[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]



 
 DOCUMENT TAMPERING AND MISHANDLING AT THE U.S. DEPARTMENT OF VETERANS 
                                AFFAIRS

=======================================================================

                             JOINT HEARING

                               before the

                 SUBCOMMITTEE ON DISABILITY ASSISTANCE
                          AND MEMORIAL AFFAIRS

                                and the

                     SUBCOMMITTEE ON OVERSIGHT AND
                             INVESTIGATIONS

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 3, 2009

                               __________

                            Serial No. 111-4

                               __________

       Printed for the use of the Committee on Veterans' Affairs

For Sale by the Superintendent of Documents, U.S. Government Printing Office
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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     HENRY E. BROWN, Jr., South 
Dakota                               Carolina
HARRY E. MITCHELL, Arizona           JEFF MILLER, Florida
JOHN J. HALL, New York               JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois       BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia      DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico             GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas             VERN BUCHANAN, Florida
JOE DONNELLY, Indiana                DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia

                   Malcom A. Shorter, Staff Director

                                 ______

       SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

                    JOHN J. HALL, New York, Chairman

DEBORAH L. HALVORSON, Illinois       DOUG LAMBORN, Colorado, Ranking
JOE DONNELLY, Indiana                JEFF MILLER, Florida
CIRO D. RODRIGUEZ, Texas             BRIAN P. BILBRAY, California
ANN KIRKPATRICK, Arizona

                                 ______

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                  HARRY E. MITCHELL, Arizona, Chairman

ZACHARY T. SPACE, Ohio               DAVID P. ROE, Tennessee, Ranking
TIMOTHY J. WALZ, Minnesota           CLIFF STEARNS, Florida
JOHN H. ADLER, New Jersey            BRIAN P. BILBRAY, California
JOHN J. HALL, New York

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

                               __________

                             March 3, 2009

                                                                   Page
.................................................................
Document Tampering and Mishandling at the U.S. Department of 
  Veterans Affairs...............................................     1

                           OPENING STATEMENTS

Chairman John J. Hall, Subcommittee on Disability Assistance and 
  Memorial Affairs...............................................     1
    Prepared statement of Chairman Hall..........................    40
Chairman Harry E. Mitchell, Subcommittee on Oversight and 
  Investigations.................................................     3
    Prepared statement of Chairman Mitchell......................    41
Hon. Doug Lamborn, Ranking Republican Member, Subcommittee on 
  Disability Assistance and Memorial Affairs.....................     4
    Prepared statement of Congressman Lamborn....................    42
Hon. David P. Roe, Ranking Republican Member, Subcommittee on 
  Oversight and Investigations...................................     6
    Prepared statement of Congressman Roe........................    42
Hon. Deborah L. Halvorson........................................     6
Hon. Ann Kirkpatrick.............................................     7
Hon. Timothy J. Walz.............................................     8

                               WITNESSES

U.S. Department of Veterans Affairs:
    Belinda J. Finn, Assistant Inspector General for Auditing, 
      Office of Inspector General................................    24
        Prepared statement of Ms. Finn...........................    55
    Michael Walcoff, Deputy Under Secretary for Benefits, 
      Veterans Benefits Administration...........................    30
        Prepared statement of Mr. Walcoff........................    61

                                 ______

American Federation of Government Employees, AFL-CIO, Geneva 
  Moore, Senior Veterans Service Representative, Veterans 
  Benefits Administration Regional Office, Winston-Salem, NC, 
  U.S. Department of Veterans Affairs............................    12
    Prepared statement of Ms. Moore..............................    52
Disabled American Veterans, Kerry Baker, Assistant National 
  Legislative Director...........................................     9
    Prepared statement of Mr. Baker..............................    43
Gold Star Wives of America, Inc., Kathryn A. Witt, Co-Chair, 
  Government Relations Committee.................................    11
    Prepared statement of Ms. Witt...............................    50
National Veterans Legal Services Program, Ronald B. Abrams, Joint 
  Executive Director.............................................    10
    Prepared statement of Mr. Abrams.............................    47

                       SUBMISSIONS FOR THE RECORD

Frasier, Susan R., Albany, NY, statement.........................    66
Priessman, Master Sergeant Kurt, USAF (Ret.), Vernon, TX, 
  statement......................................................    70
Simmons, Berta M., Cohocton, NY, letter..........................    72

                   MATERIAL SUBMITTED FOR THE RECORD

News Article:
    ``Veterans Affairs Probe: Records Found in Shredder Bin--
      Employee Under Investigation,'' The State, By Chuck Crumbo, 
      November 6, 2009...........................................    74
Post-Hearing Questions and Responses for the Record:
    Hon. Ann Kirkpatrick, Member of Congress, U.S. House of 
      Representatives, to Michael Walcoff, Deputy Under Secretary 
      for Benefits, Veterans Benefits Administration, U.S. 
      Department of Veterans Affairs, letter dated March 4, 2009, 
      and VA responses...........................................    75
    Hon. John J. Hall, Chairman, Subcommittee on Disability 
      Assistance and Memorial Affairs, Committee on Veterans' 
      Affairs, to Kerry Baker, Assistant National Legislative 
      Director, Disabled American Veterans, letter dated March 
      25, 2009, and DAV responses................................    76
    Hon. John J. Hall, Chairman, Subcommittee on Disability 
      Assistance and Memorial Affairs, Committee on Veterans' 
      Affairs, to Ronald Abrams, Joint Executive Director, 
      National Veterans Legal Services Program, letter dated 
      March 25, 2009, and NVLSP responses........................    77
    Hon. John J. Hall, Chairman, Subcommittee on Disability 
      Assistance and Memorial Affairs, Committee on Veterans' 
      Affairs, to Kathryn Witt, Co-Chair, Government Relations 
      Committee, Gold Star Wives of America, Inc., letter dated 
      March 25, 2009, and GSW responses..........................    83
    Hon. John J. Hall, Chairman, Subcommittee on Disability 
      Assistance and Memorial Affairs, Committee on Veterans' 
      Affairs, to Marilyn Park, Legislative Representative, 
      American Federation of Government Employees, letter dated 
      March 25, 2009, and AFGE responses.........................    85
    Hon. John J. Hall, Chairman, Subcommittee on Disability 
      Assistance and Memorial Affairs, Committee on Veterans' 
      Affairs, to Belinda Finn, Assistant Inspector General for 
      Auditing, Office of Inspector General, U.S. Department of 
      Veterans Affairs, letter dated March 25, 2009, and response 
      letter dated April 23, 2009, from Hon. George Opfer, 
      Inspector General, Office of Inspector General, U.S. 
      Department of Veterans Affairs.............................    88
    Hon. John J. Hall, Chairman, Subcommittee on Disability 
      Assistance and Memorial Affairs, Committee on Veterans' 
      Affairs, to Michael Walcoff, Deputy Under Secretary for 
      Benefits, Veterans Benefits Administration, U.S. Department 
      of Veterans Affairs, letter dated March 25, 2009, and VA 
      responses..................................................    91
    Hon. George Opfer, Inspector General, Office of Inspector 
      General, U.S. Department of Veterans Affairs, letter to 
      Hon. John J. Hall, Chairman, Subcommittee on Disability 
      Assistance and Memorial Affairs, Committee on Veterans' 
      Affairs, letter dated March 26, 2009 [An identical letter 
      was sent to Hon. Harry E. Mitchell, Chairman, Subcommittee 
      on Oversight and Investigations, Hon. Doug Lamborn, Ranking 
      Republican Member, Subcommittee on Disability Assistance 
      and Memorial Affairs, and Hon. David P. Roe, Ranking 
      Republican Member, Subcommittee on Oversight and 
      Investigations, Committee on Veterans' Affairs.]...........    98


                 DOCUMENT TAMPERING AND MISHANDLING AT
                THE U.S. DEPARTMENT OF VETERANS AFFAIRS

                              ----------                              


                         TUESDAY, MARCH 3, 2009

     U.S. House of Representatives,        
        Committee on Veterans' Affairs,    
      Subcommittee on Disability Assistance
                              and Memorial Affairs,
              Subcommittee on Oversight and Investigations,
                                                    Washington, DC.

    The Subcommittees met, pursuant to notice, at 1:35 p.m., in 
Room 334, Cannon House Office Building, Hon. John J. Hall 
[Chairman of the Subcommittee on Disability Assistance and 
Memorial Affairs] presiding.

    Present from Subcommittee on Disability Assistance and 
Memorial Affairs: Representatives Hall, Halvorson, Kirkpatrick, 
Lamborn, and Bilbray.

    Present from Subcommittee on Oversight and Investigations: 
Representatives Mitchell, Space, Walz, Roe, and Bilbray.

               OPENING STATEMENT OF CHAIRMAN HALL

    Mr. Hall. Good afternoon. The Committee on Veterans' 
Affairs Subcommittee on Disability Assistance and Memorial 
Affairs and the Subcommittee on Oversight and Investigations 
Hearing on Document Tampering and Mishandling at the Veterans 
Benefits Administration (VBA) will now come to order. I would 
ask everyone to rise for the Pledge of Allegiance. The flags 
are at both the front and rear of the room.
    [Pledge of Allegiance.]
    I welcome you today for our first hearing during the 111th 
Congress, and I am pleased to be joined by my colleague, Harry 
Mitchell, Chairman of the Oversight and Investigations 
Subcommittee. We expect to be joined at some point by the 
Chairman of the full Committee, Congressman Bob Filner, who has 
been leading the way in making the U.S. Department of Veterans 
Affairs (VA) an advocacy system rather than an adversarial one. 
Of course, we have our Ranking Member from the Disability 
Assistance and Memorial Affairs Subcommittee, Congressman 
Lamborn, and the Ranking Member of Oversight and 
Investigations, Mr. Roe. I welcome all of you.
    Congress' accomplishments for veterans last year were great 
and substantial. I am eager to see implementation of P.L. 110-
389, the Veterans Benefits Improvement Act of 2008, that will 
take steps in righting the many wrongs in the VA claims 
processing system. However, there is still much more room for 
improvement and this promises to be a very active Congress with 
a new Secretary we are all eager to work with.
    It is regrettable that we are starting this Congress with 
so many untoward problems within the VBA claims processing 
system making news headlines. In the last few months, we have 
tracked the problems brought to our attention with misdating of 
claims at the New York Regional Office (RO), documents wrongly 
placed in shredder bins, and denying widows their survivor 
benefits.
    It pains me as a representative from the State of New York 
to say that the situation in New York was a clear attempt by 
managers to fudge performance numbers. The incorrectly entered 
data made the Regional Office look like it took fewer days to 
process claims than it did in actuality, yet still beyond 
acceptable levels to me or to most veterans. Although veterans 
were not directly harmed by this practice, perpetrators of this 
kind of dishonesty impact the entire veterans' community's 
ability to trust the institution charged with its welfare. This 
is shameful.
    On the heels of this revelation, there were reports of 
documents inappropriately placed in shredder bins, many needed 
to process claims, that would have been returned or should have 
been returned to the veteran, but were dumped for shredding. As 
a result, some veterans' claims were harmed and adjudication 
did not properly take place. This is even more shameful.
    And finally, we saw headlines about widows being cheated 
out of millions of dollars over a 12-year period while the VA 
ignored Congress' intent to help these very same widows. VA 
explains this oversight as a computer glitch. But again the 
result is shameful.
    The misdating, shredding, and glitches that the media had 
recently reported, I am afraid, are only the tip of the 
iceberg. I have heard too many accounts from veterans and their 
survivors about missing, lost, or destroyed files, and VA 
sending them multiple requests for information then still not 
knowing where a file is or who had it last.
    Even when the veteran or survivor has sent documents return 
receipt requested, VA manages to not know their whereabouts. 
Besides the infamous fire in St. Louis and the current 
shredding issue, claim folders have managed to be lost or 
destroyed in many other ways over the years. This has included 
records being misfiled or misplaced within a Regional Office, 
lost in transit between Regional Offices, medical, pension, 
insurance or debt management centers, the Board of Veterans' 
Appeals, the Appeals Management Center, or the U.S. Court of 
Appeals for Veterans Claims, not to mention the issues with the 
U.S. Department of Defense (DoD) sharing.
    Even further beyond comprehension are the accusations by 
veterans and their families that VA employees would 
purposefully and maliciously destroy, falsify, or steal a claim 
folder to avoid granting a benefit. A lot of VA employees touch 
a claim folder, but rarely is anyone held accountable or 
responsible when it is lost or destroyed. Furthermore, we are 
still talking about an outdated system that is heavily 
dependent upon paper records. So it is easy to conceive how a 
paper document can be mishandled. An electronic system from 
application to adjudication could mitigate some of these losses 
if properly implemented, unlike the way it was handled for 
widows expecting a month of death benefit or at the RO in New 
York. This is where new approaches to leadership and oversight 
are crucial and accountability is essential.
    Today's witnesses will provide us with an overview of these 
problems. We will hear from the veterans' service organizations 
and the American Federation of Government Employees (AFGE) who 
will provide us with insights into how veterans and their 
dependents are harmed when VA mishandles their documents and 
how improvements can be made to the system.
    Next, the VA Office of Inspector General (OIG) will share 
what it has learned about document mishandling. Finally, the 
Under Secretary for Benefits and the Systematic Technical 
Accuracy Review Office will give us their feedback on these 
problems and hopefully outline a strategic plan for the future 
that will correct the records mismanagement problems we have 
seen in the past. So I am grateful that the Deputy Under 
Secretary is here himself today because the accountability 
issue begins with top leadership.
    I have been on a track to modernize the VBA's antiquated 
claims processing system and envision the VA as an agency that 
we as a nation are proud of in the way that it serves the 
welfare of our disabled veterans. When it comes to discharging 
those responsibilities, shameful acts are what should be 
archaic practices. We look forward to eliminating those 
practices.
    I now yield to Congressman Mitchell, the Chairman of the 
Subcommittee on Oversight and Investigations, for his opening 
statement.
    Mr. Mitchell.
    [The prepared statement of Chairman Hall appears on p. 40.]

             OPENING STATEMENT OF CHAIRMAN MITCHELL

    Mr. Mitchell. First, thank you Chairman Hall and the 
Disability Assistance and Memorial Affairs Subcommittee for 
working with the Oversight and Investigations Subcommittee to 
convene this hearing.
    For too long, the spotty record of the Department of 
Veterans Affairs has led veterans and observers to view the 
Department as the worst kind of bureaucracy, massive, aloof, 
and unaccountable. Today, we have the opportunity to address a 
number of bureaucratic shortcomings and to take a step toward a 
more personable, accessible, and accountable VA.
    Some mistakes have already been addressed. I am encouraged 
that the VA is taking steps to compensate the widows of 
veterans whose benefits were wrongly docked when their spouses 
passed away. I look forward to receiving a status update from 
the VA.
    However, we now have learned that the shredding of 
documents may only be the tip of a very large iceberg. VA's 
Inspector General tells us that in July of 2007, the Detroit 
Regional Office had a ``mail amnesty'' during which employees 
could turn in unprocessed mail and documents without 
repercussion.
    Detroit Regional Office employees produced almost 16,000 
items, 16,000. Among these were 700 claims and 2,700 medical 
records and/or pieces of medical information. None of these 
claims or documents was in the VBA information system or 
associated claims files. The OIG was told by the VBA regional 
director that there were amnesties at other Regional Offices as 
well.
    Obviously, we are going to have to get complete information 
from VA about these amnesties. But it is impossible not to be 
shocked by the number from Detroit. Shredding documents or 
burying them in the bottom drawer is a breach of trust by the 
VA. Whether that breach of trust comes as a consequence of 
inadequate training or negligent or deliberate behavior, 
Congress must not and will not tolerate it.
    We will also hear testimony about data tampering that 
inaccurately reflected claims processing speeds at Regional 
Offices. A decision by management to lie about performance 
indicates creeping institutional decay that must be rooted out 
before it further erodes quality of care. The VA must restore 
integrity to its systems--its claim system and redeem the trust 
of veterans it serves.
    I am eager to hear a detailed account of these issues from 
the Inspector General's office. And I trust that the VA will 
provide a candid explanation about what went wrong and how they 
would ensure it never happens again.
    I am also eager to hear from the veterans service 
organizations (VSOs) about the impact of these failures on the 
veterans' community and from the American Federation of 
Government Employees about the effectiveness of VBA policy.
    Mistakes like these simply need not happen. They are 
avoidable as they are awful. And they rob us of time that could 
otherwise be spent planning outreach to veterans, easing the 
transition from soldier to civilian, or constructing a 21st 
Century benefits program.
    But, I am heartened by the vision, dedication, and know-how 
that Secretary Shinseki brings with him to the task of serving 
America's veterans. I am hopeful the VA can avoid similar 
pitfalls under his leadership.
    Thank you to our panelists for appearing today. I look 
forward to working with you to achieve the openness, 
accountability, and action that veterans deserve from the VA.
    [The prepared statement of Chairman Mitchell appears on p. 
41.]
    Mr. Hall. Thank you, Chairman Mitchell, Chair of the 
Subcommittee on Oversight and Investigations.
    I would now yield to Ranking Member Lamborn for his opening 
statement.

             OPENING STATEMENT OF HON. DOUG LAMBORN

    Mr. Lamborn. Good afternoon, Mr. Chairmen, and thank you. I 
am very happy to be back as Ranking Member of the Subcommittee 
on Disability Assistance and Memorial Affairs. I greatly 
enjoyed the favorable rapport we developed last Congress and 
the bipartisan manner in which you and I and our staffs worked 
together. I look forward to another productive session.
    I would like to welcome our colleagues from the 
Subcommittee on Oversight and Investigation and all of our 
witnesses who are here today, including my counterpart on that 
Subcommittee, the Ranking Member Dr. Phil Roe of Tennessee.
    Mr. Chairman, we made a lot of progress in the last 
Congress toward modernizing and improving the VA claims 
processing system. And it is my hope that the reforms we put in 
place in Public Law 110-389 will help prevent future document 
management problems like the ones we are examining today.
    I would also like to thank you for endorsing my idea to 
require VA to move toward a paperless rules-based adjudication 
system. While the paperless system is not a panacea, you and I 
both know that if VA's files were all electronic, the shredding 
incident could have been avoided. I thank VA for acknowledging 
that in their testimony.
    When a veteran submits a claim for disability compensation, 
they must be able to have trust that VA will adjudicate their 
claims in a timely and accurate fashion. Unfortunately, the 
shredding accident has violated this trust for many veterans. 
And it is now VA's job to regain it.
    What troubles me the most about the shredding incident is 
that the number of documents VA found during its spot check was 
merely a 1-day snapshot of what appears to be an ongoing 
problem. VA will probably never know how long this mishandling 
has been going on or how widespread the practice was.
    However, I do applaud VA for their swift action in removing 
the employees that were responsible for the documents that were 
found. I find it very unfortunate that the actions of a few 
have tarnished the work of so many dedicated VA employees.
    Veterans need to be able to trust the integrity of the VA 
system. And I believe they are on the path to regaining this 
trust. I do believe, however, that VA's current plan to have 
every document signed off by two people before it can be 
shredded is potentially inefficient. I encourage the VA to find 
a more reasonable approach to protecting claimant's files 
without adversely affecting production. And I hope today's 
discussion will produce some possible alternative solutions.
    Another focus of this hearing is the misdating of claims at 
the New York Regional Office and other offices around the 
country. As disturbing as this is, I am relieved to know that 
the actions of a few individuals have not adversely affected 
any veterans or survivors. However, these actions underscore 
the need to review and possibly change VA's work management 
program. Such review was mandated by Public Law 110-389. And I 
look forward to hearing more about this review once it is 
completed.
    I am reassured by the findings of the Inspector General 
that the problem is not believed to be systemic and that the 
employees involved in the backdating have been removed.
    That concludes my statement, Mr. Chairmen. I thank the 
witnesses for their attendance here today. And I look forward 
to their testimony. And I yield back.
    Mr. Hall. Thank you, Mr. Lamborn. Thank you for your 
steadfast advocacy of the paperless system that we are all 
hoping to move toward.
    Now I would like to yield to the Ranking Member of the 
Subcommittee on Oversight and Investigations, Congressman Roe, 
for his statement.
    [The prepared statement of Congressman Lamborn appears on 
p. 42.]

             OPENING STATEMENT OF HON. DAVID P. ROE

    Mr. Roe. Thank you for yielding, Mr. Chairman.
    I would like to start by saying that I am looking forward 
to working with the Members of both of the Subcommittees here 
today, and particularly with you, Mr. Mitchell, and the other 
Members of the Subcommittee on Oversight and Investigations as 
the Ranking Member of the Subcommittee.
    I understand that you and my predecessor, Congresswoman 
Ginny Brown-Waite, had an excellent working relationship on 
this Committee. And I hope that we can continue in that vein as 
we conduct oversight on issues relating to the Department of 
Veterans Affairs, and work to assist those who sacrificed so 
much for the good of our country, our Nation's veterans. We owe 
them no less.
    The issue at hand, document mishandling and shredding at 
the Department of Veterans Affairs is one of great concern. 
When these issues came to the forefront of our scope back in 
early October of last year, an investigation by the Office of 
the Inspector General showed that documents necessary for 
processing claims were found in shredding bins at several 
Veteran Benefits Administration facilities. Further issues 
arose from documents with an adjusted date-of-claims, which 
initiated a request by the Ranking Member Buyer on October 14, 
2008, for an OIG investigation into the issue.
    Our Nation's veterans deserve better than this. The 
mishandling of their claims documents is inexcusable. The VA is 
responsible for assuring our Nation's veterans that they will 
be given every opportunity to submit these claims and have 
their complete claims file reviewed in a timely manner. I 
appreciate that the former Secretary Peake took immediate 
action to address these issues. And I look forward to hearing 
from today's witnesses on what further actions have been taken 
to rectify this situation.
    Again, thank you Mr. Chairman, and I yield back.
    [The prepared statement of Congressman Roe appears on p. 
42.]
    Mr. Hall. Thank you, Dr. Roe.
    I will now recognize other Members who would like to make 
an opening statement. Mrs. Halvorson?

         OPENING STATEMENT OF HON. DEBORAH L. HALVORSON

    Mrs. Halvorson. Thank you, Mr. Chairman. I just want to say 
as one of the new people here that I'm very pleased that the VA 
seems to understand the seriousness of the situation. And I am 
very anxious to be a part of figuring out how it is that we 
continue to work toward eliminating this sort of problem and 
bring about trust back to the situation.
    Mr. Hall. Thank you, Congresswoman.
    Mr. Bilbray.
    Mr. Bilbray. Mr. Chairman, I have no opening statement. I 
just ask for--I would like to apologize. I am going to need to 
leave and enter this hearing. I just had a report by the Marine 
Corps of an incident--an aircraft incident that had fatalities. 
And so I would--it is just being released today, so I will be 
responding to that. Just so you know that I am not trying to be 
rude. It is just part of the job. Thank you.
    Mr. Hall. Okay. Thank you for the explanation in advance. 
You will be excused without any problem.
    Mrs. Kirkpatrick.

