Notice of Disagreement: Agency Information Collection Activity


Appellate review of the denial of VA benefits may only be initiated by filing a Notice of Disagreement with the Board. 38 U.S.C. § 7105(a). The VA Form 9, “Appeal to Board of Veterans’ Appeals,” is required to complete a legacy appeal to the Board. The completed form becomes the “substantive appeal” (or “formal appeal”), which is required by 38 U.S.C. §§ 7105(a) and (d)(3) in order to complete an appeal to the Board. Additionally, the proposed information collections allow for withdrawal of services by a representative, requests for changes in hearing dates and methods under 38 U.S.C. § 7107, and motions for reconsideration pursuant to 38 U.S.C. § 7103(a). The Board is requesting to revise the currently approved OMB Control No. 2900-0674, adding four information collections previously approved under OMB Control No. 2900-0085, and one new information collection. Revised Control No. 2900-0674 would contain all appeals-related information collections for the legacy and new systems. 2900-0085 will be discontinued upon approval of this request to renew 2900-0674.

An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The Federal Register Notice with a 60-day comment period soliciting comments on this collection of information was published at 83 No. 164 on Thursday, August 23, 2018, pages 42769 and 42770.

Affected Public: Individuals and households.

Estimated Annual Burden: 114,877.78 hours.

Estimated Average Burden per Respondent: 40.83 minutes.

Frequency of Response: Once.

Estimated Number of Respondents: 168,800.

  • VA Form 10182: Notice of Disagreement (new) = 40,000.
  • Nonstandard Form: Notice of Disagreement (legacy) = 60,000.
  • VA Form 9: Appeal to the Board of Veterans’ Appeals (legacy) = 64,500.
  • Nonstandard Form: Withdrawal of Services by a Representative = 500.
  • Nonstandard Form: Requests for Changes in Hearing Dates or Methods = 2,800.
  • Nonstandard Form: Motions for Reconsideration =1000.

By direction of the Secretary.

Cynthia D. Harvey-Pryor,

Government Information Specialist, Department of Veterans Affairs.

[FR Doc. 2018-24759 Filed 11-13-18; 8:45 am]


AGENCY: Board of Veterans’ Appeals, Department of Veterans Affairs.

ACTION: Notice.


In compliance with the Paperwork Reduction Act (PRA) of 1995, this notice announces that the Board of Veterans’ Appeals, Department of Veterans Affairs, will submit the collection of information abstracted below to the Office of Management and Budget (OMB) for review and comment. The PRA submission describes the nature of the information collection and its expected cost and burden and it includes the actual data collection instrument.

DATES: Comments must be submitted on or before December 14, 2018.


Submit written comments on the collection of information through, or to Office of Information and Regulatory Affairs, Office of Management and Budget, Attn: VA Desk Officer; 725 17th St. NW, Washington, DC 20503 or sent through electronic mail to Please refer to “OMB Control No. 2900-0674” in any correspondence.


Sue Hamlin, BVA, (01C2), Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420, (202) 632-5100 or email refer to “OMB Control No. 2900-0674” in any correspondence.


Start Printed Page 56919


Public Law 115-55; 38 U.S.C. 5104B, 5108, 5701, 5901, 7103, 7104, 7105, 7107.

Title: Decision Review Request: Board Appeal (Notice of Disagreement) and Appeal to the Board of Veterans’ Appeals, VA Form 10182 and VA Form 9

OMB Control Number: 2900-0674.

Type of Review: Reinstatement with Change of a currently approved collection.

VA DISABILITY EXAMS: Improved Performance Analysis and Training Oversight Needed for Contracted Exams

What GAO Found

The Veterans Benefits Administration (VBA) has limited information on whether contractors who conduct disability compensation medical exams are meeting the agency’s quality and timeliness targets. VBA contracted examiners have completed a growing number of exams in recent years (see figure). VBA uses completed exam reports to help determine if a veteran should receive disability benefits. VBA reported that the vast majority of contractors’ quality scores fell well below VBA’s target—92 percent of exam reports with no errors—for the first half of 2017. Since then, VBA has not completed all its quality reviews, but has hired more staff to do them. VBA officials acknowledged that VBA also does not have accurate information on contractor timeliness. VBA officials said the exam management system used until spring 2018 did not always retain the initial exam report completion date, which is used to calculate timeliness. In spring 2018, VBA implemented a new system designed to capture this information. GAO-19-13: Published: Oct 12, 2018. Publicly Released: Nov 8, 2018

VBA monitoring has addressed some problems with contractors, such as reassigning exams from contractors that did not have enough examiners to those that did. However, the issues GAO identified with VBA’s quality and timeliness information limit VBA’s ability to effectively oversee contractors. For example, VBA officials said they were unable to track the timeliness of exam reports sent back to contractors for corrections, which is needed to determine if VBA should reduce payment to a contractor. The new system implemented in spring 2018 tracks more detailed data on exam timeliness. However, VBA has not documented how it will ensure the data are accurate or how it will use the data to track the timeliness and billing of corrected exam reports. VBA also has no plans to use the new system to analyze performance data to identify trends or other program-wide issues. Without such plans, VBA may miss opportunities to improve contractor oversight and the program overall.

A third-party auditor verifies that contracted examiners have valid medical licenses, but VBA does not verify if examiners have completed training nor does it collect information to assess training effectiveness in preparing examiners. While VBA plans to improve monitoring of training, it has not documented plans for tracking or collecting information to assess training. These actions could help ensure that VBA contractors provide veterans with high-quality exams and help VBA determine if additional training is needed.

Why GAO Did This Study

In 2016, VBA awarded 12 contracts to five private firms for up to $6.8 billion lasting up to 5 years to conduct veterans’ disability medical exams. Both VBA contracted medical examiners and medical providers from the Veterans Health Administration perform these exams, with a growing number of exams being completed by contractors. Starting in 2017, VBA contracted examiners conducted about half of all exams. GAO was asked to review the performance and oversight of VBA’s disability medical exam contractors.
This report examines (1) what is known about the quality and timeliness of VBA contracted exams; (2) the extent to which VBA monitors contractors’ performance; and (3) how VBA ensures that its contractors provide qualified and well-trained examiners. GAO analyzed the most recent reliable data available on the quality and timeliness of exams (January 2017 to February 2018), reviewed VBA and selected contract documents and relevant federal laws and regulations, and interviewed agency officials, exam contractors, an audit firm that checks examiners’ licenses, and selected veterans service organizations.

What GAO Recommends

GAO recommends VBA (1) develop a plan for using its new data system to monitor contractors’ quality and timeliness performance, (2) analyze overall program performance, (3) verify that contracted examiners complete required training, and (4) collect information to assess the effectiveness of that training. The Department of Veterans Affairs agreed with GAO’s recommendations.
View Report (PDF)


VA: Actions Needed to Address Employee Misconduct Process and Ensure Accountability

Employee misconduct at VA’s medical facilities can have serious consequences for veterans. We looked at how VA deals with employee misconduct and found several opportunities for improvement. For example:

VA doesn’t always maintain required files and documents for adjudication, suggesting that employees may not have received due process.

VA officials found guilty of misconduct sometimes received a lesser punishment than recommended or no punishment.

Whistleblowers were 10 times more likely than their peers to receive disciplinary action within a year of reporting misconduct.

 Why GAO Did This Study

VA provides services and benefits to veterans through hospitals and other facilities nationwide. Misconduct by VA employees can have serious consequences for some veterans, including poor quality of care. GAO was asked to review employee misconduct across VA. This report reviews the extent to which VA (1) collects reliable information associated with employee misconduct and disciplinary actions, (2) adheres to documentation-retention procedures when adjudicating cases of employee misconduct, (3) ensures allegations of misconduct involving senior officials are reviewed according to VA investigative standards and these officials are held accountable, and (4) has procedures to investigate whistle-blower allegations of misconduct; and the extent to which (5) data and whistle-blower testimony indicate whether retaliation for disclosing misconduct occurs at VA.
GAO analyzed 12 information systems across VA to assess the reliability of misconduct data, examined a stratified random sample of 544 misconduct cases from 2009 through 2015, analyzed data and reviewed cases pertaining to senior officials involved in misconduct, reviewed procedures pertaining to whistle-blower investigations, and examined a nongeneralizable sample of whistle-blower disclosures from 2010 to 2014.

