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More evidence the VA is improperly delaying or denying community care to eligible veterans

Jan 28, 2022 by AFPF

Americans for Prosperity Foundation has obtained new documents in its ongoing Freedom of Information Act lawsuit against the Department of Veterans Affairs.

These documents provide even more evidence that the VA is failing to comply with the community care standards created by the VA MISSION Act, which was meant to give veterans more access to non-VA medical care.

The documents confirm that the VA is issuing guidance that disregards access standards and unlawfully adds layers to eligibility determinations not found in statute or regulation.

In one training document, the VA creates a new layer of review to a veteran already eligible community care:

“After eligibility has been confirmed, clinical review is performed to determine if the requested services are clinically appropriate to be authorized for delivery in the community.”

This extra step is not required in the VA MISSION Act or implementing regulations, but it could lead to longer wait times or denial of community care.

Inaccurately calculating appointment wait times

The Designated Access Standards from the Veterans Community Care Program regulations are clear: the relevant metric for eligibility starts at the date of request from the veteran.

Instead, the VA is using its own improper standard not found in law or regulation – denying or delaying eligible veterans from seeking community care.

When are veterans eligible for community care?

Legal Requirements
Primary Care If the VA cannot schedule an appointment “[w]ithin 20 days of the date of request unless a later date has been agreed to by the veteran in consultation with the VA health care provider.”
Specialty Care If the VA cannot schedule an appointment “[w]ithin 28 days of the date of request unless a later date has been agreed to by the veteran in consultation with the VA health care provider.”

Instead of starting the clock when a veteran requests an appointment, the VA calculates eligibility for community care by “patient indicated date” or “PID,” which is set by the VA scheduler.

PID is not found in the text of the VA MISSION Act or the implementing regulations for the Veterans Community Care Program, but the VA’s guidance and training documents unlawfully rely on it.

VA training documents obtained by AFPF demonstrate how the VA is giving staff guidance that does not comply with the Designated Access Standards.

In one audit example, the appointment is 48 days after the date of request, and the veteran would have been eligible for community care.

But under VA’s improper PID standard, the PID was “0”, and the veteran was not eligible for community care. The record, said “GOOD JOB” because it incorrectly labeled the audit as “CORRECT” and denied the veteran eligibility for community care.

In another example of distorted wait time calculations from training, the VA misrepresents a 79-day wait time from the date of request as only 23 days by improperly using PID.

The training documents also include two hypothetical examples where appointments cancelled and not rescheduled due to COVID-19 are not considered eligible for community care despite the wait time being well outside of the 20/28-day designated access standard.

The Office of Community Care Field Guidebook also includes directives such as  “For Veterans with a Return to Clinic order with a CID greater than 20/28 days, the wait time standard is considered waived.”

Only the veteran-patient can waive wait time standards. When the VA waives wait time standards on their own, they are denying eligible veterans community care.

VA guidebook shifts power from providers to administrative staff in response to increased use of community care

The Veterans Health Administration’s Referral Coordination Initiative Implementation Guidebook (updated Oct. 28, 2021) details the VA’s push to reduce community care because of “more Veterans being referred to the community than expected.”

The VA’s solution to the widespread use of community care was to shift the responsibility of referring to community care from health care providers to “dedicated clinical and administrative staff.”

These VA documents confirm the community care problems outlined in various reports from the Government Accountability Office and VA Office of Inspector General. The VA cannot continue to flout the law and regulations of the Veterans Community Care Program.

Our veterans deserve a VA that’s committed to allowing eligible veterans to receive community care.

Litigation Documents:

AFPF FOIA Complaint

FOIA Productions:

Records from the first production can be found here.

About Americans for Prosperity Foundation

AFP Foundation educates and trains Americans to be courageous advocates for the ideas, principles, and policies of a free and open society.

Among other things, AFP Foundation, through its grassroots education project Concerned Veterans for America Foundation, educates and empowers veterans to lead healthy and prosperous lives, including educating on the privileges and benefits afforded to veterans under the law.

About the VA MISSION Act

The VA MISSION Act was developed with the goal of better integrating the VA with community health care providers, fixing structural issues with the VA’s outside care programs, and ultimately improving access to care while expanding the health care options available to veterans through the VA.

Notably, it was also endorsed by over 30 veteran service organizations and passed with overwhelming bipartisan support before being signed into law by President Trump in June 2018.