The Department of Veterans Affairs (VA) is committed to providing comprehensive healthcare services to eligible veterans, and dental care is a crucial component of this commitment. Recognizing that access to timely and convenient care is paramount, the VA offers the Community Care Dental Program. This program allows eligible veterans to receive dental services from community providers when VA facilities are geographically inaccessible, appointment wait times are excessive, or when community care is deemed to be in the veteran’s best medical interest.
In Fiscal Year 2022, the VA demonstrated its significant reach in veteran dental health by providing care to approximately 607,000 veterans. A substantial portion of this care was delivered through community partnerships, with 186,500 veterans being referred to non-VA dentists within their communities. This reliance on community care highlights the program’s importance in extending dental services beyond the VA’s direct infrastructure. However, the increasing utilization of both VA and community dental care has led to considerable cost increases. Between Fiscal Years 2018 and 2022, costs associated with VA dental care have risen by 65 percent, while community dental care costs have surged by a significant 173 percent. It’s important to note that VA payments for community dental care are contingent upon prior authorization from VA dentists for specific procedures.
To ensure financial accountability and program integrity, the VA Office of Inspector General (OIG) conducted an audit to assess the extent to which the Veterans Health Administration (VHA) might be incurring improper payments for unauthorized dental procedures performed in the community. The OIG’s investigation focused on identifying instances where community dentists performed procedures without proper VA authorization.
The OIG’s findings revealed a concerning trend of potential improper payments. Their estimates project that between Fiscal Years 2022 and 2025, the VA is at risk of improperly paying $325.5 million for an estimated 847,800 unauthorized dental procedures carried out by community dentists. This substantial figure includes $139.1 million already estimated to have been improperly paid in Fiscal Years 2022 and 2023. Furthermore, if corrective measures are not implemented, an additional $186.4 million in improper payments is projected for Fiscal Years 2024 and 2025. The audit identified three primary categories of unauthorized dental procedures contributing to these improper payments: major alterations to veterans’ treatment plans without authorization, minor modifications to treatment plans exceeding VHA’s allowable limits within a 12-month period, and referrals lacking the necessary specification of authorized dental procedure codes.
In response to these findings, the OIG has put forth five key recommendations aimed at assisting the VA in mitigating improper payments and strengthening the oversight of the Community Care Dental Program. These recommendations are directed to the under secretary for health and focus on enhancing prepayment adjudication processes, reinforcing postpayment review mechanisms, and ensuring strict adherence to preauthorization requirements. By implementing these recommendations, the VA can work towards ensuring that veterans receive necessary dental care through the community program while safeguarding taxpayer dollars and maintaining program integrity.
