[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
EXPLORING VA'S OVERSIGHT OF CONTRACT DISABILITY EXAMINATIONS
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HEARING
BEFORE THE
SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
THURSDAY, NOVEMBER 15, 2018
__________
Serial No. 115-81
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Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
35-835 WASHINGTON : 2019
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COMMITTEE ON VETERANS' AFFAIRS
DAVID P. ROE, Tennessee, Chairman
GUS M. BILIRAKIS, Florida, Vice- TIM WALZ, Minnesota, Ranking
Chairman Member
MIKE COFFMAN, Colorado MARK TAKANO, California
BILL FLORES, Texas JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American ANN M. KUSTER, New Hampshire
Samoa BETO O'ROURKE, Texas
MIKE BOST, Illinois KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine J. LUIS CORREA, California
NEAL DUNN, Florida CONOR LAMB, Pennsylvania
JODEY ARRINGTON, Texas ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto
Rico
BRIAN MAST, Florida
Jon Towers, Staff Director
Ray Kelley, Democratic Staff Director
SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS
MIKE BOST, Illinois, Chairman
MIKE COFFMAN, Colorado ELIZABETH ESTY, Connecticut,
AMATA RADEWAGEN, America Samoa Ranking Member
JACK BERGMAN, Michigan JULIA BROWNLEY, California
JIM BANKS, Indiana CONOR LAMB, Pennsylvania
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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Thursday, November 15, 2018
Page
Exploring VA's Oversight Of Contract Disability Examinations..... 1
OPENING STATEMENTS
Honorable Mike Bost, Chairman.................................... 1
Honorable Elizabeth Esty, Ranking Member......................... 2
Honorable Phil Roe, Chairman, House Veterans Affairs Full
Committee...................................................... 3
WITNESSES
Ms. Elizabeth H. Curda, Director, Education, Workforce, and
Income Security Team, U.S. Government Accountability Office.... 5
Prepared Statement........................................... 21
Ms. Margarita Devlin, Principal Deputy Under Secretary for
Benefits, Veterans Benefits Administration, U. S. Department of
Veterans Affairs............................................... 6
Prepared Statement........................................... 25
Accompanied by:
Ms. Beth Murphy, Director, Compensation Service, Veterans
Benefits Administration, U. S. Department of Veterans
Affairs
Ms. Mary Glenn, Deputy Director, Compensation Service,
Veterans Benefits Administration, U. S. Department of
Veterans Affairs
Mr. Phillip W. Christy, Deputy Executive Director, Office of
Acquisition, Logistics, and Construction, U. S.
Department of Veterans Affairs
STATEMENT FOR THE RECORD
Veterans of Foreign Wars of The United States (VFW).............. 27
EXPLORING VA'S OVERSIGHT OF CONTRACT DISABILITY EXAMINATIONS
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Thursday, November 15, 2018
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Disability Assistance
and Memorial Affairs,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 10:30 a.m., in
Room 334, Cannon House Office Building, Hon. Mike Bost
[Chairman of the Subcommittee] presiding.
Present: Representatives Bost, Coffman, Radewagen, Esty,
and Lamb.
Also Present: Representative Roe.
OPENING STATEMENT OF MIKE BOST, CHAIRMAN
Mr. Bost. Good morning and welcome. This oversight hearing
of the Subcommittee on Disability Assistance and Memorial
Affairs will now come to order. Veterans who apply for
compensation may receive a disability exam. The purpose of the
examination is to determine if the veteran has a disability,
the extent of the disability, and whether the disability is
linked to his or her military service. In other words, the
medical evaluation is a key part of the VA exam process, and we
have an obligation to ensure that these exams are completed
accurately and within a responsible amount of time.
Some people may be surprised to learn that the disability
exam may not be performed by the VA employee. In the past
years, VA has been using independent vendors to carry out these
exams. From January 1, 2017, to April 2018, contractors
performed about 1 million exams, or about half of all
disability exams.
And in fiscal year 2017 and fiscal year 2018, VA actually
paid contractors $639 million and $919 million, respectively.
So given how important disability exams are, I was very
concerned when the GAO recently released a report that found
serious gaps in the way the VA is overseeing the contract
examiners.
As a businessman, I know that you have to stay on top of
contractors to ensure that the program is working as well as it
should. One of the biggest concerns is the -- and the most --
one of the biggest concerns, that most contractors are not
meeting the VA's quality goal of 92 percent accuracy. In fact,
GAO reports that quality scores for contracts rating -- ranging
from only 62 percent to 92 percent. Of course, that raises the
question of whether veterans are getting correct decisions if
the exams are not accurate.
GAO also says that VA does not have a way to verify whether
or not contractors are taking the required training, which may
explain why the quality of exams is so low. Now, that isn't to
say that the vendors wouldn't welcome feedback on how they can
improve service to veterans. I am almost -- but I am also
frustrated that GAO found that the VBA could not accurately
measure whether contractors are meeting timelessness goals.
Providing exams within a reasonable time frame is very
important to the compensation-claims process. Unnecessary
delays in scheduling exams force veterans to wait longer for
decisions and add to the backlog. According to VA, it did not
have the staffing and IT needed to effectively oversee the
program. I am concerned the VA chose to expand a potentially
$6.8 billion program without having the necessary controls in
place to hold the vendors accountable.
The contract specifically -- hold on.
The contract specifically -- financial incentives are
penalties for the vendors based on their performance. However,
last year, VA did not have the resources required to timely
verify the contractors' invoices for accuracy, much less
quality. It is unfair for veterans and taxpayers to pay the
price of a potentially mismanaged program. That being said, we
don't know what this is, in fact, a mismanaged program. The
issue -- if this program is mismanaged, the issue is, the VA
does not have the data that Congress needs to make such a
determination.
I know the VA set up an exam program office to improve
oversight of contractors. I am interested in learning more
about how this office will help improve contract exams, as well
as getting an update on the VA's progress in implementing GAO's
recommendations. Again, I want to thank everyone for being
here.
Now I would like to turn to our Ranking Member for any
opening statements she might have. Ms. Esty?
OPENING STATEMENT OF ELIZABETH ESTY, RANKING MEMBER
Ms. Esty. Thank you, Chairman Bost. I want to thank you
very much for calling this hearing today, and for taking the
lead in requesting the GAO report, which is the basis of this
oversight hearing of the VA's contract medical examination
program.
Well before I joined this Committee, I was involved with
improving the medical evaluation system used by the VA to
determine a fair level of compensation for veterans who are
injured, or made ill as a result of their military service. I
heard often from veterans in my home State of Connecticut that
their lack of faith in the medical evaluations they received
was a major reason why they filed appeals.
In the past, veterans would tell me that the outside
doctors who they saw for evaluation sometimes didn't appear to
have the necessary understanding of their illness or injury to
make a valid medical determination. And they also described
that -- a feeling of being, frankly, pushed around by the
bureaucracy. For example, people were sent from rural
Connecticut to New York City for an exam which fit within the
VA's mileage criteria, but didn't take into account the
transportation difficulties for an elderly, World War II
veteran in rural Connecticut to make it in the middle of winter
for an exam.
Others had the experience of having the three required
notification phone calls, all received on the exact same day,
to provide them notice of when their exam is. Again, those are
the sorts of frustrations that we received.
Over the last couple of years, VBA has worked to create a
new system that veterans can have more faith in. In order to
get the exams they need to support their claims, the use of
outside contractors has increased to the point that about 50
percent of all of the medical exams are being done by outside
contractors at this point. We applaud the progress VBA has made
in timeliness and efforts towards improved quality, and I
invite the program directors here today to describe that
progress, especially in timeliness. Nevertheless, the GAO
findings that the training doctors are supposed to receive is
not always verified independently, concerns me.
I am also concerned about whether veterans travel
reimbursements are being tracked and accounted for by VBA. This
is a particular issue we have heard about involving contract
exams, and whether those reimbursements actually ever reach the
veterans as intended.
And, of course, this Subcommittee is always concerned that
the IT infrastructure necessary for this key element of the
disability compensation claims process is up and functioning
well.
So while we all applaud VBA's progress, it is our job to
ensure that the system is being managed to a standard that
earns veterans' trust and doesn't leave them feeling as if they
are a profit center for outside contractors. They should be
treated as heroes. So, thank you to our witnesses for their
commitment to veterans and for being here on this snowy
morning, which we did not all anticipate. I look forward to
hearing your testimony, and with that I yield back.
Mr. Bost. Thank you.
I also want to welcome Full Committee Chairman, Phil Roe,
to this hearing. Chairman Roe, would you like to say a few
words?
OPENING STATEMENT OF PHIL ROE, CHAIRMAN, HOUSE VETERANS AFFAIRS
FULL COMMITTEE
Mr. Roe. Thank you, Mr. Chairman and Ranking Member Esty,
for holding the hearing, I appreciate that. And one of the
priorities as Chairman of the House Committee on Veterans'
Affairs is ensuring the Nation's veterans receive timely and
accurate compensation decisions. Timely and accurate disability
exams are a key input into those decisions.
Some of you may not know that in 1996, Congress approved
the use of contract examiners to allow VHA to focus more on its
resources of treating patients and to expedite the scheduling
of disability exams. And that is to be commended because the VA
is short-staffed now. So I think that was probably a good move.
As Chairman Bost pointed out in his statement, since
Congress originally authorized the pilot program, the
Department has dramatically expanded both the size and cost of
the program. While it is important for VA to schedule
examinations in a timely manner, it is equally important that
contract examiners are rendering accurate and consistent
medical opinions.
For these reasons, when I first became -- came on as
Chairman as of the Full Committee, I immediately requested that
GAO investigate whether VA is effectively overseeing contract
exams.
When I reviewed the report, I was incredibly frustrated to
learn that VA does not have procedures in place to monitor a
program that is vital to providing the medical information
needed to decide veteran claims. Moreover, of the last 2 fiscal
years, the contract exam program cost almost $1.6 billion, and
the VA cannot timely verify if contractors are charging the
correct amount.
As a physician, I know that my medical practice would not
have succeeded if I were unaware of whether my patients were
receiving quality and timely care. Unfortunately, VA hasn't
been collecting information necessary to assess whether the
contract exams are satisfactory, and to hold the vendors
accountable if not.
