Jul 15, 2025
Statement of
Kristina Keenan, Director
National Legislative Service
Veterans of Foreign Wars of the United States
Before the
United States House of Representatives
Committee on Veterans' Affairs
Subcommittee on Health
With Respect To
“Right Time, Right Place, Right Treatment with VA Community Care”
Washington, D.C.
Chairwoman Miller-Meeks, Ranking Member Brownley, and members of the subcommittee, on behalf of the men and women of the Veterans of Foreign Wars of the United States (VFW) and its Auxiliary, thank you for the opportunity to provide the VFW’s and my personal remarks on this important topic.
The VFW believes the Department of Veterans Affairs (VA) community care program and its Community Care Network (CCN) of providers are a vital component of VA health care as it delivers the care and services that VA hospitals and community-based outpatient clinics either cannot or do not provide. Since no institution can be everything for everybody, community care providers are force multipliers, allowing VA to continue providing the world-class care that veterans prefer, deserve, and have earned, while also ensuring they have access to the range of services they may need throughout their lives.
When appropriately used, community care can save lives and improve the health outcomes for countless veterans, but the problems that arise can drive people away from the care they have earned. We have also called on VA to rely on its third-party administrators to ensure consistent delivery of community care to eligible veterans. The VFW has been unequivocal that community care must be a part of VA care since the 2014 Phoenix crisis. It always has been. However, veterans expect consistency. When 23 Veterans Integrated Services Networks interpret the VA MISSION Act of 2018 in 23 different ways, veterans are overlooked, as the VA Inspector General pointed out last year in Buffalo, New York.
Background
VA provided fee-based care through non-VA providers before 2014, under limited circumstances, to veterans residing in rural areas who could not access a VA facility, and for services that the local VA facility could not provide. Following the VA wait-time scandal in Phoenix, the Veterans Access, Choice, and Accountability Act of 2014, called the Choice Act, was passed to establish the Veterans Choice Program (VCP). The Choice Act enabled eligibility for community care for those living far from a VA facility or facing excessive wait times, which was overseen by third-party administrators managing provider networks. In 2018, VCP was replaced with the more unified and permanent Veterans Community Care Program (VCCP) through the passage of the VA MISSION Act of 2018. This change provided community care if VA services were not available in a timely manner, were not readily accessible, were in the veteran's best medical interest, or if the veteran and provider agreed that community care was the best option. Currently, VCCP eligibility is determined based on clinical need, rather than distance or wait time. It is coordinated through VA Care Teams, which include urgent care, primary care, specialty care, and mental health services. Third-party administrators manage community care networks, such as Optum Serve (East Region) and TriWest Healthcare Alliance (West Region).
Specialty Care
VCCP provides a wide range of specialty care services to ensure that veterans can access medical care that may not be immediately available in VA facilities. These may include cardiology, audiology, otolaryngology, gastroenterology, dental and oral surgery, mental health and behavioral services, and women’s health, among others.
As the number of women serving in the military has increased, so has the women veteran population. For these VA patients, community care has become essential, particularly for their gender-specific services like mammograms, fertility treatment, and maternity care. Veterans living in rural and underserved areas that are greater distances from VA medical facilities rely heavily on this option. Additionally, veterans experiencing mental health crises who require inpatient care may need to be referred to community care providers for specialized treatment. All veterans must receive timely, high-quality, and consistent care that meets their individual needs and preferences.
My Story
I use VA for all my health care except dental care, which is not currently covered for veterans without a dental-related service-connected disability. The specialty care that I have received as part of VA’s community care program includes mammograms and maternity care.
The care I have received through VA’s community care providers has been high quality and has met my needs and preferences. VA coordinated my care during a pregnancy last year, which sadly ended in miscarriage. I became pregnant again this spring, and VA is again coordinating my maternity care in the community. In both instances when I became pregnant, a VA maternity care coordinator sent me a list of 27 medical facilities for covered maternity care within the Washington, D.C. metro area. I was able to select both the facility and provider of my choice based on availability. I selected a hospital five miles from my home (which is 30 minutes of city driving time), and that is next to my VA medical center. I was pleasantly surprised to learn that I could even select midwifery services at my hospital of choice, which was my top preference for maternity care. I appreciated the exceptional compassion and bedside manner of my providers, especially during the difficulties of my first pregnancy. In both cases, VA processed my community care referrals in a timely manner, and I received communications both electronically and by phone about my health care through a maternity care coordinator.
While I have had very positive experiences with community care, I have also encountered several challenges along the way in how that care was coordinated by VA. First, for my mammogram screening, I received a bill for nearly $700 that VA failed to pay even though it made the appointment for that care. Each time I received a bill, I called the community care provider and gave my VA referral information. As I continued to receive bills and saw the threatening words in red letters that I could face collections if I failed to pay, I would call again and was always told it would be taken care of. After approximately six months of receiving bills and calling to try to remedy the situation, the bills finally stopped.