             OPENING STATEMENT HON. ANN KIRKPATRICK

    Mrs. Kirkpatrick. Thank you, Mr. Chairman. I am honored to 
be here today with you and the other distinguished Members on 
the Subcommittee on Disability Assistance and Memorial Affairs. 
Thank you to all of you for taking the time and making the 
journey to be with us today.
    Events like those discussed today remind me why this 
Committee's work is so important. We are here to ensure our VA 
operation and our country live up to and fulfill our commitment 
to our veterans. This is an important opportunity to discuss 
and evaluate the impact of VA policies on the real-life 
experience of veterans and their families.
    Trust needs to be the starting point when it comes to our 
veterans. When they sign up, our servicemembers put the 
entirety of their trust in their government. They trust that 
while serving they will be well equipped, that they will deploy 
responsibly, and they will be treated with dignity and fairness 
after their tour, enlistment, and service is complete.
    And in return for that trust, our servicemembers give 
entirely of themselves. I have met with many veterans. And no 
matter how many times I hear their stories, I am reminded that 
the pride, honor, and sacrifice with which they have lived 
their lives is truly special. We owe our veterans for their 
courage, their willingness to serve, and sacrifice.
    Now I don't have to tell any of the veterans here that 
there is no place where rumors circulate faster than inside a 
military barracks or inside a Veterans of Foreign Wars hall.
    So when veterans and servicemembers hear about things like 
shredding of claims documents, backdated forms, or unpaid 
widows, it creates cynicism within the ranks and among our 
veterans. It hurts recruiting numbers. But most of all and most 
importantly, it undermines the compact of trust we have entered 
into with our veterans.
    To the leadership of the Veterans Affairs, I am heartened 
by your quick action. I know that the behavior discussed today 
is not representative of your leadership nor the vast majority 
of the employees within the VA.
    However, I don't think it can be repeated enough just how 
serious these events are. This past Saturday I had an 
opportunity to visit the veterans' hospital in my district, 
which is in Prescott, Arizona. And I also went to the American 
Legion and visited with veterans there.
    The veterans I represent expressed skepticism and often 
frustration regarding the distant, often faceless claims 
process. To gain back their trust, I hope you understand that 
you will have to work twice as hard to not only hold 
accountable those responsible, but to find and address the 
underlying issues that caused this to happen in the first 
place.
    Chairman Hall, I look forward to working with you and 
learning from my colleagues on both sides of the aisle. I hope 
we can take the extra step, as our veterans have to make sure 
that they receive the benefits they have earned.
    Thank you and I yield back my time.
    Mr. Hall. Thank you, Mrs. Kirkpatrick.
    Mr. Walz, do you have an opening statement?

           OPENING STATEMENT OF HON. TIMOTHY J. WALZ

    Mr. Walz. Just a brief one. And thank you, Mr. Chairman, 
both Chairmen and both Ranking Members, for your ever diligent 
work, and to the staffs on both these Subcommittees. You have 
been absolutely relentless in making sure we get it right for 
our veterans. So I thank you for that. And for all of our 
witnesses who are here today.
    I would have to say and I would associate myself with--Mr. 
Lamborn brought up a very good point, I think. The incredible 
work that the VA does on behalf of our veterans. And I see it 
every day. When I am out there I talk to our veterans. 
Rightfully called the best health care anywhere. And we know 
that is the case. And we also know that it is our job and it is 
these VSOs' job to not only be the biggest supporters but to be 
the harshest critics.
    Painting it with a broad brush. Heaven knows this group up 
here, we get painted with a pretty broad brush. But the fact of 
the matter is we have taken jobs of leadership, both the VA and 
us sitting up here. And it is a zero sum game. We always have 
to strive for absolute perfection when it comes to the care of 
our veterans. We may not always get there. But it has to be in 
the best efforts. So this is an important issue we are dealing 
with. It is a challenging one. Again, I would associate myself 
with my colleagues on the VA's effort on this and their 
forthrightness is greatly appreciated.
    But we have got much work to do. And especially in this 
environment where reform and efficiency are going to be the 
key. There are scarce resources. They must be delivered 
correctly. And we have to find a way to get better at that. And 
I am still baffled that I can send a package anywhere in the 
world and get online and track that through UPS and know right 
where it is and who signed it. And yet I have got veterans 2 
years later wondering where in the heck their file is, who saw 
it, and what is going on with it.
    So we have got to just get this done. We have got to move 
forward. And if you don't need any more proof than that, I will 
tell you I have seen this group speak often. And Ms. Witt is 
going to speak in a moment. When our Nation's Gold Star Wives 
have to come in front of us and tell us what is going wrong and 
the difficulties they have receiving benefits after their 
spouses gave their life in defense of this country, the bottom 
line is we are wrong. And it needs to be fixed. And we need to 
get there together. Bringing the two Subcommittees together is 
absolutely what we need to do, cut through this, find some 
solutions, cut down on the backlogs of claims, get them right, 
and get the trust built back up. That is our responsibility. 
And that is our charge.
    So, Mr. Chairman, thank you for holding this hearing. And I 
yield back.
    Mr. Hall. Thank you, Mr. Walz. I think you may have come up 
with the solution. It is sort of like that commercial I have 
been seeing on TV where you put a delivery company in charge of 
getting kids to schools.
    Mr. Space, I yield to you for an opening statement.
    Mr. Space. In associating myself with remarks of Mr. Walz, 
I yield my time.
    Mr. Hall. Thank you, Mr. Space. Thank you to all of our 
witnesses for being here today. I would remind you that your 
complete written statements will be made a part of the hearing 
record, so you can limit your remarks. That way we will have 
sufficient time to follow up with questions once everyone has 
had the opportunity to provide their testimony.
    On our first panel, is Mr. Kerry Baker, Assistant National 
Legislative Director for Disabled American Veterans (DAV); Mr. 
Ronald Abrams, Joint Executive Director for the National 
Veterans Legal Services Program (NVLSP); Ms. Kathryn Witt, Co-
Chair, Government Relations Committee for Gold Star Wives of 
America, Inc.; and Ms. Geneva Moore, Senior Veterans 
Representative--Service Representative for the Veterans 
Benefits Administration Regional Office in Winston-Salem, North 
Carolina.
    Welcome, Mr. Baker, you are now recognized for 5 minutes.

   STATEMENTS OF KERRY BAKER, ASSISTANT NATIONAL LEGISLATIVE 
 DIRECTOR, DISABLED AMERICAN VETERANS; RONALD B. ABRAMS, JOINT 
 EXECUTIVE DIRECTOR, NATIONAL VETERANS LEGAL SERVICES PROGRAM; 
KATHRYN A. WITT, CO-CHAIR, GOVERNMENT RELATIONS COMMITTEE, GOLD 
STAR WIVES OF AMERICA, INC.; AND GENEVA MOORE, SENIOR VETERANS 
   SERVICE REPRESENTATIVE, VETERANS BENEFITS ADMINISTRATION 
REGIONAL OFFICE, WINSTON-SALEM, NC, U.S. DEPARTMENT OF VETERANS 
  AFFAIRS, ON BEHALF OF THE AMERICAN FEDERATION OF GOVERNMENT 
                       EMPLOYEES, AFL-CIO

                    STATEMENT OF KERRY BAKER

    Mr. Baker. Mr. Chairman and Members of the Subcommittees, 
it is a pleasure to be here today on behalf of the DAV. I look 
forward to discussing the recent document tampering and 
mishandling by the VA.
    The issues of concern began on or about August 20th, 2008, 
when VA's Office of Inspector General initiated an audit of 
mail processing at four different locations. The team found 36 
pieces of active mail and 93 other pieces of documents in the 
shred bins.
    The documents identified were both original claims and 
evidence in support of existing claims. The VA's Secretary 
ordered all shredding stopped followed by a search of all VA 
Regional Offices where approximately 500 other documents were 
found marked for unauthorized shredding.
    The VA then drafted an action plan that implemented 
numerous overlapping procedures to eliminate any repeat records 
mishandling. The draft plan even included the creation of 
additional positions within VA that require active, hand's on 
management of all documents marked for destruction.
    In addition to the action plan, special but temporary 
procedures were also put in place concerning VA claimants who 
assert they have been harmed by these mishaps.
    The DAV will not attempt to minimize the severity of this 
situation. The questions of how long this has been going on and 
how many VA claimants have been affected will forever go 
unanswered.
    However, scrutinizing and casting blame is easy. If we all 
are to act as leaders in the veteran community, then we must 
recognize the challenge before us. Not merely how to prevent 
such acts in the future, but how to recognize the faults in the 
current system that allow these actions to take place. Once 
acknowledged and understood, we must progressively change the 
structure to remove those faults. In our written testimony, we 
commended the VA for having detected these unlawful deeds 
through its own audit functions in implementing such a detailed 
plan meant to prevent similar actions in the future. We 
reiterate that commendation here today.
    Nonetheless, we also recommended that Congress amend the 
law to punish VA employees who unlawfully withhold benefits 
from claimants, the same as it punishes those who unlawfully 
obtain benefits. The message must be that if you illegally 
destroy records, you will go to jail. Ultimately, the DAV 
believes these were desperate, albeit irresponsible and 
unlawful acts, of a workforce near its breaking point.
    The solution is clear. The VA must go paperless. This has 
long been a goal of Congress and the VA. The VA must be up for 
the challenge. And Congress must provide any needed funding.
    The VA has already begun to utilize paperless solutions in 
many of its functions. While they are promising, each of these 
programs are small compared to the remaining bulk of VA's 
paper-locked workload.
    The DAV believes the one solution that Congress must 
consider above all else is to immediately authorize and fund 
the formation of one or more large-scale imaging centers. Such 
facilities should have the sole function of transforming paper 
records into electronic format.
    The formation of imaging centers could then free VA's 
moderate-sized staff who are tasked with receiving incoming and 
managing existing paper records. VA managers could then utilize 
the sizable workforce required for these functions to assisting 
claims development and adjudication.
    The idea of transforming the paper-locked records system to 
an electronic system is neither novel nor new. Rather it has 
been the centerpiece of all legitimate discussions on improving 
the claims process. Ultimately denying earned benefits by 
illegally destroying records should serve as the wake-up call 
that signals the urgency of this overdue transformation. It 
should be one of the highest priorities within the Benefits 
Administration.
    Mr. Chairman, that concludes my oral statement. It has been 
an honor to testify before you today. And I look forward to any 
questions you may have.
    [The prepared statement of Mr. Baker appears on p. 43.]
    Mr. Hall. Thank you, Mr. Baker.
    Mr. Abrams, you are now recognized for 5 minutes.

                 STATEMENT OF RONALD B. ABRAMS

    Mr. Abrams. Thank you Mr. Chairmen and Members.
    I am honored to be here again today to talk about this very 
serious problem. Rather than go over what happened, I am going 
to try and focus on why it happened and what we can do about 
the problem.
    I would like to start by reminding some of us who are my 
age that there was a television show back in the fifties, Lucy. 
And there was an episode in Lucy where she and her friend Ethel 
got a job at a candy factory producing candy. And they were 
working on a production line. And they were told that if they 
let one piece of candy pass them without getting wrapped, they 
would be fired. So what happened? First the candies came out 
slowly. And then the supervisor came by and yelled, ``Let her 
roll.'' And the candies came out faster and faster. And no one 
could wrap them. So what did Ethel and Lucy do? They put them 
in their blouse; they put them in their pockets; they put them 
in their hat; and put the hat back on. They had one of those 
candy hats. And they ate them. They cheated.
    This is analogous to what is happening in the VA. Too many 
claims, too fast, a production quota or--it is not a real 
quota. But it is a system that pushes production. It is not 
right.
    We at NVLSP believe that longstanding VA policies were the 
major cause of this employee misconduct. Essentially the way 
the VA grants work credit and assesses the performance of VA 
workers and managers is the main problem.
    In our experience, most of the problems are an attempt by 
VA workers to prematurely issue a decision on a claim before 
the evidence the VA is required to get to help the veteran is 
associated with the file. And this rush causes many incomplete 
VA claims adjudications. The VA emphasizes quantity over 
quality.
    This work system, this work measurement system, needs to be 
changed. It needs to be changed, because it creates a cynicism 
among VA workers. They think it is okay to go too fast, to not 
get all evidence. And that might lead to hiding evidence, 
putting it in a drawer, throwing it away. We need to change 
that. We need to promote managers who manage people who do good 
work as well as fast work.
    So here are some of the things that we think should be 
done. First, we need to hold VA adjudicators and managers 
accountable for the quality of their work. We need rational 
performance standards. The VA employees I know are good. They 
want to do a good job. But they are pressured to go very, very 
fast.
    Second, they need to change the way they measure work. Work 
credit should not be granted until the actual appellate period 
ends. In that way all work will be done up front.
    And third, the VA needs to create an independent quality 
review system that is outside the supervision of VBA.
    Thank you for letting us testify today.
    [The prepared statement of Mr. Abrams appears on p. 47.]
    Mr. Hall. Thank you, Mr. Abrams. Good timing.
    Now I would like to recognize Ms. Kathryn Witt for 5 
minutes.

                  STATEMENT OF KATHRYN A. WITT

    Ms. Witt. Thank you for allowing Gold Star Wives the 
privilege of testifying today.
    I tend to agree with both of the people who spoke before me 
that the employees are under too much pressure. They do this to 
get rid of this back load. The inability to get rid of the back 
load tends to create a greater back load, because when they 
can't find the claim, then the veteran or the survivor 
resubmits it again and again. I have one lady that has been 
asked to prove that she was married to her husband and they had 
three children three separate times. I have another lady that 
has filed four appeals, two of which have been lost twice.
    What they need to do is automate the system. Most records 
as they come in the door need to be scanned into a computer and 
assigned a line number or a customer number and cross indexed 
against the veteran's Social Security--the veteran's name and 
Social Security number so that they--the previous documents and 
claims can be retrieved.
    They also need an explanation when they send a claim out of 
what they have actually paid, and why they paid it, and how. 
Usually known as a detailed--an itemized voucher. Our survivors 
frequently get claims they have no idea what they are for. And 
if they have several claims, they have no idea what has been 
processed. And they submit another claim.
    We have concern about the backlog on--particularly on 
Dependency and Indemnity Compensation (DIC). It is taking a 
long time to process DIC. It often leaves the widows destitute. 
They have no other funds. If their husbands have been service 
connected and they have been at home caring for them, his check 
stops. And his compensation check stops. And they have no other 
income. We are concerned about the delay in that.
    And we are concerned about the delays in processing 
CHAMPVA, which is the VA's health insurance. It frequently 
takes--I am hearing 9 to 12 months to get an application for 
CHAMPVA processed and approved. Both of those are pretty cut 
and dried claims that could easily be processed by computer.
    I believe that every claim that the VA receives should be 
scanned--completely scanned into the computer. I think that is 
the only way you are ever going to get rid of this backlog. And 
then you can track them and cross index them by name and Social 
Security number. And at least respond to people when they call 
about their claim to say yes we have it, so that you don't get 
four or five more claims in.
    Thank you.
    [The prepared statement of Ms. Witt appears on p. 50.]
    Mr. Hall. Thank you, Ms. Witt.
    I would like to at this time recognize Geneva Moore, Senior 
Veterans Service Representative for the VBA Regional Office in 
Winston-Salem. You are recognized for 5 minutes.