What GAO Found

The Department of Veterans Affairs (VA) collects data related to employee misconduct and disciplinary actions, but fragmentation and data-reliability issues impede department-wide analysis of those data. VA maintains six information systems that include partial data related to employee misconduct. For example, VA’s Personnel and Accounting Integrated Data system collects information on disciplinary actions that affect employee leave and pay, but the system does not collect information on other types of disciplinary actions. The system also does not collect information such as the offense or date of occurrence. GAO also identified six other information systems that various VA administrations and program offices use to collect specific information regarding their respective employees’ misconduct and disciplinary actions. GAO’s analysis of all 12 information systems found data-reliability issues—such as missing data, lack of identifiers, and lack of standardization among fields. Without collecting reliable misconduct and disciplinary action data on all cases department-wide, VA’s reporting and decision making on misconduct are impaired.
VA inconsistently adhered to its guidance for documentation retention when adjudicating misconduct allegations, based on GAO’s review of a generalizable sample of 544 out of 23,622 misconduct case files associated with employee disciplinary actions affecting employee pay. GAO estimates that VA would not be able to account for approximately 1,800 case files. Further, GAO estimates that approximately 3,600 of the files did not contain required documentation that employees were adequately informed of their rights during adjudication procedures—such as their entitlement to be represented by an attorney. The absence of files and associated documentation suggests that individuals may not have always received fair and reasonable due process as allegations of misconduct were adjudicated. Nevertheless, VA’s Office of Human Resource Management does not regularly assess the extent to which files and documentation are retained consistently with applicable requirements.
VA did not consistently ensure that allegations of misconduct involving senior officials were reviewed according to investigative standards and these officials were held accountable. For example, based on a review of 23 cases of alleged misconduct by senior officials that the VA Office of Inspector General (OIG) referred to VA facility and program offices for additional investigation, GAO found VA frequently did not include sufficient documentation for its findings, or provide a timely response to the OIG. In addition, VA was unable to produce anydocumentation used to close 2 cases. Further, OIG policy does not require the OIG to verify the completeness of investigations, which would help ensure that facility and program offices had met the requirements for investigating allegations of misconduct. Regarding senior officials, VA did not always take necessary measures to ensure they were held accountable for substantiated misconduct. As the figure below shows, GAO found that the disciplinary action proposed was not taken for 5 of 17 senior officials with substantiated misconduct.
Action Proposed in Department of Veterans Affairs (VA) Office of Accountability Review’s Legacy Referral Tracking List Compared with Final Action Taken

Action Proposed in Department of Veterans Affairs (VA) Office of Accountability Review’s Legacy Referral Tracking List Compared with Final Action Taken

*Adverse action.
As a result of June 2017 legislation, a new office within VA—the Office of Accountability and Whistleblower Protection—will be responsible for receiving and investigating allegations of misconduct involving senior officials.
VA has procedures for investigating whistle-blower complaints, but the procedures allow the program office or facility where a whistle-blower has reported misconduct to conduct the investigation. According to the OIG, it has the option of investigating allegations of misconduct, or exercising a “right of first refusal” whereby it refers allegations of misconduct to the VA facility or program office where the allegation originated. VA does not have oversight measures to ensure that all referred allegations of misconduct are investigated by an entity outside the control of the facility or program office involved in the misconduct, to ensure independence. As a result, GAO found instances where managers investigated themselves for misconduct, presenting a conflict of interest.Data and whistle-blower testimony indicate that retaliation may have occurred at VA. As the table below shows, individuals who filed a disclosure of misconduct with the Office of Special Counsel (OSC) received disciplinary action at a much higher rate than the peer average for the rest of VA in fiscal years 2010–2014.
Data and whistle-blower testimony indicate that retaliation may have occurred at VA. As the table below shows, individuals who filed a disclosure of misconduct with the Office of Special Counsel (OSC) received disciplinary action at a much higher rate than the peer average for the rest of VA in fiscal years 2010–2014.

Comparison of Adverse Disciplinary Action Taken for Nonanonymous Department of Veterans Affairs (VA) Employees Who Reported Wrongdoing and Those Who Did Not, 2010–2014
Employee category Percentage for whom adverse actions were taken
Prior to disclosure Year of disclosure Year after disclosure
Individuals who filed a disclosure 2 10 8
Rest of VA 1 1 1

Additionally, GAO’s interviews with six VA whistle-blowers who claim to have been retaliated against provided anecdotal evidence that retaliation may be occurring. These whistle-blowers alleged that managers in their chain of command took several untraceable actions to retaliate against the whistle- blowers, such as being denied access to computer equipment necessary to complete assignments.

What GAO Recommends

GAO makes numerous recommendations to Veterans Affairs to help enhance its ability to address misconduct issues.
GAO recommends, among other things, that the Secretary of Veterans Affairs

  • develop and implement guidance to collect complete and reliable misconduct and disciplinary-action data department-wide; such guidance should include direction and procedures on addressing blank fields, lack of personnel identifiers, and standardization among fields;
  • direct applicable facility and program offices to adhere to VA’s policies regarding misconduct adjudication documentation;
  • direct the Office of Human Resource Management to routinely assess the extent to which misconduct-related files and documents are retained consistently with applicable requirements;
  • direct the Office of Accountability and Whistleblower Protection (OAWP) to review responses submitted by facility or program offices to ensure evidence produced in senior-official case referrals demonstrates that the required elements have been addressed;
  • direct OAWP to issue written guidance on how OAWP will verify whether appropriate disciplinary action has been implemented; and
  • develop procedures to ensure (1) whistle-blower investigations are reviewed by an official independent of and at least one level above the individual involved in the allegation, and (2) VA employees who report wrongdoing are treated fairly and protected against retaliation.

GAO also recommends, among other things, that the VA OIG

  •  revise its policy and require verification of evidence produced in senior-official case referrals.

VA concurred with nine recommendations and partially concurred with five. In response, GAO modified three of the recommendations. The VA OIG concurred with one recommendation and partially concurred with the other. GAO continues to believe that both are warranted. GAO modified three of the recommendations. The VA OIG concurred with one recommendation and partially concurred with the other. GAO continues to believe that both are warranted.

Employee misconduct at VA’s medical facilities can have serious consequences for veterans. We looked at how VA deals with employee misconduct and found several opportunities for improvement. For example:VA doesn’t always maintain required files and documents for adjudication, suggesting that employees may not have received due process.VA officials found guilty of misconduct sometimes received a lesser punishment than recommended or no punishment.Whistleblowers were 10 times more likely than their peers to receive disciplinary action within a year of reporting misconduct.

BVA No 09-48865 Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia, depression, and post-traumatic stress disorder (PTSD).

BVA NO. 09-48 865 Citation Nr: 1717500 Decision Date: 05/19/17 Archive Date: 06/05/17
On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona


Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia, depression, and post-traumatic stress disorder (PTSD).
Veteran represented by: Disabled American Veterans
The Veteran
Kate Sosna, Associate Counsel


The Veteran had active duty service from October 1972 to April 1977, as well as subsequent periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) with the Wisconsin Army National Guard from January 1985 to January 1986.
This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona.
The Veteran testified at an RO hearing in October 2009 and a Board hearing at the local RO before the undersigned Veterans Law Judge in May 2012. Transcripts from these hearings have been associated with the record.
The case was remanded by the Board for additional development in January 2013 and July 2014.
In November 2015, the Board denied entitlement to service connection for an acquired psychiatric disorder. The Veteran appealed the Board’s November 2015 denial of service connection for an acquired psychiatric disorder to the United States Court of Appeals for Veterans Claims (Court), which, in June 2016, on the basis of a May 2016 Joint Motion for Partial Remand (JMPR), vacated the Board’s decision and remanded the matter to the Board for further action. Thereafter, in October 2016, the Board remanded the claim again for additional development pursuant to the JMPR.
A review of the record reveals that additional documents were added to the file after the issuance of the February 2017 supplemental statement of the case. However, in a February 2017 submission, the Veteran’s representative waived the right to have any additional evidence submitted by the Veteran considered by the RO. 38 C.F.R. § 20.1304(c) (2016). Therefore, the Board may properly consider such newly received evidence.
This appeal was processed using the Virtual VA (VVA) and Virtual Benefits Management System (VBMS) paperless claims processing systems.


1. The Veteran does not have PTSD as a result of a verified in-service stressor.
2. An acquired psychiatric disorder other than PTSD is not shown to be causally or etiologically related to any disease, injury, or incident during service, and a psychosis did not manifest within one year of the Veteran’s discharge from active service.


The criteria for establishing service connection for an acquired psychiatric disorder, to include PTSD, have not been met. 38 U.S.C.A. §§ 101(24), 1101, 1110, 1112, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.1(d), 3.6(a), 3.102, 3.303, 3.304, 3.307, 3.309 (2016).