Second, the process to set up my initial appointments during my maternity care was quite confusing. It was unclear to me if VA was going to set up the first community care appointment or if I needed to call providers from the approved VA list. The first time, I was told to wait for VA to call me to schedule the appointment. Then, after a couple of weeks, I was told that I could make the appointment myself. Once I received the VA referral, I made an appointment with the approved provider, but at the same time VA made an appointment with that same provider though my name was misspelled. When I tried to cancel the VA-scheduled appointment, which was weeks later than the appointment I had scheduled, the CCN provider could not locate it because of the misspelling. When I called the VA appointment phone number, I was told that VA was obligated to keep the scheduled appointment even if I did not attend it, so there was no way for me to cancel or change that appointment.
Third, also during my maternity care, my CCN provider attempted to send a prescription to my VA pharmacy for me to pick up since this was the only way that VA would cover the cost of the medication. I asked for a written prescription to hand carry to the pharmacy, but my provider said that prescriptions could only be sent electronically. I walked over to the VA medical center, across the street from my community care facility and waited for it to be filled. Once it was clear that VA never received the request, I walked back to the CCN provider, but by then it was late in the afternoon on a Friday and already closed. I walked back to the VA pharmacy and was told I should have requested a paper prescription or had the provider send it by fax. None of this information was provided to me or the CCN provider, nor was it on my VA referral documents. Frustrated with the situation, the pharmacist advised me to walk to the VA women’s clinic and attempt to speak with my primary care physician. I spoke with a nurse, and she was able to relay a message to my doctor. When the nurse returned, she said that my doctor had put in an electronic prescription request for the same medication at the VA pharmacy. I was grateful that the staff at my VA facility were there to help me before the facility closed for the weekend. This could have been avoided with better information sharing between VA and the CCN provider.
Fourth, during my first pregnancy, which ceased to be viable after the first few weeks, I received a phone call from my VA maternity care coordinator. She said that she had been informed that I wanted to terminate my pregnancy. I had the impression that she was calling to tell me that VA could not cover the termination. She said she thought I was happy to have become pregnant. The information she received was incredibly hurtful and completely incorrect. I informed her that my pregnancy was likely not viable and that I may need additional care to manage the miscarriage. She apologized and reassured me that my care would be covered. I learned later that the care I opted for did in fact need VA approvals. My coordinator called me again to ask why I had received a certain procedure related to my miscarriage that was not normally approved by VA. Again, she had been misinformed because I had not had any procedures at that point. Accurate information sharing between VA and community care providers is absolutely critical to ensure providers have all the information needed to provide high-quality continuity of care. The need for accuracy of medical records cannot be understated. Additionally, when veterans receive care within VA, there is never a worry about insurance or coverage because VA providers can be clear about what they can and cannot provide. Using community care exposes veterans to confusing insurance coverage and required approvals that can cause delays and frustration.
Lastly, during my current pregnancy, my community care provider indicated that I should have three genetic tests performed to rule out certain conditions that may affect my baby. She said that because of my age, these tests were critical and, depending on the results, could require me to take additional medications or treatments during my pregnancy to lower the risks of negative outcomes for my child. My VA referral document simply states that it covers “Laboratory and pathology services to include screening and testing as clinically indicated and relevant….Also includes medically indicated genetic testing.” Since the referral did not list any specific tests, I have not scheduled any yet, but contacted my VA maternity coordinator to inquire if they are covered. The coordinator asked me what the billing codes are for the recommended tests. She also sent me a list of 173 billing codes, some of which were accompanied by the text “Pre-Certification Required.” At my next appointment two weeks later, I asked my CCN provider about the billing codes for the recommended tests. She said they can be found online simply by using Google. I sent my VA coordinator a follow-up message with the codes that I researched myself for the three recommended tests. Even though all three of the billing codes were on the VA list of approved screenings, two of them required pre-certification. This means that I need to wait until my next monthly appointment with my CCN provider so they can fill out a VA Form 10-10172, Request for Additional Services (RFS). After several secure messages and a follow-up phone call with my maternity coordinator, it was explained to me that I would have to send these VA forms back to her and she would then forward them to both my VA primary care physician and the VA community care office for approval. If approved, she advised me to ensure that when I received the screenings, likely at a Labcorp office, I should also be sure that the tests are indeed covered by VA’s insurance provider, Optum Serve.
The problem with these challenges in the coordination of my specialty care in the community is that it would have been easier to disregard the tests or pay my prescriptions out of pocket, rather than experience the extensive amount of bureaucracy. In these cases the costs have been high, so I have been extra vigilant to ensure VA will cover the expenses. I have had VA deny medical bills, even for urgent care that was coordinated by VA, so I am being particularly careful with potentially costly maternity care.
Despite the fact that I have had wonderful care in the community, the coordination of that care has been particularly stressful. As a woman veteran who cannot receive any of these services within VA itself, it is disappointing that I must manage these challenges at a time when additional stress is detrimental to my health and that of my baby. Issues with scheduling, pharmacy, screenings, coverage, information sharing, and billing need to improve before VA sends more veterans to community care providers.
