VHA Risks Overpaying Community Care Providers for Evaluation and Management Services

Report Information

Issue Date
Report Number
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Audits and Evaluations
Report Type
Report Topic
Community Care
Financial Management
Major Management Challenges
Stewardship of Taxpayer Dollars
Questioned Costs
Better Use of Funds
Congressionally Mandated


The OIG conducted this review to determine the risk of the Veterans Health Administration (VHA) improperly paying community care providers for evaluation and management services not supported by medical documentation. The review team found that some providers are billing VA at a significantly higher rate for high-level evaluation and management services than their peers in the same specialty. The team determined that in fiscal year (FY) 2020, more than 37,900 non-VA providers billed and were paid for significantly more high-level evaluation and management codes than were all providers in that specialty on average. These non-VA providers received about $39.1 million (13 percent) of the approximately $303.6 million paid for all non-VA evaluation and management services. Additionally, some providers billed separately for evaluation and management services during periods when the global surgery package was in effect. This package is supposed to cover all surgery-related services for a set period. The review team identified more than 45,600 providers who were paid about $37.8 million in FY 2020 for these evaluation and management services. Improper payments were not easy to detect because VHA staff did not retrospectively audit medical documentation as required. Additionally, the OIG found no evidence that VHA or contractors trained non VA providers on documenting evaluation and management services, similar to how VA providers are trained. The OIG determined VHA risked overpaying for evaluation and management services by about $19.9 million in FY 2020. The OIG made two recommendations to the under secretary for health related to (1) reviewing medical documentation for evaluation and management services billed by non-VA providers and then developing processes to act on the results of those reviews; and (2) ensuring non-VA providers receive current and future continuing education materials on proper medical documentation for evaluation and management services.

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)
Direct the Health Information Management program office, in coordination with the Office of Community Care and facility chiefs of staff, to ensure facilities are conducting post payment audits of billed evaluation and management services to verify non VA providers are properly supporting their claims, including a focus on providers who frequently bill high level evaluation and management services and/or submit charges during periods when global surgery packages are in effect, and develop processes for corrective actions based on audit results.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Ensure the Office of Community Care and the Health Information Management program office make any current and future continuing education material related to documenting evaluation and management services available to non VA providers.
Total Monetary Impact of All Recommendations
Open: $ 59,600,000.00
Closed: $ 0.00