Veteran Oversight Now

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Deputy Assistant IGs Discuss Two Burn Pit Reports Aug 25, 2022

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Related Reports:

Airborne Hazards and Open Burn Pit Registry Exam Process Needs Improvement
Since 1990, some 3.5 million veterans have served in areas that potentially exposed them to airborne hazards and open burn pit toxins, which have been associated with health problems. In 2013, Congress ordered VA to establish a registry to research the potential health impacts of exposures. The VA Office of Inspector General (OIG) reviewed the management of registry exams, including whether VA medical facilities conducted them within the 90-day prescribed period. The Veterans Health Administration (VHA) began collecting and recording data in the registry in May 2014 through an online questionnaire and free in-person exams. The OIG found many veterans did not complete the 140-item questionnaire, which is not clear and veteran-centric. Veterans also did not always realize they were responsible for scheduling their own exams. Improvements in the registry exam process would help ensure more eligible and interested veterans receive them. VHA plans to establish a call center to assume some of the scheduling and coordination responsibilities by October 2022. This is well-timed given the number of veterans indicating they would like an exam has further increased since August 2021, when VA established a presumptive “service connection” for respiratory conditions due to exposure to particulate matter, such as asthma, sinusitis, and rhinitis. Whether the call center will mitigate the issues identified by the OIG cannot yet be determined, and its rollout does not negate the need for corrective actions. The OIG made seven recommendations to the under secretary for health that include revising the questionnaire to be more veteran-centric, identifying whether veterans with unscheduled exams are still interested in one, and implementing processes and metrics to ensure exams are completed. Further, the OIG recommended developing guidance to ensure responsible parties review and discuss performance data and the enhancement of registry information systems.

Veterans Prematurely Denied Compensation for Conditions That Could Be Associated with Burn Pit Exposure
VA recognizes exposure to smoke from the large burn pits used by the US military to dispose of waste from its bases in Iraq, Afghanistan, and Djibouti as a potential cause of disabilities. Veterans Benefits Administration (VBA) staff processed more than 21,100 burn pit-related claims from June 2007 through September 2021. Given the potential impact on many eligible veterans, the VA Office of Inspector General (OIG) conducted this review to determine whether VBA staff followed regulations and procedures when addressing conditions that could be associated with burn pit exposure. VBA treats burn pit-related claims like most other disability compensation claims, though it also considers exposure to environmental hazards based on a veteran’s service location. VBA provides medical examiners a burn pit fact sheet to help ensure any opinion is fully informed based on all known objective facts. The review team examined three distinct samples of claimed conditions potentially related to burn pit exposure completed from May 1, 2020, to May 1, 2021, and found VBA could improve its processing and oversight. Though VBA staff nearly always made the correct decision in granting compensation for conditions identified as burn pit-related, the OIG found most denials were premature. The OIG made seven recommendations to VBA management, including correcting four errors involving improperly granted conditions, and reviewing denied cases, correcting errors they identify, and certifying that corrections were made. VBA should also update its adjudication procedures manual to provide separate and specific guidance for handling claims based on burn pit exposure and modify its examination request application to add specialty language from the burn pit fact sheet into medical opinion requests. Finally, VBA should update training materials and ensure they are consistent with the adjudication procedures manual guidance.

VA OIG Director Discusses Forensic Auditing Jul 15, 2022

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The Office of Investigations investigates potential crimes and civil violations of law involving VA programs and operations committed by VA employees, contractors, beneficiaries, and other individuals. These investigations focus on a wide range of matters including healthcare, procurement, benefits, construction, and other fraud; cybercrime and identity theft; bribery and embezzlement; drug offenses; and violent crimes. The office is staffed by special agents with full law enforcement authority, forensic auditors, and other professionals. Learn more at https://www.va.gov/oig/about/investigations.asp

Senior Benefits Inspector Discusses Risks with VA's Contract Medical Exam Program Jun 22, 2022

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Report summary:
Given the importance of medical exams to disability claims and the high cost of VA’s contracts with exam vendors, the VA Office of Inspector General (OIG) set out to determine whether the Veterans Benefits Administration (VBA) oversaw contract medical disability exams to ensure they met quality standards and contractual requirements, established procedures for correcting errors, and gave feedback to vendors to improve exam quality.

VBA’s governance of and accountability for the exam program needs to improve. The identified deficiencies appear to have persisted, at least in part, because of limitations with VBA’s management and oversight of the program at the time of the review. The OIG found VBA’s program was deficient because it hindered the ability to hold vendors accountable for correcting errors and improving exam accuracy. VBA should improve the program to help ensure vendors produce accurate exams to support correct decisions for veterans’ claims.

Contract exams are a significant investment, and VA has spent nearly $6.8 billion since fiscal year 2017. Some of the exams produced by vendors have not met contractual accuracy requirements. As a result, claims processors may have used inaccurate or insufficient medical evidence to decide veterans’ claims. Therefore, it is vital for VBA to improve the governance and accountability of the program.

The OIG made four recommendations to the acting under secretary for benefits, including ensuring vendors can be held contractually accountable for unsatisfactory performance and establishing procedures for vendors to correct errors. The OIG also recommended requiring the Medical Disability Examination Office to communicate vendor exam errors to the Office of Field Operations and the regional offices and demonstrate progress in correcting them, and analyze all available data to identify systemic errors and provide systemic exam issues and error trends to vendors.