I. Due Process Considerations

The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2016).
In the instant case, VA’s general duty to notify was satisfied by a March 2008 letter sent prior to the issuance of the rating decision on appeal. Thereafter, a March 2013 letter and attachment provided the Veteran with the notice required for claims for service connection for PTSD (to include, as requested in the January 2013 remand, claims for service connection for PTSD based on personal assault), and a PTSD stressor questionnaire for the Veteran’s completion was attached to this letter. While this letter was not provided prior to initial adjudication, the deficiency in the timing of this notice was remedied by readjudication in subsequent supplemental statements of the case in December 2013, December 2014, and February 2017. See 38 U.S.C.A. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); Mayfield v. Nicholson, 444 F. 3d 1328, 1333-34 (Fed. Cir. 2006); Prickett v. Nicholson, 20 Vet. App. 370 (2006).
The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This “duty to assist” contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4).
In the instant case, the Board finds that all relevant facts have been properly developed and that all evidence necessary for equitable resolution of the issues decided herein has been obtained. The Veteran’s service treatment records (STRs), service personnel records, and post-service VA and private treatment records have been obtained and considered. He has not identified any additional, outstanding records that have not been requested or obtained.
Additionally, the Veteran was afforded a VA examination in December 2013 and addendum opinions were provided in September 2014 and January 2017 addressing the claim decided herein. The conclusions reached following these examinations and in the addendum opinions are, in their totality, based on an interview with the Veteran, a review of the record, and a full psychiatric examination. Moreover, the clinicians offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A]medical opinion…must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). Accordingly, the Board finds that VA’s duty to assist with respect to obtaining a VA examination and opinion regarding the issue decided herein has been met.
The Veteran also offered testimony before a Decision Review Officer (DRO) of the RO in October 2009 and the undersigned Veterans Law Judge at a Board hearing in May 2012. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the DRO or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked.
During the October 2009 DRO hearing and the May 2012 Board hearing, the DRO and the undersigned Veterans Law Judge noted the issue on appeal. Also, information was solicited regarding the Veteran’s in-service experiences he alleges resulted in his psychiatric disorder, the type and onset of symptoms, and his contention that his military service caused his psychiatric disorder. Therefore, not only were the issues “explained…in terms of the scope of the claim for benefits,” but “the outstanding issues material to substantiating the claim,” were also fully explained. See Bryant, 23 Vet. App. at 497. As the hearing discussions raised the possibility that there were outstanding treatment records available through the Veteran’s National Guard unit, the Board remanded the case to obtain such records. Additionally, the testimony suggested the need for a VA examination addressing the claim for service connection adjudicated herein, and as indicated above, such was conducted in December 2013, and addendum opinions were obtained in September 2014 and January 2017. Under these circumstances, nothing gives rise to the possibility that evidence had been overlooked with regard to the Veteran’s claim decided herein. As such, the Board finds that, consistent with Bryant, the DRO and the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claim based on the current record.
Furthermore, the Board finds there has been substantial compliance with the Board’s January 2013, July 2014, and October 2016 remand directives and no further action in this regard is necessary. See D’Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268, 271 (1998)). In January 2013, the Board directed the Agency of Original Jurisdiction (AOJ) to afford the Veteran notice of the types of evidence that may be considered in a personal assault claim under 38 C.F.R. § 3.304(f) and request that he provide a detailed description of the incidents of personal assault. Such was accomplished by way of the aforementioned March 2013 VCAA letter. The January 2013 remand also directed the AOJ to obtain the Veteran’s service personnel records, which was accomplished in May 2013, as well as records regarding the Veteran’s period of service with the Wisconsin Army National Guard, which were received in May 2013 as well as in August 2014, after the July 2014 remand requesting additional records. The January 2013 remand also directed that the Veteran be provided an opportunity to identify any outstanding records and obtain updated VA treatment records, which was accomplished in the March 2013 VCAA letter and VA treatment records dated through December 2013 were subsequently obtained. Notably, while VA treatment records have not been associated with the record since that time, the Veteran has not reported and the record does not suggest that any outstanding, relevant treatment records exist. Finally, the January 2013 remand directed that the Veteran be afforded a VA examination in order to determine the current nature and etiology of his claimed disorders, which was accomplished in December 2013.
Additionally, and as requested in the July 2014 remand, an August 2014 letter from the AOJ asked the Veteran to provide more specific dates with respect to the injuries he claimed occurred during his time with the Wisconsin Army National Guard, and to provide any ACDUTRA or INACDUTRA orders. However, he did not reply to such letter. Therefore, development to obtain any additional National Guard records is not indicated. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Moreover, the Veteran did not complete the PTSD stressor questionnaire provided to him in March 2013, and given the nature of the stressors as described below, which are inherently unlikely to be verified (even if they were sufficient to result in a valid diagnosis of PTSD), the Board finds that additional development with regard to stressor verification is also not indicated. Id. Finally, as directed by the July 2014 remand, an addendum opinion was obtained in September 2014.
Most recently, in October 2016, the Board remanded the appeal for procurement of a medical opinion as to whether there is evidence of behavioral changes to indicate that any incidents of personal assault occurred, to specifically include the Veteran’s claimed stressor of being the victim of a mugging while he was in service. The requested addendum was provided in January 2017 and, as discussed above and further discussed below, the Board finds that the opinion is adequate to decide the claim.
Therefore, the Board finds that the AOJ has substantially complied with the January 2013, July 2014, and October 2016 remand directives such that no further action is necessary in this regard with respect to the claim adjudicated below. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet, App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board’s remand instructions were substantially complied with), aff’d, Dyment v. Principi, 287 F.3d 1377 (2002).
In light of the foregoing, the Board finds that VA’s duties to notify and assist have been satisfied. Thus, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993).

