Review of Medical Facilities’ Management of Specialty Care Calls

The OIG conducted this review to determine whether VA medical facility leaders ensured that staff answered veterans’ specialty care phone calls from August 2024 through July 2025 in accordance with performance standards.

The review found that veterans frequently encountered inaccurate phone numbers, misrouted calls, and voicemail issues and VHA lacked reliable call‑tracking for specialty care clinics. Of 219 numbers tested, 36 percent were incorrect, leading to about 20 percent of 2.9 million calls routed to wrong or nonfunctional lines. Eleven of 15 facilities lacked interactive routing options to reach specialty clinics directly, contributing to about 18 percent of 2.9 million calls going to voicemail, many of which were not returned. Facilities also did not track nearly half of specialty care call attempts—over 1.3 million calls—hindering leaders’ ability to address problems. Clinics using centralized, trackable call queues generally performed better.

These issues occurred because many VHA leaders initially thought call performance standards applied only to clinical care, not specialty care clinics. This misunderstanding resulted in limited oversight, unclear guidance, and inconsistent policy implementation. Leaders later acknowledged that the standards do apply to specialty care, but the lack of defined responsibilities, reliable data, and routine reviews prevented VHA from ensuring veterans received timely access.

VA began implementing changes in early 2026, including updating inaccurate phone numbers, revising automated prompts to include specialty options, expanding call queueing systems, and launching a national voicemail dashboard. These efforts should help reduce delays when veterans schedule or manage specialty care by phone.

The OIG made five recommendations to address the identified weaknesses. VHA concurred or concurred in principle with all recommendations and provided acceptable action plans.