… In February 2023, VHA’s Office of Integrity and Compliance, in collaboration with VA’s Office of Information and Technology, paused operations of the tool after becoming aware of issues with its database code logic and of compromised stored data. This pause was intended to allow VHA to further evaluate the Program Integrity Tool’s processes, data, documentation, and its underlying information technology system architecture, and to determine the cause of potential data errors and identify improvement opportunities….
Requested Action
VHA should ensure that Revenue Operations has sufficient resources and processes to timely bill the backlog of community care claims once the Program Integrity Tool resumes operations. Additionally, VHA should take action to establish alternative or redundant processes to aggregate community care claim data to prevent future disruption with revenue collection. Furthermore, VHA should ensure the Office of Integrity and Compliance has resources to perform timely fraud, waste, and abuse examinations of the backlog of community claims once the Program Integrity Tool resumes operations.
VA Management Comments
VHA’s under secretary for health stated that Revenue Operations has made significant progress increasing opportunities to bill private health insurance, especially for community care encounters subject to filing deadlines. For example, VHA developed a patch for the Veterans Health Information Systems and Technology Architecture to add timely filing parameters to insurance files and has made multiple enhancements to the workflow tools to improve the accuracy of claims information. The under secretary also noted that since 2022, VHA has billed third-party payers about 561,000 times, resulting in approximately $98 million in revenue. Appendix A includes the full text of the under secretary’s comments.
VA’s assistant secretary for information and technology and chief information officer stated that the Office of Information and Technology has made significant progress to resolve defects and bring the Program Integrity Tool back online. He noted that since the summer of 2023, his office has prioritized ensuring data accuracy for Revenue Operations billing and ensuring accuracy for the billing process. In addition, billing has resumed for VA Choice system data, and the Office of Information and Technology anticipates that the remaining systems will be available for billing before the end of June 2024. The Office of Information and Technology’s comments are in Appendix B.
OIG Response
The OIG acknowledges that Revenue Operations worked through the previous backlog of community care claims during the Program Integrity Tool’s pause. However, the OIG remains concerned about whether Revenue Operations will have sufficient resources to timely bill the backlog of community care claims that result from the pause, and how the pause will affect fraud, waste, and abuse activities for community care claims. In addition, the OIG currently has three open recommendations from the 2022 report related to Revenue Operations’ private health insurance billing for community care.14 While the Office of Information and Technology has resolved multiple defects related to the Program Integrity Tool, their continued involvement will be necessary to resolve the remaining issues and make sure Revenue Operations receives all data necessary to bill veterans and private insurers. Further, the Office of Information and Technology will need to continue working with the Office of Integrity and Compliance to support their fraud, waste, and abuse activities for community care. 14 VA OIG, VHA Continues to Face Challenges with B
Not Yet a Premium Partner/Sponsor? Learn more about the OS AI Premium Corporate and Individual Plans here. Plans start at $250 annually.