Inside Oversight

Adam Roy
Hello, this is Adam Roy with the Veterans Affairs Office of Inspector General. You’re listening to Inside Oversight, our podcast that dives into our published work and features interviews and discussions with the OIG employees who do the work.
Today I am speaking with Geoff Ferguson and Gris Soto about two related reports that the VA OIG published in December 2021. Geoff is a senior auditor, and he led a team that prepared the report titled VHA Improperly Paid and Reauthorized Non-VA Acupuncture and Chiropractic Services. Gris is also a senior auditor, and her team wrote the report VHA Risks Overpaying Community Care Providers for Evaluation and Management Services.
In the first report, the VA OIG audited acupuncture and chiropractic care by non VA providers after becoming aware of patterns that suggested questionable billing practices by those providers.
In the second report, the VA OIG conducted a review to identify and evaluate the VHA’s risk of improperly paying community care providers for evaluation and management services not supported by medical documentation. How are these two reports connected? Whereas the first report looked at the specifics of acupuncture and chiropractic care and the risks there, the second report builds on all management and evaluation services and looks at the program from a higher level.
Geoff, Gris, it is good to have you both here today, and I thank you for joining the program.
Gris Soto:
Thank you, Adam, for having us on this program.
Geoff Ferguson
Thanks, Adam. Glad to be here.
Adam Roy
Great, thanks. Geoff, could you start by explaining how these two reports are related?
Geoff Ferguson
Both projects dealt with reimbursing third-party administrators for care delivered by non-VA providers in the community. For the acupuncture and chiropractic audit, we evaluated whether the payments were authorized and supported by appropriate medical documentation, and for the evaluation and management services review, we assessed the risks that there were overpayments for those services.
Adam Roy
So, we’re talking about care away from a VA facility. An outcome of the Choice Act, correct?
Geoff Ferguson
That’s right. The Veterans Access, Choice, and Accountability Act of 2014, or as we call it the Choice Act, increased veterans’ access to private, local providers of medical services, that includes acupuncture and chiropractic care, which the VA has promoted for pain management. Now since 2017, VHA payments to all community providers has increased by 350 percent for evaluation and management services, which is essentially a physician diagnosing a patient through medical history or evaluation, which can be billed for almost every specialty.
Adam Roy
So, in this instance why did we specifically audit non-VA acupuncture and chiropractic care?
Geoff Ferguson
Well, we regularly receive briefings from our data scientists on various areas of interest. One such briefing indicated that acupuncture and chiropractic care in the community should be examined due to several identified issues. Also, our investigative division was looking into healthcare fraud and they identified programmatic risks associate with acupuncture that led us to take a closer look, and eventually initiate this audit.
We looked at whether the acupuncture and chiropractic care that was paid for was authorized—meaning did VA approve it before it was actually provided. We also looked at whether the care was supported by medical documentation. We found problems across both areas of focus; however, the lack of supporting medical documentation was much more pervasive and had a higher dollar impact.
Adam Roy
To summarize, it sounds like VA generally approved, or authorized, care prior to payment. But the lack of documentation to support why that care was approved was prevalent in your findings. Is that accurate?
Geoff Ferguson
That’s exactly right. And what made this review challenging was the process we went through identify this specific issue.
Adam Roy
Let’s talk about that. Explain how your team evaluated the medical documentation.
Geoff Ferguson
Well, it’s complicated. We actually had to bring in some help. We contracted with medical coding specialists, who evaluated the medical documentation to determine whether it followed American Medical Association and Centers for Medicare and Medicaid Services guidelines as required.
Adam Roy
A contract? That’s going to add some complexity to the audit, correct?
Geoff Ferguson
Absolutely. We had to go through the entire acquisition process, like an government agency would do, from developing a request for proposal and a statement of work, then we evaluated the bids, the contractor qualifications, and once we selected a contractor, we had to ensure that the contractor, VHA staff, and our office were all on the same page when it came to the evaluation criteria, what would constitute an error or deficiency in what they were evaluating, and all of the other related administrative matters with a contract.
Adam Roy
Okay, so we obtain the contract. Now the team begins the documentation review process. Big picture, what did that look like?
