The short answer
If a CHAMPVA Explanation of Benefits shows care you never received, or care that looks different from what you got, report it. Start with CHAMPVA at 800-733-8387 or VA's Program Integrity team at OCCProgramIntegrityTeam@va.gov. For possible crimes or serious misconduct, use the VA Office of Inspector General Hotline.
What counts as fraud, waste, or abuse?
VA's Office of Integrity and Compliance uses three terms:
- Fraud: lying or misrepresenting something on purpose to get money or another benefit.
- Waste: misusing money or resources, even without intent or illegal conduct.
- Abuse: improper or unreasonable behavior, or misuse of a position.
A wrong claim is not automatically fraud. A coding error, a wrong date, or a duplicate claim usually just needs to be corrected. Billing for care that never happened, a repeated pattern of false claims, or deliberately describing a service as something it was not is more serious.
What warning signs should I watch for?
The CHAMPVA Guidebook lists these:
- a provider bills CHAMPVA for a service or supply you never received;
- a provider bills for something different from what you received;
- a provider routinely does not collect a cost share you owe; or
- a provider says a service is not normally covered but they know how to bill it so CHAMPVA pays.
The cost-share sign needs context. CHAMPVA waives the deductible and cost share for some services, so a $0 visit can be correct. Check CHAMPVA Cost Share and CHAMPVA Services With No Deductible or Cost Share before treating it as a problem.
How do I check a claim that looks wrong?
Compare the EOB with what actually happened. Use the EOB, the provider's statement, appointment records, and receipts to answer:
- Did the beneficiary see this provider on the date shown?
- Does the billed service match the care that was given?
- Is the provider name and location right?
- Does this look like a billing mistake or something done on purpose?
- Is it one item or a pattern?
If it looks like a simple mistake, ask the provider's billing office and CHAMPVA to fix it. If the care never happened, or the facts suggest it was deliberate, save the records and report it.
What should I include in a report?
The CHAMPVA Guidebook asks for the facts of the questioned claim. Include what you have:
- the provider's name and address;
- the beneficiary's name;
- the CHAMPVA claim number;
- the date of service;
- the service or item you believe was not provided or was billed wrong;
- why you think it should not have been paid; and
- any other facts or records that support your concern.
Keep a copy of the EOB and your records. Note when you contacted anyone and what they said. Stick to the facts; you do not need to prove anyone's motive.
Where do I report it?
CHAMPVA and Program Integrity
Call CHAMPVA at 800-733-8387, listed on VA's CHAMPVA page. The CHAMPVA Guidebook also lists the VHA Office of Integrated Veteran Care Program Integrity team:
- Email: OCCProgramIntegrityTeam@va.gov
- Fax: 303-398-5295
VHA integrity and compliance
VA's Office of Integrity and Compliance takes reports of health care fraud, waste, and abuse through:
- the VHA Compliance Helpline at 866-842-4357;
- email at vhaoichelpline@va.gov;
- a local VHA Integrity and Compliance Officer; or
- VA Form 10-390, the VHA Fraud, Waste, and Abuse Complaint Form.
VA Office of Inspector General
The VA OIG Hotline takes complaints about possible crimes, rule violations, fraud, waste, abuse, and gross mismanagement in VA programs. Use its secure online form or call 800-488-8244. The OIG takes electronic complaints through its web forms, not regular email.
How do beneficiaries protect their CHAMPVA information?
The CHAMPVA Guidebook says to guard your CHAMPVA card and give your member number only to people and offices you know are legitimate. An EOB for care you never received can also mean someone is misusing your information, so do not write it off as paperwork. See CHAMPVA ID Card and Payer Information for what providers normally need.
What should providers do?
Keep claims matched to the service and the record. When you find an honest error, fix it through the normal correction process. See Correcting or Resubmitting a CHAMPVA Claim.
When the concern is fabricated care, intentional misbilling, or a pattern of improper claims, save the records and use a VA integrity channel. Do not handle it as a routine correction.
What should I avoid?
- Assuming every wrong claim is fraud.
- Ignoring an EOB for care that never happened.
- Changing records to make a questioned claim look right.
- Sending sensitive information through a contact you cannot verify.
- Mistaking a valid cost-share waiver for a provider skipping a cost share you owe.
For other CHAMPVA phone numbers and addresses, see CHAMPVA Contacts, Addresses, and Forms.