Members Push Back After Vets Left on the Hook for Emergency Care

• Letter to Wilkie cites report VA wrongly denied emergency care claims
• Watchdog said VA stressed claim processing speed over accuracy

(Updates with department comment starting in fourth paragraph.)

A bipartisan, bicameral group of lawmakers are demanding answers from the Department of Veterans Affairs after a watchdog report revealed thousands of veterans were wrongly denied claims for emergency health care visits outside the VA system.

“Facing a medical emergency can be stressful for any patient; however, the financial toll on veterans when VA erroneously denies or rejects payment can also be devastating,” the members wrote in their letter to VA Secretary Robert Wilkie.

Among the more than 30 lawmakers signing the letter were House Veterans’ Affairs Committee Chairman Mark Takano (D-Calif.), ranking member Phil Roe (R-Tenn.), and Sen. Jon Tester (D-Mont.), the top Democrat on the Senate Veterans’ Affairs Committee.

The department “appreciates the lawmakers’ concerns and will respond to them directly,” Susan Carter, director of the VA’s Office of Media Relations, said in an email.

“VA appreciates the inspector general’s oversight, which in this case highlights claims processed up to more than two years ago,” Carter said.

(Joe Raedle/Getty Images)

An estimated 31% of denied or rejected non-VA emergency care claims were inappropriately processed, affecting 60,800 veterans, the VA’s inspector general found during a six-month audit. The report said about 17,400 of those veterans probably should have been reimbursed for emergency care services and had bills totaling at least $53.3 million.

“Hospitals may send veterans’ emergency care bills to collection. Non-payment can bankrupt and destroy veterans’ credit histories,” the members wrote. “These administrative errors can remain with veterans for the rest of their lives.”

The inspector general report also found that the department’s claim processing unit failed to inform individuals that their claims had been denied, or informed them too late to resubmit or appeal.

“This meant many veterans were blindsided by bills from emergency care providers due to VA’s non-payment, and some were unable to appeal due to an expired appeal deadline,” lawmakers said.

Quantity Over Quality

Veterans are allowed to receive emergency care at non-VA medical facilities and subsequently file a claim with the department for the costs. The latest issues with reimbursements come at a time when the VA is expanding options for private medical services under a community care overhaul supported by President Donald Trump.

The inspector general reported that the work culture in the Claims Adjudication and Reimbursement Directorate in the VA’s Office of Community Care placed more emphasis on the number of claims processed than on accuracy.

Members said they were “equally alarmed” by the finding.

“VA’s culture incentivized meeting unrealistic productivity standards that drove some claims processing staff to simply deny or reject emergency care claims rather than adjudicate them properly because doing so took less time,” lawmakers wrote.

Some examiners said they were verbally encouraged to deny non-VA care claims to meet production targets while others said they felt “systemic pressure to favor speed over accuracy.” There were also incentives tied to meeting claims processing goals, such as overtime and telework privileges.

They were “told to process faster, even if that means inaccuracy. Click and pick,” one examiner said.

The VA directorate also lacked sufficient quality control, with half the examiners saying they were not aware of supervisors reviewing their work for accuracy.

‘Not New Territory for VA’

Lawmakers said it was disappointing that VA hadn’t done enough to change its processing of non-VA emergency care claims after a Government Accountability Office report identified similar issues five years ago.

“This is not new territory for VA,” members wrote to the VA secretary.

Lawmakers pressed Wilkie for answers, such as whether there were still incentives that could cause employees to choose quantity over quality and how VA plans to re-adjudicate the 17,400 veterans’ claims the inspector general determined that the VA probably should have paid.

They also asked for a timeline for complying with the inspector general’s recommendations, including implementing a strategic plan that emphasizes the accuracy of claims processing decisions and developing a standardized process for monitoring processors for accuracy.

“Prior to the report’s release, VA had self-identified the majority of the IG’s concerns, starting numerous efforts to fix them more than a year ago,” Carter said.

The report estimated that if corrective actions aren’t taken, the errors could result in $533 million in improper underpayments over five years.

To contact the reporter on this story: Megan Howard in Washington at mhoward@bgov.com

To contact the editors responsible for this story: Loren Duggan at lduggan@bgov.com; Jodie Morris at jmorris@bgov.com