Congress needs this information to determine if the
contract examiners are effectively serving veterans, and to
ensure that the program is a wise use of taxpayer funding.
Today I am interested in hearing how the VA is addressing the
GAO's recommendations to improve how VA evaluates contractor
performance.
For example, GAO suggested that VA develop and implement a
plan for how we use EMS to oversee the contractors. I am
looking forward to hearing from VA about how the Department
intends to use EMS in a way that will prevent -- will benefit
veterans while holding vendors responsible for any delay or
inadequate exams.
Additionally, I am concerned by GAO's findings that VA does
not monitor the adequacy of its training for medical examiners.
If VA's training is not sufficient, then examiners may render
an inaccurate medical opinion, which could result in a rater
denying a veteran's claim.
Ultimately, I am committed to ensuring that the men and
women who served our country receive the benefits that they
have earned, and I am looking forward to hearing from today's
witnesses about ways to improve VA's oversight of contract
exams.
And, again, Chairman Bost, I appreciate you holding this
hearing, and I yield back my time.
Mr. Bost. Thank you, Mr. Chairman.
I want to welcome all the witnesses who have joined us here
this morning, and thank you for taking the time out of your day
to be here. Joining us from the VA is Ms. Margarita Devlin, who
is the Principal Deputy Under Secretary for Benefits. She is
accompanied by Ms. Beth Murphy, the Director of Compensation
Services for VBA. Also with Ms. Mary Glenn, the Deputy Director
of Compensation Services for the VBA, and Mr. Phillip Christy,
the Deputy Executive Director of the OALC.
Also joining us today is Ms. Elizabeth Curdy -- Curda --
I'm sorry -- the Director of Education Workforce and Income
Security Team for GAO.
We want to welcome all of you, and I want to remind the
witnesses that your complete written statement will be entered
into the hearing record. I want to make sure -- Ms. Curdy -- or
Curda, I have done that twice to you, I apologize -- you are
now recognized for 5 minutes.
STATEMENT OF ELIZABETH H. CURDA
Ms. Curda. Chairman Bost, Ranking Member Esty, and Members
of the Subcommittee, thank you for inviting me to discuss GAO's
findings on VBA's oversight of its contracted examiners.
In addition to VHA physicians, VBA relies on private
physicians via contracts to examine veterans who claim benefits
for a service-connected disability. Between 2012 and 2017, the
number of exams completed by contracted examiners more than
tripled to about 600,000, and currently accounts for about half
of all exams. All told, VBA awarded five private firms
contracts that are worth up to $6.8 billion over 5 years.
Today, I will highlight the findings and recommendations
from our recently issued report in three areas: First, what is
known about the quality and timeliness of VBA contracted exams;
second, the extent to which VBA monitors contractors'
performance; and, third, how VBA ensures that its contractors
provide qualified and well-trained examiners.
Regarding the first area, VBA lacks accurate and complete
information on whether contractors are meeting the agency's
quality and timeliness targets. As of last summer, VBA staff
had not completed reviews of the quality of the contracted
exams for the latter half of 2017. Of those that VBA had
completed, the agency reported that almost all contractors
missed VBA's quality target of 92 percent in the first half of
calendar year 2017, with scores ranging from 62 to 92 percent.
Further, VBA could not accurately assess the timeliness of
the contracted exams. Per the contracts, VBA should measure
timeliness as the amount of time it takes for a contractor to
complete and submit the initial exam report, and exclude any
time taken to make corrections. However, VBA systems did not
accurately capture the date that corrected exams were initially
reported.
Although the timeliness data could not be used to assess
contractor compliance, we analyzed the data on all contracted
exams completed between February 2017 and January 2018,
including the corrected ones. We found that about half of the
exams completed were done within the general 20-day target,
while the other half exceeded 20 days, and 12 percent took more
than twice as long to complete.
VBA officials told us they planned to hire additional staff
by the end of fiscal year 2018 to complete the remaining
quality reviews. In addition, VBA officials said their new
information system would more accurately track contractor
timeliness. However, at the time of our review, the system was
not yet producing accurate data.
Regarding the second area, on monitoring contractors, VBA
identified and addressed some contractor issues, such as delays
in completing specific exams. However, VBA lacked adequate data
and plans for overseeing contractors' overall performance. For
example, without sufficient quality and timeliness information,
VBA could not apply financial penalties for exams needing
correction or for contractor performance that did not meet
timeliness or quality targets.
Further, VBA has not conducted any comprehensive analyses
that would allow it to identify and address higher-level trends
and program-wide challenges. For example, such analyses could
identify challenges in conducting exams across different
contractors, geographic regions, exam types, or other relevant
factors.
To address these issues, we recommended that VBA develop
and implement a plan for using data from the new exam
management system to regularly monitor contractor performance.
We also recommended that VBA regularly assess aggregate
performance data, higher-level trends and program-wide
challenges. VA agreed with these recommendations.
Finally, regarding examiner qualifications, we found VBA
had systems in place to check that examiners had proper
credentials, such as licenses, to perform exams. However, VBA
lacked information it needed to verify that contracted
examiners had taken required training. Instead, the
contractor's self-reported this information.
VBA also lacked plans to evaluate the quality of the
training it provided to examiners, to ensure that they are able
to provide high quality exams and reports. This is particularly
problematic given the low-quality scores VBA gave to many of
the contractors.
To address this, we recommended that VBA implement a way to
verify that contracted examiners have completed required
training. We also recommended VBA assess the effectiveness of
its training and make improvements as needed. VA agreed with
our recommendations.
In summary, we found that several gaps in the information
VBA needs to effectively manage and oversee contract
performance. As VA continues to rely on contracted examiners,
it is important that the agency is well-positioned to carry out
effective oversight of contractors to help ensure that veterans
receive high quality and timely exams and contractors are paid
correctly.
This concludes my prepared statement, and I will be happy
to address the Subcommittee's questions.
[The prepared statement of Ms. Curda appears in the
Appendix]
Mr. Bost. Thank you, Ms. Curda.
Ms. Devlin, this is your first time testifying before the
Subcommittee. We thank you for being here, and you are
recognized for 5 minutes.
STATEMENT OF MARGARITA DEVLIN
Ms. Devlin. Good morning. Thank you, Chairman Bost and
Ranking Member Esty, and Members of the Committee. We
appreciate the opportunity to come and speak to you about our
contract medical disability examination program, or MDE. I
would like to take a moment to just provide an overview of our
MDE program. VBA requests a disability exam or a medical
opinion when necessary to adjudicate a disability claim for
disability or pension, commonly referred to as C&P exams.
For a decade, VA relied only on VHA to provide these exams.
Then in 1996, as you mentioned, Congress provided VA the
authority to contract exams using the mandatory fund. VA began
using this authority in 1998, which was originally limited to
10 regional offices. After 16 years, the statutory authority
was extended to 12 regional offices in fiscal year 2015 and in
2016, as many regional offices as the Secretary deemed
necessary, starting in fiscal year 2017.
Claims processors at VBA's 56 regional offices now can use
an online tool, enabled by real-time data, to assess by exam
type if VHA has the capacity to conduct the exam, and if not,
to direct that exam to a contract vendor.
VBA's current contract is structured in five districts
across the continental United States, with two vendors per
district. There is also an overseas contract -- or overseas
district served by one vendor, and an additional district with
one vendor serving our transitioning servicemembers who go
through our pre-discharge program such as benefits delivery at
discharge, or BDD, and integrated disability evaluation system,
or IDES.
VBA's contract vendors have also begun conducting exams for
incarcerated veterans where the prison systems will allow us
in. Over 1.3 million veterans or servicemembers received C&P
exams in fiscal year 2017, with vendors fulfilling more than 45
percent of those requests. For fiscal year 2018, vendors
performed nearly 60 percent of the 1.4 million exam requests
completed. This included more than 14,000 veterans and
servicemembers overseas, where VHA has no footprint and our
contract vendors are the only method to provide this service.
The total cost over the last 2 fiscal years for contract
vendor exams, including the ancillary support contracts, were
approximately $765 million in fiscal year 2017, and $896
million in fiscal year 2018. Each exam request can contain one
or more disability benefits questionnaires, or DBQs. The
average number the DBQs per exam request is between three and
four.
After the award of VBA's contract in 2016, there were
multiple protests and an appeal of the award in the five
continental U.S. districts, followed by contractual ramp-up
time periods. Based on these events, the evaluation period for
Districts 1 through 5, did not begin until September 27th, of
2017. To ensure seamless service to veterans, VBA relied on a
series of bridge contracts as necessary to avoid any gap in
service. VBA anticipates continuing to use these bridge
contracts until December of 2018.
Execution of the current MDE contracts was impacted by many
unforeseen challenges, including the award protests I just
mentioned, one nonperforming vendor who is no longer working
under contract for VBA, and system limitations for managing
exam requests. These issues have since been resolved.
Also VBA worked with our industry partners to modify the
contracts more than a hundred times to enhance service delivery
to veterans and servicemembers.
VBA concurs with the recommendations in the report released
this week by the Government Accountability Office. As stated in
the report, GAO reviewed timeliness and quality data through
February of 2018. The GAO findings validate the issues VBA was
already working on, and VBA has already implemented many
improvements. For example, our exam management system is fully
operational, and we are on track to finish all of our quality
reviews.
Also, I am pleased to announce that the contracting officer
is sending out today, for signature and award, the new
contracts for Districts 1 through 5, with updated terms based
on all the lessons we have learned and our current business
needs.
VBA appreciates the authority provided by Congress to
obtain contract exams to supplement VHA's capabilities. The MDE
program enabled VBA to obtain the necessary evidence in
deciding 1.4 million disability rating claims in fiscal year
2018, in an average of under a hundred days processing time
with 95 percent quality. This would not have been possible if
we had to rely only on VHA's capacity.
VBA is committed to continuous improvement of the MDE
program. We know how important it is to get this right for
veterans.
Mr. Chairman and Ranking Member, this concludes my
statement. My colleagues and I welcome any questions that you
have.
