Alleged Nonacceptance of VA Authorizations by Community Care Providers, Fayetteville, North Carolina

The VA Office of Inspector General (OIG) conducted this audit to determine whether community care providers associated with the Fayetteville, North Carolina, VA Medical Center (VAMC) stopped accepting Non-VA Care (NVC) and Veterans Choice Program (Choice) authorizations. In July 2017, the OIG received an allegation that two orthopedic community providers stopped accepting VA patients because claims were not paid timely. The OIG substantiated the allegation and determined that at least 15 community providers stopped accepting VA patients from January 2015 through July 2017 primarily because claims were not being paid timely and there was difficulty resolving unpaid claims. The VA’s Office of Community Care is responsible for paying NVC claims. The network’s third-party administrator, Health Net, is responsible for paying Choice claims. The OIG determined community providers who stopped accepting NVC authorizations waited, on average, about 46 days for their claims to be processed in 2017. The OIG also found provider frustration over unpaid Choice claims stemming from Health Net’s clearinghouse automatically rejecting some claims and not notifying providers. Fewer community providers affected the ability to schedule patients for dermatology, neurosurgery, orthopedic, and urology services in the community. Also, VA paid about $156,000 in interest on delayed payments. If there is no improvement in the timeliness of payments, and if VA staff do not effectively address community provider medical claim inquires, additional providers may stop accepting VA patients, presenting a risk of increased wait times and travel distances. The OIG made six recommendations including ensuring community care provider participation is monitored at the local level, dedicating staff needed to process medical claims, ensuring staff are not inaccurately rejecting claims and notifying providers when claims are rejected, implementing controls to ensure the timely resolution of medical claim inquiries, and overseeing procedures to ensure the resolution of medical claim inquiries.