VA’s Office of Community Care (OCC) Payment Operations and Management (POM) directorate has seen its non-VA care claims backlog increase since at least October 2016. 1 VHA’s Fee Basis Claims System data showed the claims backlog increased from over 239,000 claims in October 2016 to over 988,000 as of October 2018. This backlog further increased to over 1.3 million claims as of April 2019. VHA’s Fee Basis Claims System data showed POM received about 19.4 million claims in fiscal year (FY) 2018, over 4.2 million more claims in FY 2018 than in FY 2017. While POM processed over 6 million more claims in FY 2018 than in FY 2017, POM still received about 542,000 more claims during this two-year period than it processed. The audit team determined that the number of claims processors increased by only about 10 during the same period, and POM also used contract support staff to process claims.2 To reduce this backlog, the OCC published a community care bulletin in 2015, and POM leaders emailed staff over several subsequent years encouraging overtime be used to process POM’s outstanding non-VA care claims backlog. 3 While OCC and POM leaders encouraged staff to use overtime to reduce the claims backlog, neither established a policy that required staff to use overtime exclusively to process those claims or detailed appropriate uses for overtime. The VA Office of Inspector General (OIG) recognizes that resolving the potentially significant financial burden for veterans caused by backlogged payments to community healthcare providers required swift action by VA. The use of overtime, in and of itself, can be an acceptable option, but must be closely assessed and monitored. The OIG conducted this audit to examine OCC POM’s use of overtime to process non-VA care claims, the effect overtime had on claims backlog reduction, and whether claims processors and nurses abused overtime.4 What the Audit Found OIG auditors found that although reducing the backlog was a stated priority rather than a requirement, POM leaders did not effectively ensure their staff used overtime primarily to process claims. During FYs 2017 and 2018, POM supervisors approved more than 677,000 overtime hours at a cost of about $23.8 million. The OCC’s policy states that “OT [overtime] is to be used only when absolutely necessary to accomplish the mission” of the organization and “should be kept to a minimum,” such as when mission-critical work “cannot be completed by on-duty personnel during regular working hours alone….
Read the full 43-page report here.
Source: Overtime Use in the Office of Community Care to Process Non-VA Care Claims Not Effectively Monitored – June 23, 2020. VA OIG.