II. Analysis

A Veteran is a person who served in the active military, naval, or air service and who was discharged or released under conditions “other than dishonorable.”
38 C.F.R. § 3.1(d). The term “active military, naval, or air service” includes:
(1) active duty; (2) any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty; and (3) any period of INACDUTRA during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty. 38 U.S.C.A. § 101(24); 38 C.F.R. § 3.6(a).
Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R.
§ 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).
Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996) [(table)].
Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, to include psychoses, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service.
38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. According to 38 C.F.R. § 3.384, as applicable in the instant case, the term ‘psychosis’ includes a brief psychotic disorder; delusional disorder; psychotic disorder due to general medical condition; other specified schizophrenia spectrum and other psychotic disorder; schizoaffective disorder; schizophrenia; schizophreniform disorder; and substance/medication-induced psychotic disorder.
Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. The United States Court of Appeals for the Federal Circuit clarified that the law providing for awards of service connection on the basis of continuity of symptomatology is limited to “chronic” diseases such as psychoses listed under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).
In addition to the general principles governing service connection, to establish entitlement to service connection for PTSD the evidence must satisfy three basic elements. There must be: 1) medical evidence diagnosing PTSD; 2) a link, established by medical evidence, between current symptoms of PTSD and an in-service stressor; and 3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). A diagnosis of PTSD must be established in accordance with 38 C.F.R. § 4.125(a). In this regard, the Board notes that for cases certified to the Board prior to August 4, 2014, as is the case here, the diagnosis of PTSD must be in accordance with the DSM-IV.
With regard to the second PTSD element as set forth in 38 C.F.R. § 3.304(f), evidence of an in-service stressor, the evidence necessary to establish that the claimed stressor actually varies depending on whether it can be determined that the Veteran “engaged in combat with the enemy.” See 38 U.S.C.A. § 1154(b); 38 C.F.R. 3.304(d).
If it is determined through military citation or other supportive evidence that a Veteran engaged in combat with the enemy, and the claimed stressors are related to combat, the Veteran’s lay testimony regarding the reported stressors must be accepted as conclusive evidence as to their actual occurrence and no further development or corroborative evidence will be necessary. See 38 C.F.R. § 3.304(f).
Additionally, effective July 13, 2010, VA has amended its adjudication regulations governing service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard for establishing the required in-service stressor.
Personality disorders are not “diseases” for which service connection can be granted, and as a “matter of law” are not compensable disabilities. 38 C.F.R.
§ 3.303(c); Beno v. Principi, 3 Vet. App. 439, 441 (1992). However, disability resulting from a mental disorder superimposed upon a personality disorder may be service-connected. 38 C.F.R. § 4.127.
Similarly, for claims filed after October 31, 1990, service connection may not be granted for substance abuse on the basis of service incurrence or aggravation. 38 U.S.C.A. §§ 105, 1110; 38 C.F.R. § 3.301 (a); VAOPGCPREC 2-98. However, the law does not preclude a Veteran from receiving compensation for an alcohol or drug abuse disability acquired as secondary to, or as a symptom of, a service-connected disability. Allen v. Principi, 237 F.3d 1368 Fed. Cir. 2001).
When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).
The Veteran contends that he has an acquired psychiatric disorder as a result of his military service.
Review of the Veteran’s service personnel records do not reflect that he served in combat. As such, his unsupported assertions of service stressors are not sufficient to establish the occurrence of such events. Rather, his alleged service stressors must be established by official service records or other credible supporting evidence. 38 C.F.R. § 3.304(f); Cohen v. Brown, 10 Vet. App. 128 (1997); Doran v. Brown, 6 Vet. App. 283 (1994). The regulatory requirement for “credible supporting evidence” means that “the Veteran’s testimony, by itself, cannot, as a matter of law, establish the occurrence of a non-combat stressor.” Dizoglio v. Brown, 9 Vet. App. 163 (1996).
However, VA recognizes that, because a personal assault is a personal and sensitive issue, many incidents are not officially reported, which in turn creates a proof problem in establishing they did. It is not unusual for there to be an absence of service records documenting the events the Veteran has alleged. Therefore, evidence from sources other than service records may corroborate an account of a stressor incident that is predicated on a personal assault. See, e.g., Patton v. West, 12 Vet. App. 272, 277 (1999). Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. 38 C.F.R. § 3.304(f)(5).
Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in the mentioned sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. VA may submit any evidence that it received to an appropriate mental health professional for an opinion as to whether it indicates that a personal assault occurred. Id.
The STRs, to include the February 1977 discharge examination, do not reflect a psychiatric disability. The Veteran did report having “nervous trouble” on a medical history completed in conjunction with separation from service. A service hospital report for treatment for hepatitis showed that the Veteran reported a history of nervous condition prior to service. He had seen a psychiatrist, but no diagnosis was given.
The Veteran was discharged because he had been found to be dependent on alcohol or other drugs. In April 1977, he was treated at the VA for drug abuse, and an October 1977 VA examination showed a diagnosis of drug abuse, opiate type, in remission, by history. No other psychiatric diagnosis was given, although the Veteran reported previously being diagnosed with schizophrenia.
In July 1981, the Veteran was admitted to the VA following a suicide attempt. The diagnosis was mixed personality disorder with borderline, histrionic and explosive components. Again, in September 1987, the Veteran was admitted to the VA for a suicide attempt. The diagnosis was depression with suicidal ideation. During this period, clinical records also showed a diagnosis of PTSD and acute adjustment disorder. He was again admitted for drug abuse in May 1989. A VA treatment record in September 1993 showed that the Veteran was admitted for treatment for adjustment disorder with depressed mood. Follow up treatment records showed treatment for depression as well as PTSD. He was afforded a VA examination for pension purposes in September 1997. The examiner diagnosed major depressive disorder, but did not provide any sort of etiological opinion.
Additional VA and Vet Center records continued to document ongoing psychiatric treatment, to include in a PTSD group. In his hearing testimony, the Veteran asserted that he received psychiatric treatment while stationed at Fort Hood. He also reported that he was mugged while in service. The Veteran further alleged that he was “slapped around” by his drill sergeant and indicated that he experienced an incident where he dropped a grenade that caused him stress as well as more problems with his drill sergeant. He further claimed that he used drugs in service to self-medicate and that his symptoms have continued since service.
The January 2013 remand requested a VA psychiatric examination in which the examiner was to specifically indicate whether the Veteran met the diagnostic criteria for PTSD. In making this determination, the examiner was directed by the Board to offer an opinion as to whether there was evidence of behavioral changes to indicate that any incidents of personal assault occurred during service and, if so, whether any currently diagnosed PTSD was causally related to such incidents. For each currently diagnosed acquired psychiatric disorder other than PTSD, the examiner was to offer an opinion as to whether such was as least as likely as not related to the Veteran’s military service.
The requested VA psychiatric examination was completed in December 2013, and the conclusion, documented on the reports from this examination to have included a review of the claims file, was that the Veteran did not meet DSM criteria for a diagnosis of PTSD or other acquired psychiatric disability, and that the only current diagnosis was a personality disorder; namely, “Personality Disorder NOS with antisocial, narcissistic, schizotypal, and schizoid traits.” The examiner indicated that the Veteran’s personality was longstanding, beginning in his late adolescence, and was manifested as a “pervasive and persistent pattern of behaviors and cognitions that deviate from the cultural norm.” The Veteran’s stressors reported at that time were recorded as: an incident in which a drill sergeant embarrassed him in formation for marching in the wrong direction by slapping him on the side of his head, and another incident in which a drill sergeant yelled at him and embarrassed him when he dropped a hand grenade during training; the Veteran apparently did not report the alleged mugging incident. The examiner noted that neither of the reported stressors was adequate to support a diagnosis of PTSD and that neither stressor was related to a personal assault.
As noted in the July 2014 remand, the December 2013 examiner did not address whether the personality disorder diagnosed at this examination was subject to a superimposed disease or injury that resulted in additional disability. Additionally, while the 2013 examiner determined that the Veteran’s alleged stressors were insufficient to support a diagnosis of PTSD and that the Veteran had no other psychiatric disorder other than a personality disorder, she did not reconcile these determinations with the evidence of record showing diagnoses and treatment for a variety of disorders, such as major depressive disorder, reflected on records contemporaneous to the VA examination, including December 2013 VA treatment records. As such, in July 2014 the Board remanded the appeal and requested an addendum opinion from the December 2013 VA examiner. The examiner was asked to identify all of the Veteran’s acquired psychiatric disorders that met the DSM criteria and offer an opinion as whether (1) the Veteran’s personality disorder was subject to a superimposed disease or injury during service that resulted in additional disability; and (2) reconcile the determination at the December 2013 VA examination that the Veteran did not have a psychiatric disorder other than a personality disorder with the substantial evidence of record showing diagnoses and treatment for a variety of acquired psychiatric disorders, to include major depressive disorder, contemporaneous to the VA examination, i.e., in December 2013 VA treatment records.
The requested addendum opinion, by the mental health professional who conducted the December 2013 VA examination, was completed in September 2014. She found with respect to Question 1 posed in the July 2014 remand that there was “no supporting documentation that would indicate a nexus for his…personality disorder, which has progressed normally, with[out] any service related event or diagnosis.”
As for Question 2 posed in the in the July 2014 remand, the clinician responded as follows:
At the time of the December 2013 exam[,] the patient had been carrying only the following [diagnoses]: depression by history, alcohol dependence by history, [and] polysubstance abuse by history[.] [The Veteran was] discharged from therapy by both his psychiatrist 9/2/12 and his psychologist 5/10/13. He returned to care Nov 8, 2013 but continued to carry [diagnoses] only [of] depression by history, and r/o anxiety disorder or PTSD. On Nov 22, his psychologist diagnosed him with Major Depression, however the symptoms which were described at this time were not sufficient to support such diagnosis. After a review of the patient’s records in their entirety including efile, and remand, and the C&P exam and interview of Dec 2013, it is the opinion of this examiner that the patient meets DSM[-]5 criteria for the following diagnoses: Personality Disorder NOS with borderline, antisocial, narcissistic, schizotypal and schizoid traits….
The patient over an 18 year period has been variously diagnosed with Major Depression, adjustment disorder, polysubstance dependence, cocaine dependence, anxiety disorder nos, alcohol dependence, depression nos, r/o [] schizophrenia, PTSD, and since 8/12/11 by psychiatrist H[] and psychologist D[] with “depression by history, polysubstance abuse by history, and alcohol abuse by history.” A diagnosis which contains the phrase “by history” does not imply that the patient meets criteria for that diagnosis at the time of the note, otherwise it would simply be noted as “Depression,” rather it indicates either that the patient has a history that contains that diagnosis and/or that the patient has some symptoms of that diagnosis but does not fulfill sufficient diagnostic criteria to support the diagnosis. In the case of [the Veteran], this has consistently been the case.
The patient over the years has consistently exhibited or reported the symptoms which support the DSM[-]IV and DSM[-]5 diagnosis of Personality Disorder NOS as described above with the most frequent symptoms reported being irritability and rumination about incidents during which he felt he was not sufficiently appreciated or respected. His mood component has always been reactive and generally related to issues of abandonment or rejection, and again the symptoms [the Veteran] reports consistently are irritability or anger over his treatment by others. There is nothing which connects the patient’s personality disorder to his military experience. Although he has some DSM[-]IV symptoms of PTSD[,] there is nothing in his reported military stressors which would support this diagnosis, which fact has been noted by several providers most recently Dr. H[]. He was given a diagnosis of MDD on 11/22/13[,] however the provider’s assessment did not document symptoms which would support this diagnosis and indeed the assessment in this note does not vary from previous notes which indicated that he met only criteria for depression by history. Additionally[,] his note of 12/18/13 lists his mood as “happy go lucky” by his own report. Given his history, his affective symptoms are clearly accounted for most effectively by the DSM[-]IV and DSM[-]5 diagnosis [of] Personality NOS as described above.
In light of the above, it is the opinion of this examiner that the patient meets most clearly the criteria for a diagnosis of Personality Disorder NOS which has progressed normally without evidence of exacerbation or aggravation and that he has met this criteria for many years and that it is less likely than not that his Personality Disorder NOS was caused by or the result of by any event in his military service.
In the June 2016 JMPR, the parties found that, as the 2013 and 2014 opinions did not address whether “any incidents of personal assault occurred[,]’ and “whether any currently diagnosed PTSD [was] related to such incident[,]” the VA examiner did not address the Veteran’s claimed stressor of being the victim of a mugging while he was in service. Thus, in October 2016 the Board remanded the appeal to obtain an addendum medical opinion to specifically address the Veteran’s claimed stressor of being the victim of a mugging while he was in service.
Accordingly, in January 2017, the VA examiner who performed the 2013 examination and provided the 2013 and 2014 opinions provided another addendum opinion to specifically address the whether the Veteran meets the DSM-IV criteria for PTSD based on a personal assault. Following a comprehensive review of the record, the examiner found that there is no evidence of an eligible or credible stressor that occurred in the military and, therefore, the Veteran cannot meet the DSM-IV or DSM-5 criteria for PTSD, and he did not meet the DSM-5 criteria for any diagnosis with a clear nexus to his military service.
Regarding the Veteran’s claim for PTSD, the examiner reviewed all of the Veteran’s claimed stressors, starting with his most recently alleged stressor and working backwards. First, she noted the alleged stressor of a suicide attempt during service. The examiner observed that there was no record of this event nor any mental health issue (besides substance abuse) in the Veteran’s STRs or for some time after service. Here, the Board observes that the examiner erroneously noted 1987 as the Veteran’s first suicide attempt but the records indicate an attempted in 1981; however as neither date was during the Veteran’s service, the Board finds this error is without consequence. Returning to the alleged in-service attempt, the examiner further noted that not only were there not records of such in the Veteran’s STRs, but that his post-service reports regarding the attempt were inconsistent in that the Veteran alternatively reported that he made the attempt by slashing his wrists, overdosing, and/or hanging.
Turning to the second alleged stressor, the Veteran reported being involved in a “serious” bus accident and hospitalized thereafter. However, the examiner noted that the Veteran’s STRs do not support his assertion that the accident was traumatic or serious in nature. In fact, the Board observes that the STRs do not reflect an accident occurred; rather such show that the bus stopped suddenly to avoid an accident. Specifically, the March 1975 record states that the Veteran was “involved in [an] accident while on [a] Greyhound bus…talking to another passenger behind him when the bus made [a] sudden stop[,] avoiding accident[.]” Moreover, as acknowledge by the examiner, the Veteran was not hospitalized after the accident. He was seen in sick call and advised to apply heat to his back which he injured when the bus suddenly stopped.
The third alleged stressor of being slapped “upside” the head by a drill instructor was address in the 2013 and 2014 opinions. The examiner again found that this stressor was insufficient to support a diagnosis of PTSD. Similarly, the fourth stressor of being humiliated in front of his peers when a drill instructor yelled at him for dropping a grenade was also addressed by the examiner previously and was found not to support a diagnosis of PTSD.
The fifth stressor involved the Veteran’s reports that a drill sergeant “jumped him and beat him up[.]” However, the examiner noted that there was no record of this in the Veteran’s STRs and that the report was not consistent with the Veteran’s reports during the 2013 examination with regard to his interactions with his drill instructor.
The sixth alleged stressor was being “stabbed by an ice pick” during service. Here, the examiner observed that an August 1975 STR (discussed below) notes the Veteran’s report that he was “playing around” with a friend when he was accidentally stuck with a hair pick. Thus, the examiner noted that being accidentally struck with a hair pick was not sufficient to support a diagnosis of PTSD and that the Veteran had provided inconsistent information regarding the incident.
The seventh alleged stressor relates to the alleged personal assault via mugging. In this regard, the Veteran reported someone was going to hit him over the head (apparently with a knife) but that he blocked the attack with his arm resulting in a serious laceration to his arm. The examiner observed that there was no evidence of this alleged attack in the Veteran’s STRs, despite the fact that “he used sick call frequently and in fact used it for several of his other reported traumas including the ‘bus accident’ and being ‘stabbed with an ice pick.'” The examiner further noted that there was no military police report regarding this alleged attack.
The eighth stressor was an alleged attack with a straight razor during a card game. Like the alleged mugging, the examiner observed that there was no documentation of treatment related to this incident and that there was no police report related to it.
The ninth and final stressor relates to the Veteran’s reports that he was a combat veteran who began using drugs in Vietnam and that “in situations when he has felt like others were attacking him or humiliating him[,]” he spoke in Vietnamese. However, the examiner found that the Veteran was never in Vietnam and his DD 214 does not show that he had any overseas service.
In addition to reviewing the Veteran’s reported stressors, the examiner also considered whether the Veteran may have exhibited certain behaviors in the military indicating he had been personally assaulted but was reluctant to discuss it. Specifically, she observed that he had numerous legal issues in service including an incident of misconduct (1973), civilian confinement in jail (1973), disobeying orders (1975), sleeping on duty (1976), being absent without leave (AWOL) (1976), being continuously late for formations (1976), being AWOL (1977), and a 1976 recommendation that the Veteran be dishonorably discharged to his shirking of his duties and lying.
After reviewing the alleged stressors and the Veteran’s military record, the examiner opined that it was less likely than not that the Veteran was mugged during service as:

