Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures

Report Information

Issue Date
Report Number
22-02294-42
VISN
State
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Community Care
Medical Staff Privileging Credentialing
Patient Safety
Major Management Challenges
Leadership and Governance
Recommendations
8
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General (OIG) reviewed a former VA surgeon’s eligibility to provide health care as a participant in VA’s Community Care Network (CCN) and the Marion VA Health Care System’s (facility) management of community care patient safety events.

The OIG identified multiple failures by third-party administrator (TPA), Optum, and VA Office of Integrated Veteran Care (IVC) that undermined credentialing and oversight processes, and ultimately allowed the subject surgeon to practice in the VA community care program. First, Optum failed to address concerns identified by a third-party certified verification organization in the surgeon’s 2018 credentialing file. Second, imprecise language in the VA’s contract with the TPA did not provide adequate guidance for Optum in determining whether to exclude the surgeon from the CCN. Additionally, IVC failed to identify inconsistencies in the surgeon’s credentialing file that should have impacted credentialing decisions. Finally, misapplication of privacy rules prevented Optum’s leaders from releasing important information to IVC relevant to the surgeon’s voluntary relinquishment of the Florida medical license. The OIG concluded that the facility’s patient safety training did not include completing patient safety event reports for events in the community and the patient safety manager was unaware of the ability to contact the TPA for updates on the status of patient safety concerns reported to the TPA.

The OIG made two recommendations to the Under Secretary for Health related to review of the surgeon’s eligibility to participate in the CCN and CCN contract; four recommendations to the IVC Executive Director related to ensuring Optum’s sufficient review, documentation, and compliance of CCN providers; one recommendation to the VISN Director to review all community care provided by the surgeon; and one recommendation to the Facility Director related to patient safety event report education and follow-up.

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)

The Under Secretary for Health initiates a review of the surgeon’s eligibility to participate in VA’s Community Care Network given Optum’s lack of documentation of their review of the surgeon’s credentialing file and takes action, as indicated.

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

The Under Secretary for Health reviews community care network contracts and considers modifying contracts to ensure that voluntary relinquishments and surrenders of licenses for disciplinary reasons are disqualifying for participation in VA’s Community Care Network consistent with the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act.

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

The Office of Integrated Veteran Care Executive Director, Integrated External Networks ensures Optum’s sufficient review and discussion of community care network providers’adverse credentialing files and monitors for compliance.

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

The Office of Integrated Veteran Care Executive Director, Integrated External Networks ensures that Optum documents community care network provider credentialing decisions asrequired and monitors for compliance.

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

The Office of Integrated Veteran Care Executive Director, Integrated External Networks ensures that Optum complies with community care contract provisions to provide Integrated Veteran Care with accreditation and credentialing documentation in accordance with federal privacy laws and VA’s community care network contract.

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

The Office of Integrated Veteran Care Executive Director, Integrated External Networks verifies that providers identified on the 2021 Government Accountability Office list are eligible to provide care in the VA Community Care Network.

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

The VA Heartland Network Director initiates a review of all community care provided by the surgeon.

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

The VA Marion Health Care System Director ensures primary care and patient safety staff receive education on their responsibility for Joint Patient Safety Reporting and follow-up of patient safety events related to community care, and monitors compliance with patient safety event reporting and follow-up.