                   STATEMENT OF GENEVA MOORE

    Ms. Moore. Thank you. Chairman Hall, Chairman Mitchell, 
Members of the Subcommittee, it is my honor and pleasure to be 
here today to testify on behalf of the many thousands of VBA 
employees represented by the AFGE.
    I am a retired Marine Corps Master Sergeant and a proud 
Gulf War veteran. I am equally proud of the important work that 
I do as a Senior Veteran Service Representative (VSR) to ensure 
that my fellow veterans are properly compensated for their 
service-connected disabilities.
    More than half of the employees at our Regional Office are 
veterans and most are service-connected disabled. As veterans 
helping veterans, we who also borne the battle, do our jobs 
with tremendous sympathy and compassion for our fellow 
veterans.
    AFGE absolutely does not condone what has gone on with 
regard to misplaced or shredded claims files. We are 150 
percent committed to do all that we can do. And we want to help 
VBA fix this problem. But management is not willing to come to 
the table with us to come up with a workable solution to the 
shredding problem.
    If I were in management, it would make perfect sense to me 
to solicit the input from the employees who actually process 
the claims. In the Marine Corps, we work as a team. And we are 
able to resolve problems through effective, positive 
communication. But VBA has shut us out completely, the 
employees.
    I was at the VBA Academy when I first heard the shredding 
reports. Management presented us with the national rules of 
behavior and demanded that we sign on the spot without any 
training or opportunity to ask questions or seek further 
guidance. We were told that we would face discipline or 
possible termination if we did not sign this national rules of 
behavior.
    When I returned back to my RO, we were given only 1-day 
notice of a desk audit. They told us that we had to clear our 
desks of every extraneous documents. In my case, I lost over 14 
years of training materials and binders that I used for unique 
cases that helped me do my job effectively.
    Management refused to give us 1 minute of deductible time 
away from case production to sort through our documents. We 
were extremely anxious about what would happen if management 
determined that we were not in compliance. So we did the only 
thing we could do, clear our desks of all training documents 
and materials.
    High production quotas are no excuse for possible improper 
document shredding. However, more realistic quotas and better 
training will reduce the problems and enhance the overall 
effectiveness of the ROs.
    When I served on the group investigating the Tailhook 
incident almost 20 years, we made the recommendation that 
manager training was essential to stopping that improper 
behavior. When VBA does provide training at the RO level, the 
quality is poor, because so many of the trainers are 
inexperienced and not subject matter experts.
    I recommend that more training of the file clerks and the 
claims examiners, in the mail room who are the first in line to 
receive veterans' documents in evidence. They work under 
constant production pressures. Mistakes will continue to be 
made if the training does not get better.
    The employees in my office have not been given any page, 
stamps, cover sheets, or other tools for discarding documents 
more quickly. We have to mark every piece of paper that we 
discard with our initials and the reasons for shredding it.
    The shredding problem has also resulted in a large number 
of unfair terminations and disciplinary actions. I am currently 
appealing the reprimand of a young lady who was accused of 
unintentionally shredding a veteran's original document. Even 
though the evidence was weak, management told us that this is a 
very high visibility case, so they must go forward with the 
reprimand.
    We are very pleased that Congress has provided VBA with the 
funds to hire thousands of new veterans to address this 
backlog. But it is heartbreaking and frustrating to see so many 
new hires fired during their probationary period.
    Finally, much of the problems of lost and tampered files 
could be solved by VBA going paperless. There are so many Iraqi 
and Afghanistan veterans who need jobs and would be proud to 
join the VBA workforce to do the document scanning and other 
work to help VBA go paperless.
    Thank you.
    [The prepared statement of Ms. Moore appears on p. 52.]
    Mr. Hall. Thank you, Ms. Moore. Thank you for your service 
as well as your service to our veterans.
    Ms. Moore. Thank you.
    Mr. Hall. Thanks to all of our panelists for your service 
and for your service to our veterans.
    Let me just start off. My first question is for Mr. Baker. 
In general what does a service officer do when he or she cannot 
locate a claim folder or they suspect a file has been tampered 
with by the VA?
    Mr. Baker. Well as a national service officer (NSO) in a 
field office, we have about 250 plus NSOs that man every 
Regional Office in the country. Our ability is limited. Once we 
believe something is missing, and we can't confirm, for 
example, an entire claims folder is missing. We need the VA to 
help us do that. But if it has been confirmed that a claims 
folder in its entirety is missing, we have no choice at that 
point but to rely on VA to start the rebuilding procedure for 
that folder. Now some of that will come from the service 
organizations, some of it will come from the clamant. They will 
go out to various centers, wherever that person sought medical 
treatment, and try to rebuild as much of that claims folder as 
possible. It is a difficult process, because some of the 
records are simply irretrievable, some of them are 
irreplaceable.
    If we feel--now that is a missing claims file. If we feel 
evidence is missing that maybe we have submitted, we have a 
tracking system in our case management program that tells us 
everything we have done for a particular claimant. And we can 
pull up submittal letters, which are attached to medical 
evidence that we have copies of. We can take it to VA. And at 
least if we can get that particular claimant to come back up 
with the evidence, unfortunately sometimes they have to come 
back up with it again, we can show by our records that we did 
submit it to the VA. And, you know, the VA can't then say that 
they never got the evidence. We can prove that they got the 
evidence. And as far as effective date purposes or a few other 
things, you know, that kind of--that kind of partnership can 
come together for a good outcome.
    But if, you know, almost half or maybe more than half of 
the claimants out there are not represented, you wouldn't get 
that kind of benefit.
    Mr. Hall. Thank you, Mr. Baker. One more question for you. 
In your testimony you categorized incidents with shredding as 
``unlawful destruction'' and suggested that there be fines or 
imprisonment for guilty employees.
    Are you suggesting that title 38 should be amended? What 
about managers who do not comport with VA regulations that are 
complicit in improperly handling documents?
    Mr. Baker. I don't want to--I don't want my recommendation 
to be taken too much out of context. I mean, if it is found 
that somebody has illegally destroyed records, I believe that 
they should be prosecuted under title 18.
    Right now there are many provisions in title 38 that 
require VA to prosecute a veteran, a veterans' representative, 
a VA employee if they fraudulent--commit fraud against the 
government to obtain benefits. But there is nothing in title 38 
that mandates VA prosecute a VA employee if they commit fraud 
against a claimant to withhold benefits.
    Mr. Hall. Right. So in other words, if there is prosecution 
or punishment of some kind for overpaying or paying 
unnecessarily then there also should be balance. And there 
should be similar----
    Mr. Baker. There should be balance.
    Mr. Hall [continuing]. Sanctions for not paying.
    Mr. Baker. And that is not to say VA can't prosecute them 
under title 18 now.
    Mr. Hall. Right.
    Mr. Baker. But various circumstances mandate that they 
prosecute other instances under title 18.
    Mr. Hall. Have you made your recommendation for imaging 
centers to the VA?
    Mr. Baker. I have now.
    Mr. Hall. Okay. I think everybody here sort of echoes that 
recommendation.
    I want to ask Mr. Abrams. It seems that you agreed that the 
work credit system currently in place incentivizes employees to 
take short cuts. I love the Lucy and Ethel picture. And I would 
also agree that measuring for quality and accuracy could 
improve the system. How would you suggest that that be 
implemented and what about production?
    Mr. Abrams. Well, I think we should reward managers who are 
able to supervise people who do work well and do lots of work. 
Once we get started on that track, people will be promoted who 
are good, who do work well, and the VA will have to accept that 
it will have to report numbers to Congress and to the public 
that show it takes longer to do a claim in the first instance 
than what they expect now. It will be shorter over all. The 
backlog will go down. But it will take longer to do the claim 
right in the first instance.
    And that was why in my formal testimony I said we should 
give amnesty to the managers now, because the statistics that 
you are going to get, if they are honest, are going to shock 
you, just like you were shocked in the OIG report. There are 
cases that are in drawers now that are going to have to come 
out. And you are going to see old, old claims. And that is 
going to have to get on the table in order to know where we are 
to get better.
    Mr. Hall. Thank you, Mr. Abrams. I am sorry I have--I am 
running out of time here in this round. But I want to ask Ms. 
Witt. In your experience with the legislation that we passed 
last year creating the New Survivor Office at the VA, has Gold 
Star Wives called--asked the VA to call survivors when needing 
to retrieve funds, and if so what was the VA's response?
    Ms. Witt. We have not asked them to do that. I think it 
would be an extremely good idea if they did.
    Mr. Hall. This is all a work in progress. That legislation 
is fairly recent. We have a new Secretary, and there will be 
new direction coming from the top leadership at the VA. So I 
presume that these things should start to happen and the office 
is to be fully staffed. And we will see changes. But that would 
be probably a wise thing to do.
    Ms. Witt. We have already seen significant progress from 
the VA office.
    Mr. Hall. Ms. Moore, does the AFGE train employees in how 
to report unethical or improper document handling if they 
witness it in the field?
    Ms. Moore. Yes, sir, absolutely. We have a training program 
in place now that does train the AFGE leadership to report 
mishandling of documents and shredding, illegal shredding.
    Mr. Hall. What process is used to determine if an employee 
has intentionally engaged in that behavior?
    Ms. Moore. Well, actually what happens is that it is 
reported to the managers, management, upper-level management 
when it is brought to AFGE's attention, we have to go through 
management.
    Mr. Hall. Thank you very much. I would like to recognize 
Mr. Mitchell, the Chairman of the Subcommittee on Oversight and 
Investigations.
    Mr. Mitchell. Thank you. Mr. Baker, in her testimony the 
VA's Assistant Inspector General for Audit tells us the so 
called mail amnesties in Detroit and New York uncovered 16,000 
pieces of mail and other documents that had not been processed.
    I have a three-part question. Had you ever heard of these 
mail amnesties for one? And second, how often do veterans tell 
you that they have submitted paperwork to the VA, and that they 
had to resubmit the same paperwork? And third, how well does 
the VA deal with these situations?
    Mr. Baker. I have never heard of the amnesty until now. 
Hearing it when you mentioned it earlier was the first time. I 
was shocked to hear that there were that many that turned up in 
the amnesty. Again, I hadn't heard that. So I will say that 
that is a first for this type of situation.
    Mr. Mitchell. The second part of that question is how often 
do veterans tell you that they have to submit--when they submit 
paperwork, they have to resubmit it for the same thing?
    Mr. Baker. I spent a number of years in the field at 
various locations throughout the country. And I would probably 
hear it weekly. That is not to say it was always--a lot of 
times it was found later. I mean, if you have ever been to, and 
I am not saying you haven't, some of the Regional Offices out 
there, you know, the paperwork piles are tremendous. So in 
realizing what they have to work with, it--you know, it is very 
believable that you would lose a few documents a week out of 
thousands that are handled. But a lot of them eventually turn 
up.
    Mr. Mitchell. And the third part of that question is how 
well does the VA deal with those situations?
    Mr. Baker. When the documents are found, I think the VA 
deals pretty good with them. A lot of times they have already 
been received by VA, so we can prove when VA--you know, VA 
dated them.
    It is when they are not found. And those records are not 
replaceable. At those points a lot of problems are created for 
the claimant. Most of the time when you lose records that are 
irreplaceable, if it is the one piece of proof that a claimant 
needed, you see the benefit get denied. But you don't know what 
that evidence was. You don't know what it said, you know, if 
you can't come up with it. A lot of times it is just--it is too 
bad for the claimant. And that is a very unfortunate situation 
in many of those.
    Does that answer your question?
    Mr. Mitchell. Another question is you indicate in your 
testimony that you are aware of the document handling 
procedures that are now in place. Do you believe this new 
procedure is sufficient to protect our veteran's claims until 
the IT solution is complete, or do you have some concerns about 
the potential mishandling of records?
    Mr. Baker. I think it is sufficient. I don't want to see it 
have to go on on a long-term basis, because I think it is a 
form of micromanagement in overdrive. I mean, and I say that 
only because it is very labor intensive. That work could be 
used other places to help speed up the claims process.
    So I would like to see the IT get in place as fast as 
possible, so that VA doesn't require to have those--isn't 
required to have those types of positions to oversee everybody. 
There are a lot of VA employees that do their job very well 
that don't shred documents that are now under the gun because 
of this.
    Mr. Mitchell. Thank you. Ms. Witt, as you know, the IT-
focused system takes time to set up. And the VA is working 
toward this paperless system right now. But in the meantime, do 
you have any suggestions of how the VA should proceed to ensure 
that claims and documents are properly handled and processed?
    Ms. Witt. My only idea would be that they log each one in 
and give it a number so that they could track it. But if you 
are going to go totally manual system, they would have to 
number them and record them in a PC so that they could track 
whether they received them or not. Put a rubber band around 
them. Make sure they stay together.
    I am a retired computer programmer. I come up with the ways 
to do it on the computer, you know, to automate it. I don't 
really think they have a hope of ever straightening out the 
backlog unless it is automated.
    Mr. Mitchell. I thank you. And I yield back the balance of 
my time.
    Mr. Hall. Thank you, Mr. Mitchell.
    Ranking Member Roe.
    Mr. Roe. Thank you, Mr. Chairman.
    Mr. Baker, it is a monumental undertaking to do all this 
scanning. We just took a 70 doctor practice and 350 employees. 
And it almost drove us crazy. So this is a huge undertaking. 
But I totally agree it is absolutely mandatory just from what I 
have heard here today. There is no way in the world you can 
keep up with all this paper. It can't be done.
    And what--Ms. Witt, what you have said, I have heard over 
and over again. We have a large VA hospital in my district. And 
I hear it practically every week, someone is complaining. How 
many of these scanning centers would you think? Are you a 
little concerned about--we scanned it in various different 
sites. And our practice is divided, so we used various sites. 
That would seem to be a smarter thing to set up across the 
country instead of going to a central point.
    Ms. Witt. I would think that you would need one for each 
Regional Office where they are processed. And then----
    Mr. Hall. Ms. Witt, excuse me, could you speak closer to 
the microphone? Pull the microphone down there a little bit if 
you would.
    Ms. Witt. I would think that you would need a scanning 
place in each individual office that processes claims. And I 
think that is the Regional Offices. Then those could be put 
into a common database of the whole VA, the records of the 
scanning, so that they could be retrieved.
    Mr. Roe. Mr. Baker, do you approve, agree?
    Mr. Baker. I agree with you, sir. I don't think one is the 
proper solution. I mean, I could imagine the size of something 
like that would have to be.
    At the same time, I would have to disagree with Ms. Witt. I 
wouldn't want to see them in every single VA Regional Office, 
because it is just too hard to manage. I know Lockheed did this 
for the Social Security Administration. They have a 5-year 
contract. I am not suggesting VA use a contract. I think it 
would be better for them to do it with their own people. But if 
you had centers, regional centers, such as the Social Security 
Administration currently has, they could be--every piece of 
mail could be managed centrally. The end user could still look 
at the evidence once it is electronically recorded into an 
electronic claims file. It could be sent anywhere.
    Now there is probably a lot of ways to do this. I am not an 
IT specialist. But I don't think it should be one. I think it 
should be regional. And there may be much better ideas out 
there than mine.
    Mr. Roe. One of the things that, Mr. Abrams, you mentioned, 
and I did see that Lucy show, that was good, but that was a 
comedy show. And the care of our veterans is not. And so we can 
do better. And I want to brag on our VA. We are so blessed to 
have the VA system. I, as a veteran, appreciate the quality 
care that we get at the VA. And we certainly forget, Ms. Moore, 
sometimes all the literally millions of claims you do right. 
But we need to strive to do better. And I would argue, Mr. 
Abrams, just your comment briefly, I certainly found this out. 
It is a lot better and quicker to do it right the first time 
than to redo it 15 times. I mean, first of all, what you are 
doing is incredibly labor intensive. It is a one-on-one.
    When somebody in my district office calls the VA system, it 
is one person working with another person. And if there is a 
mistake made, you have just compounded that. And another 
mistake and it takes--I think that is what adds a lot of the 
time. I think you are absolutely dead on right is to do it 
right the first time. Comment?
    Mr. Abrams. Yes. And we have been saying that--I have been 
saying that since 1985 when I was working for the VA. And I 
think that got me out. But if we do it right, the managers and 
the workers have to be encouraged with a system that rewards 
them for doing it right. Right now they are rewarded, in our 
opinion, for doing it fast.
    So if you hold back the work credit until the appeal period 
is over, then people are going to say if we do it right, then 
we don't have to worry about that. If they appeal, we don't 
have any more to do. We can move this case on. How many times 
does a case go to the board where the board sends it back for 
extra evidence? Where a Decision Review Officer says they 
didn't develop the claim in the right way. These things can be 
stopped if people are incentivized to go do it right.
    Mr. Roe. And I think just one last time. This is a massive 
undertaking. I can tell you just from what we did in our 
medical practice, it was a huge undertaking. This is going to 
have to--there is going to be a learning curve. And there is 
going to be a time where it will probably actually slow things 
down as you scan all this data in. But, it is going to require 
some patience. But in having said that, it has to be done.
    Thank you.
    Mr. Hall. Thank you, Mr. Roe.
    And I would just comment that we did pass a bill last year. 
It was signed into law by President Bush, P.L. 110-389. It was 
unanimously supported in both the House and Senate, which among 
other things requires review of the work credit system. It, 
unfortunately, doesn't happen just because we passed the bill. 
It has to be implemented and planned. And with the new 
Administration getting up to speed, I hope we will see some 
progress, and all of these ideas that we are talking about will 
be looked at.
    Mrs. Halvorson, you are now recognized for 5 minutes.
    Mrs. Halvorson. Thank you, Mr. Chairman. You know, it is a 
shame one of the biggest casualties here is trust and faith in 
our VA. And I know we work every single day to reinstate that 
trust and faith.
    And Mrs. Moore, I just want to commend you, because it is 
true, we focus on some--the few things that go wrong. Just as 
what we go through, people want to point out the bad instead of 
talking about the good. I want to commend you on what you do 
and all the good things.
    The question I have though is I know from hearing from my 
constituents, and even when I served in the State Legislature, 
people still came to me with VA issues. But is it--I know that 
it is a lack of maybe enough working people. I mean, do you 
have--you are understaffed in many cases. Is that true?
    Ms. Moore. Yes, we are currently understaffed. But I think 
that if we had proper training, if the focus was on training, 
the employees that we have in place and getting them the 
information that is needed, we would overall be better.
    Mrs. Halvorson. And why are you lacking the training?
    Ms. Moore. Well, I mean, the training is there. It is just 
that the trainers are inexperienced. They are just entering the 
VA system. They are not, in my opinion, subject matter experts.
    Just like was mentioned on this Committee that if you 
produce cases quickly, you are promoted. It is production. It 
is the production line. So----
    Mrs. Halvorson. So then we are taking people's lives and 
trying to skip through them quickly so that people are promoted 
within their jobs instead of taking care of our veterans.
    Ms. Moore [continuing]. That is what I am seeing at the 
Regional Office at----
    Mrs. Halvorson. And who makes those decisions?
    Ms. Moore [continuing]. Top management.
    Mrs. Halvorson. Okay. Then we also hear from--I hear from 
constituents also that their cases are denied, because it is 
easier to deny a case than to deal with it. Is that going on?
    Ms. Moore. I see some of that going on, yes.
    Mrs. Halvorson. Does anybody else care to talk about that 
issue?
    Mr. Abrams. Yes.
    Mrs. Halvorson. Mr. Abrams?
    Mr. Abrams. Yes. It is much easier to get work credit when 
a claim comes in, and you need to get a couple medical 
opinions, and you need to go out for lay evidence, and you need 
to give the veteran time to get things to prove certain things 
than it is to skip that, deny the claim, and say, as we have 
heard all over--we have been to over 40 ROs. I worked in the VA 
for almost 20 years. Let the Board of Veterans' Appeals decide. 
And so people appeal.
    If the ROs were told you have to develop this, because we 
get burned if the claim goes on and on and on, they wouldn't do 
that. They would go get that crucial evidence.
    Mrs. Halvorson. So instead----
    Mr. Abrams. They would----
    Mrs. Halvorson [continuing]. We now have to help our 
constituents who are constantly having to appeal. So these are 
people that have served our country. They have done everything 
right. And now we expect them to constantly appeal so they get 
taken care of, because people who are working in the offices 
find it is easier to get themselves promoted if they deny our 
people who have served their country benefits.
    Mr. Abrams. You can look at the remand and reversal rates 
at the Board of Veterans' Appeals and see they are much too 
high. And then you can look at what happens at the Court of 
Appeals for Veterans Claims where they have over a 50-percent 
remand reversal rate. It is the highest rate of any appellate 
court. And this is--this is to be a non-adversarial system 
where the VA is obligated to help people get evidence to win 
their claims.
    Mrs. Halvorson. Well, to me this is very adversarial. And I 
think we need to do a better job taking care of our veterans. 
And I am hoping that I can be of assistance in any way to make 
sure that we can do something to not only train the people who 
are dealing with these claims, but to do something about taking 
care of the people, because now it has almost become automatic 
that people are appealing their cases, which now makes you have 
to deal with the person at least twice instead of once when you 
could have just taken care of it right away. So I am hoping 
that I can be a big part of maybe helping somehow deal with 
fixing something that to me just doesn't make sense.
    Thank you, Mr. Chairman.
    Mr. Hall. Thank you, Mrs. Halvorson.
    Mrs. Kirkpatrick, you are recognized for 5 minutes.
    Mrs. Kirkpatrick. Thank you, Mr. Chairman.
    My question is for Ms. Moore. Regarding shredding, I am 
glad to hear that AFGE feels to strongly that improper 
shredding is totally unacceptable. And that you feel that 
making veterans wait over a 6-month period for their claims to 
be processed is also unacceptable.
    You state that the VBA could have struck a better balance 
if VBA had consulted with their front-line employees prior to 
implementing its shredding policy. What advice would you give 
VBA to strike a better balance in its shredding policy?
    Ms. Moore. The consultation and the advice from the 
employees that actually do the work. We are the front-line 
employees. We do the work. We are on the floor. We see the 
claims that are processed. We see the evidence that comes 
through the mail room.
    I think that if VBA top management would just sit down at 
the table and communicate with the employees and solicit our 
input, we could be a resounding resource. But that is not 
happening. We want to help. We want to be there, because we are 
veterans serving other veterans. So we feel left out.
    But I think that if they solicit--I am urging the Committee 
to have top VBA to solicit the input from the employees, the 
front-line employees, that actually do the work.
    Mrs. Kirkpatrick. And just to follow up on that, do you 
think there have to be safeguards put in place so that those 
employees don't feel inhibited during that process, because 
they are going to be talking to their supervisors, their 
managers?
    Ms. Moore. Well, you know, I think that if VBA would have a 
partnership with the employees and their representatives, that 
would make it so much better. But VBA does not want to have the 
partnership with AFGE. AFGE represents the employees. We are 
there for the interests of the employees as well as the 
veterans. So we have a twofold job here.
    And my job is extremely difficult, because I am the Vice 
President of the American Federation of Government Employees at 
Winston-Salem. So not only do I process claims, but I also 
represent employees. So I think we can--we can strike an equal 
balance here if we work together. We need to work together.
    Mrs. Kirkpatrick. So there is a way to strike sort of a 
win-win between----
    Ms. Moore. I think so.
    Mrs. Kirkpatrick [continuing]. Employees and management?
    Ms. Moore. I really do. I really do believe that from the 
bottom of my heart.
    Mrs. Kirkpatrick. Thank you. I yield back my time.
    Mr. Hall. Thank you, Mrs. Kirkpatrick.
    Mr. Walz, you are now recognized.
    Mr. Walz. Thank you, Mr. Chairman, and thank you to each of 
our witnesses. One thing I really appreciate is your desire and 
your hard work to truly solve this. Some of you have been 
fighting this for decades. And you haven't lost the desire to 
get it right. You are still continuing to be there.
    But I have to tell you it gets hard to hear these. All of 
us have been there. And we continue to hear this. We continue 
to hear the problems. We have got to get it right. The momentum 
is there to do that. But we have to be smart about this.
    So there are a couple of things I want to address. I think 
Dr. Roe is bringing up a really important point. This is going 
to be monumental in what it is going to take to do it.
    And it is something that I--spending 24 years in uniform in 
watching these things happen. And I have been there when the 
DoD has lost stuff. I don't know how many of us here receive 
nine extra shots that you knew you had. But there was no record 
of it. And every time I am telling them, ``Well, I am the guy 
who was there signing off,'' that didn't matter.
    We have got tools now to be able to get there. We have got 
computers, and we have got electronic records. And I am 
convinced that, yes, we have got to get this claim that is 
there. We have got to take away exactly the things you are 
focusing on.
    But I think we have to back up a step further and get to 
the systemic problem here, which is that seamless transition 
issue. That record should be in far better shape when that 
individual, that warrior, leaves the DoD and gets into the VA 
system. We end up trying to track back records into the other 
side of the house on DoD. And it becomes a dang nightmare.
    And that I think is the first step. I think it sets the 
tone for streamlining this process. It puts things in. It gets 
us electronic--from the electronic medical record (EMR) to the 
electronic enlistment record and everything else that moves 
with this person. DoD has got to start seeing themselves as not 
just the war fighters. They can't just sign off on this piece 
of equipment that was a warrior. And they go into the VA. That 
is where a lot of our problems are starting.
    So I am going to ask you, Mr. Baker. And it got touched 
upon. How do we do this? How do we front load this thing? And 
maybe, you know, we have got to get to the computer experts. 
And we will ask the VA in all of that. But do you agree this is 
part of the issue that if we can front load this, getting the 
records compiled in the right place, having that documentation 
there, that that should start to clear the backlog?
    Mr. Baker. It absolutely would front load it in a lot of 
good ways. And we have had a lot of different hearings in both 
the House and the Senate on the claims process and the appeals 
process.
    And personally I look at the whole picture from start to 
finish in various sections. You can't look at it in one. 
Everybody is different, whether you are a Vietnam vet or a vet 
just getting out of service.
    And how you--how do you process that claim when evidence is 
all over the country----
    Mr. Walz. That is right.
    Mr. Baker [continuing]. Is different in every situation. So 
I think what you are talking about is one segment from military 
to veteran status. If that were seamless, than that segment is 
then almost taken care of. You don't have to go back and trace 
records down somewhere down the road. So you are right. If you 
could do that, you have just made a monumental step forward.
    At the same time, now I know the BDD system, the Benefits 
Delivery at Discharge, has recently gone paperless. Now I don't 
know to the extent that that is up and running. That for some 
of those veterans is an answer if they go through the BDD 
process. But a lot of them don't.
    Mr. Walz. Yeah.
    Mr. Baker. So that kind of takes up for a difference in the 
DoD system versus VA system. But it doesn't solve the problem 
that is between those two systems. So absolutely----
    Mr. Walz. Okay.
    Mr. Baker [continuing]. It worked out 100 percent.
    Mr. Walz. Okay. And I would--Ms. Witt, this issue on 
survivor's benefits, the Ranking Member Buyer has got a piece 
of legislation I think he is going to roll out pretty soon to 
start addressing some of these issues. We know there are 
problems in that DIC. We know that there are things that need 
to be addressed. And we will start to get there.
    My last question, Master Sergeant Moore, again, thank you 
for your service. And, again--and Mr. Lamborn mentioned it and 
other Members here is that we are absolutely committed to the 
men and women in the VA. They are veterans for the most part, a 
large number of them.
    But we do have problems. We have got some cultural issues 
there. And I know this is somewhat subjective. But after this 
story came out about the shredding, it seemed to me you might 
be kind of intimating a little bit. Has the pressure fallen 
heavily on the processors, and to find scapegoats, and 
releasing people? Do you kind of feel that is happening? It is 
falling heavily on you and----
    Ms. Moore. I know that to be happening. VBA was more or 
less caught with this problem. And in order to rectify it or to 
provide answers to this Committee or whatever Committee, they 
had to find evidence of whomever was committing these acts. And 
there were I am sure at some ROs people doing this. But at 
other ROs, the instance that--I don't think--I think we--
Winston-Salem we didn't have a lot of incidents. But the 
pressure is there.
    And you have to now--you have to initial every piece of 
paper that you get in a veteran's file, put it in a red folder, 
give it to your supervisor. Then your supervisor has to review 
it and determine if it is shreddable. I am paid $75,000 a year. 
And I think I can make that decision.
    Mr. Walz. Do you think that those procedures have done 
anything to stop the person who was going to destroy one for a 
work product issue?
    Ms. Moore. I don't see where it is really helping. I really 
don't.
    Mr. Walz. Okay. Well, I appreciate your candor. Thank you. 
I yield back, Mr. Chairman.
    Mr. Hall. Thank you, Mr. Walz. You just asked my last 
question. And you just answered it, Ms. Moore.
    So I want to thank you. I want to note that both Mr. Baker 
and Mr. Walz talked about the two tracks, the new veterans who 
are separating now from service and have a DoD electronic 
health record that can be handed off. That, obviously, is the 
best world. Records are going to be much easier to deal with if 
you are starting out with an electronic record.
    Then there are the older veterans who have operated under a 
system in which the health records are printed out, and have 
rubber bands around them, and sticky Post-it notes put on them, 
and get passed from one desk to another. Those will need to be 
scanned or date entered and in certain instances character 
recognition software run.
    In the cases where a doctor has scribbled in the margin, if 
it is like my doctor, I don't know that the character 
recognition software would work. But nonetheless, we are 
trying, as you know, to make this happen.
    We appreciate your testimony and your input. Thank you for 
your testimony and, again, for your service. The first panel is 
now excused.
    Now we would ask our second panel to join us. Ms. Belinda 
Finn, Assistant Inspector General for Auditing at the Office of 
the Inspector General for the U.S. Department of Veterans 
Affairs; accompanied by Mr. James O'Neill, Assistant Inspector 
General for Investigations at the Office of Inspector General 
for the U.S. Department of Veterans Affairs.
    Welcome to both of you. Make yourselves comfortable. Your 
full statement is entered in the record, so feel free to 
deviate from it, or shorten it, or whatever you choose to do.
    Ms. Finn, you are recognized for 5 minutes.

