Denials of Emergency Care Claims

This VA Office of Inspector General (OIG) management advisory memorandum notified the under secretary for health that Veterans Health Administration (VHA) claims‑processing practices for non‑VA emergency care appeared inconsistent with federal law.

The Cleland–Dole Act of 2022 requires third‑party organizations seeking reimbursement or direct payment for a veteran’s non‑VA emergency treatment to file claims within 180 days of the last date of care. Despite this requirement, VHA continued applying an older, 90‑day regulatory deadline until October 2025. Although VHA had since updated its internal process, the OIG found that the revised approach—allowing processors to choose between the 90‑day and 180‑day windows—still did not fully comply with the law.

VHA’s Office of Finance identified about 78,000 third‑party claims, totaling more than $373 million in billed charges, that were denied under the outdated 90‑day deadline after the law changed in December 2022. As of late 2025, these claims had not been reviewed for potential errors, and corrective payments had not been initiated. VHA had begun work to update relevant regulations but had not completed them as of May 2026, leaving claims adjudication vulnerable to continued inconsistencies.

The OIG concluded that denying third‑party claims submitted within the 180‑day statutory period appeared inconsistent with the Cleland–Dole Act. The memorandum asked the under secretary for health to review the issues and report any resulting actions. The under secretary acknowledged the findings and stated that VHA was reviewing affected claims, refining internal guidance, and accelerating necessary policy and regulatory updates. The OIG issues advisory memoranda when prompt attention can reduce risks to veterans or prevent significant financial losses.