Geoff Ferguson
Well, we had to get the documentation. So first we looked at the patient records to find the relevant medical documentation for all of these claims. If we couldn’t find any documentation in the patient records, we looked through third-party administrator portals. These portals are online, and they’re managed by VA contractors to help coordinate care in the community between the VA and those community providers. These portals are secure, and they provide a way for community providers and VA staff to upload and review information. Once we got all the documentation, specifically, the doctors’ notes for these visits on these claims, and all the other related materials, we had our contracted medical coding specialists review it. The specialists determined whether the medical documentation was complete, whether it was accurate, and whether it supported VHA’s payment for is care. When we couldn’t find any documentation in a patient’s record or in admin portal, we asked VHA to help us obtain it from the community providers. But that didn’t always work out.
Adam Roy

Understandable. How so? How didn’t it work out?
Geoff Ferguson
Well, despite the efforts that we made, we were not able to get medical documentation for about 19 percent of the codes on the acupuncture claims reviewed and about 14 percent of the codes on the chiropractic claims reviewed.
Adam Roy
Let’s breakdown these numbers a little bit more. Talk sample that size and what exactly does that 19 and 14 percent represent.
Geoff Ferguson
Sure. Our sample size, or the total number of claims we reviewed, was 360. We looked at 180 acupuncture claims, and we looked at 180 chiropractic claims. So, for the 180 acupuncture claims, 19 percent of them, or almost one in every five codes, were missing the appropriate documentation. And for the chiropractic claims, about one in every seven was missing this documentation.
Adam Roy
That’s a lot of missing documentation. And when you project these findings across the total number of claims from October 2017 to September 2019, we’re talking about significant issues related medical documentation.
Geoff Ferguson
Definitely. Considering that within the timeframe that we reviewed, there were over 600,000 acupuncture claims and over 800,000 chiropractic claims. So, these results influenced our recommendations that the Office of Community Care ensure VA facilities are verifying that non-VA providers are supporting their claims.
Adam Roy
So, we’ve discussed missing medical documentation, what about claims with documentation? The report highlighted issues here as well.
Geoff Ferguson
It sure did. As it relates to whether the medical documentation supported the payments, we found that most of it didn’t—accounting for about $130 million in improper payments for fiscal years 2018 and 2019. And as we previously discussed, some of these payments were improper because we could not obtain the documentation; and therefore, we just said it was not supported. Our specialists reviewed all the medical documentation we did find, and they found a varying degree of documentation deficiencies. An example of this would be a provider may have not documented the time that an acupuncture procedure took, which is required by AMA and CMS, or they may not have documented that more than one set of needles were inserted or a claim could have both of these problems. And for chiropractic providers, a common issue was the community practitioners did not identify which region of the spine was treated. They just said that a procedure was conducted. As my colleague, Gris, will discuss shortly, we found that the overwhelming majority of evaluation and management services were not supported on either the acupuncture or chiropractic claims.
Adam Roy
That’s very interesting. How did VHA react to these findings, and did they know that the medical documentation did not sufficiently support the community acupuncture and chiropractic services?
Geoff Ferguson
Well, the team presented the results of the review to VHA, and they concurred. We made the analysis available to the VHA representatives that we met with and had a follow-up meeting to answer any questions that they might have.
And as to whether or not VA knew, the short answer is no.
VA is required to ask community providers for documentation for any care given to veterans, but sometimes these providers don’t supply the documentation. And, while facilities are required to audit this documentation, these audits weren’t being conducted. So, they weren’t aware of the shortcomings the medical coding specialists assisted us in finding.
Adam Roy
Was there anything VHA did not agree with as it pertains to the medical documentation evaluation piece of this audit?
Geoff Ferguson
VHA generally agreed with all of our findings and recommendations except for one comment that kept cropping up. Specifically, the OIG interpreted that VHA’s Health Information Management and Health Records handbook also applied to community, or non-VA, providers based on the language within that handbook. VHA disagreed with our interpretation. They said that the documentation standards in the handbook were only applicable to VA providers. But considering that medical documentation requirements weren’t different—in that both VA and non-VA providers are required to use the American Medical Associations’ standards, which also happens to be the standard for the entire healthcare industry—the difference in interpretation didn’t affect the outcome of the findings or the recommendations.

Adam Roy:
To recap, we’ve talked about how missing or poor medical documentation led to unsupported care. Now, let’s transition and talk about how unauthorized claims contributed to improper payments by VHA.
Geoff Ferguson:
Sure, so under both the Choice and MISSION Acts, any community care has to be authorized by VA before any such care can be provided by an outside provider. There was a special rule for veterans who were eligible for care because they were a certain distance from VA’s medical centers. And for these veterans, third-party administrators could authorize their non-VA care after VHA confirmed their eligibility. i.e., after VHA verified these veterans lived a certain distance away from medical facilities. Then these third-party administrators could go ahead and authorize the care without further VA involvement. This rule helped reduced travel time for these veterans. And for patients that were not mileage eligible—i.e., weren’t that far away—but received non-VA care, the authorizing documentation would be in the patient record.