 STATEMENT OF BELINDA J. FINN, ASSISTANT INSPECTOR GENERAL FOR 
   AUDITING, OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT OF 
 VETERANS AFFAIRS; ACCOMPANIED BY JAMES J. O'NEILL, ASSISTANT 
   INSPECTOR GENERAL FOR INVESTIGATIONS, OFFICE OF INSPECTOR 
          GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS

    Ms. Finn. Thank you very much. Chairman Hall, Chairman 
Mitchell, Members of the Subcommittees, thank you very much for 
having us here today.
    We are going to discuss issues affecting the handling and 
processing of veterans' compensation claims. My colleague from 
the OIG is with me today, Mr. James J. O'Neill. He is the 
Assistant Inspector General for Investigations.
    In September of 2008, we were conducting an audit of claim-
related mail processing, in the Detroit Regional Office. At the 
suggestion of a VBA employee, we looked in the shred bins and 
found claim-related documents. We continued our work in the 
Waco, St. Louis, and St. Petersburg Regional Offices, finding a 
total of 132 documents, about 45 of which could have affected 
benefits.
    On learning about this issue, the Under Secretary for 
Benefits immediately directed every Regional Office to suspend 
document shredding and inventory the contents of the shred 
bins. That search found 474 claim-related documents at 41 
Regional Offices.
    During this time, the Office of Investigations investigated 
the circumstances surrounding every instance where a document 
could be traced back to an individual. The results of our 
investigative efforts are outlined in our written statement for 
the record.
    Neither we, nor VBA, can determine with any accuracy how 
long documents may have been discarded or how many documents 
were lost. In fact, I note that the shred bins we looked in had 
been emptied fairly recently and contained only about 14 days 
worth of documents.
    At the time of our audit, VBA did not have a policy 
governing what documents could be placed in shred bins and no 
review checks to determine if documents were appropriate for 
shredding. Following this disclosure, in November, VBA issued 
sweeping new procedures for the maintenance, review, and 
appropriate destruction of hard copy documents. We will be 
reviewing the effectiveness of those controls during our future 
visits to VBA offices.
    In October 2008, we began another review at the request of 
Congressman Steve Buyer to evaluate the accuracy of 
compensation and pension claim receipt dates. The impetus for 
this work was a VBA report that management at New York had 
directed staff to intentionally record false claim receipt 
dates. This was done to improve their reported claim processing 
time.
    In reporting this, VBA assured everyone that the errors did 
not affect payments to veterans or beneficiaries. To determine 
if this issue was a problem elsewhere, we evaluated over 1,500 
claims from the Albuquerque, Boston, San Diego, and Winston-
Salem Regional Offices.
    We found the majority of the claim receipt dates were 
accurate. A small percentage of claims, however, had no 
documentation in the claim file to support the date that had 
been recorded. Most importantly, we were able to confirm that 
these incorrect claim receipt dates did not cause any harm to 
veterans or beneficiaries, because VBA personnel verified the 
amount and date of each payment before authorizing payments. 
Further, we found in only one instance that any evidence 
existed that this was an intentional act.
    We recommended that VBA take actions. And they have 
accepted our recommendations.
    During 2008, my office has visited about 16 regional VBA 
offices. In addition to the two reviews discussed here, we are 
conducting audits or reviews on VBAs quality assurance 
programs, its management controls over large retroactive 
payments, and VBA systems to track and control records.
    We will be glad to provide our reports on each of these 
reviews after we complete our work.
    In addition to our National reviews, we are beginning an 
inspection program to evaluate operational issues at specific 
Regional Offices. We will start our work this month and plan to 
cover all 57 offices within 5 years.
    Mr. Chairmen, thank you, again, for the opportunity to 
testify and for your continued support of the Office of 
Inspector General. Mr. O'Neill and I would be pleased to answer 
any questions at this time.
    [The prepared statement of Ms. Finn appears on p. 55.]
    Mr. Hall. Thank you, Ms. Finn. I would start by asking is 
there a systemic document handling problem within the VA--VBA, 
or is this--would you say New York was systemic to management 
there, and that the rest of it is within the level of tolerance 
that one would attribute to mistakes, or accidental 
mishandling?
    Ms. Finn. That was our conclusion for the four offices that 
we visited and reviewed. New York was unique in that management 
had directed the incorrect dates. And there was a systemic 
pattern of it. We did not find, obviously, any evidence of that 
in other offices.
    Further, the pattern of the claim dates was different in 
New York. Over 50 percent of the dates were inaccurate. And, 
most of the inaccurate dates after the claim was actually 
established to make the processing time look better.
    In the other offices we saw inaccurate dates on both sides, 
either before or after the date. And we felt this was much more 
indicative of unintentional error.
    Mr. Hall. Thank you. What do you think of the VA's response 
to the problems with shredding and its new policies? Had the 
OIG ever audited mail rooms or shredder bins before to your 
knowledge, and what were those results?
    Ms. Finn. To my knowledge, we had not conducted any audits 
or reviews of mail rooms or shred bins before. I will caveat 
that by saying I have only been with the VA OIG for about 2 
years. But I think I would have heard if we had done earlier 
reviews.
    VBA took very swift action. And they established sweeping 
policies. I think these policies are a big step in the right 
direction to have a policy and a procedure where none existed 
before.
    Mr. Hall. I am glad to hear that the Office of Inspector 
General is creating a Benefits Inspection Division and will be 
doing evaluations at the 57 Regional Offices. What will be the 
primary focus of these inspections, and will there be a 
standardized protocol?
    Ms. Finn. Yes. We will be using a standardized protocol. 
The focus will be to evaluate the accuracy of claims processing 
and action affecting claims processing. We will be evaluating a 
wide range of issues.
    We are still developing all of those protocols to make sure 
we have the most effective use of our time. But we will be 
issuing standard reports on each visit. And we plan to issue 
them about 60 days from the start of our work, so it will be a 
fairly quick review.
    Mr. Hall. And is a 4-year cycle for inspections going to be 
efficient enough to catch systemic problems?
    Ms. Finn. It is the schedule we can currently handle with 
our resources. As to whether or not it will get around to every 
office quick enough is--I think remains to be seen.
    Mr. Hall. Do you need more resources to do this in a timely 
fashion?
    Ms. Finn. We would need to dedicate more resources, yes, in 
order to visit the offices and complete the cycle quicker.
    Mr. Hall. So I guess we talk to Secretary Shinseki and ask 
him if he can move them from somewhere else or whether we in 
Congress need to allocate more funds. Do you know about how 
much more funding would be necessary for you to have sufficient 
staff to do these inspections?
    Ms. Finn. Our current resource limit and level for this 
effort will be ten professional staff. And that will allow us 
to complete all 57 offices within about 5 years.
    If we wanted to complete all offices within a 3-year cycle, 
then we would probably need to double the resources.
    Mr. Hall. Okay. If you would submit to us at your earliest 
convenience a written summary of what you think you would need 
to be able to do that, I would appreciate it.
    Ms. Finn. Yes, sir.
    [The information was provided in a follow-up letter from 
Hon. George Opfer, Inspector General, U.S Department of 
Veterans Affairs, dated March 26, 2009, which appears on p. 
98.]
    Mr. Hall. I will now recognize Mr. Mitchell.
    Mr. Mitchell. Thank you, Mr. Chairman.
    Ms. Finn, you talked about, at least in your written 
testimony, about the amnesties that occurred in Detroit. And 
you uncovered 16,000 pieces of mail and other documents that 
had been processed. Did you come across amnesties in any other 
offices, or is this just in one particular place? And what do 
these amnesties tell you or indicate to you?
    Ms. Finn. At the risk of sounding like a popular book, I 
will say that everything we know about amnesty we learned from 
VBA. We did not actually witness or observe any of the 
amnesties. So we have information from VBA about the 16,000 
documents and how effective the amnesty was. But I really don't 
have any firsthand information.
    [The information from the VA OIG is included in the 
response to Question #5 in the Post-Hearing Questions and 
Responses for the Record, which appears on p. 89.]
    Mr. Mitchell. Do you think that as a result of there being 
an amnesty, that, obviously, management knew that something was 
wrong. That not all these claims were being processed. That is 
the reason they had an amnesty. Otherwise they wouldn't need 
one.
    Ms. Finn. Yes, I think definitely management realized that 
there was a need for an amnesty and that documents or mail that 
was not being processed that could be hidden or lost somewhere 
in the RO. And that is why they went with the amnesty. I think 
it is similar to the library that has an amnesty program for 
your overdue books.
    Mr. Mitchell. Do you have any indication of how many 
amnesties they have? Is it one every so many months, years, or 
anybody else have them?
    Ms. Finn. I believe we heard that two out of four of the 
area offices that we visited knew of amnesties or had had 
amnesties. But I really don't have any detailed information.
    Mr. Mitchell. Do you believe that the misdating and the 
shredding that was discussed was the result of improper 
training or supervision or the result of widespread culture in 
the VA that tolerated or maybe even encouraged employees to 
behave in this way?
    Ms. Finn. We have not done any specific audits or reviews 
to evaluate the training on this issue. And we have noted that 
the policies and procedures before October were geared mainly 
toward ensuring the privacy of veteran's information and really 
did not cover shredding or placing documents in a drawer or 
anything like that.
    In my experience, I have often seen that measurement 
systems or work measurement systems have unintended 
consequences. And that people could take an unaccepted shortcut 
to achieve a metric.
    Mr. Mitchell. Thank you. And I yield back the balance of my 
time.
    Mr. Hall. Thank you, Mr. Mitchell.
    Mr. Roe, you are now recognized for 5 minutes.
    Mr. Roe. Thank you, Mr. Chairman. Just a comment or two and 
then a question. If one veteran falls through the crack it is 
one too many, because that veteran is only interested in what 
is going to happen to me, not the other thousands we have got 
right. So that is why we have got to get them as close to 100 
percent as we can.
    And if we don't--I guess maybe I always understood who I 
worked for as a doctor. I always worked for my patient. There 
would be no need to have a VA if we didn't have veterans, so 
they are who we work for. And so we should--it is not the other 
way around.
    Sometimes I think institutions get confused, hospitals do. 
And I think we need to think about that from the top down is 
that our idea is we serve these veterans. They served us. And 
now we serve them.
    Just out of curiosity, I know, Ms. Finn, and you all 
probably have done this, but you have only been there 2 years, 
maybe Mr. O'Neill should answer it, but why hasn't the OIG done 
regular RO inspections before now or have you done them before 
now?
    Ms. Finn. Actually I can answer that. We were doing 
combined assessment reviews of the Regional Offices for a 
number of years. We stopped them in 2006 in the Office of Audit 
so that we could focus our attention on national issues 
affecting VBA operations. And we believe those reviews have 
been very effective at identifying issues and the need for 
change.
    The impetus for the inspection program is coming actually 
from the Senate Veterans' Affairs Committee. And it was part of 
our appropriation and our marching orders for next year.
    Mr. Roe. I think you speak again why we need to get to a 
paperless system to be able to manage this information. It 
would make your job much easier if you had a computerized 
system where you could do your work much easier and probably 
more efficient with fewer people.
    Just a question, and you may or may not have this answer 
here. But I would like to know how many people were terminated, 
or moved, or were they actually terminated that deliberately 
shredded these documents? I find that just incomprehensible 
that you would just shred documents so you didn't have to do 
something.
    Ms. Finn. I do know that VBA terminated or took 
administrative action against a number of people. I don't have 
the exact number. And I am sure they will be able to address 
that.
    Mr. Roe. Terminated means gone though, right?
    Ms. Finn. Yes, it does.
    Mr. Roe. Not moved somewhere else.
    Ms. Finn. Generally terminated means having left Federal 
service.
    Mr. Roe. Okay. Well that is--because sometimes it can mean 
being moved somewhere else and continuing your poor work.
    I do appreciate what you do, because anything that I did as 
a physician, you may be thinking you are doing things real well 
until you have someone independently come in, audit that 
situation, and find out, hey, we are not doing nearly as good a 
job as I thought I was.
    So thank you for what you are doing to keep this 
information flowing our way. And I yield back my time.
    Mr. Hall. Thank you, Mr. Roe. Mrs. Halvorson?
    Mrs. Halvorson. Thank you, Mr. Chairman. I have just a real 
short one. In the panel before you, we were talking about the 
fact that there was not enough training. And that the trainers 
weren't trained well enough to do the training. Is this a 
problem and is this widespread? Could you maybe give us a 
little insight, or is it like not under your purview?
    Ms. Finn. I wish I could. It would be under our purview. We 
just have not done any recent work in that area to evaluate the 
training program.
    Mrs. Halvorson. Mr. O'Neill, maybe?
    Mr. O'Neill. No, I wouldn't be able to comment on it.
    Mrs. Halvorson. Okay.
    Mr. O'Neill. I am responsible for the oversight of----
    Mrs. Halvorson. Sure.
    Mr. O'Neill [continuing]. Criminal investigations.
    Mrs. Halvorson. Great, okay. I completely understand. Thank 
you. Thank you, Mr. Chairman. I yield back.
    Mr. Hall. Mrs. Kirkpatrick?
    Mrs. Kirkpatrick. Thank you, Mr. Chairman. My question is 
for Ms. Finn. In my law practice I helped veterans put together 
claims and also widows submit their claims. And, you know, I am 
just wondering if we need to look at the type of documentation 
we are asking them to submit for redundancy and for things that 
may not make sense. And I am just wondering in your review if 
you developed an opinion about that?
    For instance, certified copies of documents are very 
difficult to obtain. Some places don't even certify documents. 
And yet there is a requirement that you have to submit a 
certified document. I mean, I just wonder if we really need to 
look at, you know, the type of documents, whether we need to 
have originals, whether copies would suffice, and what your 
opinion is of that?
    Ms. Finn. I have not looked at that. I don't know that my 
office has. I think you raise some interesting points. And I 
would like to keep that in mind for some future reviews if you 
don't mind.
    Mrs. Kirkpatrick. Thank you. I yield back my time, Mr. 
Chairman.
    Mr. Hall. Thank you, Mrs. Kirkpatrick.
    We would appreciate that at some future time if you respond 
to us for that question. I want to thank you for your 
testimony, and for being here today, and the work you do on 
behalf of our veterans, and especially sorting through this 
particular problem.
    We have votes coming up at 3:00, around 3:30. So we will 
excuse our second panel and move right along to our third 
panel, which consists of Michael Walcoff, Deputy Under 
Secretary for Benefits at the Veterans Benefits Administration 
at the Department of Veterans Affairs. Mr. Walcoff is 
accompanied by Mr. Bradley Mayes, Director of Compensation and 
Pension Service of the VBA at the U.S. Department of Veterans 
Affairs, and Ms. Diana M. Rubens, Associate Deputy Under 
Secretary for Field Operations of the Benefits Administration 
at the U.S. Department of Veterans Affairs.
    Mr. Walcoff, your full statement is entered for the record. 
So you know how this goes. You are now recognized for 5 
minutes.

   STATEMENT OF MICHAEL WALCOFF, DEPUTY UNDER SECRETARY FOR 
BENEFITS, VETERANS BENEFITS ADMINISTRATION, U.S. DEPARTMENT OF 
   VETERANS AFFAIRS; ACCOMPANIED BY BRADLEY MAYES, DIRECTOR, 
      COMPENSATION AND PENSION SERVICE, VETERANS BENEFITS 
   ADMINISTRATION, U.S. DEPARTMENT OF VETERANS; AND DIANA M. 
RUBENS, ASSOCIATE DEPUTY UNDER SECRETARY FOR FIELD OPERATIONS, 
 VETERANS BENEFITS ADMINISTRATION, U.S. DEPARTMENT OF VETERANS

