GAO: VA Behavioral Health Referrals Lack Oversight, Undermine Care Continuity

A new report from the Government Accountability Office is raising red flags about the Department of Veterans Affairs’ management of its behavioral health referral process. The May 2025 GAO report found that the VA does not track whether community-based mental health providers are sending back medical records after treating veterans which is a gap that directly threatens care continuity and undermines the department’s broader modernization goals.

From fiscal year 2021 through 2023, veterans used more than 350,000 referrals to access behavioral health services from non-VA providers. According to GAO, approximately one-third of those referrals lacked documentation from initial visits. The agency does not currently collect data on whether records from final visits are submitted at all.

These findings follow a 2024 Office of Inspector General report that documented complaints from VA providers who said care is often delayed or duplicated when they lack timely updates from community partners. In behavioral health settings, that fragmentation can significantly affect clinical outcomes, especially when medication history, diagnosis changes or treatment responses are not clearly communicated across care teams.

VA officials told GAO that community care coordination is essential, particularly when veterans move between external and internal care environments. Still, the report found that the department has yet to implement systemwide monitoring or standardize expectations for medical record exchange. Additionally, only 2% of community providers with behavioral health referrals had completed any of the department’s eight recommended trainings on suicide prevention, opioid safety and veteran-centered care.

Documentation Gaps Highlight Operational Weakness

The VA’s partial agreement with GAO’s five recommendations, fully concurring with one and concurring in principle with four, signals that policy alignment is underway, but operational execution remains limited. The recommendations include establishing measurable performance goals, creating systems to monitor documentation return rates, and tracking community provider training compliance.

The findings come at a time when VA continues to rely on its Community Care Network to meet rising demand for mental health services. The program, originally designed to improve access and reduce wait times, has succeeded in expanding referral capacity. But without accountability mechanisms to ensure data sharing and training standards, that access may come at the cost of quality and care integration.

While the VA has made progress in streamlining referrals and claims processing, the absence of enforceable documentation requirements for community providers represents a major vulnerability in the care coordination process. In the private sector, providers are increasingly held to interoperability and quality benchmarks through value-based contracts. Similar expectations may be necessary within the VA’s extended network if the agency hopes to maintain continuity of care and clinical accountability.

Next Steps for VA Community Care Oversight

GAO’s report adds pressure on the VA to strengthen oversight of its behavioral health referral infrastructure. Federal watchdogs have now issued multiple warnings that the lack of documentation not only impacts veteran safety but also hampers VA clinicians’ ability to make informed treatment decisions.

The current referral model depends heavily on the assumption that community providers will send records without formal performance incentives or reporting requirements. That assumption is proving unreliable. Going forward, VA leadership may need to treat data exchange and training compliance as non-optional components of its care delivery agreements.

As the agency continues to modernize its health IT infrastructure and expand its provider network, integrating documentation tracking and clinical training verification into its community care contracts could become a baseline requirement.

Failure to do so may leave veterans caught between disconnected care settings and exposed to avoidable clinical risk which is a scenario the VA can ill afford to sustain.