[The prepared statement of Ms. Devlin appears in the
Appendix]
Mr. Bost. Thank you. And you hit that right on 5 -- for
this, your first time, you hit it right on 5 minutes. That was
really good. But I am going to start with questioning. I am
going to allow myself 5 minutes if I can.
Ms. Curda, please provide your perspective on the extent to
which VBA was adequately prepared to manage and oversee the
contract exam program once the contracts were put into place in
the summer of 2017.
Ms. Curda. Overall, we found that VBA was not prepared to
manage the contractors and provide adequate oversight at the
time. Early on, we found that some contractors did not have the
capacity to do the exams that were assigned to them and had to
be reassigned.
There were, as I mentioned earlier, some problems with the
quality of the exams, and the systems that VBA was using at the
time could not provide accurate timeliness information which is
necessary to execute and monitor the contracts.
And some of the causal factors I mentioned in my oral
statement, that there were inadequate number of staff in the
program management office to oversee the contracts, both in
terms of quality reviewers and contractor-officer
representatives. And as I mentioned, the system at the time was
not producing accurate timeliness data.
Mr. Bost. Ms. Devlin, has VA exercised any physical --
fiscal incentives or penalties to contractors based on their
quality or timeliness performance?
Ms. Devlin. We have not.
Mr. Bost. Okay. Can you tell us if there are any new plans
in place -- first off, why not?
Ms. Devlin. I will defer to our acquisition colleague here
to answer that.
Mr. Christy. Hi, good morning. To pick up that, the one
contractor that did not perform, we did go through a settlement
to mitigate the nonperformance there, but no incentives or de-
incentives were made. We did do the settlement to make sure
that the work that needed to be done, that they did not do, was
picked up by the other contractors. And they were required to
pay that -- that amount to make sure that that work could be
done. Once those other contractors picked up, the contractor
did not perform, was just, through the settlement, no more work
was provided to them, and that contract ended for them.
Mr. Bost. So, Mr. Christy or Ms. Devlin, either one, so
what are we -- what are our plans in the future to make sure
that we actually have penalties and have those things in place
to make sure they are doing the timeliness and all of the
things that are required under the contract?
Mr. Christy. I will answer from the procurement side very
specifically. So both the current contracts and the ones that
are being awarded this morning, have incentives and de-
incentives in them for timeliness and quality. The procurement
vehicle itself, the contract has that built into it. I will
defer now to the program, and I think they are going to talk to
you about the things that have gotten better and improved over
the last year, and I think that has been a good teaming
arrangement, actually, between industry, program, and the
procurement folks.
Go ahead and I will let you finish that good-news story
there.
Ms. Devlin. Yes, thank you for the question. First of all,
we are almost caught up on our quality reviews and have
submitted many of them to the acquisition office for review.
Secondly, I would like to point out that while we had not
submitted those reports at the time of the GAO report, we had
been conducting reviews and having feedback sessions with our
contractors on a regular basis. We issue memorandum with
guidance memos on a routine basis, based on lessons learned,
based on the quality reviews that we have done.
In addition, with the new contract, we were able to staff
up our business office to the 17 people. We have got two left
to get on board so that we can conduct our quality reviews in a
timely manner and get any feedback to the contracting office as
quickly as we can.
Mr. Bost. Just real quick, because I am going to run out of
time, I am afraid, but what are you doing as far as, from here
on out, to do the proper audits, to make sure that we know and
you know that the contractor is doing everything they are
supposed to be doing?
Ms. Devlin. We actually have another contract that comes in
and does invoice audits as well. And in addition to those --
because we are now staffed appropriately to conduct the quality
reviews, we will do those quality reviews in a timely manner
and get them to the contracting office and then take any
actions, both related to incentives or disincentives, in a
timely manner. And I would like to, if it is okay, allow my
colleagues to elaborate.
Ms. Murphy. Sir, I just wanted to add that our new exam
management system, EMS, which is now functional, has that
automatic invoicing, auditing, built in, so that we are able to
do a better job going forward, validating the invoices.
Mr. Bost. I am out of time, so I am going to go ahead and
yield to the Ranking Member, 5 minutes.
Ms. Esty. Thank you, and I want to thank the witnesses for
joining us here today.
Quick question for Ms. Devlin. Do you feel, with 17 full-
time equivalents who are now about to be on boarded, will that
be a sufficient number to do the kind of oversight and review
that we need? Do you believe that is a sufficient number?
Ms. Devlin. Yes. Based on our estimates, we believe it is.
Ms. Esty. All right. I think we will be revisiting that in,
you know, 6 months' time to verify if, in fact, it is, because
we all want to be providing the resources necessary, and if
that proves not to be, then we need to know that and not wait
for another GAO report.
I am interested about, I am looking at the testimony that
we received today about concerns about this process. So I want
to know if the VSOs are part of that feedback loop. There ought
to be continuous improvement in this process on both timeliness
and quality. And the people on the front lines, you have 17
full-time equivalents who are supervising the program. We have
thousands, probably tens of thousands of VSOs around the
country. They can, and should be, eyes and ears about what is
going on. How are they involved with you in ensuring that you
are getting on-the-ground feedback about timeliness and
quality?
Ms. Devlin. That is a great question. We collaborate with
our VSO partners regularly, and on this topic, as well as other
topics, we have quarterly training sessions with our VSOs where
we talk to them about various initiatives. And we have talked
to them about the MDE program in particular, to make sure that
we are explaining to them where we are in the process and to
get feedback from them about what they are hearing on the
ground.
In addition to the quarterly training sessions, we have
regular meetings with the Under Secretary for Benefits and
VSOs, as well as other meetings at the staff level.
Ms. Esty. Thank you. I want to, again, because, to
highlight from the written testimony today, the VFW listed five
major concerns they are still seeing: late notification of
exams, and I mentioned that; lack of options for veterans to
reschedule exams, that can be important, depending on health,
transportation, weather; lack of availability of adequate
examiners within a reasonable distance from the veteran; no
adequate review of the veteran's claim filed prior to the exam.
I can tell you personally I have heard about that from folks in
my district, that they did not get a review sufficiently ahead
of time; and inadequate time for providers due to the volume
and the pressure and turnaround time.
So those are the specific issues we are concerned about,
and that goes to the totality of the experience. I have a
specific question, though, on the ``20-day within the system,
30-day outside of the system'' timeliness criteria. We want it
to be timely, but even more important, it has to be accurate.
If it is not accurate, people are going to file claims, and
they should. That will slow down the whole system, gum up the
works, cost money, and lead, most importantly, to veterans not
trusting the results.
So what do you -- do you feel that those are reasonable
time goals? And if not, you know, how are we going to make a
determination? Because we are hearing someone anecdotally, I
can say, I am hearing from VSOs, they do not want to be a slave
to that 20- or 30-day time period. So I want to make sure we
are not measuring the wrong metrics and losing something more
important, which is faith and quality in the system.
Ms. Devlin. Thank you for that question. I would like to
start and then allow my colleagues to elaborate. We take
quality very seriously. And as I indicated, our disability
claims quality is at 95 percent for the end of the fiscal year,
and, of course, the disability exams are part of that process.
So I feel confident in the quality of our disability-claims
decisions.
With respect to the quality of the exams, I did want to
point out that when we review for quality, we review a
combination of technical accuracy and administrative accuracy.
So when you look at the statistics provided in the GAO report,
I would just like to point out that some of that includes
errors based on administrative procedures.
For example, if the provider failed to put their license
number on the DBQ, or on the report, or if they failed to check
a box of something that is administrative and not related to
the disability exam itself, those are counted as errors as well
and will be reflected in the scores. We do take quality very,
very seriously. I will allow my colleagues to discuss the 20-
day time frame.
Ms. Murphy. I did want to elaborate on a couple of the
points she made. I saw in the VFW testimony, I am pleased to
say that they are hearing frequent positive comments about the
contract, and it is important to note, they are a key piece of
our oversight. They are partners with us. Mary and I meet with
them regularly, and we always emphasize that it is important
that if they hear individual, specific situations of the nature
you described, we want to hear about that. And they do funnel
those to us and we follow-up on every single one.
As far as the timeliness goals, I understand your concern,
and we share that concern. We want to make sure we are doing,
not only a timely job, but also a quality job. Because that is
what is important, and that is how we best serve veterans. We
have taken that into account.
I think another thing that is important to going forward is
that under this new contract, we have done the research and the
homework, done the analysis, including with VHA partners, on
how better to balance rural and urban areas within the
districts, which will enable the vendors to set up a healthier
infrastructure footprint, and then that can help them meet the
timeliness measures as well.
Ms. Esty. Thank you, and I am over time.
Thank you.
Mr. Bost. Thank you.
Chairman Roe?
Mr. Roe. Thank you, Mr. Chairman.
To follow along with what Ms. Esty was talking about, I
would like to know how you -- if I am doing the disability
claim for VA, how do you train me? And then how do you assess
that I am doing a quality exam?
Ms. Glenn. Yes, sir. We use the same training methods that
VHA does. We use the same training materials that they do. We
also have an additional training --
Mr. Roe. I mean, do I do an online class? Do you come to my
office? Or what do you do?
Ms. Glenn. It has been somewhat of both of those things. We
have used train-the-trainer method where we pulled the vendors'
training officers together in one location and trained them. We
have online materials that they use. So we use whatever
training method works and makes sense for whatever the topic
is.
Mr. Roe. And then to measure the quality, how do you do
that? And I agree with Ms. Devlin, if you miss checking a box,
that is not really an issue about the quality exam that you
gave. And I do understand why you need -- the VA needs help to
evaluate 1.4 million claims. You just don't have the internal
capacity to do that, I don't think. You barely have the -- I
mean, 35 percent of the health care the VA provides outside
now. I know they don't have the capacity to see all those
patients in addition.
Ms. Glenn. So, sir, when we do our quality reviews, if you
are talking about how do we maintain quality for --
Mr. Roe. How would you evaluate me, to know that I am
providing quality care?
Ms. Glenn. When we do our quality reviews, if we notice
that there is one specific doctor or one specific vendor that
continues to have problems -- and this is something that we do
track -- we notify the vendors and --
Mr. Roe. Well, what is a problem? That is where I don't --
when you say that, what does that mean?