    Mr. Walcoff. Nice to see you again.
    Mr. Hall. Good to see you, sir.
    Mr. Walcoff. Mr. Chairmen, Members of the Committee, I 
appreciate the opportunity to appear before you today to 
discuss the critical issue of proper handling of veterans' 
claims documents at VA Regional Offices, as well as issues 
involving proper date of claim for workload and performance 
tracking.
    I am accompanied by Ms. Diana Rubens, Associate Deputy 
Under Secretary for Field Operations, and Mr. Bradley Mayes, 
Director of the Compensation and Pension (C&P) Service.
    As described in my written testimony in response to an OIG 
audit of mail handling procedures, VBA implemented a 
comprehensive plan of action to strengthen our policies and 
procedures to safeguard veterans' paper records. This action 
plan implements tighter controls to protect veterans' 
applications and claims-related documents and ensures measures 
are in place to prevent future incidents of employees 
inappropriately discarding veterans' paperwork.
    Working with veterans service organizations and 
Congressional staffs, we also developed special temporary 
claims handling procedures for veterans and claimants who 
assert VA did not process their claims because documents they 
previously submitted to VA to support their claim were shredded 
or otherwise improperly disposed.
    These special procedures for missing documents were 
officially released on November 14, 2008. Since that date, we 
have received 335 requests from veterans or beneficiaries for 
review of their claims under the temporary procedures.
    I extend my sincere appreciation to the Senate and House 
Committee staffs and to the veteran service organizations for 
their input as we developed our action plan. We will need your 
continued support as we work to ensure anyone potentially 
affected by this situation is assisted in filing a claim under 
these special procedures.
    As long as VBA continues to establish and store paper 
claims folders, we will be vulnerable to misplacement or 
misfiling of records, damaged records, and occasionally losing 
files. VA has very clear and specific guidelines covering lost 
folders and rebuilding folders.
    ROs are obligated to conduct an exhaustive search within 
their facilities before declaring a folder lost. When these 
searches are completed and responses properly documented, the 
RO is responsible for rebuilding the folder.
    The process of rebuilding folders includes replicating all 
evidence available to the VA. If there is evidence pertinent to 
a pending claim that VA does not have, all development is 
redone to obtain that evidence.
    In addition, VA is required to notify the veteran and his 
or her representative of the lost folder and request any 
documents pertinent to the successful rebuilding of the folder.
    If the original claims folder is subsequently located, the 
RO is obligated to combine the contents of both the claims 
folder and the rebuilt folder.
    Control over all documentation is imperative. And while we 
recognize that paperless is not a cure all, the use of 
technology will allow VA to maintain electronic documents, 
copies of documents, which cannot be shredded or lost.
    Mr. Chairman, you also requested a status on the proper 
date stamping of documents at ROs. During a routine site visit 
to the New York Regional Office, the C&P Service discovered 16 
of 20 claims reviewed and an incorrect date of claim 
established in the electronic claims tracking program. The New 
York RO was establishing claims using an unsupported date of 
claim, which resulted in erroneous timeliness on this data.
    It is important to note that no veterans were impacted by 
these actions. Subsequently, C&P staff members conducted an on-
site review of a statistically valid sample of pending claims 
to assess data integrity at the New York Regional Office. In 
addition, the Eastern Area Director convened an administrative 
investigative board to conduct a thorough and comprehensive 
investigation on site in New York.
    Of the 335 additional claims reviewed, 56 percent had 
inaccurate dates of claim. As a result of the findings of the 
New York Office, the Office of Field Operations and C&P Service 
conducted a full-scale claim--full date of claim review.
    The purpose of the review was to determine if ROs are using 
the proper date of claim. And if not the reasons for using an 
incorrect date. The review also required each RO to determine 
whether any use of an improper date of claim was to the 
advantage of the RO.
    Findings showed an average of 6.7 percent of cases 
nationwide were established with improper dates of claim. 
However, the errors were unintentional and payment dates to 
veterans were not affected.
    The OIG also reviewed four Regional Offices to evaluate 
accuracy of benefit claim receipt dates. The findings issued on 
February 27, 2009, showed a range of inaccuracy between 3 and 
10 percent among the four offices. The OIG concluded that 
inaccurate dates were unintentional and did not cause any 
veteran to receive inaccurate or delayed benefit payments.
    VBA implemented several measures in response to the 
findings of these reviews. Each area office began conducting 
additional unannounced site visits at ROs under their 
jurisdiction. Beginning in November 2008, the C&P Quality 
Assurance staff added date of claim accuracy reviews to all-
STAR quality reviews. The C&P site visit staff will continue to 
conduct date of claim reviews during routine site visits. The 
information documented from both C&P and area office site 
visits is provided to leadership at the RO level as well as 
senior leadership in VBA.
    Based on the findings from ongoing date of claim reviews, 
VBA will continue to provide training, guidance, and reminders 
to the field of the importance of proper date of claim.
    Finally, I would like to mention changes to month-of-death 
payment processing. Due to problems implementing a change of 
law, some surviving spouses did not receive the veterans' 
compensation or pension benefit for the month of death. And I 
have heard this referred to as a computer glitch. And I want to 
make it clear that it was not a computer glitch. This was an 
improper interpretation of the law by us.
    Over 10,000 surviving spouses have been identified so far. 
And payments to those spouses have been made. Procedures are 
being revised to automatically issue the month-of-death benefit 
immediately on processing the notice of death where VA knows of 
a surviving spouse. No application is required to make payment. 
We expect to issue new procedures later this month.
    Mr. Chairmen, I have worked for the VA for 35 years. During 
that time, I worked with many dedicated employees who devoted 
their careers to serving veterans. The events I discussed in 
this testimony, particularly the shredding of documents, go 
totally against the responsibilities we have as public 
servants.
    The veterans have lost trust in VA. That loss of trust is 
understandable. And winning back that trust will not be easy. 
We are committed to doing whatever we can to accomplish this.
    Mr. Chairmen, this concludes my statement. I would be happy 
to answer any questions you or the Members of the Committee 
might have.
    [The prepared statement of Mr. Walcoff appears on p. 61.]
    Mr. Hall. Thank you, Mr. Walcoff. I appreciate you and your 
colleagues and all of those who work for the VA and your 
sincere wish and motivation to help our Nation's veterans.
    How well would you say the new shredding policy is working? 
And have you conducted follow-up reviews?
    Mr. Walcoff. The new policy was put in effect after every 
Regional Office certified that the training had been done. That 
certification took place on December 31st of 2008. We are 
planning after 90 days to review what has been found during all 
of these various reviews at Regional Offices. And at that 
point, we will make a determination as to whether and how long 
the additional scrutiny that is being placed on all documents 
to be shredded needs to continue.
    We feel that while these measures are very burdensome, as 
was testified to by earlier panels, it is necessary for us to 
do this, because we need to show veterans that we are able to--
we are willing to do whatever it takes to make sure that their 
paperwork is not being mishandled.
    And, you know, when we are confident that these procedures 
are working and that our employees are doing what they need to 
do and doing it correctly, then we will talk about whether it 
is time to ease back a little bit. We are not going to go 
totally back. We are going to feel it necessary that there has 
to be some extra look at documents before they are shredded. 
But, you know, we would have to make a determination as to 
whether we want to continue what we are doing now.
    Mr. Hall. Would you care to comment on Ms. Moore's 
statement in our first panel that those who are doing the 
training aren't knowledgeable enough about the policy 
themselves? If I understood her correctly, that is what I 
thought she said.
    Mr. Walcoff. Yeah. And I wasn't sure whether she was 
talking about the training specifically for the shredding or 
generally our training and claims adjudication. And with all 
due respect to her, I would disagree with her statement.
    I believe that we do put, you know, our people that have a 
combination of technical knowledge, which is important. But 
also they have to have the ability to teach. And we look for 
that combination in the people that we use as instructors. We 
do send them specifically to an instructor development class 
that takes place at our training academy in Baltimore with the 
idea of trying to come up with that combination of expertise 
plus skills in platform areas.
    Mr. Hall. In preparing for this hearing, staff was told 
that the primary way files are missing, that they go missing 
and disappear, is that they are lost in transit. Have you 
reviewed how many files are lost in transit between offices and 
Medical Centers? How is a file tracked? What is the chain of 
responsibility? And what about the custody of brokered claims?
    Mr. Walcoff. I can tell you that in terms of lost files 
through sending them through the mail, it has--it has certainly 
happened. I wouldn't say that that is the primary way that 
files are lost. But I can tell you that it is something that we 
certainly have some concern about.
    We require that any files that are sent through the mail 
are sent through a system that has a tracking device. In other 
words, you can't just take a C-file and drop it off in the mail 
and just send it regular mail. It has to be using whatever form 
of delivery would allow us to be able to track the document if 
it comes up missing.
    Now that is not the cheapest way to send a file, frankly. 
As a matter of fact it is a lot more expensive. But we felt 
that that was needed in order to be able to locate missing 
files if they do not show up where they are supposed to show 
up. So that is a precaution that we do take with the brokering.
    And I will tell you that, you know, we keep hearing about 
paperless and electronic and how that is the answer to a lot of 
the problems. And frankly, it is the answer to a lot of our 
problems, not all them, but a lot of them. And certainly I 
can't wait until we get to the point where we can move files 
around without ever having to actually physically move 
anything. That when we are in a paperless system, that if I 
want a file that starts in Des Moines to be done in Los 
Angeles, I can have people at both stations go into the 
electronic site and have access to that file rather than us 
having to physically mail a file.
    Mr. Hall. Yes. I remember you testifying about that last 
year when we were passing legislation to start the process, 
which we hope to see adopted soon.
    What are the consequences to employees when a file is lost 
while under their control, or for that matter, what are the 
consequences to managers? How is their performance measured 
when folders or documents go missing from their control? And 
does it affect their bonuses?
    Mr. Walcoff. I am going to let Diana, you may want to take 
that. I will tell you that often when a document or a file 
disappears, it is not easy to figure out who had last custody 
of it. And I think the OIG could probably testify to that. When 
they went in and investigated, the documents that wound up 
where they shouldn't have been, they were only able to track 
back to a specific individual, a very, very small number of 
those pieces of paper.
    So because of the process and the way we--the way things 
move around in our operation, it is often very difficult to be 
able to say exactly when and where and who was involved when 
the folder disappeared. Certainly if we ever have any 
indication that an individual intentionally either lost, or 
shredded, or in any way mishandled a piece of paper or a file, 
serious action is taken.
    And I can tell you that the individuals who we were able to 
trace the shredding incident back to, have been terminated as 
was said. And I do mean in this case that they were removed 
from their position in the government.
    Mr. Hall. According to Mr. Abrams on our first panel, the 
VA does not have the authority to establish dates for which to 
allow claimants a window to file claims without proper 
documentation. Did you explore this with General Counsel prior 
to sending instructions to the field?
    Mr. Walcoff. Do you want to take that?
    Mr. Mayes. Yes, we did, Mr. Chairman. We consulted with 
General Counsel. And we came up with the procedures that would 
allow us to accept an asserted claim. And we felt that the 
Secretary did have authority to take those claims. I know that 
was an unprecedented procedure that we put out there. But I 
think we needed to do that, as Mr. Walcoff said, to begin to 
restore the faith and the confidence in VA.
    Mr. Hall. Thank you, Mr. Mayes. Before I turn it over to 
Dr. Roe, I will ask you, Mr. Walcoff, if you would respond to a 
number of questions we didn't get to and rather than ask you to 
wait while we are over there for voting for however long that 
is, we would like to follow up with you on the question of mail 
amnesty, in particular the comment today. I would like your 
commitment to us that you will fully and expeditiously respond 
to information requests from staff on that.
    Mr. Walcoff. Absolutely.
    [Post-Hearing Questions and Responses for the Record from 
VA appear on p. 91.]
    Mr. Hall. Thank you. Dr. Roe.
    Mr. Roe. Thank you, Mr. Chairman. It was stated several 
times that--and also, Mr. Walcoff, thank you for 35 years of 
service to our veterans---that no veteran was adversely 
affected. And yet in your testimony you said they had lost 
trust, so all of us were adversely affected. When you lose 
trust in the system, then when a veteran's claim doesn't get 
done, has mine been shredded. And that is all we have is our 
word and trust. That bond we have that we are going to do 
everything we can to adjudicate your problem, not the other 
thousands that are out there, but your problem. You are the 
most important person in the world right now when you are that 
veteran.
    So I would argue we have got to gain their trust back, 
because I hear that. And I would ask that same question, did my 
record get shredded if it wasn't, didn't get appropriately 
looked into? So I would argue and certainly inadvertent dating 
is--I mean, I have written the third down when it was the 
fourth, everyone has done that. But when you deliberately do 
something like these folks did, that is not ever acceptable. So 
I would argue that is the case.
    And I think that just a statement and then your answer. It 
seems to me that throughout the testimony we have heard today, 
it is clear that we need a paperless, electronic system. And I 
completely agree with you. It is still garbage in and garbage 
out. I mean, when you do--have a system there, it won't solve 
all the problems. Our EMR system created some problems. And 
there will be some things you are not even expecting that are 
going to happen when you go to this system.
    And I will assure--I am going to tell you right you are 
going to hear a lot of complaining when you go to this system. 
It is going to be difficult, and hard, and will take some time 
to do. It is going to take a lot of patience to do. But I 
support that. I think you have to do it. And I will support 
that.
    I want to make it clear, though, here in Congress this--the 
cost overruns, delays in delivery, all of that we have got to 
do this in a timely fashion. And not say, hey, this is hard to 
do, so I am not going to do this either, which is what will 
happen. And we expect delivery of this system be on time, and 
on budget, and perform. Certainly our veterans deserve it and 
so do our taxpayers.
    You also are correct that following up on where a chart is 
is one of the most frustrating things in the world in my own 
office is to start looking for a chart. And it is on this one's 
desk, and it is over here, and it is over there. So to try to 
ever find one sometimes or to put a finger on who was 
responsible for that chart, when it is lost, what I found is 
nobody was responsible for it. It didn't happen on anybody's 
shift. You probably have experienced the same record I--I mean, 
same situation. I will stop and let you answer or just comment.
    Mr. Walcoff. Well, if I can--there are two things that I 
want to comment on. First of all, I appreciate your comments 
about our plan to go paperless and the importance of staying on 
that plan and finishing on time.
    We recently, I guess it was probably about 2 months ago, 
gave a briefing to the staffers of this Committee on the status 
of our paperless initiative. And at that time, expressed a 
willingness to brief this Committee and its staffers as many 
times as they wish, so that they feel comfortable with the fact 
that we are staying on schedule.
    We have started working with a lead systems integrator. We 
are working on--with another contractor working on business 
transformation. We are looking at some of the things that were 
talked about here about scanning options and whether you do it 
in one place or whether you do it in 57 places. So these are 
all issues that have to be resolved in order to get it right.
    But we are still on schedule for being paperless by 2012. 
That was the schedule that--it was the charge we got from the 
Deputy Secretary last year. And we are committed to meeting 
that deadline. So I appreciate your comments on that.
    As far as the difficulty in tracking who is responsible, I 
know exactly what you are saying. And our process does require 
the file to move to many different places. And that is one of 
the things that we look at and the way--the process we are 
using to work claims. And as we look at--we are constantly 
looking at that process. The many hand offs that are involved 
is one of the things that we are looking at and saying is this 
necessary?
    So, I don't know what that--where we are going to go with 
that. But it is certainly an issue, as you have mentioned. And 
it is something that makes it difficult to trace back to any 
particular individual when something goes missing.
    Again, electronic I think, you know, if you have somebody--
if you have a way to make it so that every time somebody 
touches that electronic file it is recorded, then you know who 
has touched that file.
    Mr. Roe. I thank you. Mr. Chairman, thank you for your 
indulgence. And for the remainder of the hearing I would like 
to ask unanimous consent that Minority Counsel be permitted to 
ask questions of the witnesses.
    Mr. Hall. Without objection, after other Members have had 
their chance.
    Mrs. Halvorson, you are recognized.
    Mrs. Halvorson. Thank you, Mr. Chairman.
    I have a couple of questions. But thank you again panel. 
And, Mr. Walcoff, I understand that if this was easy to fix, 
you have been there 35 years, you would have done it already. 
So this isn't something that can simply just be fixed 
overnight.
    However, I do have one question. I can't help myself. I do 
have to ask. You know, in the first panel we were discussing 
the fact that it is just so much easier to deny everybody's 
benefits. And it forces them to appeal. Why is it that we just 
can't go the extra mile to help our veterans and get through it 
first instead of just denying and forcing everybody to go and 
appeal, which forces you to have to deal with something twice 
and even sometimes more?
    Mr. Walcoff. If you will, I will just have to tell you that 
I disagree with the premise that it is easier to deny. What we 
find is we do have a lot of complaints about our work, our work 
measurement systems. When I say work measurement, I am talking 
about the way we evaluate individuals.
    And I think there seems to be a consensus among everybody 
on both sides of the table that we need to look at that. The 
law that you passed last year requires us to look at it. 
Frankly we were going to look at it anyway.
    But what is interesting is that a lot of our managers are 
unhappy with those same standards. But they are unhappy about 
it because they feel it rewards an individual VSR for what we 
would call over developing a case, because they get credit. 
Every time they go out and ask for evidence, they get credit 
for that.
    Mrs. Halvorson. Yeah.
    Mr. Walcoff. That counts toward their production goals. So 
they feel that there is sometimes is an incentive for employees 
to go out and ask for something that they don't really need. 
They already have enough evidence to grant. But yet they go out 
and ask for another piece, because they will get more credit.
    So, you know, that is certainly not something that is the 
right thing to do, nor, obviously, would be----
    Mrs. Halvorson. Right.
    Mr. Walcoff [continuing]. What you were describing where 
they deny just to get the case off their desk.
    Mrs. Halvorson. Mm-hmm.
    Mr. Walcoff. So I think the answer is that we agree that we 
need to look at the way we measure individual performance. And 
we need to make sure that the way we do it is what is best for 
the veteran. And it encourages the types of behavior that are 
right for veterans.
    The one thing I do want to disagree with that was said by 
Mr. Abrams is that all we care about is productivity and we 
don't care about quality. If you look at the individual 
performance standards that we have on individuals, there is 
obviously a component for production. But there is an equal 
component for quality. And they are both measured for 
individuals. And they are both measured when we evaluate our 
directors and the performance of stations. Both are important. 
And, you know, I certainly want to make that clear that we do 
not ignore quality.
    Mrs. Halvorson. And that is good to hear, because it 
saddens me to think that the veteran who has done everything 
that they can--the only thing I want to do is just ask--I want 
to know what steps you are taking to ensure that our veterans--
that this is not the culture in the VA. The fact that these 
incidents that we are discussing today, the shredding of 
documents, the misdating of claims, are all terrible 
reflections on the VA. We need to get that trust back. I just 
would like to know what steps we are taking to ensure that our 
veterans--that we can go back and tell our veterans that this 
is not the culture of our VA. And what kind of sort of behavior 
are we going to tell them that we are not going to tolerate, 
that we are going to turn this around. Do you have any ideas?
    And why have we only heard about the mail amnesty through--
or why is it that we have only heard of the mail amnesty 
through the OIG's testimony, not anywhere else?
    Mr. Walcoff. I know that I was going to answer the mail 
amnesty question in writing.
    Mrs. Halvorson. Oh, that is right. Since we are going to 
have to vote, maybe----
    Mr. Walcoff. Yeah.
    Mrs. Halvorson [continuing]. That is probably best, because 
that might take a while.
    Mr. Walcoff. Because I want to specifically talk about 
that. But I think your question is a very fair one. And this 
came up at the roundtable that Chairman Filner had back in 
December.
    Mrs. Halvorson. Yes.
    Mr. Walcoff. And his point was that there was a--this was 
something that was in our culture, you know, this dishonesty, 
and that veterans have lost trust in us because of that. And I 
don't agree that it is in our culture. I think that I can't 
deny, obviously, that individual events happened.
    But I will tell you that in terms of the shredding, for 
instance, we found, and the OIG concurred, that the 
overwhelming percentage of cases where there were documents 
where they shouldn't have been, were placed there inadvertently 
through carelessness, which I am certainly not defending but 
not through intentional acts.
    And we believe that by properly training, by putting a 
system in place where we have checks and checks on actions 
taken by individuals, that we can set up a system that is a 
deterrent that causes people to say, hey, I have got to be 
thinking about what I am putting here, you know, rather than 
just picking up pieces of paper and not caring that maybe there 
is a piece of paper in the middle of that file that shouldn't 
be there.
    So I think that we are trying to set things up that will 
send a message to employees that it is part of their 
responsibilities to ensure that these things don't happen. Even 
if we know that--we say we know you are not doing it 
intentionally, but yet you still have a responsibility to make 
sure you know what you are doing.
    Mrs. Halvorson. All right. Thank you very much. I yield 
back.
    Mr. Hall. Thank you, Mrs. Halvorson.
    Mrs. Kirkpatrick.
    Mrs. Kirkpatrick. Thank you, Mr. Chairman. I just simply 
want to thank you for having this hearing today and thank our 
panelists. It has been very, very enlightening to me. I do have 
some questions, but since we have been called to the floor, I 
am going to submit them in writing. So thank you very much. And 
I yield back.
    Mr. Hall. Thank you, Mrs. Kirkpatrick. Would Minority 
Counsel like to ask a question or two, or submit them in 
writing with our questions?
    Mr. Wu. Yes, sir.
    Mr. Hall. Okay. We will combine our questions and send it 
to you and ask for a response as soon as it is possible.
    Thank you once again for your testimony. Thank you for 
taking the initiative that you did to find out once you 
discovered that something was amiss, especially in the New York 
RO. As a representative from the State of New York, I want to 
thank you for our veterans in New York.
    We are happy to hear that individual veterans received 
their claims and did not suffer directly as a result. But as 
many Members said, and as you said, the trust, the bond of 
trust between our veterans and the VA needs to be strengthened. 
These kinds of things can only weaken it.
    So thank you for the work you are doing on this. We are 
looking forward to that next briefing on the paperless system 
and anything we can do. As you can hear the enthusiasm from 
outside of the table for it. We are looking forward to that 
being the case.
    Ms. Rubens, Mr. Mayes, and Mr. Walcoff thank you again for 
being here. This hearing is now adjourned.
    [Whereupon, at 3:37 p.m., the Subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              

           Prepared Statement of Hon. John J. Hall, Chairman,
       Subcommittee on Disability Assistance and Memorial Affairs

    Good Morning Ladies and Gentleman:
    I welcome you today for our first hearing during the 111th Congress 
and I am pleased to be joined by my colleague, Harry Mitchell, Chairman 
of the Oversight and Investigations Subcommittee. We are also being 
joined by House Committee on Veterans Affairs Chairman, Bob Filner, who 
has been leading the way in making the VA an advocacy system instead of 
an adversarial one.
    Congress' accomplishments for veterans last year were great. I am 
eager to see implementation of P.L. 110-389, the Veterans Benefits 
Improvement Act of 2008 that will take steps in righting the many 
wrongs in the VA claims processing system. However, there is still much 
more room for improvement and this promises to be a very active 
Congress with a new Secretary we are eager to work with.
    It is regrettable that we are starting this Congress with so many 
untoward problems within the VBA claims processing system making news 
headlines. In the last few months, we have tracked the problems brought 
to our attention with misdating of claims at the New York Regional 
Office, documents wrongly placed in shredder bins, and denying widows 
their survivor benefits.
    The situation in New York was a clear attempt by managers to fudge 
performance numbers. The incorrectly entered data made the regional 
office look like it took fewer days to process claims than in 
actuality--yet still beyond acceptable levels to me--or to most 
veterans. Although veterans were not directly harmed by this practice, 
perpetrators of this kind of dishonesty impact the entire veterans' 
community's ability to trust the institution charged with its welfare. 
This is shameful!
    On the heels of this revelation, there were reports of documents 
inappropriately placed in shredder bins--documents needed to process 
claims or that should have been returned to the veteran were dumped for 
shredding. As a result, some veterans' claims were harmed and 
adjudication did not properly take place. This is even more shameful!
    And finally, we saw headlines about widows being cheated out of 
millions of dollars--over a 12-year period--while VA ignored Congress' 
intent to help these very same widows. VA explains this oversight as a 
computer glitch. But again, it's shameful!
    The misdating, shredding, and glitches that the media recently 
reported, I am afraid, are only the tip of the iceberg. I have heard 
too many accounts from veterans and their survivors about missing, 
lost, or destroyed files, and VA sending them multiple requests for 
information then still not knowing where a file is or who had it last.
    Even when the veteran or survivor has sent documents return receipt 
requested, VA manages to not know their whereabouts. Besides the 
infamous fire in St. Louis and the current shredding issue; claim 
folders have managed to be lost or destroyed in many other ways over 
the years. This has included records being misfiled or misplaced within 
a regional office or lost in transit between regional offices, medical, 
pension, insurance or debt management centers, the Board of Veterans' 
Appeals, the Appeals Management Center, or the U.S. Court of Appeals 
for Veterans Claims--not to mention the issues with Defense Department 
sharing. Even further beyond comprehension are the accusations by 
veterans and their families that VA employees would purposefully and 
maliciously destroy, falsify, or steal a claim folder to avoid granting 
a benefit.
    A lot of VA employees touch a claim folder, but rarely is anyone 
held accountable or responsible when it is lost or destroyed. 
Furthermore, we are still talking about an outdated system that is 
heavily dependent upon paper records. So, it is easy to conceive how a 
paper document can be mishandled. An electronic system from application 
to adjudication could mitigate some of these losses--if properly 
implemented--unlike the way it was handled for widows expecting a month 
of death benefit or at the RO in New York. This is where new approaches 
to leadership and oversight are crucial and accountability is 
essential.
    Today's witnesses will provide us with an overview of these 
problems. We will hear from the veterans' service organizations and the 
AFGE who will provide us with insights into how veterans and their 
dependents are harmed when VA mishandles their documents and how 
improvements can be made to the system.
    Next, the VA Office of the Inspector General will share what it has 
learned about document mishandling. Finally, the Under Secretary for 
Benefits, and the Systematic Technical Accuracy Review Office will give 
us their feedback on these problems and hopefully will outline a 
strategic plan for the future that will correct the records 
mismanagement problems we have seen in the past. So, I am grateful that 
the Under Secretary is here himself today because the accountability 
issue begins with top leadership.
    I have been on a track to modernize the VBA's out of date claims 
processing system. I envision VA as an Agency that we as a nation are 
proud of in the way that it serves the welfare of our disabled 
veterans. When it comes to discharging those responsibilities, shameful 
acts are what should be archaic practices.

                                 
          Prepared Statement of Hon. Harry Mitchell, Chairman,
              Subcommittee on Oversight and Investigations

    First, thank you to Chairman Hall and the Disability and Memorial 
Affairs Subcommittee for working with the Oversight and Investigations 
Subcommittee to convene this hearing.
    For too long, the spotty record of the Department of Veterans 
Affairs has led veterans and observers to view the Department as the 
worst kind of bureaucracy--massive, aloof, and unaccountable. Today, we 
have the opportunity to address a number of bureaucratic shortcomings 
and take a step toward a more personal, accessible, and accountable VA.
    Some mistakes are already being addressed. I am encouraged that the 
VA is taking steps to compensate the widows of veterans whose benefits 
were wrongly docked when their spouses passed away. I look forward to 
receiving a status update from the VA.
    However, we have now learned that the shredding of documents may 
only be the tip of a very large iceberg. VA's Inspector General tells 
us that in July 2007, the Detroit regional office had a ``mail 
amnesty'' during which employees could turn in unprocessed mail and 
documents without repercussion. Detroit regional office employees 
produced almost 16 thousand items. Sixteen thousand! Among these were 
700 claims and 2,700 medical records and/or pieces of medical 
information. None of these claims or documents was in VBA information 
systems or associated claims files. The IG was told by VBA regional 
directors that there were amnesties at other regional offices as well. 
Obviously we are going to have to get complete information from VA 
about these amnesties, but it is impossible not to be shocked by the 
numbers from Detroit. Shredding documents, or burying them in the 
bottom drawer, is a breach of trust by VA. Whether that breach of trust 
comes as a consequence of inadequate training or negligent or 
deliberate behavior, Congress must not and will not tolerate it.
    We will also hear testimony about data tampering that inaccurately 
reflected claims processing speeds at regional offices. A decision by 
management to lie about performance indicates creeping institutional 
decay that must be rooted out before it further erodes quality of care. 
The VA must restore integrity to its claims system and redeem the trust 
of the veterans it serves.
    I am eager to hear a detailed account of these issues from the 
Inspector General's office, and I trust that the VA will provide a 
candid explanation of what went wrong and how they will ensure it never 
happens again.
    I am also eager to hear from the VSOs about the impact of these 
failures on the veterans' community, and from the American Federation 
of Government Employees about the effectiveness of VBA policy.
    Mistakes like these simply need not happen. They are avoidable as 
they are awful, and they rob us of time that could otherwise be spent 
planning outreach to veterans, easing the transition from soldier to 
civilian, or constructing a 21st century benefits program. But, I am 
heartened by the vision, dedication, and know-how that Secretary 
Shinseki brings with him to the task of serving America's veterans, and 
I am hopeful the VA can avoid similar pitfalls under his leadership.
    Thank you to our panelists for appearing today. I look forward to 
working with you to achieve the openness, accountability, and action 
that veterans deserve from the VA.
                                 
  Prepared Statement of Hon. Doug Lamborn, Ranking Republican Member,
       Subcommittee on Disability Assistance and Memorial Affairs

    Good Afternoon Mr. Chairman. I am very happy to be back as Ranking 
Member of the Subcommittee on Disability Assistance and Memorial 
Affairs. I greatly enjoyed the favorable rapport we developed last 
Congress, and the bipartisan manner in which you and I and our staffs 
worked together. I look forward to another productive session.
    I would like to welcome our colleagues from the Subcommittee on 
Oversight and Investigation and all of our witnesses here today, 
including my counterpart on the Subcommittee on oversight and 
investigations, the Ranking Member Dr. Phil Roe of Tennessee.
    Mr. Chairman, we made a lot of progress in the last Congress toward 
modernizing and improving the VA claims processing system, and it is my 
hope that the reforms we put in place in Public Law 110-389 will help 
prevent future document management problems like the ones we are 
examining today.
    I would also like to thank you for endorsing my idea to require VA 
to move toward a paperless, rules-based adjudication system. While the 
paperless system is not a panacea, you and I both know that if VA's 
files were all electronic, the shredding incident could have been 
avoided. I thank VA for acknowledging that in their testimony.
    When a veteran submits a claim for disability compensation, they 
must be able to have trust that VA will adjudicate their claims in a 
timely and accurate fashion. Unfortunately the shredding incident has 
violated this trust for many veterans and it is now VA's job to regain 
it.
    What troubles me the most about the shredding incident, is that the 
number of documents VA found during its spot check was merely a 1-day 
snapshot of what appears to be an ongoing problem. VA will probably 
never know how long this mishandling has been going on or how 
widespread the practice was.
    However, I do applaud VA for their swift action in removing the 
employees that were responsible for the documents that were found. I 
find it very unfortunate that the actions of a few have tarnished the 
work of so many dedicated VA employees.
    Veterans need to be able to trust the integrity of the VA system, 
and I believe they are on the path to regaining this trust. I do 
believe, however, that VA's current plan to have every document signed 
off by two people before it can be shredded is highly inefficient. I 
encourage VA to find a more reasonable approach to protecting 
claimant's files without adversely affecting production, and I hope 
today's discussion will produce some possible alternative solutions.
    Another focus of this hearing is the misdating of claims at the New 
York Regional Office and other offices around the country. As 
disturbing as this is, I am relieved to know that the actions of a few 
individuals have not adversely affected any veterans or survivors.
    However, these actions underscore the need to review and possibly 
change VA's work management program. Such review was mandated by P.L. 
110-389, and I look forward to hearing more about this review once it 
is completed.
    I am reassured by the findings of the Inspector General that the 
problem is not believed to be systemic, and that the employees involved 
in the backdating have been removed. That concludes my statement, Mr. 
Chairman. I thank the witnesses for their attendance, and I look 
forward to hearing their testimony. I yield back.

                                 
  Prepared Statement of Hon. David P. Roe, Ranking Republican Member,
              Subcommittee on Oversight and Investigations

    Thank you for yielding, Mr. Chairman.
    I would like to start by saying that I am looking forward to 
working with the Members on both of Subcommittees here today, and 
particularly with you, Mr. Mitchell, and the other Members on the 
Subcommittee on Oversight and Investigations as the Ranking Member of 
the Subcommittee. I understand that you and my predecessor, Ms. Ginny 
Brown-Waite, had a good working relationship on this Committee, and I 
hope that we can continue in that vein as we conduct oversight on 
issues relating to the Department of Veterans Affairs, and work to 
assist those who sacrificed so much for the good of our country, our 
Nation's veterans.
    The issue at hand, document mishandling and shredding at the 
Department of Veterans Affairs is unacceptable. When these issues came 
to the forefront of our scope back in early October of last year, 
during an investigation by the Office of the Inspector General showed 
that documents necessary for processing claims were found in shredding 
bins at several Veteran Benefits Administration (VBA) facilities. 
Further issues arose from documents with adjusted ``date-of-claims'' 
which initiated a request by Ranking Member Buyer on October 14, 2008 
for an OIG investigation into the issue.
    Our Nation's veterans deserve better than this. The mishandling of 
their claims documents is inexcusable. The VA is responsible for 
assuring our Nation's veterans that they will be given every 
opportunity to submit their claims, and have their complete claims file 
reviewed in a timely manner. I appreciate that former Secretary Peake 
took immediate action to address these issues, and I look forward to 
hearing from today's witnesses on what further actions have been taken 
to rectify this situation.
    Again, thank you Mr. Chairman, and I yield back.

