OIG audit reveals lack of data sharing led to $128M in duplicate payments by Medicare, VA

Medicare paid for medical services that the Veterans Health Administration (VHA) had also paid for, resulting in duplicate payments of up to $128 million over five years, revealed an audit performed by the Office of Inspector General (OIG).

The federal oversight agency reported that Medicare could have avoided the loss if proper controls had been implemented.

The audit, performed by the Department of Health and Human Services’ OIG, reviewed Medicare and VHA benefits paid for by the VA’s community care programs. The audit covered $19.2 billion in Medicare Parts A and B payments for 36.3 million claims for individuals eligible for Medicare and VHA benefits who received services from VA’s community providers. The audit period spanned from January 2017 through December 2021 and sought to identify duplicate payments.

“These duplicate payments occurred because [the Centers for Medicare & Medicare Services (CMS)] did not implement controls to address duplicate payments for services provided to individuals with Medicare and VHA benefits,” the report said.  “Specifically, CMS did not establish a data-sharing agreement with VHA for the ongoing sharing of data between the two agencies and did not develop an interagency process to include VHA enrollment, claims and payment data in CMS’s data repository.”

VA’s community care program offers veterans who are unable to easily access a VHA facility the option to receive care through community providers. Said providers participate in Medicare and have entered into agreements with the VA.

In the years of the audit, veterans who accessed care at these facilities increased, partially due to the June 2019 expansion of eligibility in the Veterans Community Care Program. During the 2020 fiscal year, roughly 5.6 million individuals were dually eligible for Medicare and VHA benefits.

“VHA is solely responsible for paying for the community care services it authorized,” the report said. “Medicare payment for other services not authorized by VA may be made in accordance with Medicare requirements. Duplicate claims occur when a provider submits claims for the same services to both Medicare and VHA, and duplicate payments occur when both programs pay the claims.

“Because Medicare regulations prohibit payment for services that are paid for directly or indirectly by another government entity, subject to a few exceptions, Medicare should not pay claims for services that VHA has paid.”

The audit reviewed payment details including enrollee identifiers to determine whether an enrollee had a paid claim in both the Medicare and the VHA claim data set. Duplicate payments totaled up to $128 million associated with 298,527 claims.

Federal law required that data between the two departments regarding dual enrollees be shared. Dual payments occurred due to the fact that CMS did not develop an interagency process. Additionally, CMS did not clarify that providers should not bill Medicare for a medical service that was authorized by the VHA.

The OIG recommended in its report that a comprehensive data sharing agreement be established between CMS and VHA. This would include an interagency process to integrate VHA enrollment, claims and payment data into the CMS IDR to identify Medicare fraud.

Additionally, an internal process to address duplicate payments should be formed, and guidance should be issued to providers.

In written comments to the draft report, CMS concurred with OIG’s recommendations. The department stated that it is in talks with the VHA to establish a data-sharing agreement that will include all relevant VHA data. CMS also reported to OIG that it is designing a process to address duplicate payments.

“CMS stated that it will take our recommendation into account when determining appropriate next steps to help ensure that Medicare is not paying for medical services authorized by VHA,” the report said. “CMS also stated that it has educated providers regarding coverage and payment for medical services authorized by VHA.”