Ms. Glenn. That they did not fill out the form correctly.
Mr. Roe. Okay.
Ms. Glenn. They gave inadequate information, that the DBQ,
the disability benefits questionnaire that they completed was
not adequate for rating purposes.
Mr. Roe. Okay. The other thing, I guess, once again, we are
back to IT, and anecdotally, as Ms. Esty was talking about, I
ran into a man on Veterans Day -- you run into a lot of
veterans on Veterans Day, but this fellow was asked to go get a
hearing exam 2 hours' drive up into southwest Virginia for his
disability claim, when we have one of the best hearing
departments right there in Johnson City at Mountain Home
Medical Center. He finally got it fixed where he didn't have to
drive essentially 4 hours to get this disability. Those are the
kind of things, I think, that people also get upset about, is
when they know they can have the exam right there if they can,
instead of going 2 hours.
And I think if I were a veteran, and I were given the
option, hey, you can wait a month to get seen here locally, or
you can drive in 2 weeks, 2 hours one way, I would just wait
the couple of weeks. I hadn't been able to hear for 30 years,
so why would I care about 2 more weeks? So those are the kind
of commonsense things, I think, that we need to do.
The other question I want to ask -- and this is one that
goes to, not just this particular part of VA, but we had a
hearing yesterday, we are going to have another one on the GI
bill later today -- is that, why would you expand this to all -
- other than I understand the need to get these done -- to all
56 ROs when you didn't have the IT to evaluate what GAO said?
Why would you expand a program until you had the systems in
place to adequately see if I am doing it in a timely fashion
and I am doing quality work? Why would you do that?
Ms. Murphy. So, great question, sir. Mary and I came on to
this program in about the middle of 2016, and the plans were in
place for the IT infrastructure and the program requirements
going forward. There was a protest to the original award. It
happened in March 2016, and it was over a year that we were on
a stop-work order. During that time frame, we were anticipating
that the system would be built out and we would be testing with
those vendors. That stop-work order hindered our ability to
work with these vendors to test adequately and get the system
on track on time. So, there were some delays for that reason.
We have ramped up, worked with those vendors, who have been
great partners to us, and we are in place now, going forward,
to be able to use that system effectively.
Mr. Roe. So you think you can monitor what you need --
Ms. Murphy. Yes, we can.
Mr. Roe. -- to monitor going forward? Okay.
Ms. Murphy. Yes, sir.
Mr. Roe. And I heard also that you feel like, by the end of
the year, you will have the staff and the IT. So as Ms. Esty
said, 6 months from now, we have this hearing again, we are not
going to hear the same thing again. Am I -- I want that on
record, we are correct in hearing that?
Ms. Devlin. That is correct.
Mr. Roe. Okay. I yield back.
Mr. Bost. Mr. Lamb, you are recognized for 5 minutes.
Mr. Lamb. Thank you, Mr. Chairman.
This is a question, I think, for anyone from the VA. In
Pittsburgh, Pennsylvania, near where I am from, our VBA is a
primary site for processing claims from overseas. And I was
just hoping you could fill me in a little bit on how monitoring
and overseeing the contractors for contracts that do overseas
claims might be different, or any of the specific issues you
have seen there.
Ms. Glenn. We do work very closely with the vendor who has
the overseas contract, and as far as the monitoring goes, they
are still held to quality and timeliness standards, which are
written into the contract. We also receive feedback from our
VSO partners and from the Pittsburgh regional office, as well
as anybody else who comes to VA and has a problem.
As far as I know, our overseas operations have been in
place, and, in fact, we added six more additional sites in
fiscal year 2019.
Ms. Murphy. And, Congressman, if I could add, it just so
happens, about 10 years ago, I was director of the Pittsburgh
regional office, and I know firsthand the struggles that we had
at that time in getting exams done overseas. We would work with
VHA, embassies, State Department, to try to get some solution
for exams overseas and it was very difficult.
Last year, we did about 7,000, almost 8,000 exams, through
the contract for overseas veterans, and this year, it has been
about 14,000. So it really is a solution we have never had
before.
Mr. Lamb. So the -- you are saying that the use of
contractors recently has made that easier for the overseas --
Ms. Murphy. Absolutely.
Mr. Lamb. Okay.
Ms. Murphy. The timeliness has improved. We are not
struggling and looking for alternative solutions, like next-
best solutions. We are actually being examined by people who
know how to do these exams.
Mr. Lamb. Do you -- and this is -- Ms. Curda, too, you can
answer this. I don't know who would know, but have you noticed,
is there any -- is the performance of the contractors doing
overseas examinations any better or worse when it comes to
quality and timeliness? Was that something you all looked at?
Ms. Curda. In terms of timeliness at the time of our
review, there were similar issues as the other domestic
districts. On the qualitiness -- I am sorry -- quality part of
it -- yeah, they had slightly higher scores.
Mr. Lamb. Okay. Now, when it comes to having VA doctors do
the exams, you know, in a community like ours, we are lucky to
have two VA hospitals that are in pretty close proximity to a
lot of people. So that would be kind of the best option. Would
you agree that the VA doctors, because of their skills, their
training, their experience, and also just their awareness of
veteran culture and personality and the experience, would you
agree that they tend to be a better option than the contractors
themselves?
Ms. Murphy. I think with 8,000 examiners on the contract
side, and with several hundred or a thousand on the VHA side,
that is difficult to answer, just as a generality. I know that
VHA is very committed in its mission, and our vendors are
committed in their mission as well. We use the same training
materials, as Mary said earlier. We do consult with VHA
regularly to help with our exams. So there is a good
partnership there.
Mr. Lamb. As far as making sure that the contractors have
the same kind of cultural awareness as the VA doctors, are they
VA doctors that are providing the training, or have you
contracted out the training as well?
Ms. Glenn. One of the pieces that is different for the --
the vendor training as opposed to VHA training is, we provide
and we have the vendors familiarize all of their subcontractors
with VA culture, with our benefits. They go through a whole
training program about VA benefits and the importance of
serving veterans and how we are all committed to making sure
that veterans get accurate and timely examinations in order for
their claims to be processed.
Mr. Lamb. Okay. But my question is, who is training the
person who does the exam? Is it a VA doctor? Or is a contractor
doing the training of another contractor?
Ms. Glenn. The contractor is doing a training with another
contractor, usually, using VA materials.
Mr. Lamb. Okay, thank you.
Mr. Chairman, I yield back.
Ms. Murphy. And if I could add, very specifically, we
expanded our contract in the last year so that vendors could
help do medical opinions for Camp Lejeune contaminated water
cases. We specifically had the VHA folks come with us and train
the examiners for those vendors.
Mr. Bost. The gentleman yields back. Thank you.
Mr. Coffman?
Mr. Coffman. Thank you, Mr. Chairman.
And I think, Ms. Murphy, you said that there were plans in
place with an effective date for the implementation of these
contracts. But you also said that -- that you all knew prior to
that implementation date that the IT system wasn't ready. Then
why did you all go forward with this?
Ms. Murphy. So that was a little before my time. I am not
up to speed on all of the decisions and the analysis that
happened ahead of time. I can only speak to what Mary and I
observed when we took our positions, and going forward. We made
sure that every twist and turn that hit us, with the protests,
with the systems, with the staffing, that we addressed that and
moved forward.
Mr. Coffman. Ms. Curda, could you answer that? I mean, why
did they move forward when the IT system wasn't ready?
Ms. Curda. I don't have an explanation because, you know,
we got our information from Beth. She wasn't there, so we don't
know prior to that.
Mr. Coffman. Can anybody answer that question?
Ms. Murphy. I think, to the best of my knowledge, it was
the fact that there was a plan in place, that they would
synchronize their release of the original contract with the
system. And then because of the protests and the stop-work
orders, we couldn't engage with the contractors for building
that out and testing, it delayed things by about a year.
And then once the protests and appeal period were over, we
are into June 2017. Then we had the ramp-up of 90 days for the
new vendors. It was the beginning of fiscal year 2018 before we
were up and ready to start measuring.
Mr. Coffman. It still makes no sense. It still absolutely
makes no sense. When you didn't have the systems -- the
adequate systems in place, that brought us to this situation
today, that you still moved forward. And nobody can answer,
really, give an adequate answer as to why.
Ms. Murphy. Well, I think it is important to remember that
VHA did not have the internal capacity to do these exams in a
timely manner. We are here to serve veterans in a timely and
quality way, and these contracts have been in place for 20
years. We had experience with this, and we were working through
the ramp-up the best we could. There were a lot of lessons
learned during that ramp-up period of this new contract. And
the protests are behind us, the systems are in place, the
staffing is in place. We are well-poised to do this
appropriately going forward.
Mr. Coffman. Well, you haven't done it appropriately yet.
I yield back.
Mr. Bost. Thank you.
Ms. Radewagen?
Mrs. Radewagen. Thank you, Mr. Chairman. I have a question
for Ms. Devlin.
As you know, VA has been using contract exams since 1998.
Now, I realize that you only came on board in 2016, but do you
have any idea why VA waited until 2016 to establish a contract
exam office?
Ms. Devlin. Thank you. I actually have been in the VA for
23 years, but in my current position since May of this year. I
cannot answer to the decisions going back multiple years. What
I can tell you, though, is that it was only, I believe, in
2017, that we received the authority to conduct contract exams
in all regional offices. Up until then, it was merely a pilot
program.
And I also want to kind of put some context around the IT
system. When developing an IT system that is going to be used
with contractors, of any type, we would build, with our IT
folks, the preliminary product, but the key ingredient is
enabling the contract vendor, through their IT systems, to
connect to ours. The only way to fully, sort of, complete the
system is to have contract vendors in place who help us test.
And so that was the delay that was described by Ms. Murphy as
to why we didn't have the systems in place. We had the
preliminary IT development complete, but the inability to
interact with our vendors to do the testing did not enable us
to finish that last step.
Mrs. Radewagen. So when EMS was deployed, it was not fully
interoperable with the contractors' IT systems?
Ms. Devlin. That is correct.
Mrs. Radewagen. How many claims were affected by this
issue? Ms. Devlin?