                                 
   Prepared Statement of Kerry Baker, Assistant National Legislative
                  Director, Disabled American Veterans

    Messrs. Chairmen and Members of the Subcommittees:
    On behalf of the 1.2 million members of the Disabled American 
Veterans (DAV), I am honored to appear before you today to discuss 
document tampering and mishandling within the Veterans Benefits 
Administration (VBA). In accordance with our congressional charter, the 
DAV's mission is to ``advance the interests, and work for the 
betterment, of all wounded, injured, and disabled American veterans.''
    On August 20, 2008, the VA Office of Inspector General (OIG) 
initiated an audit of the Veterans Benefits Administration's (VBA) 
regional office (RO) mail processing. The OIG audit team examined mail-
handling activities and triage areas in four VAROs. The team found 36 
pieces of active mail and 93 other original documents in the shred 
bins.
    The type of active documents identified during the audits included: 
VA Form 21-526, Veteran's Application for Compensation and/or Pension, 
VA Form 21-686c, Declaration of Status of Dependents, VA Form 21-674, 
Request for Approval of School Attendance, and documents constituting 
informal claims. The other original documents found by the OIG audit 
team should not have been designated for disposal because of their 
evidentiary value (e.g., original or certified copies of birth 
certificates, marriage certificates, DD Forms 214, Certificate of 
Release or Discharge from Active Duty, and medical evidence).
    Following the OIG's findings, the Secretary of Veterans Affairs 
(Secretary) ordered a cessation of all shredding activities in VAROs, 
effective October 14, 2008, and a search of all shred material on hand 
in field offices. The VA reported that the search identified 474 
documents requiring action or retention.
    Shortly thereafter, the VA drafted a comprehensive action plan that 
implemented numerous procedures to eliminate any repeat records 
mishandling. The draft plan included the creation of a Records Control 
Team tasked with reporting to the VA's Under Secretary all draft 
revisions to policies and procedures for proper document handling. 
Through the action plan, the VA created Records Management Officers 
(RMOs) and Division Records Management Officers (DRMOs) to oversee 
proper records handling and ensure compliance with the action plan.
    The draft plan requires a two-person review (employee and 
employee's supervisor), approval, date, and dual signatures on any 
documents marked for shredding. Documents determined inappropriate for 
shredding are returned to the employee for proper training. Further, 
the VA now requires each employee to maintain an individual shredding 
receptacle. The RCO must verify and approve every document in each 
shredding receptacle before shredding. The sequential steps in the 
foregoing new procedures are as follows:

    1.  Documents will be bundled by claimant name.
    2.  Employee will sign, date, and record reason for destruction.
    3.  Hand carry documents with claims' file to supervisor for review 
and approval.
    4.  Supervisor will review, sign, and date documents/envelope, if 
approved; if not approved, the supervisor will return the records to 
the employee for additional training.
    5.  Documents will be placed in appropriate container. Each day (or 
as directed) container will be hand carried to the DRMO.
    6.  The DRMO will review documents for appropriateness of 
destruction and forward those that are appropriate to the RMO.
    7.  The RMO will, if appropriate, place the material in the 
shredding bin.

    The VA's new document handling procedures contain many other 
specific instructions, such as those for out-based and work-at-home 
employees, handling destruction of sensitive material, and handling 
from non-VBA organizations. The draft plan also requires regular 
systematic analyses of operations; enhanced training on proper document 
handling; and, enhanced management oversight, which includes 
unannounced site visits.
    Special, but temporary procedures were also put in place concerning 
VA claimants who asserted they were harmed by improper document 
handling. Essentially, the Secretary determined that temporary special 
claims handling procedures were appropriate. He therefore relaxed 
certain administrative claim submission requirements for claimants who 
assert they submitted a claim or evidence within the 18 months 
proceeding the date that shredding activities ceased in VA regional 
offices. This includes claims or evidence submitted between April 14, 
2007, and October 14, 2008.
    These temporary procedures were established to accommodate for any 
loss of claims' information or evidence that may have occurred as a 
result of inappropriate document disposal during this period. RO 
personnel were given specific instructions on the use of temporary 
special claims handling procedures.
    Claimants who believe their claim was affected by improper document 
handling must assert their request for consideration under the 
temporary special claims handling procedures in response to the records 
incident within 1 year from November 17, 2008. RO personnel will 
exercise the Secretary's authority to recognize a claimant or 
representative's assertion that a claim and/or supporting evidence had 
been previously submitted to VA during the 18-month window from April 
14, 2007; to October 14, 2008. The effective date will be established 
as though the claim was received on the date asserted by the claimant. 
Effective dates earlier than April 14, 2007, may be established based 
upon receipt of credible evidence supporting the earlier date of 
document submission. Fortunately, VA officials report that there have 
been less than 300 claims filed under the relaxed evidentiary 
standards.
Analysis
    The DAV cannot and will not attempt to minimize the severity of 
this situation. A snapshot in time was taken of VBA field stations. 
That snapshot revealed nearly 500 documents improperly marked for 
destruction. Were these shredding bins already emptied for the month, 
or had this number accumulated over several weeks? Were any offices 
tipped off regarding the forthcoming events in order to prepare? Over 
the course of a year, and certainly numerous years, even the most 
conservative answers to these and other questions equal thousands of 
veterans and their dependents potentially harmed by such unlawful acts.
    A large section of the veteran community and representatives of the 
community have long felt that VBA operates in such a way that stalls 
the claims process until frustrated claimants either give up or die. 
The DAV is confident in stating that no such attitude exists within any 
section of VA's leadership. Nonetheless, DAV's reassurance will not 
change some of the public's mind concerning this notion, at least with 
respect to rank and file VA employees, because the unlawful destruction 
of these and other records has done nothing but reinforce this opinion.
    Whether we are leaders in Congress, leaders in the VA, or leaders 
in the veteran community, we all fail in those roles if we do nothing 
more than scrutinize and cast blame rather than working to erase this 
stain on VA's reputation. The challenge before us is not merely how to 
prevent such actions in the future, but how we recognize the faults in 
the current system that allowed such actions to take place. Once we 
acknowledge and understand the faults, the challenge then is 
progressively changing the structure of the system to prevent such 
actions.
    One demand from the collective veteran community is accountability 
for those guilty of the unauthorized willful destructions of records. 
This request does not insinuate that VA's leaders take this situation 
lightly. On the contrary; first, the VA should be commended for its own 
audit functions having detected the problem in the first place. Second, 
the VA's action plan as described above is unprecedented.
    The action plan implemented by VBA's leadership indeed exemplifies 
the magnitude of oversight that its leadership is willing to employ to 
protect the integrity of important claimant records. However, in 
understanding (1) the foundation upon which the claims process is 
built; (2) the sheer volume of work and labor-intensive nature of the 
process; and (3) the pressure on VA employees to manage that work, 
together with the potential impact such deliberate and near systematic 
actions have on the integrity of the system and the trust of its 
stakeholders, then it is easy to understand why oversight of this scope 
is necessary.
    Much of the veteran community nonetheless desires to see more 
accountability for such acts. We understand that the VA has taken 
various steps to punish those guilty of wrongdoing, but we are unaware 
of those exact steps. Actions such as reassignments, demotions, even 
termination, is not, however, our focus. Our focus is on the lack of 
accountability built into the law for government employees that commit 
fraudulent acts against VA beneficiaries.
    The law that governs all benefits administered by the VA is 
contained in title 38 of the United States Code. Many chapters and 
sections of law in title 38 deal with punishment such as fines and 
imprisonment for various fraudulent acts. For example, chapter 19 
contains provisions that punish VA beneficiaries who commit insurance 
fraud. Chapter 61 is an entire chapter dedicated to penal and 
forfeiture provisions, such as those that mandate fines and 
imprisonment for VA claimants who commit fraud in order to receive 
benefits. Chapter 59 even contains provisions specific to ``agents and 
attorneys'' who wrongfully withhold benefits from a VA claimant in the 
course of representation. Provisions in each of these chapters impose 
punishment such as fines and/or imprisonment. Indeed, the VA has 
punished many veterans, veterans' representatives, and VA employees in 
accordance with these provisions.
    History has proven a need for each foregoing section of law. 
Ironically, no section of law in title 38 imposes punishment 
specifically upon VA employees who fraudulently withhold benefits from 
VA claimants, such as the act of destroying claims and evidence in 
support of claims. Without further discussion, the actions we are 
addressing today unquestionably reveal a need for changes in law that 
equally punish VA employees who fraudulently withhold benefits as it 
currently punishes those who fraudulently obtain benefits. The message 
must be clear--if you destroy a veteran's records, whether through 
malice or desperation, you will go to jail.
    The DAV ultimately believes the cause of unlawful records' 
destruction is clear. They are desperate, albeit irresponsible and 
unlawful, acts of a workforce nearly at its breaking point. The cause 
of the breaking point is also clear--the massive claims backlog, 
including appeals; the increasing number of annual claims received; and 
the production goals VA places on employees.
    The VA received over 880,000 ``rating claims'' in fiscal year (FY) 
2008, over 88,000 more than anticipated in the FY 2008 Budget 
Submission, and 50,000 more than it received in FY 2007. This kind of 
increase in claims' receipt has held steady since the beginning of the 
ongoing armed conflicts and shows no immediate sign of slowing. 
Likewise, according to VA's weekly workload report, as of February 14, 
2009, there were 667,043 rating and non-rating cases pending in VBA, 
and 191,043 pending appeals, totaling 858,764 pending cases in VBA. 
This is nearly 29,000 more than the same time last year, and over 
75,000 more than the year before.
    Our objective in highlighting the above statistics is not to 
reprimand the VA on claims or appeals backlog, but to highlight the 
reality of how labor and paper-intensive the claims process has become. 
Nearly all of the foregoing statistics represent a claims' file 
consisting of a paper record containing hundreds, if not thousands of 
pages. While there is no excuse for the deliberate destructions of 
records, it is entirely conceivable that factors discussed herein 
provide a basic explanation as to what may have driven some employees 
to resort to these unlawful acts.
    As clear as we believe an explanation exists for these acts, there 
exists a solution. The VA must go paperless. This has been a goal of 
Congress and the VA for some time. The DAV fully understands the 
monumental nature of such a challenge, but we also believe the VA can 
meet the challenge with proper support from its stakeholders and from 
Congress.
    VA has already begun to utilize advanced information technology 
(IT) solutions in many of its functions. For example, VA's Pension 
Maintenance Centers have been paperless for a number of years. 
Recently, VA announced that its Benefits Delivery at Discharge (BDD) 
program has gone paperless. Veterans can also use the Veterans Online 
Application System (VONAPPS) to file a claim via the Internet. In fact, 
VONAPPS allows veterans to upload evidence in support of the claim and 
attach it to the online application for benefits; however, it does not 
yet allow a claimant to check the status of a claim online, which is 
one of VBA's ultimate goals.
    Each of these programs are promising; however, they are also 
minuscule when compared to the remaining bulk of VBA's paper-locked 
workload. The primary challenge therefore is how the VA can transform 
its current inventory of paper-based claim files into electronic 
format.
    The DAV believes the one solution that Congress must consider above 
all else, is to immediately authorize and fund the formation of one, or 
more if necessary, large-scale imaging centers. Such facilities should 
have the sole function of transforming paper records into electronic 
format to include incoming evidence in support of existing claims. 
Rather than utilizing every Regional Office in the Country, a facility 
with such a function would centralize VA records' management into a 
single location where the VA could ensure the integrity of a claimant's 
evidence.
    The formation of these imaging centers could free VA's current 
moderate-sized staff who are tasked with receiving incoming and 
managing existing paper records. This sizable reduction in resources 
required for such tasks would then allow VBA managers to utilize those 
same resources to assist with claims development and adjudication.
    The idea of transforming the paper-locked records system to an 
electronic records system is neither novel nor new. Rather, it has 
nearly been the centerpiece of all legitimate discussions on improving 
the claims process. Denying earned benefits by illegally destroying 
records should serve as the proverbial wake-up call that signals the 
urgency of this overdue transformation.
    Prior to leaving office, the Honorable James B. Peake, M.D., 
Secretary of Veterans Affairs, agreed wholeheartedly. In an October 
2008 letter to the U.S. Senate, Secretary Peake stated the following:

     The shredding of documents that affect the benefits of veterans 
cannot be excused. As I have testified, we must move rapidly to the 
paperless processing of claims. There is no excuse for failing to 
leverage industry standards and technology in support of our veterans.

    While this transformation takes place, the VA should update its 
basic IT infrastructure in order to accommodate the increase in 
electronic workload demand. For example, it would do the VA little 
good, if any, if 100 percent of its workload was in electronic format 
but its backbone could only handle 1 percent at a time.
    The VA would not have to invent the wheel for such an ambitious 
task--successful examples already exist. For example, an Electronic 
Disability (eDIB) was a major Social Security Administration (SSA) 
initiative to automate and improve its disability claims process. Under 
eDIB, an electronic claims folder was created for individuals applying 
for Disability Insurance benefits.
    Before the implementation of eDIB, the disability claims process 
involved gathering paper evidence and assembling the documents into a 
paper-based disability claims folder, exactly like VA's process. The 
paper folder was then mailed to the SSA components responsible for 
processing the claim.
    Using eDIB, SSA captures disability evidence electronically and 
stores it in an electronic claims folder. The electronic folder can be 
easily and instantly accessed by all components involved in processing 
a disability claim, thereby eliminating the delay involved with mailing 
paper folders between components.
    Under eDIB, any paper medical and non-medical evidence received to 
support a disability decision is converted to a digital image. To aid 
in this process, in August 2005, SSA entered into a 5-year Blanket 
Purchase Agreement (BPA) with Lockheed for nationwide scanning 
services. Under the BPA, Lockheed scans paper documents, creates 
digital images, and securely transmits the images to SSA. Lockheed also 
stores and destroys the imaged paper documents and protects the 
confidentiality of both the electronic images and the paper documents 
in its custody. The cost of the scanning service over the 5-year period 
was estimated at about $124 million.
    The SSA contract with Lockheed is only one example of success in 
transforming large paper-based systems to electronic format. There are 
many others of varying scale. The required technology is more cost 
effective now than ever. Therefore, the VA could likely reduce costs 
further by managing such a task internally. Nonetheless, initial 
contractual agreements are an option at the government's disposal.
Conclusion
    The laws that guarantee benefits to the Nation's service-connected 
disabled veterans instantly reveal to anyone willing to undertake the 
challenge of understanding those laws, the true magnitude of the 
Nation's gratitude paid to those who have born the battle. The VA's 
entire body of law is written with the veteran and his or her 
dependents in proper focus. The law is non-adversarial, pro-claimant, 
and veteran-friendly--this is not now, nor should it ever be in 
dispute. Simply put, Congress wrote the existing law in an honorable 
manner, equaled only by the honorable service disabled veterans 
provided to this great country.
    It should therefore be understood that when addressing the claims 
process; the appeals process; the case backlog; or like today, these 
unfortunate records-shredding incidents, we are highlighting problems 
in VA's people- and administrative-processes, some of which require 
retooling from the foundation, such as transforming paper records to 
electronic records. Some require significant strengthening, such as 
enhanced VBA training and accountability. Others only require minor 
adjustments. None of these changes, however, require modifying the 
sacred structure of laws that actually provide the benefits for which 
veterans have fought for decades.
    Nonetheless, these acts undermine the very foundation upon which 
benefits law is structured--its overwhelming fairness. Reasonable minds 
can always disagree on complex matters, but destroying records equates 
to a matter of simplicity. It turns a fair process into an obstacle 
impossible to overcome. For this reason, our recommendation should be 
considered one of VBA's highest priorities and implemented immediately.
    It has been an honor to testify today before your Subcommittees.

                                 
   Prepared Statement of Ronald B. Abrams, Joint Executive Director,
                National Veterans Legal Services Program

    Mr. Chairman and Members of the Committee:
    I am pleased to have the opportunity to submit this testimony on 
behalf of the National Veterans Legal Services Program (NVLSP). NVLSP 
is a nonprofit veterans service organization founded in 1980 that has 
been assisting veterans and their advocates for 28 years. NVLSP has 
trained thousands of service officers and lawyers in veterans benefits 
law, and has written educational publications that thousands of 
veterans advocates regularly use as practice tools to assist them in 
their representation of VA claimants. NVLSP also conducts quality 
reviews of the VA regional offices on behalf of The American Legion. 
NVLSP also represents veterans and their families on claims for 
veterans benefits before VA, the U.S. Court of Appeals for Veterans 
Claims (CAVC), and other Federal courts. Since its founding, NVLSP has 
represented over 1,000 claimants before the Board of Veterans' Appeals 
and the Court of Appeals for Veterans Claims (CAVC). NVLSP is also one 
of the four veterans service organizations that comprise the Veterans 
Consortium Pro Bono Program, which recruits and trains volunteer 
lawyers to represent veterans who have appealed a Board of Veterans' 
Appeals decision to the CAVC without a representative.
Background
    The VA has been rocked by a series of scandals during the second 
half of 2008. In July 2008, the VA's Compensation and Pension Service 
conducted a routine site visit at the VA Regional Office (RO) in New 
York City and discovered that 16 of 20 cases had an incorrect date of 
claim in a computer database that the VA uses to track and manage 
pending claims. It is clear that this regional office had a 
longstanding practice of manipulating statistics. For example, a later 
review of 390 cases showed a 56.4 percent error rate in the date of 
claim entered into the database. Then another review of 386 sample 
cases completed at the New York RO from fiscal year (FY) 2007 to the 
middle of FY 2008 revealed that 21.5 percent of cases had an incorrect 
date of claim entered in the VA computer database. In response to these 
reviews, the VA asserted that no payments to veterans were affected by 
these actions and that the errors ``were a result of 
miscommunication.''
    This practice was not the only abuse found at the New York RO. 
During the fall of 2008, the VA Inspector General (IG) uncovered a 
significant amount of unopened or unprocessed mail and documents 
relevant to claims for benefits improperly placed in office shredder 
bins. The mishandling of documents was shown to be widespread. For 
example, an IG report found that 700 pieces of mail were found 
unprocessed during an October 6, 2008 visit. These deceptive practices 
led to the reassignment of the Director and Assistant Director of the 
New York RO. Also, four other VA managers from the New York RO were 
placed on administrative leave.
    The news gets worse. By mid-October 2008, investigations by the VA 
IG revealed that other ROs were guilty of mishandling documents as 
well. Several ROs were improperly placing original documents necessary 
to the outcome of veterans' claims in shredder bins. On October 16, 
2008, the VA Secretary suspended all document shredding until the IG 
and VA could determine the extent of the problem. Four ROs--Detroit, 
St. Petersburg, St. Louis and Waco--were named in the shredding scandal 
as of the end of October 2008, with more than two-thirds of VAROs in 
question.
New VA Policy on Managing Paper Records
    The VA, in response to the shredding scandal, announced it 
tightened policies for the maintenance, review and destruction of 
paper. The new policies went into effect on November 14, 2008. Under 
the VA's new policy, RO shredding equipment and operations are 
controlled by the facility's records management officer. Every employee 
will have a separate envelope and a separate box for papers that are to 
be shredded. These containers are subject to review by supervisors and 
other officials. Before any document related to a claim can be 
shredded, there must be two signatures (the employee's signature and 
the employee's supervisor's signature). (See VBA Letter 20-08-63 (Nov. 
14, 2008)).
VA Corrective Action:
``Special Claims Handling Procedures for Missing Documents''
    Special procedures now apply to veterans (and other claimants) 
whose claims may have been affected by the recent shredding abuses. The 
new policy is called the ``Special Claims Handling Procedures for 
Missing Documents.'' The policy covers documents allegedly filed during 
the 18-month period preceding the date that VA stopped the shredding of 
documents. This means that it affects documents purportedly filed 
between April 14, 2007 and October 14, 2008. See VA Fast Letter 08-41 
(Nov. 14, 2008). The VA should have, but did not, promulgate a 
regulation to implement this special procedure.
    If a veteran or VA claimant believes that documents submitted in 
support of a claim may have been lost or destroyed during the covered 
period (April 2007 to October 2008), they may review their claims 
folder at the RO to see if the documents in question have been 
associated with the claims file. Veterans and claimants concerned that 
documents may be missing can contact VA toll free at 1-800-827-1000 or 
send an inquiry to [email protected]. Any request to the VA should mention 
the ``Special Claims Handling Procedures for Missing Documents.''
    Veterans must file a request under the ``Special Claims Handling 
Procedures for Missing Documents'' by November 17, 2009. As noted, the 
request should include the date the document was originally submitted 
to VA and, if possible, a copy of the missing documents. If the veteran 
does not have a copy of the document(s) submitted, the VA says it will 
assist the veteran in obtaining a duplicate copy of evidence if it 
pertains to a VA medical record, a private medical record, or other 
supporting evidence--providing that the veteran or the veteran's 
representative, if any, gives the VA as much information as possible to 
specifically identify the document.
    If the missing document is an application for benefits, the veteran 
should complete another application for benefits and submit it with a 
request for consideration under the Special Claims Handling Procedures 
for Missing Documents, providing the date that the original application 
was filed. If the veteran has already resubmitted an application for 
benefits but wants the VA to consider the effective date of the 
original application filed, a request for consideration under the 
Special Claims Handling Procedures for Missing Documents should be 
made. A grant of benefits based on a duplicate application should be 
paid from the date of original submission.
    If a veteran believes that documents (including applications) 
submitted before April 14, 2007 were lost or destroyed, then credible 
corroborating evidence to support a finding that such documents were 
filed must be submitted. This is a much higher standard than the 
standard that applies to missing documents submitted between April 14, 
2007 and October 14, 2008--which basically allows consideration of 
earlier submissions based on little evidence or on the word of the 
veteran.
What to Do Now
    It is clear that the VA has very serious problems in its claims 
adjudication system. What we need to do now is determine both the cause 
of the problems (statistical manipulation and shredding) and the cure 
for these problems.
What Caused This Disgraceful Problem
    NVLSP believes that longstanding VA policies were the major cause 
of this employee misconduct. The method that the VA uses to grant work 
credit and assess the performance of VA officials is the main culprit. 
The performance of VA employees/managers is judged (in part) by the 
number of benefits claims completed during a given time period, usually 
a calendar or fiscal year. Completion of a large number of claims is 
essentially considered the equivalent of good work performance.
    In the experience of NVLSP, (over 10 years of quality reviews, in 
conjunction with The American Legion of approximately 40 different 
VAROs combined with extensive NVLSP representation before the CAVC and 
the BVA), most of the most egregious VA errors and misconduct involve 
an attempt to prematurely issue a decision on a claim before the 
evidence the VA is required to obtain to help the veteran substantiate 
his or her claim is associated with the VA claims file. This rush to 
judgment is caused by pressure to quickly complete adjudications. Many 
VA managers emphasize quantity over quality. VA employees have formally 
complained that the culture in the VA regional offices emphasizes 
quantity to the detriment of quality.
    The major cause of VA employee misconduct is a VA work credit 
system that prevents the fair adjudication of many claims for VA 
benefits generating extra work for the VA and major problems for 
claimants. Also, the inadequate quality of many VA adjudications and 
the inadequate number of trained adjudicators contribute to the size of 
the backlog which pressures VA employees to take unlawful shortcuts in 
adjudicating claims.
The Unfair VA Work Measurement System
    The current VA work credit system prevents the fair adjudication of 
many claims for VA benefits and encourages the type of misconduct that 
has so embarrassed the VA. The current VA work credit system needs to 
be overhauled because the current system rewards VA managers and 
adjudicators who claim multiple and quick work credit by not complying 
with the statutory duties to assist claimants obtain evidence that 
would substantiate their claims and notify claimants of what evidence 
would substantiate their claims.
    The VA work credit system tends to create cynical and corrupt VA 
employees. Some VA adjudicators who are pressured to take shortcuts and 
to make premature adjudications, may decide that destruction of records 
or statistical manipulation of dates of claim, are ``not such a big 
deal''--because these actions promote a temporary reduction of the 
claims backlog and because unlawfully inflated production statistics 
support bonuses and promotions for VA adjudicators and managers.
    The VA work measurement system tends to drive what and whom it 
measures. VA managers are evaluated by how many end products (i.e., 
work credits) they produce, how quickly they can take credit for end 
products, how many employees they need to produce these end products, 
and last, the quality of the work in the office they manage. Because it 
is in the best interest of the VA managers to complete as many cases as 
quickly as they can, the interests of VA managers in many cases stands 
in opposition to the interests of claimants for VA benefits.
    Responsibilities of VA managers that protect the fairness of the 
adjudicatory process--such as ``control'' of claims, supervisory review 
of unnecessarily delayed claims, thorough development of the evidence 
needed to decide a claim properly, recognition of all of the issues 
involved, provision of adequate notice, documentation that notice was 
given, and careful quality review--all adversely affect the 
productivity and timeliness statistics (that is, how many decisions on 
claims are made final within a particular period of time) for the VA 
manager. Consequently, proper attention by VA managers to their legal 
obligations very often adversely affects the statistics upon which 
their performance is rated.
    The work measurement system creates a tension between claimants and 
VA bureaucrats that fosters the current corrupt VA adjudication 
climate. This is an untenable situation. Fortunately, because we have a 
new Secretary and because the current scandals have brought these 
problems to the public's attention, we have a chance to fix most of 
these problems.
Solutions
    The VA has been studied by blue ribbon panels, by the Government 
Accountability Office (GAO), by the VA Inspector General, by various 
other special commissions, and even by university professors. Most 
solutions focus on reducing the VA backlog by reducing or even 
eliminating the procedural rights veterans enjoy today. NVLSP believes 
that the primary goal of any proposed solution is to ensure that 
deserving claimants are paid their service-connected disability 
benefits correctly, promptly, and efficiently.
    NVLSP suggests that the cure needs to fix the fundamental problems 
that corrupt the current VA claims adjudication process. At a minimum, 
there are three things the VA must change in order to improve its 
claims adjudication system.
    First the VA must hold VA adjudicators and managers accountable for 
the quality of their work they produce. The following are some examples 
that could be implemented to support accountability.

