Community Care Billing Irregularities at Selected VA Medical Centers

Review of overpayments and underpayments in the Veterans Community Care Program.

Hypothesis

The Veterans Community Care Program (VCCP) allows eligible veterans to receive care from non-VA providers when VA cannot provide timely or accessible care. Billing is governed by the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act and associated regulations. We hypothesize that (1) a material proportion of VCCP claims are paid at rates that exceed the contracted or statutory rate for the service, (2) duplicate payments occur when both VA and community providers bill for the same episode of care, and (3) underpayments to community providers may be causing network adequacy problems that VA has attributed to other factors. We will test these hypotheses by analyzing claims data, contract rate tables, and VA’s own program integrity reports.

Latest Update

We have obtained a sample of VCCP claims data through FOIA and are comparing line-item payments to the VA Fee Schedule and to Medicare rates for the same procedures. Early analysis suggests rate variance in both directions; we are building a full dataset before drawing conclusions. The VA OIG has published related work on community care oversight; we are aligning our definitions with theirs for comparability. No advisory has been issued yet; we expect to complete the analysis phase by end of Q2 2026.