Improved Oversight Needed to Evaluate Network Adequacy and Contractor Performance

Report Information

Issue Date
Report Number
23-00876-74
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
Leadership and Governance
Recommendations
8
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The Veterans Community Care Program allows the Veterans Health Administration (VHA) to purchase care for veterans through Community Care Network (CCN) contracts or veterans care agreements. While the CCN groups VA medical facilities into regions managed by third-party administrators (TPAs), the Office of Integrated Veteran Care (IVC) is responsible for overseeing execution of CCN contracts.

The VA Office of Inspector General (OIG) conducted this audit to determine whether VHA provided effective oversight of its TPAs and VA medical facilities. The review team evaluated IVC’s oversight of the TPAs’ adherence to four contract requirements designed to ensure facilities have enough community providers to administer care within the timeliness and drive-time standards established in the contracts. The OIG found that IVC did not hold TPAs accountable for implementing these contract requirements, causing staff to struggle to convince TPAs to add community providers to their networks at the eight facilities the audit team visited.

While IVC provided proof of TPA discussing community care needs with three facilities, similar evidence for other facilities was not provided. Furthermore, IVC did not conduct any analyses of facilities’ network adequacy needs to help TPAs build provider networks and did not ensure TPAs maintained provider networks that were accepting VA patients. IVC also did not position itself to defend facilities’ needs for additional community care providers.

The OIG recommended to the undersecretary for health that the IVC holds future TPAs accountable for operational readiness and provider network adequacy; develop processes to update and maintain CCN data, challenges, and needs; conduct Advanced Medical Cost Management Solution training on evaluating network adequacy through the tool for community care staff; and not only develop its own network adequacy performance reports but also evaluate TPAs’ reports, holding them accountable for resolving identified issues.

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)

Holds future third-party administrators accountable for operational readiness and provider network adequacy at each facility by the time the contracts are implemented.

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

Develops a process to make sure the third-party administrators regularly update their Community Care Network provider lists to reflect accurate provider contact information and annotate providers who are not currently accepting VA patients.

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

Develops a mechanism for facilities to effectively report, track, and monitor challenges with access to specialty care services; trains all relevant staff on how to use the mechanism; make sure facilities use the mechanism routinely; and then helps facilities resolve access challenges.

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

Develops and communicates to facilities a standard process to request and document their needs for additional providers.

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

Evaluates the effectiveness of the third-party administrators’ quarterly and monthly reports for assessing network adequacy and then, if needed, modifies the language in its current contracts and makes changes to the applicable contract language for future Community Care Network contracts.

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

Develops its own network adequacy performance reports for each facility and communicates the results to the facilities monthly.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Conducts Advanced Medical Cost Management Solution training for community care staff at each facility on evaluating network adequacy through the tool.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Routinely evaluates the third-party administrator’s network adequacy performance reports to ensure the reports are sufficiently reliable and comply with contract requirements, and then holds third-party administrators accountable for resolving identified issues.