Issues Reported by VFW Members
Billing issues and confusing VA referrals related to community care have also affected veterans and VFW members nationwide. One problem is the lack of communication regarding the appropriate procedures veterans must follow when receiving care in the community, including whether a referral is involved, as well as who to contact for assistance.
Consider the case of an 88-year-old veteran in Pennsylvania who collapsed in a VA parking lot a few years ago. He was transported by ambulance to a civilian hospital for treatment. Instead of billing Medicare first, the civilian hospital billed VA. VA authorized and paid for the service, but then billed the veteran more than two years after the incident. This delayed billing occurred beyond any timeframe for disputing charges with either VA or the civilian facility. Despite the veteran having settled all debts, he continues to receive additional bills for this care. Upon reviewing the situation, it became clear that the veteran was not at fault. The initial error arose from the civilian facility's decision to bill VA before Medicare, and VA's subsequent coverage of those costs. Unfortunately, VA took several years to bill the veteran due to an internal processing issue. As a result, the veteran is being held financially responsible despite not being at fault. This situation is causing significant financial stress and creating barriers to accessing care. Further review also revealed that the veteran has been paying copayments that he should not have had to cover.
In a separate case in Washington, D.C., veterans were approved to visit urgent care facilities. However, the urgent care institution faced difficulties processing the billing under VA authorization and reached out to VA for assistance, but received no response. VA instructed the veterans to pay out of pocket for the care, which they did. This situation arose from an authorization and billing issue that required submission for upfront VA coverage, but VA was unable to assist. If VA authorized the care, why was it unable to provide the appropriate billing codes? Veterans should not be burdened with costs due to VA's inability to provide accurate billing information to CCN providers.
A veteran from Virginia received a referral for CCN dental care, however, when the dentist determined that surgery was necessary, the veteran had to wait for VA approval. This required a further evaluation by a VA dentist to get the needed procedure approved. As a result, previous referrals for preventive dental care were canceled.
In California, veterans have experienced issues with referral approvals, possibly linked to TriWest Healthcare Alliance system problems, resulting in inconsistent care appointments. One veteran has had an active referral for 12 specialty service sessions scheduled between April 1, 2025, and September 30, 2025. Unfortunately, no further care was provided after the initial appointment. The veteran reported that VA instructed the CCN provider to hold off on care. The reason is unknown.
Several veterans received letters from both VA and their CCN providers stating that the CCN provider could no longer offer the specified care and that they would begin receiving services through VA instead. This change required veterans to travel excessive distances for appointments, sometimes multiple times a week, which significantly impacted their ability to work and manage other responsibilities.
In Texas, a veteran was referred to community care for vision care but was informed by the CCN provider that surgery was required. Both the CCN provider and the veteran notified VA, which then scheduled the veteran for a VA follow up to determine the next steps. The veteran is currently frustrated about having to wait beyond the required timeframes to be seen by VA, especially after being referred to CCN due to long wait times for his vision care.
Solutions
VA’s community care program is plagued with numerous challenges that require thoughtful solutions. Care in the community is necessary for some veterans, but if given the choice, our members routinely tell us they prefer VA direct care. Negative experiences with the community care coordination process contribute to that sentiment. We must fix those issues because our veterans have earned quality care regardless of who provides it.
The VFW supports H.R. 740, Veterans’ ACCESS Act of 2025, as it represents a critical step forward in enhancing access to care for veterans, particularly in ensuring timely, effective, and consistent health care options through the CCN to streamline care, reduce bureaucratic obstacles, and expand access to care. Key provisions include codifying community care access standards based on wait times and driving distance, notifications regarding available services and provider preferences, transparency about denials of community care services and appeals rights, extensions for billing deadlines, and expedited access to mental health services.
The VFW appreciates the provision to improve the policies and processes that govern access to VA’s Mental Health Residential Rehabilitation Treatment Program (MH RRTP) as we recognize it needs serious attention. We would ask that the standards for accessing these programs be thoughtfully considered due to their different nature. Priority admission standards should be developed differently than routine admission standards because many of these programs, whether VA-provided or in the CCN, are typically not local to veterans.
Additional legislative measures should also be considered to improve VA’s community care program. Sharing health records and care integration must be addressed and improved between VA and community care providers. We urge the committee to prioritize not only the improvement of community care coordination but also the continuous support and enhancement of VA direct care services. This approach will help prevent over reliance on the community care system and ensure that veterans receive the comprehensive care they rightfully deserve. We owe it to our veterans to ensure that their access to care is not hindered by bureaucracy or geographical limitations. Expanding and integrating community care options is not just a policy choice; it is a moral obligation to those who have served.
Chairwoman Miller-Meeks, Ranking Member Brownley, this concludes my testimony. I welcome any questions from you or members of the subcommittee.
Information Required by Rule XI2(g)(4) of the House of Representatives
Pursuant to Rule XI2(g)(4) of the House of Representatives, the VFW has not received any federal grants in Fiscal Year 2025, nor has it received any federal grants in the two previous Fiscal Years.
The VFW has not received payments or contracts from any foreign governments in the current year or preceding two calendar years.