Ms. Devlin. As I understand it, no claims were affected
directly. Any exams that did not go to the contract vendor
correctly were pulled back and manually reassigned to another
contract vendor. The system was basically getting exam requests
stuck when we first deployed, and we were manually unsticking
those exam requests so that the veteran did not suffer, because
the exam would still be completed, and they would get their
rating decision completed.
Mrs. Radewagen. So what short- and long-term steps are you
taking to ensure that exams are not getting stuck in EMS? You
may have partially answered it already, but -- Ms. Devlin?
Ms. Devlin. We have made multiple fixes to the system with
our IT partners. In fact, all of the fixes to the system that
have been completed to date have tested well, and we have been
able to point forward, assure that no other exams will be
stuck. Those problems have been fixed. We still have a few
exams in the system that we are manually rerouting, but point
forward, the system is now fixed.
Mrs. Radewagen. Thank you, Mr. Chairman.
I yield back.
Mr. Bost. Thank you.
We are going to go a second round of questioning, because
there are some things I feel like we really need to get to,
that need to be on record, and vitally important to this issue.
And so I want to tell the Members that if they have other
questions, that they will get that the other time.
Let me go back, when we were talking about the audit and
what could be done. And Mr. Christy, this is specifically to
you. What resources is realistically available to the VA and if
the VA finds that, as a result of the audit, the Department was
overcharged, given that those at the MSLA invoices have already
been paid, what are the options to draw back on that
overpayment if they are there?
Mr. Christy. Right. And so with these audits, the fact
pattern will kind of -- really kind of tell a story, and with
our legal counsel we will look at that. It is kind of a -- a
tough situation to give you exact details without actually
having the facts, so that we can work through that with our
legal counsel.
As we talked about yesterday, as the reports are now
starting to come in and we start looking at that data, I think
there will be challenges on the government side for the work
that was already paid for in the previous submittals, but there
are remedies there that we could explore. But we are still
trying to adjudicate that data.
Mr. Bost. And that is the problem when we are all asking
the questions and why we are -- and I know it happened before
you were there, I understand that. But there is three things --
two things, really, that are vitally important. One is, three,
the timeliness and the quality of the exam. But also, we have a
fiduciary duty, and that fiduciary duty, it falls, falls, falls
on you. And that is, that if all of a sudden we continue to let
a train run down the track without the ability to implement the
drawbacks and/or audit of those people who are private
contractors providing a service, and now we are, all of a
sudden, coming back later, and the legal problem we are going
to have to try to get back the money that the taxpayers gave,
and gave probably in a situation where the people weren't doing
their job correctly.
Mr. Christy. This will be a challenge. The good news, as I
have mentioned, as was mentioned this morning, new awards are
literally taking place this morning. The new EMS system and the
hiring and the oversight, myself and Mary had very strong
conversations the last few days about the new contracts being
awarded this morning, and the oversight of that. And to the
six-month leap forward when we come back here and present the
data that went on record here earlier, we all believe we are in
a really good spot going forward. I can't pull back what
happened, and there will be challenges from the data that we
get, if it is not favorable --
Mr. Bost. And the problem we all have, as Members of
Congress, is the fact that we go back and talk to our
constituents, and then we have to answer to them, for where our
levels of bureaucracy have failed, where they should have never
been put in the position where they were going to fail in the
first place, when they told us they could do it.
My hope is, Ms. Devlin, when we come back, that in 6
months, your statement is correct, and that this will be
operating correctly. With that, I am going to yield to Ranking
Member Ms. Esty for 5 more minutes.
Ms. Esty. Thank you very much. So two things I want to
actually start where my friend, Chairman Bost, ended. I want
clarity on what is different now. Number 1, we have got a
better oversight system in place with the exam management
system, right, with EMS, we have got that in place. But I want
clarity, and I think that sounds like you, Mr. Christy. Is the
language different in the new contracts that specifically
provides for authority and/or for authority for either claw
back or withholding until we guarantee? Is the language
different than it was in previous contracts?
Mr. Christy. So the procurement vehicles that are in place
today, and being awarded today, are very similar in nature.
There are some nuances maybe on percentages for the incentives
and decentives. A lot of this is going to come back to the
programmatics of making sure that we have the proper oversight
that was not at its best in the previous versions of these
contracts. And so, I am going to ask help from the program when
we talk about the guarantees on EMS.
I know, from my perspective in the procurement world, we
have the CORs that all have been appointed, properly trained,
the right level of talent and skill set, and the follow-on
people that support those CORs are in place from a procurement,
contracting perspective. Those are ready to go, signed. Before
the awards were even made, that was all in place. I will
default a little bit back to EMS and the staffing levels to the
VBA here.
Ms. Esty. All right, so then what I am hearing is, this was
not an issue of not having authority on the contracts. This was
an issue of not having the data, or not having the data in a
timely fashion that put you in a position to have enforcement.
So what we want to know is, will you now have the data?
Will you now be getting it in a timely fashion so that you can
guarantee that that oversight is happening sufficiently rapidly
that you can put a stop to payments if it turns out people are
failing -- grotesquely failing on timeliness, or failing on
quality? Is that -- what I am hearing is, you are saying, yes,
but I want that on the record, that you are saying, yes, you
believe you will now have the data to make timely
determinations to activate the clauses that were already there
in the contracts which you chose not to activate, because it
was so far late in time, is what I am hearing, and you needed
that money to get them to pay somebody else to do the work they
didn't do? Is that correct?
Ms. Devlin. I will answer for that. So, yes, ma'am, to your
question about are we equipped now to perform the oversight
that we need to perform, we are. We have the exam management
system, which is functional and ready to provide us all the
data we need. We are now also staffed. We have our last two
people reporting soon, to get the full 17 staff in the office,
so that we can conduct quality reviews in a timely manner, and
get them turned into the acquisition professionals, so that if
action is necessary with our contractors, they can take those
actions accordingly.
The other thing I just wanted to, again, reiterate for the
record, is that our quality reviews and the feedback that we
have been giving to our contractors does not reflect any
egregious issues that we haven't been able to -- any small
issues that we have been able to deal with, as Mary Glenn
indicated, we have been able to deal with on the spot. But we
do have all the -- everything in place with this new contract,
to start fresh with all the data that we need and all the
oversight capabilities. And if I have missed anything, Ms.
Murphy will add.
Ms. Murphy. I do want to add that the quality review piece
that we have talked about is part of a larger staff of 84, who
are dedicated to this mission. Among our comp service staff,
who are all very talented, these are some of the hardest
working folks, and the highly manual reporting and redirecting
of work and monitoring that was caused by our nonperforming
vendor last year, in four of our five districts in the U.S.,
was very challenging. It was unexpectedly taking more bandwidth
to manage this from the staff we had than we anticipated.
Ms. Esty. All right, well, thank you. It is important to
get that on the record so we all have the same understanding of
what the challenges were and the same assurance going forward.
The last thing I want to flag, which I mentioned in my
opening, was about the travel reimbursements, and so that
people understand there is a different travel reimbursement
system that is used for contract exams. And I think it is
important -- four of the five of you were at the table with me
yesterday in my office. I think it is very important that you
put in place a system to verify that when contractors receive
reimbursement for the VA, for having paid travel
reimbursements, we need to guarantee they have actually sent
those travel reimbursements to the veterans. And, anecdotally,
we are hearing they are not always getting that.
So that is -- again, that is part of that feedback, to make
sure they are not getting paid for something they haven't
actually done. So we look forward to hearing that down the
road, what system you have in place to track that. Thank you.
Mr. Bost. It is my understanding, Mr. Coffman, you don't
have any more questions.
Ms. Radewagen, you are recognized.
Mrs. Radewagen. I thank you, Mr. Chairman.
Ms. Devlin, I want to come back to you. You didn't really
answer my question, and that is -- let me just rephrase it --
how many cases got stuck in EMS?
Ms. Devlin. I don't have that exact number off the top of
my head, but I will ask if Ms. Glenn has that exact number.
Ms. Glenn. Yes, ma'am. We had about 45,000 cases get stuck
in EMS at some point. We are now down to half a day's work in
the EMS, and we are manually working those every day. And we
expect to have that cleaned up by the next version of EMS that
goes forward in December.
Ms. Murphy. And, ma'am, if I could add, the period of time
was around March, April, until around July, August, so there
was that time period, and these cases -- these exam requests,
as they tried to move forward to the vendor, and the reports
coming back, they would hang up at different junctures; some
for a day, some for several days, several weeks. And as Mary
mentioned, we had patches and fixes that helped move those
forward in batches. We are also doing it manually, and we are
down to just a handful now.
Mrs. Radewagen. Thank you, Mr. Chairman. I yield back.
Mr. Bost. With that, thank you to the witnesses for
participating in the hearing, and with that, I will also yield
to the Ranking Member for any closing statement that she might
have.
Ms. Esty. Again, I want to thank the Chairman for convening
this hearing today. I want to thank GAO for their work in
allowing us to do our sworn duty to be oversight, both as
responsibility to the taxpayers, and to the veterans who
deserve to have a timely, appropriate, and careful, quality
treatment. So, again, I want to thank you for appearing today
and our shared commitment to continue to do better.
And, again, whatever those metrics are -- and metrics are
important -- this shouldn't be the ceiling for what we are
doing for our veterans. It needs to be the floor. And we need
to be continuously improving what we are doing, finding ways to
do it faster, cheaper, better, on behalf of veterans. So please
understand, if what we are doing in terms of metrics, or
something else, is impeding our effort to get closer to the
kind of care that our veterans deserve, we need to hear from
you. Don't wait for us to ask. Assume that is a constant
request -- what can we be doing smarter, better, more
efficiently for taxpayers, and serving our veterans better. And
you are better positioned to know that, as our partners at the
VSO are.
So let's not lock in the technology, the practices of past;
let's continue to look for better ways to do that. And with
that, again, I want to thank my friend, the Chairman, and thank
all of you for joining us here today.
Mr. Bost. So I want to thank everyone for being here, both
the witnesses and the Members, and as earlier had been said,
the complete, written statements of today's witnesses will be
entered into the hearing records. I ask unanimous consent that
all Members have 5 legislative days to revise and extend their
remarks and include extraneous material.