      Rational and realistic performance standards should be 
established.
      Bonuses and promotions should be awarded to managers and 
adjudicators who are both productive and accurate.
      VA managers should be provided statistical amnesty 
because current VA statistics are not (as the current scandal reveals) 
reliable. In order to obtain accurate data VA managers should be 
encouraged to present truthful statistics even if they are much worse 
than what has previously been reported.
      VA managers (Service Center Managers and VA Directors) 
should be regularly transferred in order to foster consistency in 
adjudication and to prevent balkanization.
      The claims process improvement model (CPI) should be 
eliminated and the VA should go back to the case management concept. 
The CPI reduces accountability and creates the impression that the VA 
adjudication divisions are producing widgets.
      Managers who manipulate statistics should be severely 
punished.

    Second, in order to properly measure its work, in order to properly 
hold employees and managers accountable and in order to provide an 
incentive to VA employees to take the time to fairly adjudicate 
claims--the VA needs to change the way it measures its work. Work 
credit should not be awarded until after the appellate period expires 
or the appeal is resolved. This would promote quality work and speed 
the overall adjudication process because it would reduce and in some 
cases eliminate repeated BVA remands.
    Third, in order to enforce the fairness of the system (for 
claimants and for VA employees) the VA needs to create an independent 
quality review system that is outside the supervision of the Under 
Secretary for Benefits.

      The Central Office quality review team should be 
supervised by an official who will not be adversely impacted by 
negative findings.
      The VA Central Office quality review program should be 
amended so that the quality review team reviews entire file (as opposed 
to just a current action) and the VARO is held accountable for all 
errors noted.
Streamlining
    Once the above three solutions have been implemented, then it is 
time to streamline the VA claims adjudication process. For example,

      The VA has many hearing loss claims and expends a lot of 
time trying to resolve the dispute whether the veteran was exposed to 
acoustic trauma during service. The entitlement criteria should be 
simplified through the creation of a presumption that all veterans were 
exposed to acoustic trauma in service. It costs more money for the VA 
to develop the evidence on, and adjudicate this issue than it is worth. 
Of course, this does not mean all veterans with hearing loss will 
receive service-connected disability benefits. It means that veterans 
who can link their current hearing loss to service can have their 
claims promptly adjudicated.
      Another time consuming issue for VA adjudicators is 
deciding whether a veteran who has applied for service-connected 
disability benefits for PTSD was exposed during service to a stressful 
event. The entitlement criteria should be simplified through a rule 
requiring VA to agree that a veteran suffered from a stressful event 
during service if the veteran served in a combat zone and submits a 
sworn statement that he or she suffered from a stressful event while in 
that combat zone.
      Under current law, whenever the claimant submits 
additional evidence after submitting a notice of disagreement to appeal 
an RO denial of benefits, the RO must readjudicate the claim by 
reviewing all of the evidence in the claims file, writing a new 
decision, and sending it to the claimant--even if the veteran intended 
the new evidence to be reviewed by the Board of Veterans' Appeals in 
the first instance. The system should be streamlined to avoid 
unnecessary and repetitive decisionmaking through a rule requiring VA 
to provide the claimant an opportunity to choose in writing whether the 
claimant wants the RO or the BVA to consider the new evidence in the 
first instance.

    Other streamlining ideas that deserve a fair hearing are:

    1.  Permit appellants the option to either appeal to the Board of 
Veterans' Appeals or appeal directly to the Court of Appeals for 
Veterans Claims (AVC) after a Decision Review Officer decision.
    2.  Reduce the percentage evaluations under any DC to fewer levels 
than currently exist (but not eliminating a zero percent evaluation);
    3.  Limit the number of decisions (or set a time certain) in which 
a RO can render decisions prior to the time a case must be submitted to 
the BVA; and
    4.  Limit the number of claimants any one advocate can represent at 
any one time.

    Thank you for permitting NVLSP to testify on such an important 
issue.

                                 
            Prepared Statement of Kathryn A. Witt Co-Chair,
    Government Relations Committee, Gold Star Wives of America, Inc.

    ``With malice toward none; with charity for all; with firmness in 
the right, as God gives us to see right, let us strive to finish the 
work we are in; to bind up the Nation's wounds, to care for him who has 
borne the battle, his widow and his orphan.''
     . . . President Abraham Lincoln, Second Inaugural Address, March 
4, 1865
    Thank you for inviting Gold Star Wives of America (GSW) to 
participate in this Hearing.
    Gold Star Wives is a congressionally chartered Veterans Service 
Organization for the surviving spouses of military servicemembers who 
died on active duty or as the result of a service-connected illness or 
injury.
    I would like to share some of the difficulties that surviving 
spouses encounter due to the mishandling of documents at the Department 
of Veterans Affairs (VA).
    The VA employees who answer the phones frequently have little or no 
knowledge or information about survivor benefits, and they tend to give 
inappropriate or incorrect answers to questions. Due to the lack of 
appropriate responses survivors are deprived of the benefits due to 
them or do not receive those benefits for several years.
    GSW met with Secretary Peake last year and discussed the problems 
our members were having with obtaining information about benefits and 
with claims processing. Secretary Peake arranged to have all survivor 
claims processed through the three VA pension offices starting sometime 
this year. This will allow the VA personnel working in those offices to 
develop knowledge and expertise about survivor benefits and claims, and 
therefore process them in a timely, efficient manner. GSW is very 
grateful to Secretary Peake for this initiative. We think it will solve 
many of the problems with claims and information concerning VA survivor 
benefits.
    We are also very grateful to Congress for approving the Office of 
Survivors Assistance at the VA. Linda Piquet, the Acting Director, has 
already instituted several initiatives to assist survivors. Although 
this office does not process claims, Linda has been most helpful when 
problems do occur.
Claims Processing:
    We have had numerous complaints that surviving spouses have 
submitted claims for Dependency and Indemnity Compensation (DIC) or 
claims for money that was due to their deceased spouse. When they call 
to check on the status of the claim, they are often told that the VA 
has no record of their claim, and that they should resubmit their 
paperwork.
    I think that much of the VA claims backlog is due to resubmitting 
and appealing claims that were lost or improperly processed.
    One of our members had to submit documentation to the VA three 
times to prove that she was married to her husband and that they had 
three children. Another member has four different appeals pending; two 
of those appeals were submitted twice because the VA had no record of 
receiving them the first time.
    The delays in processing claims for DIC often leave the survivors 
without income and, in some cases, destitute.
    Many of our widows are eligible for ChampVA, the VA's health 
insurance program. Several of our members have told me that it 
sometimes takes 9 months or more to process a claim for ChampVA.
    One widow told me that her claim for ChampVA including the 
documents she provided was shredded and that she was without health 
insurance for over a month. Several of her health insurance claims were 
rejected during that time.
    Claims for ChampVA need to be processed expeditiously. No one 
should be without health insurance coverage for any length of time.
Recommendations:
    The VA needs a computer system that scans in the claim and the 
backup documents provided by the veteran or survivor. This system could 
then generate a claim number and date on a sheet of paper so that the 
original documents and claim number could be returned to the veteran or 
survivor. This would allow the veteran or survivor to call and refer to 
a specific claim number when they call to check on the status of the 
claim. This claim should then be cross-indexed with the veteran's name 
and Social Security number so that any pertinent information and 
documents already in the VA computer systems could be readily 
retrieved. Such a system would preclude the need to submit documents 
such as marriage certificates and birth certificates numerous times.
    Such a scanning system could be used as a front end to a computer 
system that could process simple, straightforward claims such as claims 
for ChampVA. These claims could then be reviewed by a claims analyst to 
ensure that all the necessary information and documentation is included 
and then be completely processed by a computer program.
    A computer program to process simple, straightforward claims such 
as ChampVA claims could be developed quickly and then modules added to 
the computer program to process claims that are more complex.
    The VA backlog of claims would be significantly reduced if claims 
could be properly logged-in and tracked and the need to submit 
duplicate and triplicate claims submission eliminated.
    We also receive many complaints that claims must be resubmitted or 
appealed because they were not properly processed the first time. 
Processing claims properly the first time would also help to reduce the 
VA backlog significantly.
Itemized Vouchers:
    Another significant problem with VA claims processing occurs when a 
veteran or survivor receives a payment with no itemized voucher 
accompanying the payment. Some people have several claims pending; 
without an itemized voucher, they have no way of knowing the purpose of 
that particular payment, how the payment was calculated or if the 
payment is for the correct amount.
Recommendation:
    I recommend that itemized vouchers that explaining the purpose of 
the payment and how the payment was calculated accompany all payments 
from the VA with the exception of routine monthly payments.
Last month of VA Compensation:
    We have recently had a much-publicized problem with a ``computer 
glitch'' that caused the last month of the VA Compensation to be 
retrieved from a deceased veteran's bank account and never returned to 
the surviving spouse. This happened in spite of a law that specified 
that the last VA Compensation payment would not be retrieved.
    A new widow recently told me that the VA recouped the last month of 
pay and then returned it later after her claims were processed. Even 
this retrieve and return process causes great financial distress for 
many surviving spouses.
    Taking the last month of VA Compensation directly out of a 
veteran's bank account causes great financial hardship to the survivors 
and in many cases leaves them virtually destitute. This is especially 
true if the money has already been used to pay the monthly bills. 
Checks the veteran or surviving spouse have written bounce and the bank 
then assesses numerous fees.
    In many cases it leaves the survivors totally without funds.
Recommendation:
    After my husband died, Social Security contacted me by phone and 
asked me to have the bank return his last month's Social Security 
payment. If it is necessary to retrieve funds from a veteran or 
survivor, I believe that this system is far more considerate of the 
survivors than directly debiting their bank account for money that may 
or may not be there.
    Thank you for your attention.

                                 
      Prepared Statement of Geneva Moore, Senior Veterans Service
   Representative, Veterans Benefits Administration Regional Office,
       Winston-Salem, NC, on behalf of the American Federation of
                     Government Employees, AFL-CIO

    Dear Chairmen and Members of the Subcommittees:
    The American Federation of Government Employees, AFL-CIO (AFGE), 
which represents more than 600,000 Federal employees who serve the 
American people across the Nation and around the world, including over 
160,000 employees in the Department of Veterans Affairs (VA), is 
honored to testify today regarding the issues of document tampering and 
mishandling in the Veterans Benefits Administration (VBA).
    As the labor organization that represents the vast majority of VBA 
employees, AFGE has a unique ability to offer the insights of the 
front-line employees who directly process veterans' claims and handle 
their claims files, personal documents and medical records. It was very 
heartening when Secretary Shinseki recognized the VA workforce in his 
recent testimony before the full Committee as ``an immediate and 
constant source of pride as they demonstrate their dedication to our 
mission, their devotion to our clients, and their willingness to 
continue to serve something larger than self.''
    We are equally appreciative that the House Committee on Veterans' 
Affairs and the Subcommittees holding this hearing regularly seek 
AFGE's input on pressing veterans' issues.
    First and foremost, AFGE is firmly committed to working with 
lawmakers and VBA to eliminate document shredding, tampering and other 
mishandling. AFGE and all its members, including the large number of 
VBA employees who have also served in the military, are completely 
ready, willing and able to help develop solutions that protect 
veterans' files and documents without adversely impacting the quality 
or timeliness of the claims process.
DOCUMENT SHREDDING
    AFGE's unequivocal position is that improper shredding is totally 
unacceptable. At the same time, making a veteran wait over 6 months for 
his or her claim to be processed also is unacceptable. We believe that 
VBA could have struck a better balance between these two if it had 
consulted with front-line employees and their representatives prior to 
implementing its shredding policy. AFGE was only informed of the new 
policy after implementation and at that point was only able to 
negotiate a very limited memorandum of understanding with management.
    AFGE has come before you on a number of occasions to convey our 
members' frustration at the lack of new employee and current employee 
training that would help them process claims accurately while meeting 
management's production quotas. Here too, the employees wanted training 
to help them fully comply with the forty plus provisions in the new 
National Code of Behavior. But when management asked them to sign this 
document without providing any training, they signed because ``[a]ny 
refusal to sign the VA National Rules of Behavior may have an adverse 
impact on [their] employment with the Department.'' (Section 1(i)).
    What was the effect of lack of training on the new policies? First, 
employees are not sure what to shred and what to keep in the file under 
these new policies. Employees have the incentive to keep extraneous 
materials in the file rather than expose themselves to the risk of 
possible discipline for discarding the wrong materials. As a result, 
the next person, for example the RVSR getting the file from the VSR or 
the supervisor performing quality control, has to review a much thicker 
file containing more extraneous pages. Longer review time means longer 
processing time which translates to larger backlogs.
    We also question whether all recently hired Records Management 
Officers (RMO) received adequate and consistent training at the RO 
level. Our members report that RMOs have required them to spend 
unnecessary time going through certain procedures when employees were 
already in compliance. Here too, a joint labor-management team would 
have produced a better training program.
    The current work credit system is further impeding the 
effectiveness of the new shredding policies. Employees are reluctant to 
comb through their files for shreddable documents as that slows down 
their production. The current work credit system does not credit 
employees for the time required to stop case production in order to 
carry out mandatory daily reviews of shreddable materials.
    Consultation with front-line employees and their representatives 
would have also produced efficiencies at the outset as to how employees 
sort through their files. For example, initially, the employee had to 
annotate each piece of paper to be shredded with a handwritten 
explanation and his or her initials. Some, but not all offices, report 
that new methods are being implemented to speed up this process, such 
as the use of cover sheets and page stamps. These efficiencies should 
be encouraged and made uniform across ROs.
    Fortunately, Congress has provided VBA with an excellent tool for 
improving its mentoring process and work management and work credit 
systems. The Disability Claims Modernization Act (P.L.110-389), 
requires the VA to undertake studies of these two systems, and requires 
managers to pass the same skills certification tests as front-line 
employees. AFGE urges the Subcommittees to ensure that frontline 
employees and their representatives have the opportunity for meaningful 
input into the studies mandated by this valuable new law. Also, we urge 
VBA to restore labor-management collaboration on the skills 
certification testing process. Only last year, IBM conducted a study of 
the claims process for VBA without consulting a single frontline 
employee.
    Finally, with regard to shredding, some critics assert that VBA 
employees discard and mishandle veterans' claims files because they do 
not see a real person behind the file. In fact, nothing could be 
further from the truth. It is precisely the veteran that the employees 
have in mind when they work through lunch and breaks, come in early and 
leave late, and study in the evening to do their jobs better. These 
employees want more training and more credit for quality, not just 
quantity, because they want the best for the claimant behind that claim 
number. As AFGE has testified in the past, the VBA workforce 
experiences tremendous frustration with the chronic obstacles they face 
in trying to process these claims in a timely and accurate manner.
Backdating of claims
    Unfortunately, backdating of VBA claims is not a new phenomenon. 
Some of our members report receiving ``backdating'' instructions from 
managers in years past. AFGE is solidly committed to working with 
Congress and VBA to get to the root cause of the backdating problem and 
the perverse incentives in the current system that lead to this 
practice. Here too, the studies of the work credit and work management 
systems mandated by P.L.110-389 will provide essential information to 
address this problem.
    Backdating may also be a byproduct of the practice of submitting 
informal claims prior to submitting formal claims. In order to avoid 
two different ``end product'' dates, which affects station timeliness 
numbers, there is an incentive to choose the later date of the formal 
claim, which in turn, may reduce the veteran's retroactive payment. 
Better technology (including a paperless system) would help VBA keep 
the two claims properly associated.
Misplaced Files
    Clearly, if the disability claims process were already paperless, 
many of the problems being considered at this hearing today would no 
longer exist, including fewer misplaced files.The input of frontline 
employees and their representatives would ensure a smoother, more 
effective transformation to a paperless system.
    A paperless system also would enable VBA to keep the entire file 
intact when additional medical evidence or other documentation comes 
into the RO at a later date because of delays in getting private 
physician records or because the claimant has new medical evidence of a 
worsening medical condition.
    Multiple file claims also present a problem: Sometimes the RVSR 
(who is required to review the full file) is only given the most recent 
file of a multiple file claim.
    In the short term, small IT fixes such as an automatic reminder 
system would enable VBA to keep better track of files that move between 
ROs for brokering or to the Appeals Management Center, or are 
temporarily transferred to the treating physician or the C&P examiner. 
Our members report that brokering between ROs is especially likely to 
result in lost or misplaced evidence and claims and delayed association 
of evidence with claims files.
    AFGE urges the Subcommittees to further investigate the efficacy of 
VBA's brokering policies, and solicit the input of frontline employees 
and their representatives. There is no reason for programs which poorly 
serve veterans to continue through inertia. VBA should continue 
policies that are proven to work, and eliminate those which are not.
    VBA's policy of brokering cases from one RO to another also 
diminishes frontline employees' investment in their work product, since 
such an ``assembly line'' approach to developing and adjudicating 
claims shifts the responsibility for mistakes made by personnel at one 
RO to those at another RO.
    AFGE is also concerned about the impact of a new brokering process 
using newly created Appeals Resource Centers (ARC) (as detailed in VBA 
Fast Letter 09-06). This initiative will significantly increase the 
number of cases in transit, further increasing the risk of file and 
document misplacement and loss. Notably, VBA management denied the 
existence of the ARC initiative to AFGE until November of 2008, 
acknowledging its existence for the first time in the new shredding 
policy. AFGE's requests for briefing on this initiative have been 
denied to date.
Other Comments
    With regard to the problem of the widow being denied the full 
``month of death'' check, our members have not reported any management 
pressures to deviate from the requirement under current law that widows 
receive the full monthly benefit.
Conclusion
    Almost every law firm in this Nation, no matter how small, utilizes 
simple off-the-shelf, out-of-the-box software to manage and track their 
docket. Clearly, a similar, user friendly electronic tracking system is 
within VBA's reach.
    AFGE extends its gratitude to the Subcommittees for soliciting our 
views on these challenging issues. You have AFGE's full commitment to 
work with you and VBA to identify the root causes of these problems and 
work toward solutions that best serve the needs of our veterans.

                                 
   Prepared Statement of Belinda J. Finn, Assistant Inspector General
               for Auditing, Office of Inspector General,
                  U.S. Department of Veterans Affairs

INTRODUCTION
    Mr. Chairmen and Members of the Subcommittees, thank you for the 
opportunity to address important issues associated with the integrity 
and timeliness of the Veterans Benefits Administration's (VBA's) 
handling and processing of compensation claims. Accompanying me is Mr. 
James J. O'Neill, Assistant Inspector General for Investigations. We 
will discuss the vulnerability of veterans' claim records and 
documentation to improper destruction and the accuracy of VBA regional 
office (VARO) compensation and pension (C&P) benefit claim dates. In 
both of these areas, VBA lacked adequate management controls. The 
absence of controls to protect claim documentation resulted in 
unnecessary delays in providing some veterans' benefits. Our review of 
control deficiencies associated with the accuracy of claim dates did 
not identify any veterans or their beneficiaries who received incorrect 
or delayed benefit payments. However, the deficiencies could cause 
VAROs to report inaccurate claim-processing times to stakeholders such 
as veterans and Congress.
             Improper Shredding of Claim-Related Documents
    During our ongoing audit of VBA claim-related mail processing, the 
Office of Inspector General (OIG) discovered 132 claim-related 
documents needed to support and facilitate the processing of claims 
that personnel inappropriately discarded in 37 shred bins located at 
VAROs in Detroit, MI; Waco, TX; St. Louis, MO; and St. Petersburg, FL. 
After we briefed Veterans Affairs (VA) and VBA senior officials 
regarding this discovery, VBA searched shred bins in all of its 
regional offices and the St. Louis, MO Records Management Center (RMC) 
and found 474 additional claim-related documents in 41 of the 58 
locations.
    Document shredding services are generally part of routine records 
management functions performed in VAROs. Shred bins were located in 
different work areas throughout the four VAROs visited by our auditors, 
and allowed employees to deposit documents no longer considered 
necessary or redundant but containing confidential information that 
prevented the employees from depositing them in open trash collection 
bins. Three of the four VAROs (Detroit, Waco, and St. Petersburg) used 
locked shred bins, while one (St. Louis) used unlocked shred bins. 
Contractors performed shredding either weekly or bi-weekly onsite at 
three of the VAROs (Detroit, Waco, and St. Petersburg) and offsite at 
the remaining VARO (St. Louis).
    Claim-Related Documents Found in VARO Shred Bins. This issue came 
to our attention at VARO Detroit in September 2008 when an employee 
told our auditors that claim-related documents might have been 
inappropriately discarded in shred bins. On hearing this, the OIG audit 
team reviewed the entire contents of 18 shred bins at that VARO. We 
identified 80 documents that were inappropriately discarded--5 
documents that could affect claimants' benefits and 75 documents that 
would not have affected benefits but should have been retained in claim 
files.
    After finding the claim-related documents at VARO Detroit, we 
expanded our review of shred bins and found an additional 49 documents 
at 3 other VAROs. These included 31 documents that could affect 
claimants' benefits and 18 documents that would not have affected 
benefits but should have been in claim files.
    The OIG reported preliminary findings to Congress in separate white 
papers issued in October and December 2008. At that time, we reported 
identifying 129 claim-related documents inappropriately discarded in 
bins for shredding, of which 36 documents could have affected the 
benefits of 35 claimants. While working with VARO Detroit officials 
since that time, we identified an additional nine documents that could 
have affected claimant benefits. At 4 VAROs, we recovered a total of 
132 documents from examined shred bins, of which 45 documents could 
have affected claim benefits and 87 other documents, such as death 
certificates, correspondence from the veterans, and award documents 
that would not have affected claims but should have been retained in 
claims files. (See Table 1.)