Deputy Inspector General Highlights Newest VA Electronic Health Record Reports Mar 28, 2022

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In this episode of Veteran Oversight Now, guest host Deputy Inspector General David Case joins Dr. Joe Etherage, director of national reporting for the Office of Healthcare Inspections, to discuss three recently released reports on VA’s Electronic Health Record Modernization program—a 10-year, multibillion-dollar modernization effort. Since the October 2020 implementation of the system at the Mann-Grandstaff VA Medical Center in Spokane, Washington, the VA OIG has received wide-ranging complaints to its hotline as well as concerns from members of Congress. The VA OIG found deficiencies that increased risks to patient safety.

Referenced reports:

Medication Management Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington

Ticket Process Concerns and Underlying Factors Contributing to Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington

Care Coordination Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington

Senior Healthcare Inspection Leader Discusses New Vet Center Inspection Program Mar 28, 2022

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In this episode of Veteran Oversight Now, Dr. Julie Kroviak, deputy assistant inspector general for healthcare inspections, discusses her journey from medical student to VA doctor to leading teams conducting oversight of VHA. She introduces the new vet center inspection program, detailing how the VA OIG will inspect roughly 300 vet centers over the next few years. This month’s episode concludes with the VA OIG’s highlights for January 2022.

Dr. Kroviak on areas of focus for vet center inspections:

“Leadership will be a story that we tell in every single report we write from now on. We’re looking at leadership in local and regional levels for each vet center that we visit. Importantly, we’re looking for their internal quality reviews. You know care is being provided, and we need to know that there is appropriate oversight and intervention and when issues are found that plans are in place to remediate.”

The VA OIG has published inspection reports on the following vet centers since the program was launched:

Pacific District 5 Zone 1 and four selected vet centers in Bellingham, WA; Tacoma, WA; Bend, OR; and Wasilla, AK, 9/30/21
Continental District 4 Zone 2 and four selected vet centers in Alexandria, LA; Houston Southwest, TX; Laredo, TX; and Mesquite, TX, 9/30/21

Southeast District 2 Zone 2 and four selected vet centers in Clearwater, FL; Ocala, FL; Sarasota, FL; and Ponce, Puerto Rico, 9/30/21

Continental District 4 Zone 1 and four selected vet centers in Casper, WY; Denver, CO; El Paso, TX; and Midland, TX, 12/2/21

Pacific District 5 Zone 2 and four selected vet centers in Fresno, CA; High Desert, CA; Santa Cruz County, CA; and Honolulu, HI, 12/20/21

VA OIG Special Agent in Charge Discusses New Healthcare Fraud Division Mar 28, 2022

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Visit our website to learn more about the work of the VA OIG's Office of Investigations.

Report potentially unlawful activity or potential violations of rules or regulations; fraud, waste, and abuse; and gross mismanagement of VA programs and operations to the VA OIG Hotline:
Online: https://www.va.gov/oig/hotline/default.asp

Phone: 800-488-8244
Monday–Wednesday and Friday between 9:00 a.m. to 4:00 p.m. (Eastern Time) or Thursday between 9:00 a.m. to 1:00 p.m. (Eastern Time)

Fax: 202-495-5861

Mail:
VA Inspector General Hotline (53H)
810 Vermont Avenue, NW
Washington, DC 20420

VA Inspector General Interview: 86th Semiannual Report to Congress Mar 28, 2022

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The Semiannual Report to Congress summarizes the VA Office of Inspector General (OIG) oversight from April 1 through September 30, 2021.

For this period, the VA OIG identified over $2.9 billion in monetary impact for a return on investment of $29 for every dollar spent on oversight. This does not include the inestimable value of the healthcare oversight work completed to advance patient safety and quality care. The OIG hotline received and triaged 15,104 contacts in this reporting period, bringing the total to 29,233 for the fiscal year.

The Office of Audits and Evaluations (OAE) published 42 reports, including three VA management advisory memoranda highlighting issues for prompt VA response. Contract review teams also conducted 58 preaward and postaward contract reviews and six claims reviews to help VA obtain fair and reasonable pricing on products and services. OAE reports for the six-month period resulted in 184 recommendations.

The Office of Healthcare Inspections focused on veterans’ access to high-quality care and the continuity of that care even as the pandemic persisted. The VA OIG published 74 healthcare inspections and reviews during the reporting period with 559 recommendations. The reports included examinations of the criminal actions of a serial murderer and an intoxicated pathologist, including the devastating impact of these actions and how they went unaddressed for so long.

The Office of Special Reviews published a report that received significant national attention, detailing a case in which a veteran, who was missing for weeks, was found dead in a stairwell of a building on a VA medical facility campus. The report delves into the widespread confusion among VA personnel and weaknesses in policies and procedures related to searches for missing patients and residents, routine police patrols, and building-cleaning practices.

The Office of Investigations opened 169 cases and closed 207 (most of which were opened in prior periods), with efforts leading to 113 arrests. Collectively, the work during this period resulted in 729 administrative sanctions and actions involving VA personnel.

Review this report and previous semiannual reports to congress at the VA OIG website.

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