Improved Oversight Needed to Evaluate Network Adequacy and Contractor Performance

The Veterans Community Care Program allows the Veterans Health Administration (VHA) to purchase care for veterans through Community Care Network (CCN) contracts or veterans care agreements. While the CCN groups VA medical facilities into regions managed by third-party administrators (TPAs), the Office of Integrated Veteran Care (IVC) is responsible for overseeing execution of CCN contracts. The VA Office of Inspector General (OIG) conducted this audit to determine whether VHA provided effective oversight of its TPAs and VA medical facilities. The review team evaluated IVC’s oversight of the TPAs’ adherence to four contract requirements designed to ensure facilities have enough community providers to administer care within the timeliness and drive-time standards established in the contracts. The OIG found that IVC did not hold TPAs accountable for implementing these contract requirements, causing staff to struggle to convince TPAs to add community providers to their networks at the eight facilities the audit team visited. While IVC provided proof of TPA discussing community care needs with three facilities, similar evidence for other facilities was not provided. Furthermore, IVC did not conduct any analyses of facilities’ network adequacy needs to help TPAs build provider networks and did not ensure TPAs maintained provider networks that were accepting VA patients. IVC also did not position itself to defend facilities’ needs for additional community care providers. The OIG recommended to the undersecretary for health that the IVC holds future TPAs accountable for operational readiness and provider network adequacy; develop processes to update and maintain CCN data, challenges, and needs; conduct Advanced Medical Cost Management Solution training on evaluating network adequacy through the tool for community care staff; and not only develop its own network adequacy performance reports but also evaluate TPAs’ reports, holding them accountable for resolving identified issues.