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Unwarranted Medical Reexaminations for Disability Benefits VA OIG 17-04966-201

VA Disability, VA News

Why the OIG Did This Review

The OIG conducted this review to determine whether Veterans Benefits Administration (VBA) employees required disabled veterans to submit to unwarranted medical reexaminations.1
VBA employees have authority to request reexaminations for veterans “whenever VA determines there is a need to verify either the continued existence or the current severity of a disability,” and when there is no exclusion from reexamination.2 While reexaminations are important in the appropriate situation to ensure taxpayer dollars are appropriately spent, unwarranted reexaminations cause undue hardship for veterans. They also generate excessive work, resulting in significant costs and the diversion of VA personnel from veteran care and services.

What the Review Found

VBA employees did not consistently follow policy to request reexaminations only when necessary.3 The OIG team reviewed a statistical sample of 300 cases with reexaminations from March through August 2017 (review period) and found that employees requested unwarranted medical reexaminations in 111 cases. Based on this sample, the review team estimated that employees requested unwarranted reexaminations in 19,800 of the 53,500 cases during the review period (37 percent). VBA employees requested reexaminations for veterans whose cases qualified for exclusion from reexamination for one or more of the following reasons:

  • Over 55 years old at the time of the examination, and not otherwise warranted by unusual circumstances or regulation
  • Permanent disability and not likely to improve
  • Disability without substantial improvement over five years
  • Claims folders contained updated medical evidence sufficient to continue the current disability evaluation without additional examination
  • Overall combined evaluation of multiple disabilities would not change irrespective of the outcome of reexamining the particular condition
  • Disability evaluation of 10 percent or less
  • Disability evaluation at the minimum level for the condition4

The review team estimated that during the six-month review period, VBA spent $10.1 million on unwarranted reexaminations—$5.3 million involving Veterans Health Administration clinicians and $4.8 million involving VBA contractors.5 The review team estimated that VBA would waste $100.6 million on unwarranted reexaminations over the next five years unless it ensures that employees only request reexaminations when necessary.
In assessing the unnecessary burdens for veterans, the review team estimated that VBA required 19,800 veterans to report for unwarranted medical reexaminations during the review period. Reinforcing the needlessness of the reexaminations, approximately14,200 veterans experienced no change to their disability evaluations because of their reexamination. The review team estimated that the reexaminations resulted in proposed benefit reductions for about 3,700 veterans.6 At the conclusion of the review period, these proposed reductions remained subject to a final decision and an appeal process; therefore, the OIG did not make a determination on whether the reductions were justified.7 Unwarranted reexaminations also created unnecessary work for Veterans Affairs employees, which reduced VBA’s capacity to process benefits claims and the Veterans Health Administration’s (VHA’s) capacity to provide healthcare services.

