Unauthorized Community Care Dental Procedures Risked Improper Payments

VA provides dental care to a wide range of eligible veterans. Those eligible can be referred to the community for this care if they do not live near a Veterans Health Administration (VHA) facility, are expected to experience lengthy wait times for an appointment, or community care is in their best medical interest.In fiscal year (FY) 2022, VA provided dental care to about 607,000 veterans and referred 186,500 veterans to the community, where they received care from non-VA dentists. Between FY 2018 and FY 2022, VA and community dental care costs have increased 65 percent and 173 percent, respectively. VA is required to pay for dental care in the community only when VA dentists provide authorization for the specific dental procedures to be performed. The VA Office of Inspector General (OIG) conducted this audit to determine the extent to which VHA may be paying for unauthorized community care dental procedures.The team estimated that between FY 2022 and FY 2025 VA will improperly pay $325.5 million for 847,800 unauthorized dental procedures performed by community dentists. This includes $139.1 million that the OIG estimated has already been paid in FY 2022 and FY 2023 and another $186.4 million that VA will pay in FY 2024 and FY 2025 if it does not reduce payments for unauthorized procedures. The unauthorized dental procedures fell within three categories: major changes to veterans’ treatment plans, minor changes to treatment plans that exceeded VHA’s maximum allowed amount during a rolling 12 month period, and referrals that did not specify the authorized dental procedure codes as required.To help VA address these improper payments, the OIG made five recommendations to the under secretary for health related to strengthening prepayment adjudication and postpayment review processes, as well as ensuring preauthorization requirements are followed.