Adam Roy:
So, how did your team approach the evaluation of claims to determine whether authorization was given or not?
Geoff Ferguson:
Generally, acupuncture and chiropractic care is authorized for a series of visits, similar to someone whose insurance covers say 10 visits a year to a chiropractor, and after that the individual is responsible for the care. So, after a veteran completes his or her series of visits, the VA needs to determine whether additional care is appropriate. VHA sets how many visits a patient can have and what procedures a provider is allowed to bill for in guidelines, and they’re called standard episodes of care or SEOCs, for short. Both the acupuncture and chiropractic initial SEOCs, or the SEOC that governs the first instance a veteran is prescribed either acupuncture or chiropractic care, these allowed for 12 visits for most of the period under our review.
The VHA facility would use the SEOCs to determine how much care was authorized, and most of the time, we found these authorizations in the patient records. However, if a patient was authorized for 12 visits and one of the sampled claims indicated it was the patient’s seventeenth visit, then we considered that sample unauthorized because the number of visits exceeded what they were supposed to receive. We also evaluated whether the procedures that the community acupuncturists and chiropractors billed for were allowed on the SEOCs. So, these SEOCs also limited the procedures these community providers were allowed to do. So, an example of this would be the acupuncture SEOC only allowed for needles to be reinserted once for a total of two sets of needles per visit, but we found cases where the community acupuncturists billed for three sets or more, which is in violation of what VA would allow.
Adam Roy:
Those are really, really good examples. Thanks, Geoff. When we start to look at the bigger picture, how much money are we talking here?
Geoff Ferguson:
For fiscal years 2018 and 2019 improper payments for unauthorized acupuncture and chiropractic care accounted for more than $20 million. But, as we mentioned before, we had other improper payments that were made earlier, and we wanted to make sure we weren’t double counting the same errors to come up with a bigger number. And we had to separate out those figures. When we take into account those claims to make sure they weren’t double counted, our total for improper payments for fiscal years 2018 and 2019 for unsupported and unauthorized acupuncture and chiropractic care was about $137 million. And we forecasted those payments through fiscal year 2022 for a total estimate of almost $342 million in improper payments.
Adam Roy:
Wow. What factors allowed this to happen?
Talk about VA’s reimbursement system and how those improper payments were processed.
Geoff Ferguson:
VA’s Office of Community Care had a service level agreement with the Financial Services Center, and the Financial Services Center provides common administrative services to VA and other government clients. This service level agreement allowed the Financial Services Center to reimburse the third-party administrators that we mentioned before on VA’s behalf. When the payment system was initially set up, it was set up to pay any claim that was made from one year of the authorization. And this creates a problem in and of itself. Plus, we found a lack of automated controls within the payment system itself to check whether procedures being charged were allowable according to the SEOCs. This means that, if the VA authorized 12 visits to your community chiropractor, the chiropractor could, in theory, bill the third-party administrator for the next year for as many visits as they wanted, and VA would just automatically reimburse all those visits. In addition, chiropractors that were seeing patients could bill for acupuncture services or other unallowable treatments, and those would also be repaid because the system didn’t check any of those things.
Adam Roy:
Before your team looked in this, did the Office of Community Care review the agreement and reimbursement system?
Geoff Ferguson:
Well, we determined that the Office of Community Care does, in fact, complete internal audits; but they did not do an audit focused on whether the number of visits and treatments exceeded authorizations or SEOCs.
Adam Roy:
Ultimately, what recommendations did your team make to address these improper payments?
Geoff Ferguson:
For the unauthorized payments, we recommended that VHA implement automated payment controls and focus internal audits on whether payments were appropriately authorized. For the payments that were not supported by medical documentation, we recommended that VHA conduct post-payment audits and develop a process to then use the results of those audits. We also recommended education for non-VA providers.
Adam Roy:
Thank you. Let’s transition to the report’s second finding. Specifically, that VHA staff did not follow guidance when reauthorizing non-VA acupuncture and chiropractic care. Let’s break this down a little bit more for the listener. What are we talking about here?
Geoff Ferguson:
Sure, so we looked at providers who were billing much more frequently than their peers, which might be an indicator of fraud. And while we didn’t find any fraud, we did notice that VA’s process for re-authorizing community care was inconsistently applied. The Office of Community Care establishes guidelines for re-authorizing care in its field guidebook. These guidelines require approving officials at the facilities to document an evaluation of prior community care. Our analysis indicated that VHA did not follow their process for about 35 percent of the samples we reviewed.
