Some VA employees involved in processing claims from veterans for emergency care received outside the department’s own system say they “were verbally directed or encouraged to deny claims to meet production standards,” says an IG report that has drawn the interest of congressional leaders on veterans issues.
“Additionally, some examiners who had not been directly encouraged to reject or deny claims responded that they still felt the [claims adjudication and reimbursement directorate] culture created “systemic pressure to favor speed over accuracy. Overall, the responses showed that the claims-processing environment focused on production and prioritized quantity over quality,” a report said.
In reaction, a bipartisan group of House and Senate members wrote to the VA pointing to a 2014 GAO report raising the same issue, saying that “it is disappointing the department has not done enough to improve” over that time. They asked for information on any “explicit or implicit incentives” for processors to value quantity over quality and an action plan for complying with the report’s recommendations.
The findings also are similar to those of earlier reports concluding that some VA facilities had made it appear that veterans were getting appointments for treatment more promptly than was the case—which embroiled the department in controversies that have lasted for years.
The IG estimated that in a six-month period of 2017, 31 percent of such claims, involving more than 17,400 veterans with bills totaling above $53 million, were improperly denied or rejected. (A claim can be denied on grounds that there is not a basis for a payment, or rejected because it cannot be decided until the claimant provides additional or corrected information.) That can leave the veteran being subject to direct billing by the provider, although auditors could not determine to what extent that happened.
The report noted that under their performance rating system examiners must meet target numbers to receive a “fully successful” rating and a higher level for higher ratings. Further, they “received a work-production credit when they rejected or denied a claim, or sent the claim for payment, but did not receive credit for researching the claim and then suspending it for clinical review.”
In addition to performance ratings—which also are used in determining bonuses—“examiners felt that supervisors incentivized overtime opportunities based on production outcomes. Similarly, telework opportunities were tied to the quantity of claims processed.”
The result was that the VA has “placed more emphasis on the number of claims processed than the accuracy of the claims decisions.” Accuracy standards “were unofficial and inconsistently monitored from region to region” and more than half of examiners who responded to a survey from the IG “said they were not aware of supervisors reviewing any of their claims for accuracy.”