Paul Muschick: How mistakes cost sick veterans. One claim wrongly denied for $15,000 ER visit.

Aug. 8--Emphasizing quantity over quality seldom works out in the end. The loser this time is our nation's veterans.

The rush to process claims for reimbursement for emergency hospital care resulted in mistakes that could have cost an estimated 17,400 veterans a collective $53 million. That's according to an audit Tuesday by the inspector general for the U.S. Department of Veterans Affairs.

It said their claims were improperly handled, potentially leaving them responsible for medical bills the VA should have covered. Auditors said they had no way of knowing, however, whether the veterans were billed and, if so, how many paid those bills.

"However, the risk of undue financial burden remained for individuals who could ultimately be billed," the audit concluded.

Veterans who seek emergency care at non-VA facilities are eligible for reimbursement under some circumstances, including if they are considered permanently and totally disabled due to their military service, or if they are rated as partially disabled and the care is related to those ailments.

Veterans also can seek reimbursement for treatment unrelated to service ailments if they are enrolled in VA health care, have used VA services in the past two years, if a VA facility was not reasonably available to provide care and if a delay in seeking treatment would have threatened their health or life.

Claims can be filed by veterans, the medical facility or any other person or organization that paid for the treatment.

In fiscal year 2017, more than 4.5 million emergency care reimbursement claims were processed by the VA; 22% were accepted, 15% were denied and 63% were rejected.

A rejected claim means a decision could not be made because more information was needed. A denied claim means the VA ruled the health care was not eligible for reimbursement. Veterans can appeal denials.

But delays in mailing notices may have resulted in veterans being unable to resubmit a claim or appeal a denial before the deadline. The audit said "stacks" of unsent letters were found at three VA facilities up to two months after they had been printed.

The inspector general also found instances where veterans did not receive complete and accurate information about why their claims were not approved, possibly making it difficult to challenge the decision or provide necessary information.

The audit was done at the request of several members of Congress who raised concerns that the VA system was set up to steer claims processors to deny claims.

The inspector general concluded that their concerns were valid.

It estimated that 31 percent of claims denials and rejections from April to September 2017 were "inappropriately processed."

The audit cites several examples of claims that were wrongly denied, including a veteran who was having seizures and went to an emergency room. The veteran potentially could have been billed $15,000.

The inspector general said the VA "placed more emphasis on the number of claims processed than the accuracy of the claims decisions" as it tried to work through a backlog of claims. It said some staff were told or encouraged to deny claims "to meet production standards."

Examiners told auditors they weren't given enough time to thoroughly and completely assess claims. Auditors learned that incentives such as overtime and the option to work from home were tied to meeting or exceeding production targets, but accuracy wasn't incentivized.

"Been told to process faster, even if that means inaccuracy. Click and pick," one examiner said in a survey taken by the inspector general.

"The 'numbers' game is unofficially enforced," said another. "Management says quality over quantity, but whenever you do not meet 'their expected' quota, you are called into the office and asked why you haven't been performing."

The inspector general made several recommendations, including that the VA stop prioritizing claims productivity over accuracy; improve performance evaluation standards and review processes; and reevaluate inappropriately processed claims.

VA management concurred with those recommendations, and noted the agency had identified most of the inspector general's concerns and started making changes prior to the audit's completion.

"Paying claims timely and accurately is a priority ... and we take this responsibility very seriously," it said in its written response.

The agency's previous actions don't support that statement.

The inspector general said the VA "was aware of quality assurance deficiencies" since at least March 2014 based on a previous investigation by the U.S. Government Accountability Office.

Following that report, clinical staff began meeting regularly to audit denied claims. From August 2017 to January 2018, the group identified errors with 18% to 34% of the denials each month, but no action was taken.

Let's hope something finally gets done this time.

Morning Call columnist Paul Muschick can be reached at 610-820-6582 or paul.muschick@mcall.com

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