Adam Roy:
What I’m hearing is the guidebook wasn’t being followed.
Geoff Ferguson:
That’s exactly right. We found that the Office of Community Care had no mechanism to ensure staff followed the guidebook. And in some cases, the audit team found that veterans directly requested care through the VA, and the guidebook wasn’t clear on how the VA was supposed to handle these types of requests So VHA staff responsible for national oversight of care coordination said the guidebook was not applicable in these circumstances because local community care staff did not make the determination to authorize more care. This resulted in approvers not documenting an evaluation of prior non-VA care. In the end facility leaders were not ensuring staff followed the guidebook’s processes and procedures.
Adam Roy:
Ultimately, this finding that your team was able to abstract from your work led to two recommendations.
Geoff Ferguson:
Exactly. We recommended the under secretary for health direct facility chiefs of staff to 1) require VA doctors to document their review in the patient record before re-authorizing care and 2) require VA doctors to document their clinical justification for this additional care. That second recommendation relates to cases where VHA could not obtain the documentation from the community providers, but the veteran was seeking additional care anyway.
Adam Roy:
Geoff, thank you so much. Appreciate it. Let’s turn our attention now to the second report titled VHA Risks Overpaying Community Care Providers for Evaluation and Management Services. We’ve got Gris here. Gris, before we get into this report, can you explain what evaluation and management services are to our listeners.
Gris Soto:
Sure, Adam. I think a little background first will help. Due to legislation like the VA MISSION Act of 2018, veterans are increasingly obtaining medical care from community providers. We conducted this review to identify and evaluate the VHA’s risk of improperly paying community care providers for evaluation and management services not supported by medical documentation.
Adam Roy:
Ok, so more and more veterans are going out into the community for care, including for evaluation and management services.
Gris Soto:
Exactly. Providers for many types of services offered in the community, not just acupuncture and chiropractic care, deliver evaluation and management services to support their specialty. Generally, evaluation and management services mean the provider evaluates the patient’s history or examines the patient. These services are organized under five levels. Level 1 services are for medical encounters that contain the least complex patient visit and documentation requirements. For example, a provider may use level 1 for evaluating a minor illness, like a cold. Each subsequent level requires more complexity. Meaning that a level 5 evaluation could involve a chronic illness such as progressive severe rheumatoid arthritis. Evaluations like these are often complex and require a lot of documentation.
Adam Roy:
And to quote the report, “…documentation must satisfy all requirements for the billed codes.” So, Gris, each level and its codes have unique requirements a provider must meet when documenting services.
Gris Soto:
That’s right. Providers must adhere to those requirements when documenting. And some of these requirements have recently changed. In January 2021, the Centers for Medicare and Medicaid Services changed the standards for evaluation and management services for the first time since 1997. For many healthcare practitioners working with veterans, this is the first change to how evaluation and management services are documented they have seen in their careers.
Adam Roy:
Why make this change?
Gris Soto:
The goal of the Centers for Medicare and Medicaid Services was to reduce the amount of time it takes providers to document for these services. Some revisions include allowing code selection based on modified criteria for medical decision-making or time and eliminating the lowest level code for the evaluation and management of a new patient.
VHA’s subject matter experts told us that these updates might make it harder to determine whether medical documentation supported a billed evaluation and management charge.
Adam Roy:
Did these changes factor into the report’s recommendations, specifically did VHA make current and future education material available to non-VA providers?
Gris Soto:
It certainly did. Our other recommendation directed VHA to audit medical documentation with evaluation and management services, similar to what we recommended in the acupuncture and chiropractic report.
Adam Roy:
Let’s rewind a little bit. Tell me how did your team take the information from the acupuncture and chiropractic audit and then launch this review of the risks associated with evaluation and management services for all types of services?
Gris Soto:
As Geoff said, the coding specialists who assisted his audit team noted that the overwhelming majority of evaluation and management services were not supported on either the acupuncture or chiropractic claims. Specifically, the audit team statistically projected that 97 percent of evaluation and management services on acupuncture claims were not supported, and this projected figure was about 78 percent for chiropractic claims. Because those error rates were so high, we thought it made sense to look at the whole population of evaluation and management services and not just those attached to acupuncture and chiropractic claims.
Adam Roy:
Help the listener understand just how big the population was. What did your team evaluate?
