness.

In the report

- Obtaining payment from VHA often requires repeated submission of claims and documentation without justification. Lack of notification about claims decisions via online portal and poor customer service (waiting on hold for an hour or more while trying to follow up on upaid claims, rejection of phone calls and insead requiring to fax any questions about claim status, limitation to three claims inquiry per VHA staff member per day).

In the report

- Staff responsible for scanning papers claims and medical documentation explained that they did not have adequate scanning equipment - the scanners were small and could handle a limited number of pages a one time. With an estimated 60 percent of claims and 100 percent of medical documentation required scanning.

- Delays in documents processing adversly affected VHA's claims payment.

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