Audit of Processing of Community Care Requests for Services

Report Information

Issue Date
Report Number
25-03946-211
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Audits and Evaluations
Report Type
Review
Report Topic
Community Care
Major Management Challenges
Healthcare Services
Recommendations
6
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General (OIG) examined how quickly the Veterans Health Administration (VHA) reviewed and responded to community care providers’ requests for additional services for veterans. These requests are submitted when a community provider determines that a veteran needs more or different care than VA initially approved.

Under the MISSION Act, veterans may receive care from community providers when eligibility criteria are met, such as long drive times, long wait times, or when VA facilities cannot provide the needed service. When community providers ask for more care, VHA must make a decision and notify both the veteran and provider within three business days.

The OIG reviewed nearly 2.6 million requests entered in the Consult Toolbox—the system VHA uses to manage documentation and workflows for VA and community care—between October 1, 2024, and January 31, 2026. The audit found that VA medical facilities often did not meet the required three-business-day standard. Only about 1.2 million requests were decided on time, and only about 1.4 million resulted in notifications to either the veteran or the provider. On average, notifications took about 12 days from the date of receipt—four times longer than required. This can adversely delay or disrupt veterans’ care or result in unauthorized care.

The audit identified several barriers to meeting the three-business-day standard, including backlogs, staff shortages, manual processes, and multiple systems and steps needed to process requests. Inconsistent oversight of this process also led to inconsistent data entry and limited national data to support accountability.

VHA is undergoing major changes to its community care operations, including a new Office of Veterans Community Care and upcoming network contract updates. The OIG issued six recommendations to help VHA strengthen oversight and improve the timeliness of decisions so veterans receive the care they need without unnecessary delays.

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)

Assess options to expand and optimize automation tools, including artificial intelligence–based solutions, for request for services processing to reduce manual steps and promote efficiency.

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

Address system limitations that prevent identification of whether actions specific to requests for services have been taken or are pending, such as the delegated clinician review.

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

Review and update national standard operating procedures for request for services processing to clarify roles and responsibilities, address inappropriate practices, and reduce processing delays.

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

Develop processes or controls to help improve the accuracy and consistency of the use of the actual receipt date as the official date the Veterans Health Administration received the request for services to maintain accurate timeliness tracking.

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

Make sure facilities provide accurate notifications to community providers and notify veterans at key processing stages.

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

Implement mechanisms to provide routine oversight of the request for services process, including assessing data accuracy and the timeliness of request processing, to reinforce accountability and support corrective action.