1. It was [the Veteran’s] habit to use sick call frequently including for wounds or injuries received outside the line of duty and there is no evidence of this wound in his STRs, nor was it reported to the police/MPs.

2. There is actual documented evidence in the [Veteran]’s efile that many of [his] claimed stressors either did not occur or did not occur in the traumatic manner he has later stated.

3. During 2016 the patient did not report his mugging as being his trauma but instead specifically report[ed] his trauma was interaction with [a] drill [sergeant]…, suicide attempt while in the military…, and being in a serious bus accident and hospitalized….

[4]. The only markers (frequent disciplinary actions…) of psychological issues for this patient are entirely consistent with his known severe drug abuse diagnosis which was the focus of treatment for 5 months prior to being discharged due to rehab[ilitation] failure.”

Here, the Board also observes that there is no record of the Veteran being a victim of a mugging in his STRs. However, in March 2017, after the January 2017 addendum opinion was provided, the Veteran submitted a statement from his ex-wife and from a comrade, both of whom reported remembering the Veteran reporting to them that he had been attacked and stabbed. They reported taking him to the hospital for treatment of his alleged stab wound. Here, the Board notes that, while the Veteran, his ex-wife, and his comrade are competent to report what they witnessed, the reports regarding the mugging lack credibility in light of the evidence of record.
In this regard, the Veteran’s STRs contain records related to three left arm injuries. The first incident occurred in August 1975, and while the Veteran subsequently reported to treatment providers that he was injured by an ice pick (see above), treatment records indicate that there was a puncture wound to the left wrist that occurred “while playing around with a buddy who accidentally struck [the Veteran] with a hair comb…called a pick.” The second injury, which also occurred in August 1975, was reported as a laceration to the left forearm “while washing dishes[,]” which required stitches. Notably, the Veteran claimed at his October 2009 DRO hearing that, while he did not report the alleged mugging to any psychiatric treatment providers during service, he did report the mugging to the medical professionals who stitched his arm following the attack. Again, the records indicate that the left arm stitches the Veteran received were related to an injury incurred while washing dishes. In fact, when the Veteran sought service connection for the residual scar of his left forearm in 1994, he made no reference to a mugging, he subsequently reported in September 2002 that he received an “accidental knife wound,” and in October 2009 that he was stabbed by a fellow soldier, not an unknown assailant. The third left arm injury occurred in April 1976 when the Veteran “allegedly incurred [a left palm injury] when [he was] cleaning [a] .22 caliber pistol that fired into [his] left palm” while he was off duty. In addition to the fact that the records do not support the Veteran’s assertions of the in-service mugging, the record also indicates that the Veteran has other characteristics that call his veracity into question including the fact that he was a well-documented drug abuser during his service, he was cited for stealing property of other veterans during service, and attempted “to shirk his duties and trie[d] to lie his way out of it” during service.
Given the foregoing, the Board finds that the Veteran’s descriptions of his in-service mugging are inconsistent and not supported by the contemporaneous record, and, therefore, lack credibility. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d 78 F.3d 604 (Fed. Cir. 1996). In the instant case, the Veteran has not provided specific details surrounding such alleged stressors so as to allow verification, to include dates or names of the persons involved. Furthermore, there is no record in the Veteran’s STRs or personnel records that he ever experienced a mugging incident during his service, despite his reports to the DRO that he told the medical professionals about his mugging. In fact, the records document the Veteran’s left arm injury occurred while washing dishes, and clearly attribute his alleged injuries to other incidents, not a mugging. Finally, the Board acknowledges the Veteran’s comrade and his ex-wife’s reports that the Veteran told them he had been mugged and that they took him to the hospital for treatment of his injuries. However, neither person claims to have witnessed the mugging and their lay observations are based on the Veteran’s reports, which have been found to lack credibility. Therefore, in light of the fact that the Veteran’s statements regarding the alleged mugging are inconsistent with the available evidence, and were not reported until he had a self-interested reason for doing so, the Board finds that the Veteran’s statements describing his alleged in-service mugging to be not credible and they are afforded no probative weight. Similarly, the other lay statements of record that are based on the Veteran’s non-credible testimony are also afforded no probative weight.
Notably, in conjunction with the 2017 addendum opinion, the examiner again revisited whether the Veteran had any non-PTSD psychiatric diagnoses related to service. She acknowledged that the Veteran’s in-service diagnosis was related to substance abuse and that post-service diagnoses continued to be substance abuse. Moreover, his reports of using illicit substances to treat depression was not made until significantly after service, indicating no nexus to the Veteran’s military service. In this regard, the examiner observed that the Veteran’s post-service depression diagnoses were reactive in nature and were documented in his records as variously related to relationship issues, drug issues, legal issues, work stress, behavioral issues, anger issues, and the residuals of these. In fact, the criteria for an actual diagnosis, when met, was of an adjustment disorder with depression and anxiety, and the examiner noted that the Veteran experienced remission and/or improvement of these symptoms based on environmental factors. Thus, she found his post-service mental health disability was most consistent with an adjustment disorder, but that he did not exhibit symptomatology consistent with such a diagnosis during the appeal period.
Rather, the only diagnosis manifested during the appeal period was an unspecified personality disorder/personality disorder as was fully discussed in the 2013 and 2014 examination reports. Importantly, the parties to the JMPR found no fault in the Board’s discussion of any issue except as to whether the Veteran exhibited a PTSD diagnosis based on the alleged in-service mugging stressor. Carter v. Shinseki, 26 Vet. App. 534, 542-43 (2014), (vacated on other grounds sub nom. Carter v. McDonald, 794 F.3d 1342 (Fed. Cir. 2015) (“[W]hen an attorney agrees to a [JMR] based on specific issues and raises no additional issues on remand, the Board is required to focus on the arguments specifically advanced by the attorney in the motion, see Forcier [v. Nicholson, 19 Vet. App. 414,] 426 [(2006)], and those terms will serve as a factor for consideration as to whether or to what extent other issues raised by the record need to be addressed.”)
The above September 2014 and January 2017 addendum opinions are not directly contradicted by any other competent evidence, and the Board finds the comprehensive opinions, which clearly reflect detailed consideration of the entire record, to be definitive as to the matter of whether the Veteran has an acquired psychiatric disorder that is the result of service or a disability of in-service origin resulting from a mental disorder superimposed upon a personality disorder. See Nieves-Rodriguez, supra; Stefl, supra. In addition, given the lack of any evidence of a psychosis within one year of service, presumptive service connection on the basis of chronic disease, to include based on continuity of symptomatology, is not warranted. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309; Walker, supra.
In making this determination, the Board has considered the Veteran’s assertions with regard to why he feels his psychiatric problems are the result of his experience during service. However, a determination as to whether the Veteran has an acquired psychiatric disorder that is related to service or a mental disorder superimposed on a personality disorder requires the expertise of a mental health professional as such a determination may only be made after a clinical analysis that a lay person does not that have the requisite training or knowledge to undertake. As such, the matter of whether the Veteran has an acquired psychiatric disorder that is the result of service, or a disability of in service origin resulting from a mental disorder superimposed upon a personality disorder, are complex questions that may not be competently addressed by lay evidence, and the Veteran’s own opinion in this regard is nonprobative evidence. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Therefore, the most probative evidence of record does not support the Veteran’s contentions and, rather, his statements are substantially outweighed by the conclusions set forth in the September 2014 and January 2017 opinions. Additionally, as fully discussed above, the Board finds that his statements regarding the alleged in-service mugging, the only element of the claim with which the parties to the JMPR found fault, are not credible.
In light of the above and in conclusion, the Board finds that service connection for an acquired psychiatric disorder is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the probative evidence is against the Veteran’s claim of entitlement to service connection for an acquired psychiatric disorder. As such, that doctrine is not applicable, and this claim must be denied. 38 U.S.C.A.
§ 5107; 38 C.F.R. § 3.102; Gilbert, supra.


