VA Spina Bifida Program:

Outreach to Key Stakeholders and Written Guidance for Claims Audit Follow-up Activities Needed

GAO-14-564: Published: Jun 23, 2014. Publicly Released: Jun 23, 2014.

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Debra A. Draper
(202) 512-7114
draperd@gao.gov

 

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What GAO Found

The Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) provides information and updates on covered health care services to beneficiaries enrolled in its spina bifida program, but has conducted limited outreach with key stakeholder organizations. VHA provides information on health care benefits to enrolled beneficiaries through the program website, for example. However, VHA has conducted limited outreach with key stakeholder organizations—such as the Spina Bifida Association—that have relationships with individuals who are potentially eligible for the spina bifida program and its benefits but are not enrolled. Representatives of these organizations told GAO this has contributed to lack of awareness of eligibility and available benefits. Without this outreach, VHA may miss important opportunities to help potentially eligible individuals obtain health care benefits to which they may be entitled.

For the spina bifida program, both total claims payments, as well as the total number of claims paid, increased by more than 40 percent from fiscal year 2009 through fiscal year 2013. VHA officials attributed the increase to a 2008 legislative expansion of health care coverage under the program, and growing health care costs for beneficiaries as they age. During this 5-year period, paid claims represented about 90 percent of all claims submitted each fiscal year.

Disposition of Spina Bifida Health Care Program Claims, Fiscal Years 2009 through 2013

Disposition of Spina Bifida Health Care Program Claims, Fiscal Years 2009 through 2013

VHA primarily uses claims audits to oversee its spina bifida claims process. Auditors review a sample of claims and prepare a report with the audit's findings and any necessary follow-up activities. However, VHA does not have written guidance on how staff are to document the status of these follow-up activities to ensure their completion. Without such written guidance, VHA cannot be assured that these activities have been successfully completed or that any recommendations outlined in audit reports have been appropriately implemented.

Why GAO Did This Study

VA provides health care benefits to children diagnosed with spina bifida—a birth defect that can cause physical and neurological issues—born to Vietnam and certain other veterans. Legislation requires the provision of certain health care benefits—including home care, hospital care, outpatient care, and case management—for spina bifida beneficiaries. VHA administers the Spina Bifida Health Care Program for enrolled beneficiaries by processing and paying claims for covered services from private sector providers.

GAO was asked to evaluate VHA's administration of spina bifida health care benefits. In this report, GAO examined for the spina bifida program: (1) the extent to which VHA conducts outreach about available benefits, (2) what is known about health care claims that have been processed, and (3) what, if any, oversight, VHA conducts of the claims process. GAO reviewed the spina bifida program handbook and claims audit reports, analyzed data on submitted, paid, and denied claims from fiscal years 2009 through 2013, and interviewed VHA officials and representatives from key stakeholder organizations.

What GAO Recommends

GAO recommends that VA conduct outreach with key stakeholder groups regarding the spina bifida program and its benefits, and develop written guidance for completing and documenting the status of follow-up activities related to claims audits. VA concurred with GAO's recommendations.

For more information, contact Debra A. Draper at (202) 512-7114 or draperd@gao.gov.

Status Legend:

More Info
  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: To improve awareness of the spina bifida program's health care benefits among potentially eligible individuals and to help them obtain the benefits to which they may be entitled, the Acting Secretary of Veterans Affairs should direct the Acting Under Secretary for Health to conduct outreach with key stakeholder groups regarding the program and its benefits.

    Agency Affected: Department of Veterans Affairs

    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: To help ensure continued accurate claims processing, the Acting Secretary of Veterans Affairs should direct the Acting Under Secretary for Health to develop written guidance, consistent with federal internal control standards, for completing and documenting the status of follow-up activities for the spina bifida program's claims audits.

    Agency Affected: Department of Veterans Affairs

    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

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