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.
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
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.
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Recommendations for Executive Action
Comments: According to the 60-day letter provided by VA, the agency is on track for addressing both recommendations by the end of 2014. By way of an update from the agency comments provided in June, the agency reported that officials conducted outreach with key stakeholder groups in the summer of 2014. Specifically, VA reported that officials attended conferences held by both the Spina Bifida Association and the Vietnam Veterans of American in June and August, respectively.
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
Comments: According to the 60-day letter provided by VA, the agency is on track for addressing both recommendations by the end of 2014.
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