Service connection for an acquired psychiatric disorder, to include schizophrenia, depression, and PTSD, is denied.
Veterans Law Judge, Board of Veterans’ Appeals
Department of Veterans Affairs

VA DISABILITY BENEFITS: Opportunities Exist to Better Ensure Successful Appeals Reform GAO-18-349T: Published: Jan 30, 2018

What GAO Found

The Department of Veterans Affairs’ (VA) plan for implementing a new disability appeals process while attending to appeals in the current process addresses most, but not all, elements required by the Veterans Appeals Improvement and Modernization Act of 2017 (Act). VA’s appeals plan addresses 17 of 22 required elements, partially addresses 4, and does not address 1. For example, not addressed is the required element to include the resources needed by the Veterans Benefits Administration (VBA) and the Board of Veterans’ Appeals (Board) to implement the new appeals process and address legacy appeals under the current process. VA needs this information to certify, as specified under the Act, that it has sufficient resources to implement appeals reform and make timely appeals decisions under the new and legacy processes.
VA’s appeals plan reflects certain sound planning practices, but it could benefit from including important details in several key planning areas:
Performance measurement: VA’s plan reflects steps taken to track performance, but could articulate a more complete and balanced set of goals and measures for monitoring and assessing performance on a range of dimensions of success. Specifically, the plan reports that VA is developing a process to track timeliness of the new and legacy processes. However, contrary to sound planning practices, the plan does not include timeliness goals for all five appeals options available to veterans, does not include goals or measures for additional aspects of performance (such as accuracy or cost), and does not explain how VA will monitor or assess the new process compared to the legacy process. Unless VA clearly articulates a complete and balanced set of goals and measures, it could inadvertently incentivize staff to focus on certain aspects of appeals performance over others or fail to improve overall service to veterans.
Project management: VA’s plan includes a master schedule for implementing the new appeals plan; however, this schedule falls short of sound practices because it does not include key planned activities—such as its pilot test of two of the five appeals options. In addition, the schedule does not reflect other sound practices for guiding implementation and establishing accountability—such as articulating interim goals and needed resources for, and interdependencies among, activities. Unless VA augments its master schedule to include all key activities and reflect sound practices, VA may be unable to provide reasonable assurance that it has the essential program management information needed for this complex and important effort.
Risk assessment: VA has taken steps to assess and mitigate some risks related to appeals reform by, for example, pilot testing two of the five appeals options through its Rapid Appeals Modernization Program (RAMP). However, as designed, RAMP does not include key features of a well-developed and documented pilot test. For example, VA has not articulated how it will assess RAMP before proceeding with full implementation. In addition, RAMP is not pilot testing three options and, as a result, VA will not have data on the extent to which veterans will appeal directly to the Board when given the option. Unless VA identifies and mitigates key risks associated with implementing a new process, VA is taking a chance that untested aspects will not perform as desired.

Why GAO Did This Study

VA’s disability compensation program pays cash benefits to veterans with disabilities connected to their military service. In recent years, the number of appeals of VA’s benefit decisions has been rising. For decisions made on appeal in fiscal year 2017, veterans waited an average of 3 years for resolution by either VBA or the Board, and 7 years for resolution by the Board. The Veterans Appeals Improvement and Modernization Act of 2017 makes changes to VA’s current (legacy) appeals process, giving veterans new options to have their claims further reviewed by VBA or appeal directly to the Board. The Act requires VA to submit to Congress and GAO a plan for implementing a new appeals process, and includes a provision for GAO to assess VA’s plan.
This testimony focuses on the extent to which VA’s plan: (1) addresses the required elements in the Act, and (2) reflects sound planning practices identified in prior GAO work. GAO’s work entailed reviewing and assessing VA’s appeals plan and related documents against sound planning practices, and soliciting VA’s views on GAO’s assessments.

What GAO Recommends

In its forthcoming report, GAO is considering recommending that VA: fully address all legally required elements in its appeals plan, articulate how it will monitor and assess the new appeals process as compared to the legacy process, augment its master schedule for implementation, and more fully address risk.

Full Report

Accessible Version

Lawsuit Claims Surgeon At West Haven Veterans Affairs Hospital Left Scalpel In Patient

[no_toc]Meet our brother Glenford Turner, a 61 year old Army veteran. Last year he presented to the West Haven VA with abdominal pain. Mr Turner had a radical prostatectomy 4 years earlier and low and behold when they gave him an X-Ray to diagnose the current abdominal pain, there was a scalpel from the surgery 4 years before.
Mr Tuner’s attorney Joel Faxon described the incident as “an incomprehensible level of incompetence” and I couldn’t agree more.
Read the full story below.
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Audit of the Timeliness and Accuracy of Choice Payments Processed Through the Fee Basis Claims System – Dec 2017

This report covers the audit of payments made through VA’s Fee Basis Claims System (FBCS), encompassing claims paid via that payment process from November 1,  2014  through  September 30, 2016. A subsequent report will contain the results of an audit conducted to assess VA’s processing of payments through a “bulk payment” process during 2016 and 2017.
The Executive Summary is below followed by a link to the full report.
Why We Did This Audit
Public Law 113-146 (August 7, 2014), Veterans Access, Choice, and Accountability Act of  2014 (VACAA), Section 101(o), requires the Inspector General of the Department of Veterans Affairs to issue a report to the Secretary of VA within 30 days after the Secretary’s determination that 75 percent of the amounts deposited in the Veterans Choice Fund established by VACAA (the “Choice Fund”) have been exhausted.1 The report was to address “the results of an audit of the care and services furnished under this section to ensure the accuracy and timeliness of payments by the Department for the cost of such care and services, including any findings and recommendations of the Inspector General.”
This report covers the audit of payments made through VA’s Fee Basis Claims System (FBCS), encompassing claims paid via that payment process from November 1,  2014  through  September 30, 2016. A subsequent report will contain the results of an audit conducted to assess VA’s processing of payments through a “bulk payment” process during 2016 and 2017.


On August 7, 2014, following well-publicized issues regarding delays in accessing care at VA medical centers (particularly in Phoenix, Arizona), Congress enacted VACAA, which set forth a broader program (the “Choice Program”) to enable eligible veterans to obtain medical care from providers in their communities.2 Congress appropriated $10 billion to the Choice Fund to be spent on care and expenses specifically authorized under VACAA, including $300 million for administrative expenses associated with establishing and maintaining the Choice Program. VACAA required VA to implement key portions of the Choice Program within 90 days, and veterans began using the Choice Program by November 2014.
VA’s Office of Community Care (OCC), which is part of the Veterans Health Administration (VHA) and is under the leadership of the Deputy Under Secretary for Health for Community Care, is responsible for the administration and operation of the Choice Program.3 VA’s Patient-Centered Community Care program (PC3) is a nationwide program for delivering care in the community established in 2013. In October 2014, VA amended the PC3 contracts with Third
1 The VA Office of Inspector General, pursuant to the requirement in Public Law 113-146, released on September 12, 2017 to the Secretary of Veterans Affairs a memorandum titled “Accuracy and Timeliness of Payments Made Under the Choice Program Authorized by the Veterans Access, Choice, and Accountability Act.”
2 Public Law 113-146 (August 7, 2014), Veterans Access, Choice, and Accountability Act of 2014. Eligibility for Choice is based on specific criteria relating to wait times for appointments and distance from the nearest medical facility, and these eligibility requirements have been modified on occasion by statute and regulation.
3 OCC, the group managing Choice, was known as the Chief Business Office until October 2016, when it reorganized into the Office of Community Care. Regardless of time frame, this group will be referred to as “OCC.”
Party Administrators (TPA) Health Net Federal Services LLC (Health Net) and TriWest Healthcare Alliance Corporation (TriWest) to include administration of the Choice Program, including establishing provider networks, scheduling appointments, receiving medical documentation, and making payments for medical care on behalf of VA.
Under the PC3/Choice contracts, VA makes payments to the TPAs, not the providers. The TPAs are responsible for paying their providers. VA reimburses the TPAs for payments the TPAs make to providers for veterans’ medical care obtained through the Choice Program. TPAs’ billings are submitted to OCC electronically, and then processed by VA’s Financial Services Center (FSC) in Austin, Texas. During the period of review for this audit, the FSC processed Choice claims using FBCS.

What We Did

Choice payment data were obtained from VA’s Central Fee Files and statistically sampled for each TPA. Our audit included Choice claims processed in FBCS for payment to the TPAs from November 1, 2014 through September 30, 2016. We did not audit bulk Choice medical  payments processed outside of FBCS,4 Choice administrative payments, or payments for Hepatitis C and other non-Department care that used Choice Program funding.
We reviewed a sample of payment transactions from the approximately $649 million paid to Health Net ($69 million) and TriWest ($580 million) from November 1, 2014 through September 30, 2016, via FBCS.5 We reviewed the PC3/Choice contracts and interviewed officials from OCC, FSC, the Denver Acquisition and Logistics Center, Health Net, and TriWest. We used a third-party vendor to evaluate medical claims in our audit sample to determine if the Medicare rates applied were correct.