I also ask unanimous consent that the statement for the
record submitted by the Veterans of Foreign Wars of the United
States be included in the record. Hearing no objection, so
ordered. This hearing is now adjourned.
[Whereupon, at 11:32 a.m., the Subcommittee was adjourned.
A P P E N D I X
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Prepared Statement of Elizabeth Curda
VA DISABILITY EXAMS
Improved Oversight of Contracted Examiners Needed
Chairman Bost, Ranking Member Esty, and Members of the
Subcommittee:
I am pleased to be here today to discuss the Veterans Benefits
Administration's (VBA) oversight of disability medical exam
contractors. \1\ As you know, VBA relies on medical evidence to help
determine a veteran's eligibility for disability compensation. To
obtain such evidence, VBA staff may request that the veteran undergo a
disability medical exam through the Veterans Health Administration
(VHA) or contracted examiners. Over the past several years, VBA has
used contractors to conduct an increasing number of these disability
medical exams. From fiscal year 2012 through 2017, the number of these
exams completed by VBA contractors more than tripled. According to the
Department of Veterans Affairs (VA), it has increased its reliance on
contractors to help avoid delays in the disability claims process
related to completion of these exams.
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\1\ In this statement, we refer to examinations as exams.
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In 2016, VBA awarded 12 exam contracts to five private firms, which
cover disability medical exams conducted both in the United States and
overseas. These contracts are worth up to $6.8 billion and can last up
to 5 years. VA reported that in fiscal year 2017 the agency spent $765
million on disability medical exams conducted by these VBA contractors.
VBA contracted examiners completed about 1 million disability medical
exams from January 1, 2017 to April 2018, which is about half of these
type of exams during this time.
VBA's exam contracts outline quality and timeliness targets that
are used to assess contractor performance and may also be used to
determine financial incentives, among other things. VBA established an
exam program office in 2016 to manage and oversee contractors, monitor
their performance, and ensure that they meet contract requirements. VBA
also has an office dedicated to completing quality reviews of
contractors' exam reports, which the exam program office uses to assess
contractor performance against quality targets outlined in the
contracts. According to agency officials, in part, because VBA wanted
to update performance measures for its contractors, VA re-solicited
contracts in May 2018 for exams conducted in the United States.
My remarks today are based on our October 2018 report on VBA's
oversight of disability medical exam contractors. \2\ This testimony
addresses: (1) what is known about the quality and timeliness of VBA
contracted exams; (2) the extent to which VBA monitors contractors'
performance to ensure that they provide high quality and timely exams;
and (3) how VBA ensures that its contractors provide qualified and
well-trained examiners. I will highlight several key actions we
recommended in our October 2018 report that VA can take to better
oversee its contracted examiners.
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\2\ GAO, VA DISABILITY EXAMS: Improved Performance Analysis and
Training Oversight Needed for Contracted Exams, GAO 19 13 (Washington
D.C., Oct. 12, 2018).
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For our report, we reviewed and analyzed VBA data on the quality
and timeliness of exam reports completed from January 2017 to February
2018. We also reviewed relevant federal laws, regulations, selected
provisions of selected contract documents, and VA guidance. We
interviewed VA, VHA, and VBA officials; each of the five contractors; a
private firm that performs audits of VBA contracted examiners'
licenses; and three national veterans service organizations. More
detailed information on our scope and methodology is available in our
issued report. We conducted the work on which this statement is based
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
VBA Has Limited Information on Contractor Quality and Timeliness
VBA has limited information on whether contractors who conduct
disability medical exams are meeting the agency's quality and
timeliness targets. For example, as of late-June 2018, VBA was behind
in completing quality reviews for exams that were completed in the
second half of 2017. For those reviews that VBA did complete, the
agency reported that almost all contractors missed VBA's quality target
of 92 percent in the first half of calendar year 2017, with scores
ranging from 62-92 percent. \3\ VBA officials said the primary reason
for the delays in completing quality reviews and related quarterly
performance reports was a lack of quality review staff; however, VBA
recently hired more staff to address these delays.
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\3\ According to VBA documents, for each quality score, VBA
estimated the percentage of exam reports with no errors with a margin
of error of up to 5 percentage points at the 95 percent confidence
level.
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VBA officials also acknowledged that they did not have accurate
information on whether contractors were completing veterans' exams in a
timely manner as outlined in the contracts. VBA measures timeliness as
the number of days between the date the contractor accepts an exam
request and the date the contractor initially sends the completed exam
report to VBA. \4\ The exam management system VBA used until spring
2018 did not always retain the initial exam completion date,
specifically when VBA sent an initial exam report back to a contractor
for clarification or correction. In such cases, VBA's system maintained
only the most recent date an exam report was sent back to VBA. In such
a situation, according to agency officials, VBA would not always be
able to accurately assess a contractor's timeliness as outlined in the
contracts. Further, if VBA were to use the data to assess timeliness
against the contracts' targets, it could lead to a contractor's
timeliness score being inaccurately calculated-appearing to take longer
for initial exam completion. In spring 2018, VBA implemented a new
system designed to capture all of this information, but officials
stated that the agency was still working to resolve unexpected
technical issues with the new system.
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\4\ The contracts signed in 2016 included differing information
regarding the start date of the timeliness measure. One provision of
those contracts referred to the start date as the date VBA submits the
exam request to the contractor. VBA later clarified that it uses the
date the contractor accepts the exam request as the start date and that
it revised its timeliness measure accordingly in contract modifications
signed in December 2017 and January 2018.
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While VBA's data does not allow it to reliably assess contractor
performance against the timeliness targets in the contracts, the data
can be used in other ways. For example, we analyzed data for exams
completed between February 2017 and January 2018 to get a general sense
of how long it took contractors to complete exams (across all
contractors rather than for individual contractors)-including any time
to correct or clarify exam reports. \5\ To put our analysis into
context, we calculated the percentage of exams that were completed
within VBA's timeliness targets of 20 days for most exams completed in
the United States and 30 days for overseas exams or exams requested
through special programs. \6\ Our analysis showed that just over half
of the exams completed were done within these general targets; however,
some exams took twice as long to complete. \7\
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\5\ According to the contracts, contractors are not expected to
complete all exams within the timeliness target, but rather they should
meet the timeliness target on average in a given quarter. As such, the
results of our analysis should not be interpreted as reflecting
contractor compliance with timeliness targets under the contracts.
\6\ Special programs include programs for servicemembers, such as
Benefits Delivery at Discharge and Integrated Disability Evaluation
System. VBA officials stated that exams for special programs may take
longer because veterans who are transitioning from military service may
not be readily available for exams. Similarly, they said it may take
longer to schedule exams with veterans living overseas.
\7\ For disability medical exams conducted in the United States,
306,479 out of 575,739 exams were completed within 20 days while 12
percent took more than 40 days to complete. For disability medical
exams conducted overseas or for special programs, 39,132 out of 70,266
exams were completed within 30 days.
VBA Identified Some Contractor Issues, but Lacked Adequate Oversight of
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Contractors' Performance
VBA identified some contractor performance problems, such as
contractor delays in completing specific exams, challenges meeting the
demand for exams, and providing timely exam reports. Nonetheless, the
incomplete quality and timeliness information that I already mentioned
highlight VBA's inability to adequately oversee contracted examiners
and also contribute to other challenges managing the contracts. For
example, we reported that, according to VBA officials, VBA had not
completed all quarterly performance reports, which are key components
to effectively assessing contractor performance against VBA quality and
timeliness targets outlined in the contracts. These delays also
affected VBA's ability to allocate exam requests across contractors and
administer potential financial incentives across contractors. More
specifically, the contracts state that VBA can use performance data to
help determine how to allocate exams within specified areas in the
United States that have two contractors. However, VBA could not do this
because complete performance data were unavailable. Rather, VBA
officials told us that they allocated exams based on contractor
workload. \8\ Further, the contracts outline how VBA can use
performance data to administer financial incentives linked to
performance targets. However, because of its delays in completing
quality reviews and the lack of reliable data on contractor timeliness,
VA had not yet administered these incentives at the time of our review.
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\8\ For exams performed in the United States, two contractors share
the workload within specific VBA geographic areas. As stated in the
contracts, VBA can determine how to allocate some exams between the two
contractors based on each contractor's performance, and its capacity to
conduct exams.
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VBA officials also acknowledged that they were unable to track
exams that needed corrections or clarifications, which is needed to
determine if VBA should reduce payment to a contractor. The current
version of the contracts require that contractors correct these exams
within a certain number of days and bill VBA for these exams at half
price. However, we found that VBA did not know if contractors met
either of these requirements due to the lack of complete and reliable
information on these exams.
VBA's new exam management system, implemented in spring 2018, was
designed to capture information that allows VBA to track whether
contractors are properly discounting their invoices for corrected or
clarified exams, and should also provide accurate data on exam
timeliness. However, because not all contractors had complete
functionality with the new system, VBA officials said the agency still
did not have complete data. While officials said they are addressing
these issues, VBA has not documented how it will ensure the data in the
new system are accurate or how it will use the data to track the
timeliness and billing of corrected or clarified exam reports. VBA's
lack of accurate information is inconsistent with standards for
internal control for the federal government regarding the use of
quality information to achieve key objectives. \9\ Creating plans to
verify that exam data are accurate can help VBA ensure it pays
contractors the correct amount for corrected or clarified exams, and
accurately measures contractor timeliness.
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\9\ GAO, Standards for Internal Control in the Federal Government,
GAO 14 704G (Washington, D.C.: Sept. 10, 2014), principle 13.
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VBA has also not conducted comprehensive analyses of performance
data that would allow it to identify and address higher-level trends
and program-wide challenges across contractors, geographic regions,
exam types, or other relevant factors. Agency officials told us they
had no plans to conduct such analyses. Federal internal control
standards state that management should establish and operate monitoring
activities and evaluate the results of those activities. \10\ Without
plans to conduct comprehensive performance analyses, VBA is limited in
its ability to determine if the contract exam program is achieving its
quality and timeliness goals in a cost effective manner.
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\10\ GAO 14 704G, principle 16.
