Audit of Veterans’ Community Care Eligibility Determinations

Report Information

Issue Date
Report Number
25-01014-139
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Audits and Evaluations
Report Type
Audit
Report Topic
Community Care
Major Management Challenges
Healthcare Services
Stewardship of Taxpayer Dollars
Recommendations
6
Questioned Costs
$1,744,845,232
Better Use of Funds
$0
Congressionally Mandated
Yes

Summary

Summary

As mandated by the Senator Elizabeth Dole 21st Century Veterans Healthcare and Benefits Improvement Act, the VA OIG initiated this audit to assess whether VA accurately identified veterans eligible for community care and informed them of their eligibility, in accordance with existing criteria under the MISSION Act and related regulations.

The OIG found that VHA did not consistently identify and inform all eligible veterans about their options for receiving direct (VA-provided) or community care during the first quarter of fiscal year 2025, the review period. About 25 percent of 1.4 million veterans sent to community care did not meet eligibility requirements. Of veterans who received direct care, about 38 percent of 4.8 million veterans did not have documented evidence of being assessed for community care eligibility; about 58 percent of 1.8 million veterans who were eligible for community care but scheduled for direct care had no documentation they had opted out of community care. The OIG estimates that VHA could have potentially avoided spending about $440 million—or $1.7 billion over a full fiscal year—had eligibility determinations been made accurately and veterans been referred to VA facilities with available services.

These issues were caused in part because guidance from the Office of Integrated Veteran Care did not align with the MISSION Act; also, scheduling system limitations prevented staff from seeing appointment availability across all VA medical facilities. Schedulers also lacked complete access to community care wait time information, and VHA lacked the ability to assess accuracy of eligibility determinations. During briefings from the OIG, VHA leaders confirmed these deficiencies persisted, though system improvements demonstrated progress.

The OIG made six recommendations to strengthen community care eligibility processes and ensure veterans are fully informed of care options. VHA concurred with five recommendations and concurred in principle with one.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Establish and use agreements with other VA medical facilities to help identify and schedule direct care when local services are not available.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Assess options to improve the scheduling process and system to provide schedulers with access to community care provider appointment availability when discussing care options with wait time–eligible veterans.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Review services in the Consult Toolbox to make sure it accurately reflects available services and avoids inaccurate eligibility determinations.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Reinforce requirements for schedulers to review scheduling systems to identify the next available date for appointments and input that information in the Consult Toolbox.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Implement a process to verify that schedulers check all community care eligibility criteria for all veterans.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Emphasize to schedulers at least annually the proper methods (including the use of opt-out codes) to document when veterans opt out of community care.

Total Monetary Impact of All Recommendations
Open: $ 1,744,845,232.00
Closed: $ 0.00