What We Found

We estimated that from November 1, 2014 through September 30, 2016, payment errors were made on approximately 224,000 of 2.0 million Choice claims (12 percent)6 paid via FBCS.
These errors were of the following types:
Payment rate – Payments made on claims that did not use the appropriate Medicare or contract adjusted rate 4PC3/Choice contracts were modified in March through November 2016 to allow VCPBYPASS (payments for Choice medical claims that were not submitted to Veterans Affairs by the TPAs due to missing medical documentation) and Expedited payments for Choice medical care to TPAs. We refer to these transactions as “bulk payments” for the purpose of our report. Because these bulk payment processes were not in place when this review was planned, a second audit was started in April 2017 to address the accuracy of payments under the bulk payment process.
5FBCS is the current claims processing system used for processing and payment by VHA of claims authorized under
the non-VA Care Program which does not include PC3 or Choice claims.
6All payment error rates presented in this report are based on projections for a randomly selected sample; see Appendix C Statistical Sampling Methodology for more details.
Other Health Insurance (OHI) – Payments made on claims that were not adjusted for the amount OHI was responsible to pay the provider
Duplicate – Payments for medical claims that were submitted and paid more than once
Pass-Through – Payments where the amount the TPAs billed and were paid was more than the TPA paid the provider
We estimated that OCC payments to TPAs for approximately 1.0 million of 2 million claims   (50 percent) were  made  in  excess  of  the  30-day  Prompt  Payment  Standard  from  November 1, 2014 through September 30, 2016.
We also estimated that Health Net took 47 days on average to pay its  providers  from  November 1, 2014 through September 30, 2016. TriWest averaged 39 days to pay its providers for the same period.

Why This Occurred

The U.S. Government Accountability Office’s Standards for Internal Control in the Federal Government (Green Book) defines internal control standards for Federal Government agencies through five components consisting of 17 key principles necessary to produce an effective internal control system. In our review of the OCC Choice payment process, we found several internal control weaknesses in the payment process that contributed to the errors discussed in this report. We concluded that OCC did not design an effective internal control system for the  Choice payment process and did not appropriately follow these internal control principles:

  • Create clear written policy for the payment of claims
  • Ensure access to quality information is available for payment processing staff
  • Use a well-designed information system to address the risk of overpaying medical claims
  • Establish monitoring activities to ensure internal controls are working

OCC’s payments averaged 37 days to Health Net and 36 days to TriWest. These payment delays occurred because OCC did not accurately estimate the amount of staff necessary to process Choice claims through their Service Level Agreement with FSC. In addition, although VACAA requires VA to meet the timeliness standards of the Prompt Payment Act in paying the TPAs, the PC3/Choice contracts do not specify a timeliness standard applicable to the TPAs for their payments to providers.7
7 Public Law 113-146 (August 7, 2014) Veterans Access, Choice, and Accountability Act of 2014 (VACAA), Section 105(b)(1) and (2). VACAA requires VA to establish a claims processing system that complies with all requirements of the Prompt Payment Act, 5 CFR part 1315 – Prompt Payment.

What Resulted

OCC failed to comply with VACAA regulations when it established payment processing systems that did not function efficiently and have proper controls to ensure payment accuracy. TPAs improperly billed OCC, and OCC made an estimated 224,000 payment errors when paying the TPAs because OCC did not have in place an effective internal control system for the Choice payment process to ensure Choice payment accuracy. These payment errors resulted in an estimated overpayment of about $39 million during our period of review.
OCC did not implement an efficient claims processing system for Choice claims or adequately estimate staffing levels in the Service Level Agreement with FSC so that resources could be allocated in advance to deal with the Choice claims volume demand. Without such a system, OCC will continue to be at risk of late payments and penalty interest charges. Additionally, until OCC adds a standard for Choice payment timeliness to the PC3/Choice contracts for Health Net and TriWest, OCC will not have a control in place to enforce timely payments to Choice providers.

What We Recommended

We made these recommendations to the Executive in Charge, Veterans Health Administration:

  • Develop and issue written payment policies to guide staff processing medical claims received from TPAs as well as establish expectations and obligations for the TPAs that submit invoices for
  • Ensure payment processing staff have access to documentation from the TPAs verifying amounts paid to providers to ensure the TPAs are not billing VA more than they paid the provider for medical
  • Ensure VHA payment processing staff have access to accurate data regarding veterans’ OHI coverage and establish appropriate processes for collecting payments from these health insurers.
  • Ensure the new payment processing systems used for processing medical claims from TPAs have the ability to adjudicate reimbursement rates accurately and to ensure duplicate claims are not
  • Ensure VA performs post-payment audits on a periodic basis to determine if payments made to TPAs for medical care are
  • Ensure OCC staff and members of VA’s Office of General Counsel continue to work collaboratively with relevant government authorities to review and determine an appropriate process for
  • Ensure VHA has sufficient claims processing capacity to timely meet and process expected claim volume from the
  • Ensure that future contracts with TPAs contain payment timeliness standards for the processing of claims from health care

Agency Comments

The Executive in Charge, Office of the Under Secretary for Health, concurred with our findings and agreed that a full review of payments made under the Veterans Choice Program  and recovery of all identified overpayments is essential. The Executive in Charge stated that VHA has already taken action to identify past duplicate payments and prevent future duplicate payments to TPAs beginning in July 2017 and plans to continue working collaboratively with the Office of Inspector General (OIG) and all other relevant government stakeholders to ensure that Choice payments are thoroughly reviewed and all overpayments are recovered.
The Executive in Charge concurred with Recommendations 1, 3, 5, 6, 7, and 8 and concurred in
principle with Recommendations 2 and 4. Regarding Recommendations 2 and 4, VHA will address the documentation requirement in the upcoming Community Care Network contract.  The Executive in Charge’s planned corrective actions are acceptable. The OIG will monitor VHA’s progress and follow up on the implementation of our recommendations until all proposed actions are completed.
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VA CHOICE Program News from 2017

[no_toc]Story image for veterans affairs CHOICE from PBS NewsHour

House rejects proposed funding fix for VA Choice program

PBS NewsHourJul 25, 2017
WASHINGTON — The House has rejected a plan to allow the Department of Veterans Affairs to shift $2 billion from other programs to cover a sudden budget shortfall in its Choice program of private-sector care following opposition from veterans’ groups. The vote was 219-186 Monday on a bill to provide a six-month funding …

As the Choice program runs out of money this year, VA reiterates …

FederalNewsRadio.comJun 14, 2017
The Veterans Affairs Department is quickly running out of money in its Choiceprogram account, one of several funding streams VA uses to pay for veterans to receive community health care. This development with the Choice program is only the latest of a series of pain points for the department and Congress. Yet VA …

Congress Reaches Deal to Avert Shutdown of Veterans‘ Health …

New York TimesJul 27, 2017
Congress created the Choice program in response to a 2014 scandal over the manipulation of patient wait times at Veterans Affairs Department facilities. It was intended to temporarily relieve pressure on those facilities as the department retooled. Now, most lawmakers agree that though the program needs significant repair …

Shulkin offers first glimpse at new VA Choice plan

FederalNewsRadio.comJun 8, 2017
One day after the Senate passed long-awaited legislation that authorizes new accountability procedures at the Veterans Affairs Department, Congress is turning its focus to the next big debate at VA: the Veterans Choice Program. The Senate Veterans Affairs Committee began Wednesday the first of many discussions on the …

Trump signs bill allowing veterans to seek care outside broken VA

Washington ExaminerApr 19, 2017
President Trump signed legislation Wednesday that will dramatically expand a program at the Department of Veterans Affairs that lets patients seek care from private doctors if they want to bypass the troubled VA system. The Veterans Choice Improvement Act removes barriers that Congress placed around the original …

Trump signs $3.9 billion VA funding bill to avert crisis for Choice

Stars and StripesAug 12, 2017
WASHINGTON — President Donald Trump on Saturday signed a $3.9 billion funding deal for the Department of Veterans Affairs that will shore up the nearly bankrupt Veterans Choice Program and allow the VA to open 28 new clinics and implement new hiring programs. Trump signed the bill in Bedminster, New Jersey, …

House lawmakers: VA Choice reform bill can wait until 2018

ModernHealthcare.comDec 6, 2017
Roe and his committee passed one version of the Choice overhaul, with a price tag estimated at about $39 billion over five years by the Congressional Budget Office; the Senate Committee on VeteransAffairs passed another, which would cost about $54 billion over five years per CBO. The two bills, which a Senate …

Department of Veterans Affairs says money for private health care …

PBS NewsHourSep 26, 2017
WASHINGTON — Weeks after a veterans‘ health initiative received $2.1 billion in emergency funding, the Trump administration says the private-sector VeteransChoice health care program may need additional money as early as December to avoid a disruption of care for hundreds of thousands of veterans.

Veterans Affairs facing $1 billion shortfall because of unexpected …

AZCentral.comJun 21, 2017
At the hearing, lawmakers pressed Shulkin about the department’s financial management after it significantly underestimated costs for its Choice program, which offers veterans federally paid medical care outside the VA. Several questioned Shulkin’s claim that the VA can fill the budget gap simply by shifting funds — without …

The Overwhelmed VA Choice Program Is Running Out Of Money …

Task & PurposeSep 28, 2017
All last summer, lawmakers on Capitol Hill scrambled to find more than $2 billion in emergency funding to keep the Department of Veterans Affairs‘ top private-provider referral program from going bankrupt. After a few misfires and rounds of recriminations, that funding came through last month. But the Veterans Choice …

Funding for a new veterans choice program remains the big …

FederalNewsRadio.comOct 24, 2017
Debate over the future of the Veterans Choice Program began in earnest Tuesday, as the Veterans Affairs Secretary David Shulkin and House VA Committee Chairman Phil Roe (R-Tenn.) presented their respective proposals to make community care programs permanent. Shulkin’s proposal, called the Veterans …

VA Contracting: Improvements in Buying Medical and Surgical Supplies Could Yield Cost Savings and Efficiency

[no_toc]Last year VA launched a new program to streamline purchasing supplies for their medical centers.
As GAO lays out what the VA needed to do for the program to be successful

  • A strong strategic plan
  • Stable leadership
  • Good communications
  • Stakeholder buy-in

GAO found Veterans Affairs was missing these elements when it launched the program; as a result, the program has yet to achieve key goals of cost savings and greater efficiency.
Highlights from the report:

What GAO Found

The Department of Veterans Affairs (VA) established the Medical Surgical Prime Vendor-Next Generation (MSPV-NG) program to provide an efficient, cost-effective way for its facilities to order supplies, but its initial implementation was flawed, lacked an overarching strategy, stable leadership, and sufficient workforce that could have facilitated medical center buy-in. VA developed requirements for a broad range of MSPV-NG items with limited clinical input. As a result, the program has not met medical centers’ needs, and usage remains far below VA’s 40 percent target. VA also established cost avoidance as a goal for MSPV-NG, but currently only has a metric in place to measure broader supply chain cost avoidance, not savings specific to MSPV-NG. Also, starting in June 2015, VA planned to award competitive contracts for MSPV-NG items, but instead, 79 percent were added using non-competitive agreements. (See figure.) This was done primarily to meet VA’s December 2016 deadline to establish the formulary, the list of items available for purchase through MSPV-NG.