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To address these issues, we recommended that VBA develop and
implement a plan for using data from the new exam management system to
oversee contractors. We also recommended that VBA regularly monitor and
assess aggregate performance data and trends over time to identify
higher-level trends and program-wide challenges. VA agreed with these
recommendations.
VBA Uses An Auditor to Verify Contracted Examiner Licenses, but Does
Not Verify Training Completion or Collect Information on
Effectiveness
VBA uses a third-party auditor to verify that all active contracted
examiners have a current, valid, and unrestricted medical license in
the state where they examined a veteran. However, VBA relies on
contractors to verify that their examiners complete required VA
training, and agency and contractor officials told us that VBA does not
review contractors' self-reported training reports for accuracy or
request supporting documentation, such as training certificates, from
contractors. The contractors, rather than VBA, access the contractor
training systems to verify that examiners have completed the required
training before they are approved to conduct exams. VBA officials said
that they plan to enhance monitoring of examiner training by spot
checking training records and by developing a new system that will
allow the agency to certify that examiners have completed required
training. However, at the time of our review, VBA had not provided
details or documentation on these planned checks or this system.
Without plans to verify that training has been completed, VBA risks
using contracted examiners who are unaware of the agency's process for
conducting exams and reporting the results, which could lead to poor-
quality exams that need to be redone and delays for veterans.
VBA also does not collect information from contractors or examiners
to help determine if required training effectively prepares examiners
to conduct high quality exams and complete exam reports. Given that VBA
plans to award new contracts soon, the number of contracted examiners
who are new to VA processes may increase. Thus, collecting and
assessing regular feedback on training from contractors and examiners
could help VBA determine if training effectively prepares examiners or
if additional training courses are needed across contractors or for
specific exam types.
To help ensure that examiners are completing training and that the
training is effective, we recommended that VBA document and implement a
plan and processes to verify that contracted examiners have completed
required training, as well as collect information from contractors or
examiners on training and use this information to assess training and
make improvements as needed. VA agreed with our recommendations.
Chairman Bost, Ranking Member Esty, and Members of the
Subcommittee, this concludes my prepared statement. I would be happy to
answer any questions you or other members of the subcommittee may have
at this time.
GAO Contact and Staff Acknowledgments
For questions about this statement, please contact Elizabeth Curda,
Director, Education Workforce, and Income Security at (202) 512-7215 or
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statement. In addition to the contact above, Nyree Ryder Tee (Assistant
Director); Teresa Heger (Analyst-in-Charge); Sherwin Chapman; Alex
Galuten; Justin Gordinas; and Greg Whitney made key contributions to
this testimony. Other staff who made key contributions to the report
cited in the testimony are identified in the source product.
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Prepared Statement of Margarita Devlin
Good afternoon, Chairman Bost, Ranking Member Esty, and Members of
the Committee. We are here today to speak on VBA's Contract Medical
Disability Examination (MDE) Program. Accompanying me is Beth Murphy,
Executive Director of Compensation Service, Mary Glenn, Deputy Director
of the Contract Examination Program Office, and Phillip Christy, Deputy
Executive Director, Office of Acquisition, Logistics, and Construction.
I will provide an overview of the MDE Program including operational
aspects of working with the contract vendors and Veterans Benefits
Administration (VBA) oversight of the program.
Statutory Authority
When necessary to adjudicate disability compensation or pension
(C&P) claims, VBA orders an examination and/or medical opinion. This
occurs when there is insufficient medical evidence of record to decide
the claim (See 38 United States Code 5103A). Prior to 1996,
VA ordered C&P examinations exclusively through the Veterans Health
Administration (VHA). As a result of Public Law (P.L.) 104-275, the
Secretary of VA was authorized to contract through VBA using mandatory
funds for examinations from non-VA sources. VBA began utilizing
contract vendors to complete examinations in 1998, with the authority
limited to 10 regional offices (RO) requesting examinations through
contract.
P.L. 113-235 authorized the Secretary to expand the use of contract
examinations to 12 ROs in Fiscal Year (FY) 2015, 15 ROs in FY 2016, and
to as many ROs as the Secretary considered appropriate beginning in FY
2017. The expansion has afforded VBA a greater opportunity to complete
a larger volume of examinations with greater flexibility in a more
efficient manner. The contracts supplement VHA capacity and has enabled
VBA to provide more timely benefits decisions. Additionally, the
contract enables VBA to request exams for Veterans and Servicemembers
in overseas locations, which was not an option previously provided
through any examination.
Through these statutory authorities, all 56 ROs now have the
flexibility to request an examination or medical opinion from VHA
facilities or designated contract providers closest to where the
Veteran lives or receives regular medical treatment. Claims processors
at ROs use an online tool enabled by real-time VHA examiner
availability data and by examination type to determine whether VHA has
the internal capacity to complete an examination request or whether to
direct the examination request to a contract vendor.
Contract Vendors
As of October 1, 2016, VBA manages all VA contracts with vendors
that provide examinations in support of disability claims. VBA
currently maintains 10 contracts with 4 primary vendors across the 7
contracting districts. These vendors provide examinations nationally
and internationally to both Veterans and certain transitioning
Servicemembers going through the Benefits Delivery at Discharge (BDD)
and Integrated Disability Evaluation System (IDES) pre-discharge
programs. The current VBA contracting coverage by district is, as
follows:
------------------------------------------------------------------------
Districts Areas
------------------------------------------------------------------------
1 - North Atlantic CT, DC, DE, MA, MD, ME, NC, NH, NJ, NY, PA, RI, VA,
VT and WV
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2 - Southeast AL, FL, GA, KY, SC, and TN
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3 - Midwest IA, IL, IN, KS, MI, MN, MO, ND, NE, OH, SD and WI
------------------------------------------------------------------------
4 - Continental AR, CO, LA,
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5 - Pacific AK, AZ, CA, HI, ID, NM, NV, OR, and WA
------------------------------------------------------------------------
6 - National Providence Disability Rating Activity Site (DRAS),
Mission (IDES, Winston-Salem RAS and CPS, Seattle DRAS, Salt Lake
BDD) City RAS and San Diego CPS
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7 - International C&P, BDD, IDES within American Samoa, Australia,
Canada, Costa Rica, Germany, Guam, the Inuit
Islands, Italy, Japan, Mexico, Northern Mariana
Islands, Panama, Puerto Rico, Philippines, South
Korea, Spain, Thailand, United Kingdom, and US
Virgin Islands
------------------------------------------------------------------------
In FY 2017, vendors completed 623,810 of the total 1.36 million
examination requests. In FY 2018, vendors completed 841,852 examination
requests of the total 1.44 million examination requests. During this
same timeframe, VBA contract vendors exclusively completed 14,448
overseas examination requests compared to 7,873 in FY 2017. The
performance standards for completion of an examination request by
contract vendors (measured from date of request until return of
completed examination report(s)) is currently 20 days nationally and 30
days for pre-discharge and international cases. The total costs over
the last two fiscal years for MDE contracts, including ancillary
contracts, were approximately $765 million in FY 2017 and $896 million
in FY 2018.
After the award of VBA's current contract in March 2016, there were
multiple protests and appeal of the award, followed by contractual
ramp-up periods for the vendors. To ensure seamless service to Veterans
during protest periods, VBA relied on a series of bridge contracts.
These bridge contracts have enabled VBA to extend existing contracts in
a short term and noncompetitive manner to avoid a gap in service. VBA
anticipates these bridge contracts will continue through December 2018.
Going forward, VBA is focused on enhancing the MDE Program by
rightsizing the Program Office staffing, expanding international
coverage, such as the recently-added locations of Bahrain, Belgium,
Denmark, Dominican Republic, Netherlands, and Poland, and by awarding a
new contract with terms informed by our experience since 2016. Some of
the key lessons learned during this period are the need to better
balance between rural and urban areas within district lines and the
need for expanded capacity and additional skill sets in the MDE Program
Office for purposes of training and quality assurance.
Administration and Oversight
VBA's administration of the MDE Program employs numerous training,
quality assurance and oversight elements to ensure that any issues
identified are addressed in a timely manner. Contract examiners receive
the same training required for VHA examiners, including privacy
training, to ensure all Veteran medical information is protected under
the Health Insurance Portability and Accountability Act. The MDE
Program Office is currently hiring staff to design and track updated
training for the primary vendors and thousands of subcontractors.
Likewise, VBA has expanded the staff that assesses the quality of
completed contract examination reports and provides feedback to the
vendors. Although quality reviews for FY 2018 have not yet been
finalized, VBA anticipates that the new contract terms will enhance our
ability to provide timely feedback as we deploy training to the vendors
who conduct and document exams and to the VBA claims processors who
make exam requests.
VBA uses several ancillary contracts to strengthen the overall
performance and integrity of the MDE program. One contract administers
customer service surveys on all vendor examinations completed as a
feedback mechanism and to provide Veterans an avenue to report concerns
about a vendor examination experience. Another contract checks and
validates contract examiner medical license credentials, including
looking for past disciplinary actions. Finally, an additional contract
assists with auditing financial activities on vendor invoices and
payments. Through feedback mechanisms afforded by these ancillary
contracts, VBA can take immediate action to address contract
examination issues, such as if a license has been revoked or if a
Veteran reports a concern related to an examination from a contract
vendor.
Overall, the MDE Program Office staff monitors contractor
performance and compliance, timeliness, quality, financial management,
and customer satisfaction related to program directives. The staff
coordinates access to all MDE systems and provides training to assist
field users with understanding and utilizing the contract examination
process. Staff proactively works with the contract vendors to
investigate and take appropriate action on any concerns reported about
an examination experience.
Examination Management System
In March 2018, VBA deployed its Examination Management System
(EMS). Through integration with the Veterans Benefits Management System
(VBMS), EMS streamlines examination scheduling requests and improves
tracking and timeliness of examinations. VBMS integration provides bi-
directional system communication; automated system updates; responses;
handling and improved reporting.
Following the deployment of EMS, several defects impacting the exam
request process-and in turn, claims processing timeliness-were
identified. During this time, VBA worked closely within the agency and
with contract vendors to address the issues. Updates in software
releases have resolved most of the defects, and the remaining system
enhancements should be addressed by the end of first quarter in FY
2019.
