Veterans Health Administration (VHA) VA Community Care Program Department of Veterans Affairs (VA)

The VA Community Care Program helps ensure eligible Veterans receive timely and specialized healthcare. VA has authority under 38 U.S.C. 1703 and P.L. 113-146, as amended, to authorize Veteran care at non-VA healthcare facilities when the needed services are not available through the VA, when the Veteran is unable to travel to a VA facility, or when the Veteran is eligible for community care through the Veterans Choice Program. For purposes of this report, the VA Community Care Program does include care received through the Veterans Choice Program but does not include care received through sharing/reimbursement agreements with Indian Health Service (IHS) or Department of Defense (DOD).

Agency Accountable Official: Mr. Edward J. Murray, Acting Assistant Secretary for Management and Acting Chief Financial Officer

Program Accountable Official: Dr. Gene Migliaccio, Executive Director, Delivery Operations

Total Payments
Improper Payments
Improper Payment Rate

Supplemental Measures

Current Measure: Payments associated with non-contract authorizations totaled $1,540,152,185.00 for the second quarter of FY 2017, accounting for approximately 54 percent of VA Community Care (as defined in the summary). The target rate for payments associated with non-contract authorizations is no more than 65 percent.

Target: 65% (decrease of 4%)

Description: For the purposes of this measure, the VHA Office of Community Care tracks the payments associated with non-contract VA Community Care authorizations issued under 38 U.S.C. 1703 and the Veterans Choice Program. VA’s goal is to decrease the number of non-contract authorizations issued under 38 U.S.C. 1703 and increase the amount of non-VA health care services purchased through FAR-based contracts. Compliance with Federal Acquisition Regulations reduces improper payment designations. By September 30, 2017, the Office of Community Care will reduce payments associated with non-contract VA Community Care authorizations by 4 percentage points, from 69 percent to the target of 65 percent.

Update Frequency: Quarterly

Data Current as of: March 2017

Current Measure: 544 claims were corrected pre-payment from January 2017 – March 2017 . Target performance is 3,650 claims per year, a 5 percent increase in the annual total of claims corrected pre-payment.

Target: 3,650 claims per year (increase of 5%)

Description: The increased utilization of the analytic and qualitative tools will increase the number of non-compliant healthcare claims identified in pre-payment phase, allowing VA Community Care claims processing staff to proactively review, correct, and ultimately prevent improper payments before a payment is disbursed. By September 30, 2017, the Office of Community Care will increase the number of claims corrected in a pre-payment state by 5 percent, from 3,480 claims in FY16 to the target of 3,650 claims in FY17, through use of analytic and qualitative tools.

Update Frequency: Quarterly

Data Current as of: March 2017

Program Comments

To determine payment accuracy, VHA samples its VA Community Care Program to make certain medical care payments to non-VA healthcare providers are correct. VHA uses a statistically valid sample to determine the program payment accuracy rates. In FY 2015, VA classified payments that did not follow all Federal Acquisition Regulations and where VA exceeded its regulatory authority as improper. This is a departure from how VA has traditionally reported improper payments related to the Community Care Program. Historically, VA only reported instances of community care as improper payments where the wrong party was paid, the wrong amount was paid, a duplicate payment was made, or services were not received. However, to ensure every effort to report in compliance with the statue and promote transparency, beginning in FY 2015, the Department included transactions that did not follow acquisition regulations as improper. As a result, this decision significantly increased both percentage and amount of improper payments made in the VA Community Care Program. VA is seeking a legislative change in order to become compliant with Federal Acquisition Regulations and has been actively pursuing the required changes since the issue was first raised during the Office of Inspector General’s 2015 review of VA’s compliance with the Improper Payments Elimination and Recovery Act. Until such time as proposed legislative and contractual remedies are implemented, VA will continue to utilize individual authorizations as required in order to support Veterans’ timely access to care. Additional information on the program and detail on the progress of corrective actions can be found in VA’s Agency Financial Report.