Total Number of Items by Award Type on MSPV-NG Formulary, Jan. 2017

Total Number of Items by Award Type on MSPV-NG Formulary, Jan. 2017
The roll-out of MSPV-NG ran counter to practices of leading hospitals that GAO spoke with, which highlighted key steps, such as prioritizing supply categories and obtaining continuing clinician input to guide decision-making. VA has taken steps to address some deficiencies identified in the first phase of implementation and is considering a new approach for this program. However, until VA addresses the existing shortcomings in the MSPV-NG program, such as the lack of medical center buy-in, it will face challenges in meeting its goals.
Medical centers often rely on emergency procurements to obtain routine goods and services—some of which could be made available at lower cost via MSPV-NG. Sixteen of the 18 contracts in GAO’s sample were not competed, which puts the government at risk of paying more. For instance, one medical center procured medical gas on an emergency basis through consecutive non-competitive contracts over a 3-year period. VA policy clearly defines emergency actions; however, inefficiencies in planning, funding, and communication at the medical centers contributed to emergency procurements, resulting in the contracting officers quickly awarding contracts with no competition.

Why GAO Did This Study

VA medical centers spend hundreds of millions of dollars annually on medical supplies and services. In December 2016, VA instituted a major change in how it purchases medical supplies—the MSPV-NG program—to gain effectiveness and efficiencies.
GAO was asked to examine VA’s transition to the MSPV-NG program and its use of emergency procurements. This report assesses the extent to which (1) VA’s implementation of MSPV-NG was effective in meeting program goals, and (2) VA awards contracts on an emergency basis. GAO analyzed VA’s MSPV-NG requirements development and contracting processes, and identified key supply chain practices cited by four leading hospital networks. GAO also reviewed a non-generalizable sample of 18 contracts designated in VA’s database as emergency procurements with high dollar values; and met with contracting, logistics, and clinical officials at 6 medical centers, selected based on high dollar contract obligations in fiscal years 2014-2016 and geographic representation.

What GAO Recommends

GAO is making 10 recommendations, including that VA expand clinician input in requirements development, calculate MSPV-NG cost avoidance, establish a plan for awarding future competitive contracts, and identify opportunities to strategically procure supplies and services frequently purchased on an emergency basis. VA agreed with GAO’s recommendations.

VA failed to report 90% of potentially dangerous medical providers, GAO confirms


We aren’t asking for state of the art care, we are asking for quality competent care.

History doesn’t repeat but it often rhymes, how many times must our service be so devalued. Do we not deserve to receive the quality care we were promised, is the nations word no good to it’s own veterans. That should not be a stretch, it shouldn’t be that hard.

GAO found VA officials slow to investigate performance concerns of certain doctors. In 8 of 9 cases, VA failed to report docs who did not meet health care standards.

Highlights from the article

  • VA fails to report 90% of poor performing docs to national and state databases.
  • VA slow to investigate performance concerns.
  • VA failed to report docs who didn’t meet healthcare standards.
  • Concerns ranged from unsafe or inconsistent practices to incorrectly recording patient visits.
  • In one case a doc who had resigned while under investigation wasn’t reported and later hired by a non-VA hospital, not that surprising the doc was disciplined for the same conduct 2 years later at his/her new job.

Read the whole story be informed and outraged and share it with veterans. I’ve included the GAO report below the article link.


Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns GAO-18-63: Published: Nov 15, 2017. Publicly Released: Nov 27, 2017.

Fast Facts

The Department of Veterans Affairs requires its medical centers to review a doctor’s care if quality or safety concerns arise. If VA medical center officials decide a doctor should no longer provide care to veterans, they are required to inform hospitals and other health care entities by reporting to a national database and to the states where the doctor is licensed.

However, at the 5 VA medical centers we reviewed, we found that these reviews were not always timely. We also found that VA officials did not report 8 of the 9 doctors who should have been reported.

GAO recommends Veterans Affairs improve oversight of clinical care reviews and reporting.


What GAO Found

Department of Veterans Affairs (VA) medical center (VAMC) officials are responsible for reviewing the clinical care delivered by their privileged providers—physicians and dentists who are approved to independently perform specific services—after concerns are raised. The five VAMCs GAO selected for review collectively required review of 148 providers from October 2013 through March 2017 after concerns were raised about their clinical care. GAO found that these reviews were not always documented or conducted in a timely manner. GAO identified these providers by reviewing meeting minutes from the committee responsible for requiring these types of reviews at the respective VAMCs, and through interviews with VAMC officials. The selected VAMCs were unable to provide documentation of these reviews for almost half of the 148 providers. Additionally, the VAMCs did not start the reviews of 16 providers for 3 months to multiple years after the concerns were identified. GAO found that VHA policies do not require documentation of all types of clinical care reviews and do not establish timeliness requirements. GAO also found that the Veterans Health Administration (VHA) does not adequately oversee these reviews at VAMCs through its Veterans Integrated Service Networks (VISN), which are responsible for overseeing the VAMCs. Without documentation and timely reviews of providers’ clinical care, VAMC officials may lack information needed to reasonably ensure that VA providers are competent to provide safe, high quality care to veterans and to make appropriate decisions about these providers’ privileges.
GAO also found that from October 2013 through March 2017, the five selected VAMCs did not report most of the providers who should have been reported to the National Practitioner Data Bank (NPDB) or state licensing boards (SLB) in accordance with VHA policy. The NPDB is an electronic repository for critical information about the professional conduct and competence of providers. GAO found that

  • selected VAMCs did not report to the NPDB eight of nine providers who had adverse privileging actions taken against them or who resigned during an investigation related to professional competence or conduct, as required by VHA policy, and
  • none of these nine providers had been reported to SLBs.

GAO found that officials at the selected VAMCs misinterpreted or were not aware of VHA policies and guidance related to NPDB and SLB reporting processes resulting in providers not being reported. GAO also found that VHA and the VISNs do not conduct adequate oversight of NPDB and SLB reporting practices and cannot reasonably ensure appropriate reporting of providers. As a result, VHA’s ability to provide safe, high quality care to veterans is hindered because other VAMCs, as well as non-VA health care entities, will be unaware of serious concerns raised about a provider’s care. For example, GAO found that after one VAMC failed to report to the NPDB or SLBs a provider who resigned to avoid an adverse privileging action, a non-VA hospital in the same city took an adverse privileging action against that same provider for the same reason 2 years later.

Why GAO Did This Study

Nearly 40,000 providers hold privileges in VHA’s 170 VAMCs. VAMCs must identify and review any concerns that arise about the clinical care their providers deliver. Depending on the findings from the review, VAMC officials may take an adverse privileging action against a provider that either limits the care a provider is allowed to deliver at the VAMC or prevents the provider from delivering care altogether.
GAO was asked to review VHA processes for reviewing concerns about providers’ clinical care. This report examines, among other things, selected VAMCs’ (1) reviews of providers’ clinical care after concerns are raised and VHA’s oversight of these reviews, and (2) VAMCs’ reporting of providers to the NPDB and SLBs and VHA’s oversight of reporting. GAO visited a non-generalizable selection of five VAMCs selected for the complexity of services offered and variation in location. GAO reviewed VHA policies and files from the five selected VAMCs, and interviewed VHA, VISN, and VAMC officials. GAO also evaluated VHA’s practices using federal internal control standards.

What GAO Recommends

GAO is making four recommendations, including for VA to direct VHA to require VAMCs to document reviews of providers’ clinical care after concerns are raised, develop timeliness requirements for these reviews, and ensure proper VISN oversight of such reviews as well as timely VAMC reporting of providers to the NPDB and SLBs. VA concurred with GAO’s recommendations and described steps it will take to implement them.

Recommendations for Executive Action

Recommendation: The Under Secretary for Health should specify in VHA policy that reviews of providers’ clinical care after concerns have been raised should be documented, including retrospective and comprehensive reviews. (Recommendation 1)
Recommendation: The Under Secretary for Health should specify in VHA policy a timeliness requirement for initiating reviews of providers’ clinical care after a concern has been raised. (Recommendation 2)
Recommendation: The Under Secretary for Health should require VISN officials to oversee VAMC reviews of providers’ clinical care after concerns have been raised, including retrospective and comprehensive reviews, and ensure that VISN officials are conducting such oversight with the required standardized audit tool. This oversight should include reviewing documentation in order to ensure that these reviews are documented appropriately and conducted in a timely manner. (Recommendation 3)
Recommendation: The Under Secretary for Health should require VISN officials to establish a process for overseeing VAMCs to ensure that they are reporting providers to the NPDB and SLBs, and are reporting in a timely manner. (Recommendation 4)
As of this writing these were still open issues, click here to find the latest status.
The full report is available here.