Conclusion
In summary, the MDE Program is vital to the delivery of timely and
high-quality claims decisions. Utilizing contract vendors for C&P exams
provides more flexibility by having vendors use a fluid mix of brick
and mortar, and subcontractor footprints to deliver their products.
Additionally, these contract exams enable VBA to reach some rural areas
and individuals overseas in contrast to the limited options in rural
areas and has no option overseas.
VBA appreciates the authority provided by Congress to obtain
contract examinations for Veterans and transitioning Servicemembers as
a supplement to VHA's capabilities and for the first time to have a
viable solution to providing examinations internationally. Continuous
oversight and enhancement of the MDE Program remain priorities as well
as looking for opportunities to further streamline the examination
process.
This concludes my testimony. I would be happy to address any
questions from Members of the Committee.
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Statements For The Record
VETERANS OF FOREIGN WARS OF THE UNITED STATES (VFW)
STATEMENT OF MICHAEL FIGLIOLI, DEPUTY DIRECTOR
NATIONAL VETERANS SERVICE
Chairman Bost, Ranking Member Esty, and members of the
Subcommittee, on behalf of the Veterans of Foreign Wars of the United
States (VFW) and its Auxiliary, thank you for the opportunity to
provide our comments on the Department of Veterans Affairs' (VA)
oversight of contract disability examinations (CDEs).
Over the last 20 years, VA has more frequently contracted with
private health care providers as a way to provide sound medical
opinions with the intent to quickly and accurately adjudicate veterans'
disability benefit claims. This contracted system has proven to be
beneficial to both veterans seeking benefits and VA in ensuring
veterans can receive timely and correct benefit decisions. The VFW
fully supports VA's efforts to provide veterans with contract
disability examination options for a variety of reasons. The most
significant of which is that we believe, and veterans confirm, that
private providers can furnish a largely objective opinion in evaluating
a veteran's claimed medical condition.
Moreover, we hear frequent positive comments about contract exams
and the outcomes for veterans. Unfortunately, since VA executed its
latest contract for disability examinations in 2016 and extended work
to two new vendors, Logistics Health, Inc. (LHI) and MSLA, a Medical
Corporation, the VFW has seen new problems emerge which impelled us to
join our partners in the veterans service organization community to
call for a hearing so that this subcommittee can better assess the
situation.
Under the most recent contract, VA instituted new, incredibly rigid
timelines for contractors to complete exams and return records to VA.
Though the recent Government Accountability Office (GAO) report notes
that VA allows 20 days for vendors to conduct routine exams, in reality
the vendors tell the VFW that this leaves them a window of only about
one business week in which to conduct the exams. This is an
unreasonable expectation. These standards in no way reflect the needs
of the veteran, nor are they favorable to VA which has a well-
documented shortage of examiners at both the full-time employee and
contract levels. When we ask VA about these timelines, the usual
response is that VA believes veterans want their benefits completed
quickly. We concur. However, VA cannot sacrifice accuracy and a
positive customer experience for the sake of speed. It does not matter
how quickly a veteran receives a rating decision from VA if the
decision is wrong.
Since 2016--and amid multiple disputes about the validity of VA's
contract; extensions of bridge contracts; termination of one of VA's
new vendors; and the solicitation of new bids--the VFW has seen a
growing list of problems with VA's contract exam system. This summer,
in light of these problems, we asked VA for a report on quality for the
current contract examination system. After dragging its feet for more
than a month, VA finally replied that they could not share this
information unless the VFW filed a Freedom of Information Act request.
After reviewing the GAO report, the VFW believes that the leadership of
the Mandatory Disability Exam Office did not want to admit that they
had not completed a quality review report for any period in 2018. With
all of these factors affecting veterans' access to accurate and timely
benefits, this hearing comes at a very critical time.
The VFW can summarize the problems we have seen with the current
contract exam system as follows:
- Late notification of exams.
- Lack of options for veterans to reschedule exams.
- Lack of availability of adequate examiners with reasonable
distance to the veteran.
- No adequate review of a veteran's claim file prior to the exam.
- Inadequate time with provider due to volume and turnaround.
Late Notification of Exams
The VFW has learned from our field staff and locally in the
Military District of Washington about dozens of instances where
veterans were not notified in a timely manner that VA had scheduled
exams. In one example from Georgia, the veteran was contacted by VA's
vendor, LHI, on a Thursday afternoon for an exam scheduled on Monday
morning. When the veteran tried to reschedule with LHI, he was guilted
into rearranging his schedule for the Monday appointment and
essentially forced into calling out of work and rearranging other
health care appointments out of fear that his benefits would be
adversely affected. When the VFW reviewed the veteran's claim file, we
noticed that not only had VA sent the exam request to LHI less than a
week before the exam was scheduled, VA also failed to include accurate
contact information for the veteran, which was readily available in the
veteran's records.
Under the old contract, veterans were afforded more time to get
their affairs in order to attend contract exams. Even the legacy
contractors have complained to the VFW that the new contract makes it
harder for veterans to attend exams, resulting in higher no-shows and
returned exam requests to VA, either further delaying delivery of
earned benefits, or worse, resulting in erroneous denial of benefits.
Lack of Options to Reschedule
Given the new compressed timeline, we hear from veterans that if
they cannot make the appointments assigned to them by the contractor,
they are offered only three options: attend your appointment regardless
of conflicts; be reported as a no-show and VA will likely deny your
benefits; or have the contractor return the appointment request to VA
as a cancellation with the hope that VA issues another exam request
soon. Each of these options is bad for veterans. Under the old
contract, the legacy contractors were reasonably flexible with
veterans, ensuring exams could be completed in a matter of weeks. The
VFW received very few complaints before 2016, and even collected
positive stories about the contract exam experience.
Unfortunately, under the new contract, we have seen negative
outcomes for veterans and some potentially concerning business
practices when it comes to rescheduling or cancellation requests. The
most glaring example of this came from a veteran in Maryland who is
assisted by the VFW staff here in Washington, D.C. According to the
veteran's claim file, VA ordered a series of exams from LHI on October
17, 2018. On October 18, 2018, the veteran was listed in the Veterans
Benefits Management System as a no-show for her exams. This obviously
caught our attention and we contacted the veteran to learn what
happened. The veteran told us that she was called by LHI on October 18,
and asked if she could reschedule. LHI told her she could not, and they
would have to return the exam request to VA. Veterans seeking benefits
should not have to be concerned about contractor penalties due to their
inability to properly notify them or obtain a timely exam.
In spite of this, what concerns the VFW most about this situation
is that the veteran was reported as a no-show. Our understanding of the
contract is that this means that LHI is still paid for the exam, even
though no exam was ever completed. Again, VA's contract exams office
has not been transparent with the VFW on contract exam issues, so we
have no way to verify this, other than posing it as an assumption to
the subcommittee in this forum. Regardless, at the very least it seems
that contractors are incentivized to cut corners in an effort to meet
VA's unreasonable expectations.
Lack of Availability of Examiners
Another persistent issue we have heard from offices around the
country is that to meet the timeliness goals of the contract, each of
the contractors is forced to schedule veterans wherever they can find
an available doctor. This leads to unreasonable travel times and
unrealistic appointment expectations for veterans.
In Arkansas, one elderly veteran was scheduled for a contract exam
in Oklahoma, more than three hours away from his home. In Washington
state, another veteran in the Seattle area was scheduled for an exam
more than three hours away in Oregon. In Washington, D.C., we have seen
veterans sent to Gettysburg, Pa., for exams.
Another glaring example came from California, where a San
Francisco-area veteran was scheduled for one exam at 3:30 p.m., more
than 20 miles outside of the city, with a second exam scheduled at 4:15
p.m. back in San Francisco, making it logistically impossible for the
veteran to attend both.
Fortunately, in each of these cases, the VFW's service officers
have caught these unreasonable requests and worked with VA to resolve
the issue. However, we must question the structure of a contract that
forces a vendor to make these kinds of decisions.
No Adequate Review of Claim File/Inadequate Time with Provider
The VFW believes the final two issues are linked. We continue to
hear concerns about the adequacy of a contract examiner's review of the
veteran's claim file and the time that veterans receive with providers.
These have been issues that the VFW has raised prior to the 2016
contract, but these problems persist, and we believe they have been
exacerbated by the new timeliness requirements of the contract.
When contract providers fill out Disability Benefit Questionnaires
(DBQs) for veterans, they must verify whether or not they have fully
reviewed the veteran's file. They usually affirm that they have and
then go on to render an opinion. However, we have learned that the
vendor selects which specific files to share with a provider ahead of
the exam, meaning they likely never fully review the file. We have also
heard reports that some contract providers solely rely on the
claimant's pre-exam worksheet to evaluate the historic record of a
condition, rather than the official claim file documents. To the VFW,
both scenarios render the exam unacceptable and inadequate.
Next, we have also heard conflicting information from veterans
about the time spent with providers and the attention given to their
issues. We hear anecdotes that veterans see providers for only a matter
of minutes and that certain required measurements or evaluations are
never actually conducted, though they are reported as such on the DBQ.
We have no way to verify this independently, but the volume of
complaints that we hear from our service officers in the field and
directly from veterans once again force us to raise this issue with
this subcommittee.
The VFW does support and believe in the contract disability
examination concept. We have seen it work. In Wisconsin, we continue to
see very positive outcomes for veterans, and our service officer even
reports that when it comes to accuracy, he believes contract exams more
closely match the veteran's reported experience than exams conducted
internally by VA. This reinforces the VFW's core belief that
unaffiliated third parties are well suited to render objective
opinions. However, even Wisconsin reports that they have seen
scheduling problems for veterans they serve. We are very concerned that
VA is not adequately tracking quality and customer experience for its
contractors, meaning there is no real way for VA to monitor the
efficacy of the contract for the veterans they serve. This is why we
are left to resort to anecdotes and trends that we see around the
country for our clients.
VA has a unique opportunity now as it seeks to enter into a new
contract for CDEs. The new contract must factor in veteran experience,
measure quality outcomes, and report transparently on these outcomes.
Without this, we will continue to see erroneous denials, reported no-
shows, and contractors cutting corners to try and meet unrealistic
objectives.
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