Gris Soto:
We focused on fiscal year 2020’s evaluation and management services. During that time VA paid community providers just over $300 million for these services. In addition to the size, there is also the growth in these services that we considered when launching this review. Namely, from fiscal year 2017 to 2020 the amount VA paid community providers for evaluation and management services increased by about 350 percent from $67.5 million in 2017.
Adam Roy:
So, did your team also contract for coding specialists to review those claims?
Gris Soto:
No, our review was more analytical, and data driven in nature. Our objective was to assess the risks of billing for evaluation and management services for all specialties. Therefore, we did not test claims, rather we evaluated trends in the evaluation and management population. We thought it was more important to get this project to VA’s management as quick as possible after the audit, and that is why these reports go together nicely.
The acupuncture and chiropractic audit introduced the idea that medical documentation may not be up to snuff, and this follow-on review emphasized that it was not just those services that have risks. As Geoff’s team also did for the audit, we evaluated the risks within the evaluation and management services population.
Adam Roy:
Can you share those risks with us?
Gris Soto:
Sure, Adam. The previous audit highlighted that these services were risky in general, but we found that some evaluation and management services carried more risk than others. First, we identified community care providers who were billing the higher-level evaluation and management services significantly more often than other community care providers who delivered the same type of care. Second, we identified providers who were billing for evaluation and management services while the global surgery was in effect, when all services are typically covered under one billing.
Adam Roy:
Global surgery—that’s a new one for me. I want to ask you about global surgery in a minute. But first, let’s expand on the first issue—where non-VA providers were billing high-level evaluation and management services significantly more often than their peers. Can you talk about that?
Gris Soto:
Sure. Going back to those five levels of evaluation and management services. In addition to each level being more complex than the previous, each level is also more expensive than the previous. We considered level 4 and level 5 to be high-level evaluation and management services because of their cost to VA. We were able to identify a population of community providers who were billing these services significantly more often. And by significant, well the technical definition is that the providers in question billed high-level evaluation and management services proportionally more than one standard deviation above the mean for all non-VA providers in their specialty. But simply stated, the difference was statistically significant.
Let me give you an example. Our report describes a dermatologist who was paid for level 4 and 5 evaluation and management services more than 90 percent of the time when the provider submitted claims for evaluation and management services. This dermatologist was paid over $100,000 for these high-level services.
Adam Roy:
That’s just one dermatologist. Within the population, how many other providers were similar?
Gris Soto:
Well, we determined that almost 38,000 out of 218,000 community care providers billed high-level services significantly more often than their peers. In total, they were paid about $39 million.
Adam Roy:
So, we’re talking about a lot of money. Let’s go back and expand on the second issue, the one related to the global surgery package.
Gris Soto:
Sure. The global surgical package includes all the necessary services normally furnished before, during, and after a procedure. Further, physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. Because all services are supposed to be covered under one bill, evaluation and management services that are billed separately carry more risk.
Adam Roy:
How many providers did your team identify that billed while the global surgery package was in effect?
Gris Soto:
Our analysis identified that more than 45,000 non-VA providers were paid almost $38 million more than the costs that are generally included in the services provided within periods when the global surgery package was in effect during fiscal year 2020.
Adam Roy:
Does that mean all those payments were inappropriate?
Gris Soto:
Not necessarily. And I’m quoting the report here, “Although a provider can bill an evaluation and management treatment code during the global surgery period if it is a separate and identifiable service—for example, charged by an orthopedist for a shoulder problem the patient experiences after hip surgery—there is a higher risk that these charges are improper.” So, yes, while there could be reasonable explanations for the billing patterns related to those payments, we do believe that they warrant a closer look by VHA.
Adam Roy:
That makes sense. Thanks Gris. Is there anything you want to add before we wrap up today?
Gris Soto:
Yes. I’d like to mention the questioned costs our report identified. We estimated almost $20 million in questioned costs for fiscal year 2020, and we forecasted $60 million in questioned costs through fiscal year 2022. Combined, the two reports we discussed today questioned an estimated $400 million of non-VA community care payments—which is very impactful and noteworthy.
Adam Roy:
I couldn’t agree more. Gris, Geoff, thank you so much for joining me today and sharing your insight on these two reports.
Geoff Ferguson:
It was a pleasure to be here. Hope to see you again.
Gris Soto:
It was a pleasure to be here.
Adam Roy:
Listeners, if you want to read summaries of the reports we just talked about or download them, please visit our website and search under the reports tab. Thanks for tuning in.

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