Veterans Community Care Program: Immediate Actions Needed to Ensure Health Providers Associated with Poor Quality Care Are Excluded
Fast Facts
The Veterans Community Care Program, established in 2019, allows eligible veterans to receive care from non-VA health care providers. The VA excludes providers from participating in the program who have been disciplined for poor quality care.
But VA's processes may not prevent excluded providers from participating. For example, the VA may not always verify whether providers have lost licenses over care quality. Also, while the VA excludes providers who have been removed from VA facilities over care quality, providers who were removed before 2019 may still participate.
We recommended ways to ensure credential policies are followed and more.
Highlights
What GAO Found
The Department of Veterans Affairs (VA) has implemented contracts with Optum and TriWest to set up networks of community providers as part of the new Veterans Community Care Program (VCCP). However, the two contractors' processes for implementing eligibility restrictions established by the VA MISSION Act, as outlined in their policies and reflected in their contracts, may not consistently exclude all ineligible providers from participating in the VCCP. The VA MISSION Act prohibits providers from participating in the VCCP if they have lost a state medical license, for example, as a result of revocation or termination for cause or due to concerns about poor quality of care. However, VA's contracts with these contractors do not require the verification of providers' history of license sanctions, including a revoked license, in all states during credentialing. Only one of the two contractors has a process that includes verifying providers' licensure history in all states and neither has a sufficient process for continuously monitoring provider licenses.
Contractor Processes for Implementing VA MISSION Act Restrictions on Community Care Provider Eligibility
In May 2019, VA began tracking providers who do not meet the eligibility restrictions established by the VA MISSION Act. However, this tracking does not address providers removed from VA prior to this date. As of September 2020, VA had deactivated 136 ineligible VA providers from VCCP participation. GAO reviewed data going back to July 1, 2016 and identified an additional 227 providers that had been removed from VA employment and are potentially providing care in the VCCP. VA stated it has no plans to further review these providers. VA officials said these providers were eligible to participate in the VCCP because they were removed from VA employment before the VA MISSION Act restrictions were effective. Thus, there is a continued risk that former VA providers associated with quality of care concerns are participating in the VCCP.
Why GAO Did This Study
The VA MISSION Act of 2018 established a new community care program, the VCCP, aimed at providing care to veterans when it could not reasonably be delivered by providers at VA medical facilities. The act also requires VA to exclude from participation in the VCCP providers who lost a license for violating medical license requirements in any state or who VA removed from employment for quality of care concerns or otherwise suspended from VA employment.
The VA MISSION Act included provisions for GAO to report on the implementation of restrictions on certain health care providers' participation in the VCCP. This report examines, among other issues, VA and contractor processes to implement these eligibility restrictions on provider participation in the VCCP.
GAO reviewed VA's contracts and contractor policies related to VCCP provider credentialing, interviewed VA and contractor officials, and assessed the provider credentialing requirements and processes. In addition, GAO collected data on former VA providers and compared these data to the database of VCCP providers.
Recommendations
GAO is making three recommendations to VA, including that VA require its contractors to have credentialing and monitoring policies that ensure compliance with VA MISSION Act license restrictions and that it assess the risk to veterans when former VA providers with quality concerns continue to provide VCCP care. VA generally agreed with GAO's three recommendations.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Veterans Affairs | The Secretary of Veterans Affairs, in concert with the Undersecretary for Health, should require the Community Care Network contractors to amend their credentialing policies to ensure that providers who have violated the requirements of medical licenses that resulted in the loss of those medical licenses in any state are excluded from providing care to veterans through the Veterans Community Care Program. (Recommendation 1) |
VA concurred with this recommendation. In October 2021, VA reported that Optum updated the OptumServe Credentialing Plan to ensure providers with a license sanction resulting in loss of licensure are prohibited from participating in the Community Care Network. This updated credentialing plan states that each provider applying for participation in the Optum provider network must have a National Practitioner Data Bank (NPDB) query performed. The NPDB is an electronic repository administered by the U.S. Department of Health and Human Services that collects and releases information on providers who either have been disciplined by a state licensing board, professional society, or health care entity, or have been named in a medical malpractice settlement or judgment. Health care entities may query the NPDB and verify with the appropriate state licensing board that a provider's medical licenses are current and in good standing before appointing a provider to the entity's medical staff and when renewing clinical privileges. Performing an NPDB query will allow Optum to identify and exclude providers who have violated the requirements of their medical license(s) that resulted in the loss of a medical license in any state from providing care to veterans through the Veterans Community Care Program.
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| Department of Veterans Affairs | The Undersecretary for Health should ensure that Community Care Network contractors develop and implement a process for continuous monitoring of the eligibility requirements in section 108 of the VA MISSION Act, such as by using the National Practitioner Data Bank's continuous query function. (Recommendation 2) |
VA concurred with this recommendation. In August 2022, VA provided TriWest's updated Ongoing Monitoring of Licensure and Sanctions, Credentialing policy. The policy's updated language indicates that TriWest reviews and monitors "practitioners' state licensing boards (for each state where the practitioner has been licensed), minutes and website(s) for sanctions, restrictions and other actions taken against a provider's license on a monthly basis, documenting in writing that this review as performed." In May 2023, VA reported that Optum updated the OptumServe Credentialing Plan to indicate that "the organization obtains information on sanctions, restrictions, revocation, suspension, reprimand, probation and surrender of licensure in all states regardless of the provider practicing state." Further, the updated plan indicates that the National Practitioner Data Bank is queried monthly to review licenses in all states, among other sources that are used that may not capture licenses in all states, which allows for monthly monitoring for sanctions between re-credentialing cycles. Both TriWest and Optum's actions now allow them to continuously monitor the eligibility requirements in section 108 of the VA MISSION Act, allowing us to close this recommendation.
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| Department of Veterans Affairs | The Secretary of Veterans Affairs, in concert with the Undersecretary for Health, should identify, analyze, and respond to the risk to veterans when providers who have been removed from VA employment for failure to provide safe care are not prohibited from providing care to veterans in the community. For example, the Undersecretary for Health could direct VHA to review the list of terminated VA providers generated from our data analysis; determine whether these providers were removed from VA employment due to conduct that violated VA policy related to the delivery of safe and appropriate health care; and determine whether these providers should be allowed to provide care to veterans through the Community Care Network or a Veterans Care Agreement. (Recommendation 3) |
VA concurred with the recommendation. In June 2021, VA reported that they took action to review the 227 providers GAO identified as terminated from VA for failure to provide safe care and who were potentially providing care to veterans in the community through the Veterans Community Care Program (VCCP). Based on VA's review, it determined that 14 of the providers GAO identified had been terminated from VA for adverse employment actions and by August 5, 2021, VA had deactivated them from providing care through the VCCP. In October 2021, VA reported that it queried a second list using GAO's criteria and identified 155 providers that met exclusionary criterial under the MISSION Act. This list included the 14 providers from the GAO list that were already excluded and an additional 141 providers who were subsequently excluded from providing care to veterans through the VCCP. Further, VA continues to review providers removed from VA employment for failure to provide safe care on a bi-weekly basis, has proactively identified and excluded 224 additional providers from providing care to veterans through the VCCP.
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