Challenge
In 2015, the Veterans Health Administration (VHA) established the Office of Community Care (OCC) to encompass the role of the former Chief Business Office (CBO). Its mission is to ensure that all Veterans have access to care in their communities and that health care is coordinated effectively and efficiently. OCC is embarking on several pressing challenges, including the following:
- Weaknesses in OCC processes and controls. An integrated, enterprise-level Internal Control (IC) program was needed to provide effective oversight of its complex community care programs. In addition, recent regulatory changes mandated that government agencies comply with more stringent internal control guidelines.
- The OCC was impacted by a recent ruling issued by the Court of Veteran Appeals (COVA) that invalidated VA’s policy of disallowing cost reimbursements for non-service connected emergency care claims when a Veteran has Other Health Insurance (OHI). They needed help in rolling out processes, procedures, and implementing training to manage the transition.
Solution
OCC contracted Atlas Research to work with two VA-chartered work groups to establish an effective internal control governance structure and to update its claims adjudication process. The Atlas Team conducted a series of assessments of OCC’s current enterprise-level internal controls and developed a future state design and roadmap for transitioning to a mature internal control environment.
To assist OCC in addressing the recent COVA ruling regarding non-service connected emergency care, the Atlas Team redesigned the claims adjudication process and developed a future state and transition plan for processing these claims. The new process included detailed activities, owners, and timelines for revising regulations, establishing processes, updating IT systems, and training staff. In addition, the Atlas Team supported the VA-chartered work groups by providing project management and internal control, business process redesign, and audit readiness subject matter expertise to focus on improving key operating processes and internal control frameworks.
Result
Atlas worked with OCC to develop an enterprise-level control framework along with a high-level roadmap consisting of 28 practical projects. When fully implemented, these projects will result in a mature internal control environment that complies with government regulations, improves oversight, effectively minimizes audit exposure, and reliably provides program execution assurance. Atlas’ redesigned claims adjudication process for non-service connected emergency care claims gives OCC a way ahead following COVA’s recent decision, ensuring compliance with the ruling while keeping Veteran access to community care at the forefront.