VHA Did Not Effectively Manage Appeals of Non VA Care Claims

The VA Office of Inspector General (OIG) conducted this audit to determine whether appeals of non-VA care claims decisions were effectively managed and processed. An earlier audit identified a significant risk that the Office of Community Care’s Payment Operations and Management (POM) directorate was not effectively managing Veterans Health Administration (VHA) appeals. When POM does not effectively identify and process claimants’ appeals, veterans are at risk of becoming financially liable for wrongfully denied non-VA care claims. The audit focused on POM’s management of appeals before the Veterans Appeals Improvement and Modernization Act of 2017 took effect on February 19, 2019, as well as VHA’s readiness to implement the act’s appeals process. Before the act took effect, claimants could only send appeals of denied claims to POM for initial review. Now, veterans can choose to appeal for either a higher review or supplemental claim decision, or veterans or providers can send appeals directly to the Board of Veterans’ Appeals. The OIG found significant deficiencies with POM’s management of appeals of non-VA care claims decisions. Unprocessed and unaccounted-for appeals were stored in cabinets, boxes, and bins at facilities. Office of Community Care leaders lacked effective oversight of its appeals function, and POM leaders had not clearly defined the appeals manager’s roles and responsibilities. The audit team concluded VHA and the POM directorate failed to effectively oversee appeals management and processing before and after implementation of the new law. VHA did not effectively prepare for the new appeals process and faces significant challenges in identifying and processing appeals. The OIG made eight recommendations to improve appeals management, including identifying and processing existing appeals, ensuring incoming appeals go to facilities that will process them, providing staff clear policies and procedures, and ensuring appropriate access and use of the appeals system of record for employees.