Why This Occurred

Prior to requesting that a veteran appear for a medical reexamination, VBA policy requires a Rating Veterans Service Representative (RVSR) to review the veteran’s claims folder and determine whether the reexamination is needed (pre-exam review).8 The pre-exam review serves as an internal control to prevent unwarranted reexaminations. The review team estimated, however, that 15,500 of 19,800 unwarranted reexaminations (78 percent) lacked a pre-exam review by an RVSR, indicating that VBA management routinely bypassed this internal control. Instead, VA Regional Office (VARO) managers routed these cases directly to a Veterans Service Representative (VSR) for scheduling the reexamination.
VARO managers explained that routing cases directly to VSRs was consistent with guidance from the Executive in Charge for VBA. The guidance recommends that tasks not directly related to making a disability rating decision should not be assigned to an RVSR. The Executive in Charge confirmed that the VARO managers’ interpretation was consistent with his expectations. He explained to the review team that RVSR capacity is limited, and therefore an RVSR should not spend time on activities that do not directly relate to making rating determinations. Reinforcing the Executive in Charge’s mandate, VBA redesigned its employee performance standards in 2017. This revision resulted in RVSRs earning work credit for rating decisions but not for other transactions, such as canceling an unwarranted reexamination.
Bypassing the pre-exam review caused unwarranted reexaminations. VARO managers routed the work to VSRs who lacked the training and experience necessary to make accurate determinations about whether a reexamination was warranted. Determining whether a reexamination is necessary is an RVSR responsibility; however, VSRs were tasked with making this determination. VBA employees and managers stated that determining the necessity of a reexamination requires specialized knowledge, including the ability to review medical evidence. Similarly, 14 of the 24 VSRs interviewed told the review team that they were unfamiliar with the criteria for determining whether a reexamination was necessary.
VBA also did not invest in developing alternative internal controls to compensate for the lack of a pre-exam review. VBA could add features to the Veterans Benefits Management System (VBMS) to prevent the scheduling of reexaminations in cases that meet the exemption criteria, such as information system automation. VBA has not implemented these features in VBMS due to reported competing technology priorities and a lack of funding. In September 2017, VBA took initial steps and implemented a technology strategy designed to reduce unnecessary work by identifying and canceling work items for veterans age 55 or older that would have resulted in unwarranted reexaminations. This effort resulted in the one-time elimination of approximately 45,000 reexaminations. VBA plans to implement additional one-time cancellations in the future, and VBMS automation is scheduled for FY 2019 or later.
Finally, VBA’s quality assurance processes did not measure whether VBA employees requested reexaminations only when necessary, nor did these processes evaluate whether an RVSR conducted a pre-exam review as required by VBA policy.

What the OIG Recommended

The OIG made four recommendations to the Under Secretary for Benefits:

  • Establish internal controls sufficient to ensure that a reexamination is necessary prior to employees ordering it, and modify VBA procedures as appropriate to reflect these improved business processes.
  • Take steps to prioritize the design and implementation of system automation reasonably designed to minimize unwarranted reexaminations.
  • Enhance VBA’s quality assurance reviews to evaluate whether employees correctly requested reexaminations and to categorize unwarranted reexaminations as errors.
  • Conduct a special focused quality improvement review of cases with unwarranted reexaminations to understand and redress the causes of any avoidable errors.

Management Comments

The Under Secretary for Benefits concurred with three of the four recommendations, and concurred in principle with the fourth recommendation. The Under Secretary for Benefits provided acceptable action plans for all four recommendations. The OIG will monitor VBA’s progress and follow up on implementation of the recommendations until all proposed actions are completed.
The Under Secretary for Benefits also provided technical comments related to this report. The OIG considered those comments and made clarifications where applicable.

1 VBA also refers to medical reexaminations as routine future examinations.

2 38 CFR §3.327, Reexaminations.

3 The relevant policy is found in M21-1 Adjudication Procedures Manual, Part III, Subpart iv, Chapter 3, Section B, Topic 2, Determining the Need for Review Examinations.

4 VBA relies on these objective criteria to identify disabilities that are unlikely to improve and therefore do not merit the expense and burden of reexamination.

5 The review team estimated the cost of unwarranted reexaminations using the results of the team’s statistical sample claims review. See Appendix C for more information on the statistical sampling methodology and results.

6 The review team did not project cost savings based on the 3,700 veterans with proposed reductions because the reductions were only proposals—not final reductions. When VBA makes a final decision, the proposed reduction amount may be changed, or there may be no reduction at all.

7 The review team estimated the number of veterans who had proposed benefits reductions using the results of the team’s statistical sample. Some reexaminations resulted in increases to veterans’ benefits, but the small sample size prevented the review team from making a statistical projection to estimate the value of all increases during the review period.

8 M21-1 Adjudication Procedures Manual, Part III, Subpart iv, Chapter 3, Section C, Topic 2, Control of Future Examinations. For this report, the OIG defines the required RVSR review prior to a reexamination request as the Pre-exam Review.

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