                              Table 1. Claim-Related Documents Found in Shred Bins
----------------------------------------------------------------------------------------------------------------
                                                                                  VAROs
          Documents Identified in Shred Bins           ---------------------------------------------------------
                                                         Detroit   St. Petersburg   St. Louis    Waco     TOTAL
----------------------------------------------------------------------------------------------------------------
Documents Affecting Benefits
----------------------------------------------------------------------------------------------------------------
Original Claims                                               2                4           0        0         6
----------------------------------------------------------------------------------------------------------------
Reopened Claims                                               1               10           2        0        13
----------------------------------------------------------------------------------------------------------------
Burial Benefits                                               0                4           0        0         4
----------------------------------------------------------------------------------------------------------------
Dependency Claims                                             1                1           1        0         3
----------------------------------------------------------------------------------------------------------------
Death Benefits                                                0                1           0        0         1
----------------------------------------------------------------------------------------------------------------
Informal Claims                                               4                0           0        0         4
----------------------------------------------------------------------------------------------------------------
Miscellaneous                                                 6                6           0        2        14
----------------------------------------------------------------------------------------------------------------
  Subtotal                                                   14               26           3        2        45
----------------------------------------------------------------------------------------------------------------
Documents Not Affecting Benefits                             69               12           3        3        87
----------------------------------------------------------------------------------------------------------------
    TOTALS                                                   83               38           6        5       132
----------------------------------------------------------------------------------------------------------------


    The 45 documents fell into the following categories:

      Original claims for benefits (6). We identified six 
claims, including two from Global War on Terrorism veterans, which were 
required to have received priority processing. We found no record of 
receipt and VARO managers confirmed that the claims were never 
established.
      Reopened claims for benefits (13). These claims 
represented requests for increased compensation, new entitlement to 
pension benefits, or entitlement to service connection for additional 
disabilities. For 10 of the 13 claims, the VARO had no record of 
receipt or action to establish a claim. Although the VARO had 
established claims in the remaining three cases, the private medical 
evidence submitted by the claimant was discarded in two of them, and no 
copies were in the official records. In the third case, the VARO had 
established a claim with a later date based on a telephone inquiry.
      Claims for burial benefits (4). The VARO had no record 
documenting receipt or processing of these claims for reimbursement of 
burial expenses.
      Dependency claims (3). These claims included two requests 
for benefits on behalf of claimants' children and one application to 
add a dependent to an existing claim. The VARO had no record of receipt 
or action on the claim.
      Claim for death benefits (1). The VARO had no record of 
receipt or action upon this claim for death benefits by a surviving 
spouse.
      Informal claims (4). An informal claim preserves the 
claimant's date of eligibility for benefits for the period of 1 year, 
indicating a claimant's intent to apply for one or more benefits. The 
discarded informal claims identified the date the VARO received the 
document, which is necessary to ensure the correct date of eligibility. 
However, the VAROs had no record of receipt and control of these 
documents. For example, a veteran did not receive his full entitlement 
of disability benefits because a VARO had not taken any action on an 
informal claim received prior to discarding the claim in a VARO shred 
bin. The VARO received the veteran's informal claim on January 31, 
2008. In February 2008, the VARO received the veteran's formal claim 
and established the claim in the SHARE system, an automated computer 
system used by VBA to establish and manage pending issue claim data, 
with a February 12, 2008, date of claim. The VARO awarded benefits to 
the veteran based on the February 12, 2008, date of claim with a 
payment date of March 1, 2008. The VARO was required to have awarded 
benefits based on a January 31, 2008, date of claim with a payment date 
of February 1, 2008. As a result, the veteran did not receive the 
entitled disability benefit payment of $117 for the month of February 
2008.
      Various documents (14). These documents included write-
outs and returned mail that the VAROs had not processed and could 
affect claimants' benefits. A write-out is notification to VA that a 
discrepancy exists between a veteran's computer record and the amount 
of monthly benefits the veteran is receiving. VARO employee action is 
required to reconcile the discrepancy.

    When we completed our reviews, we worked with VARO officials and 
confirmed that the 45 claim-related documents found in the bins could 
have affected benefits and copies of the documents were not maintained 
in claim files. We returned the identified documents to the VAROs so 
that appropriate actions could be taken on these claims and the 
documents could be placed in official records.
OIG Criminal Investigation
    Special Agents assigned to VA OIG conducted investigations of 
improperly shredded claims-related documents at the following seven 
VAROs: New York, NY; Cleveland, OH; St. Louis, MO; Pittsburgh, PA; 
Columbia, SC; Detroit, MI; and St. Petersburg, FL. To avoid disclosing 
information protected by the Privacy Act, we will not associate our 
findings with specific VAROs because the employees subjected to 
administrative actions as a result of their involvement in shredding 
would be identifiable to their co-workers.
    At one VARO, an employee was observed on two occasions by two 
different employees placing claim-related documents in a shred bin. 
These documents were recovered and determined to be inappropriate for 
shredding. When interviewed, this employee did not dispute the accuracy 
of the witnesses' observations but claimed that prescribed medication 
rendered him extremely disoriented. He said he was unaware of placing 
claim-related documents in shred bins on either occasion. After 
confirming that the employee is prescribed medication, we presented the 
facts of this case to an Assistant U.S. Attorney (AUSA), who declined 
prosecution for violations of 18 USC 2071 (Concealment, Removal, or 
Mutilation Generally) because of the difficulty in establishing 
criminal intent. VA subsequently removed this employee from Government 
service.
    At a second VARO, a VBA review of all documents thought to be 
staged for shredding revealed that approximately 90 percent of claim-
related documents were discovered in a shred box under the desk of one 
employee. When interviewed, the employee denied intentionally placing 
the above documents in his shred box. We terminated the interview when 
the employee exercised his right to legal representation. An AUSA 
declined prosecution for violations of 18 USC 2071 in lieu of 
administrative remedies. VA subsequently removed this employee from 
Government service.
    At a third VARO, management learned in October 2008 that an 
employee had been discovered inappropriately shredding documents 
approximately 4 months earlier. At that time, he told prior management 
that a supervisor had instructed him to shred these documents. This 
employee and the supervisor subsequently received verbal counseling. 
VBA's investigation in October identified another employee who said 
this supervisor, prior to the incident described above, also had 
instructed him to shred documents that he thought should not be 
shredded. We re-interviewed all of the parties involved in this issue. 
The supervisor, who was on administrative leave as a result of 
involvement in another incident, denied instructing either of the above 
employees to shred documents that should not have been shredded. An 
AUSA declined prosecution for violations of 18 USC 2071 in lieu of 
administrative remedies. VA subsequently removed this employee from 
Government service.
    At a fourth VARO, in response to discoveries made by our audit 
staff during an unannounced inspection, we opened a criminal 
investigation into inappropriate shredding of claim-related documents 
which revealed that the majority of documents discovered by the 
auditors had been assigned to two employees for processing. Both 
employees denied placing these documents in a shred bin and offered to 
take polygraphs. Since there was handwritten material on one of the 
documents, we obtained exemplars from both employees. Our document 
analyst concluded that one of these employees had probably written the 
questioned material. The paucity of this material was the only reason 
the analyst had to qualify her opinion; there were no differences 
identified during the forensic examination between the known writing of 
the employee and the questioned material. When confronted with this 
forensic evidence, the employee continued to deny being the author of 
the questioned material and reasserted non-involvement in inappropriate 
shredding. The second employee also claimed no knowledge of how the 
documents found their way into the shred bin, but claimed that the 
other employee processed most of the paperwork in their unit. After we 
arranged for another law enforcement agency to administer the 
polygraphs, both employees declined to be polygraphed. An AUSA declined 
prosecution for violations of 18 USC 2071 and 18 USC 1001 (False 
Statements) in lieu of administrative remedies. On February 17, 2009, 
we provided VBA a report of our investigation so a decision can be made 
if administrative action will be taken against one or both of these 
employees.
    The investigations conducted at the other three VAROs did not 
identify anyone who willfully and knowingly shredded claim-related 
documents inappropriately.
    Response by VA and VBA. On October 14, 2008, we briefed the former 
Secretary of Veterans Affairs, the Under Secretary for Benefits, and 
other senior VA and VBA officials concerning the documents found in 
shred bins. Immediately following this briefing, the Under Secretary 
for Benefits directed every VARO to suspend all document shredding. In 
addition, the Under Secretary for Benefits instructed every VARO 
Director to review and inventory all contents in shred bins, report all 
claim-related mail or original supporting documents found in shred 
bins, and certify that documentation contained in their shred bins was 
not inappropriately destroyed.
    VBA reported to the OIG that their inventories of VARO shred bins 
nationwide located 474 documents affecting benefit entitlements and 8 
documents that were required to have been returned to claimants at 41 
locations nationwide. Of the 57 VAROs, 40 (71 percent) reported that 
shred bins included documents affecting benefit entitlements. VBA's RMC 
in St. Louis also reported that six documents were inappropriately 
discarded. Of the 474 documents, 242 (52 percent) were at 3 VAROs--
Columbia, SC (95 documents); St. Louis, MO (94 documents); and 
Cleveland, OH (53 documents). The remaining 232 documents were at 37 
other VAROs and the RMC, with the number of documents in shred bins 
ranging from 1 to 95.
    In November 2008, VBA issued a new and sweeping policy regarding 
procedures for the maintenance, review, and appropriate destruction of 
veterans' paper records located in all VBA facilities and worksites. We 
have not yet reviewed the implementation or effectiveness of this 
policy, but we plan to review compliance with the policy during future 
audits and reviews.
    Extent of Inappropriate Claim-Related Shredding Cannot Be 
Determined. We cannot determine how long this problem may have been 
occurring at VAROs or how many documents were potentially shredded. The 
bins our auditors reviewed contained 14 or fewer days of material. 
Further, we cannot project our findings or know whether the findings 
represent the typical contents for each shred bin.
    Lack of Controls Is a Contributing Factor. At the time of our 
audit, VBA had no requirement for any supervisor or other official to 
review documents placed in the shred bins. Therefore, an employee could 
easily dispose of documents, either unintentionally or purposely.
    VBA officials also said that some VAROs held ``mail amnesty'' 
periods to encourage employees to turn in unprocessed mail and other 
documents without penalty or repercussions. During an amnesty period in 
July 2007 at VARO Detroit, VARO employees turned in almost 16,000 
pieces of unprocessed mail including 700 claims and 2,700 medical 
records and/or pieces of medical information. The VARO determined that 
none of these claims or documents were in VBA information systems or 
associated claim files. VBA management told us of similar amnesties at 
other VAROs, such as an amnesty at VARO New York in December 2008 that 
recovered 717 documents from VARO employees.
    We consider any loss of claim-related documents to be unacceptable. 
These actions result in an inaccurate or incomplete record of 
activities needed to process a veteran's claim, delay claims 
processing, and potentially result in denial, under, or overpayment of 
benefits. Further, this situation increases the distrust that some 
veterans and beneficiaries already have in VA's ability to adequately 
protect documents and provide timely benefits.
    We believe that, taken together, this information indicates that 
claim-related mail processing and the protection of records submitted 
by veterans in support of claims are a high-risk area for VBA. Had we 
not discovered this situation, some veterans' claims may have 
languished with no action or been inappropriately denied. VBA took 
immediate actions to address the shredding problem. We will monitor 
these controls at the VAROs to ensure that veterans' claims and records 
are promptly processed and appropriately protected.
    Inaccurate Compensation and Pension Benefit Claim Receipt Dates
    In October 2008, at the request of the Ranking Member of the HVAC, 
Steve Buyer, we initiated a review to evaluate the accuracy of VARO C&P 
benefit claim receipt dates. VARO staffs are required to document claim 
receipt dates in claim folders and an automated computer system named 
SHARE. When VAROs use inaccurate claim receipt dates as the effective 
dates of awards, payments to veterans or their beneficiaries can 
potentially be delayed. Also, since VBA uses claim receipt and 
completion dates to measure claim processing timeliness, inaccurate 
receipt dates can cause reported claim-processing times to be 
incorrect.
    Congressman Buyer requested our review after VBA reported the 
results of its August 2008 Administrative Investigation Board (AIB) 
investigation of claim receipt dates at VARO New York. During the AIB, 
staff obtained sworn testimony from 34 employees and C&P Service staff 
reviewed receipt dates for 390 claims. The investigation concluded that 
VARO management instructed staff to intentionally establish erroneous 
claim receipt dates and staff did so for 220 (56 percent) of 390 claims 
reviewed and had been establishing erroneous dates for a number of 
years. However, VBA said that the errors did not cause any veterans or 
their beneficiaries to receive incorrect or delayed benefit payments. 
Subsequently, VBA has held several VARO New York managers accountable 
for intentionally establishing erroneous claim receipt dates.
    We evaluated a statistical sample of 1,515 total claims at VAROs 
Albuquerque, Boston, San Diego, and Winston-Salem to determine if 
inaccurate claim receipt dates caused veterans or their beneficiaries 
to receive incorrect benefit payments and if inaccurate claim receipt 
dates caused VBA to report incorrect claim-processing times to 
stakeholders. We found that the claim receipt dates for the majority of 
the 94,920 claims completed at the 4 VAROs during fiscal year (FY) 2008 
were accurate. We projected that 88,639 (93.4 percent) claim receipt 
dates were accurate, and 4,520 (4.7 percent) were inaccurate. In 
addition, we also projected that the 4 VAROs had not documented a 
receipt date for the remaining 1,761 (1.9 percent) claims and could not 
support the dates recorded in SHARE with receipt dates in claims 
folders.
    While we found some inaccurate claim receipt dates at all four 
VAROs, none of the VAROs' inaccuracy rates approached the 56-percent 
rate VBA reported for VARO New York. VARO Boston had the highest 
inaccuracy rate of 10 percent. Inaccuracy rates were 5 percent for VARO 
Albuquerque, 4 percent for VARO Winston-Salem, and 3 percent for VARO 
San Diego. The calculations of inaccurate dates do not include the 
1,761 undocumented dates. Therefore, the actual rates of inaccurate 
claim dates could be higher.
    The errors we reviewed did not cause any veterans or their 
beneficiaries to receive incorrect or delayed benefit payments. The 
payments were correct because VARO personnel used the correct claim 
receipt dates, which staff documented in claims folders, when 
establishing the effective dates of benefit awards in the C&P Payment 
Master Records system instead of relying on dates in SHARE. Interviews 
of VARO staff and reviews of claims folders indicated that the 
inaccurate dates were mostly unintentional errors. Because the 
inaccurate receipt dates were both before and after the correct dates, 
the inaccuracies did not significantly affect most of the four VAROs' 
reported FY 2008 average claim-processing times. The only exception was 
VARO Boston, where the errors caused the understatement of projected 
average processing times by 4 days (176 days using recorded dates and 
180 days using actual dates).
    Our results indicated that the claim date inaccuracies were mostly 
unintentional errors. Only 1 of the 1,515 claims folders included 
evidence of an intentional inaccurate claim date and only one VARO 
employee stated that an inaccurate date was intentional. We concluded 
that the timing of the inaccurate claim dates also indicated that the 
inaccuracies were unintentional because the inaccurate dates were 
occurring both before and after the correct dates. Inaccurate receipt 
dates that are after actual receipt dates will result in lower claim-
processing times and indicate better performance. Inaccurate receipt 
dates that are before actual receipt dates will result in higher claim-
processing times and indicate poorer performance. Therefore, if VAROs 
intentionally manipulated claim-processing times to indicate better 
performance, they would have consistently recorded SHARE receipt dates 
that were after actual receipt dates.
    Our review indicated that the majority of the inaccurate claim 
receipt dates were unintentional errors. For 109 (99.1 percent) of the 
110 inaccurate claim receipt dates, the timing of the dates, our claim 
folder reviews, and interviews of staff indicated the VARO personnel 
probably entered the inaccurate dates in SHARE unintentionally. The 
following case is an example of how the evidence indicated that the 
error was most likely unintentional.

      VARO Winston-Salem received a veteran's statement in 
support of a claim for an increased disability rating because of a 
lower back condition. The claim receipt date documented in the claim 
folder was September 28, 2007, which was the receipt date the VARO 
stamped on the document. However, the September 8, 2007, receipt date 
reported in SHARE was 20 days before the date documented in the claim 
folder. Our review of the claim folder and interviews of VARO staff 
found no evidence that the VARO intentionally reported the inaccurate 
date in SHARE. Therefore, we concluded that the inaccurate date was 
most likely the result of the Veterans Service Representative (VSR) 
erroneously entering an ``8'' instead of a ``28'' when entering the 
date in SHARE. The incorrect claim receipt date did not affect the 
veteran's benefits.
    VARO Boston Employee Intentionally Recorded Inaccurate Dates. We 
found intentional recording of inaccurate dates at one location. During 
our visit to the Boston VARO, a Senior Veterans Service Representative 
(SVSR) told us that he entered an inaccurate receipt date in SHARE. In 
this case, VARO Boston received a letter from a veteran claiming 
service-connection disability benefits for sleep deprivation. The VARO 
Triage Team correctly stamped September 24, 2007, as the receipt date 
on the back of the veteran's letter. On the last page of the letter, we 
found an annotation with no initials that established the receipt date 
as January 22, 2008. The date in SHARE was the incorrect date of 
January 22, 2008, which was 124 days after the actual receipt date of 
September 24, 2007. The incorrect claim receipt date did not affect the 
veteran's benefits, but it did contribute to the VARO Boston 4-day 
understatement of average claim processing time previously discussed.
    The SVSR told us that he entered inaccurate receipt dates in SHARE 
because he had a ``general impression'' of responsibility to help the 
Veterans Service Center (VSC) achieve the ``goal to make numbers 
meet.'' He stated that he entered receipt dates in SHARE that were 
within 30 days of the input date instead of the actual receipt date for 
claims over 1 year old. For claims that were between 7 and 30 days old, 
he entered dates in SHARE that were within 7 days of the input date. 
The employee also said he knew of no other supervisors entering 
inaccurate dates, he was unaware of any other supervisor that 
instructed staff to do this, and VARO management did not direct him to 
instruct staff to enter inaccurate claim receipt dates in SHARE. The 
SVSR retired the end of January 2009. The VARO Director is conducting a 
comprehensive investigation to assess the extent of this SVSR's 
actions.
    VARO Documentation of Claim Receipt Dates Needs Improvement. We 
found that VAROs needed to improve the documentation of claim receipt 
dates in claims folders. We projected that for 1,761 (1.9 percent) of 
the 94,920 claims the 4 VAROs completed during FY 2008, claim folders 
did not include sufficient documentation to determine if SHARE claim 
receipt dates were accurate. VARO managers could not explain why staff 
had not documented SHARE receipt dates in the sampled claims folders. 
Because we could not confirm the accuracy of the receipt dates for 
these claims, we could not determine if veterans or their beneficiaries 
received correct benefit payments or if there was any effect on the 
accuracy of reported claim-processing times.
    VBA Needs To Take Action. To help ensure the accuracy of reported 
claim-processing times, which VBA managers and stakeholders use to 
measure and monitor VARO performance, VBA needs to better monitor claim 
receipt dates and documentation. In November 2008, VBA's Quality 
Assurance Systematic Technical Accuracy Review (STAR) began evaluating 
the accuracy of receipt dates during their regular monthly VARO 
reviews.
    However, we recommended that VBA further improve the reporting 
reliability of claim-processing times by implementing two actions. The 
first action is to establish claim receipt date accuracy goals, which 
will improve transparency and accountability for VARO performance. VBA 
has used goals to help improve VARO performance in other areas such as 
accuracy rates for pension authorizations and burial claims processed. 
The second action is to require VAROs to perform Systematic Analysis of 
Operations' (SAOs) of claim receipt date accuracy and documentation. 
VAROs routinely use SAOs as a self-audit technique to improve various 
aspects of operations. Performing specific SAOs of claim receipt dates 
and documentation will help ensure VARO and VBA managers have accurate 
and reliable claim-processing time data for their decisionmaking 
purposes. We also recommended the VARO Boston Director identify any 
other claims where the SVSR intentionally entered inaccurate receipt 
dates in SHARE and ensure benefit payments related to these claims are 
correct.
    VBA Response. VBA reported that claim date accuracy reviews will be 
a permanent addition to the STAR program to ensure continued 
monitoring. VBA will collect and study accuracy data from these reviews 
and establish a sound goal by June 1, 2009. By April 1, 2009, C&P 
Service will revise its policies to add the requirement for validating 
the accuracy of claim dates to the existing ``Quality of Control 
Actions'' SAO. In addition, VARO Boston will examine claims established 
by the SVSR who intentionally entered the incorrect date of receipt 
identified by OIG and correct dates to ensure benefit payments are 
accurate. The VARO Director is conducting a comprehensive investigation 
to assess the extent of this SVSR's actions.
    Ongoing OIG Oversight Work. In addition to the two reviews already 
discussed, the OIG has been aggressively increasing its presence in, 
and oversight of, VBA's regional offices. In addition to our audit of 
VBA claim-related mail and mailroom operations and our review of claim-
date accuracy, we are also auditing two of VBA's quality assurance 
programs. These include VBA's ``Site Visit'' program that reviews C&P 
functions, and the Systematic Technical Accuracy Review program, which 
measures accuracy of claim processing decisions made in all regional 
offices. We also performed a special review of management controls to 
prevent fraudulent payments for retroactive benefits of $25,000 and 
above. This week we are also initiating an audit to evaluate the 
effectiveness of VBA's Control of Veterans Record System, which tracks 
the location of claims folders within VBA offices. We will provide 
reports on these reviews upon completion. In May 2008, the OIG issued a 
report on the impact of VBA's hiring initiative on reducing the claims 
backlog and we are planning to begin another review to examine the 
effectiveness of VBA's efforts integrating new staff into their 
workforce. OIG teams conducted evaluations onsite at 16 VAROs during 
2008 (we visited 3 VAROs twice on 2 different reviews).
    In addition, we are staffing the Benefits Inspection Division to 
provide continuous oversight of VARO operations nationwide. The 
inspections will evaluate how well VAROs are accomplishing their 
mission of providing accurate and timely benefits and services to 
veterans and their dependents. The goal of the inspection program is to 
complete at least 12 inspections each fiscal year, allowing coverage of 
all 57 VA Regional Offices within a 5-year period.
    Mr. Chairmen, that concludes our remarks and we thank you for the 
opportunity to discuss these important issues and your continued 
support. We would be pleased to answer any questions that you or other 
Members of the Subcommittee may have.

                                 
          Prepared Statement of Michael Walcoff, Deputy Under
       Secretary for Benefits, Veterans Benefits Administration,
                  U.S. Department of Veterans Affairs

    Mr. Chairman and Members of the Committee, I appreciate the 
opportunity to appear before you today to discuss the critical issue of 
proper handling of veterans' claims documents at Department of Veterans 
Affairs (VA) Regional Offices (ROs), as well as issues involving the 
proper date of claim for workload and performance tracking. I will also 
discuss recent changes to month-of-death payment processing.
    I am accompanied by Ms. Diana Rubens, Associate Deputy Under 
Secretary for Field Operations, and Mr. Bradley Mayes, Director of the 
Compensation and Pension Service.
    I would like to begin by outlining the sequence of events 
surrounding the discovery of some claims and other documents of 
evidentiary value in the shred bins of some of our ROs and the steps we 
have taken to address the situation and protect filing dates for 
veterans and other claimants whose documents may have been improperly 
shredded.
Audit by the Office of the Inspector General
    On August 20, 2008, the VA Office of the Inspector General (OIG) 
initiated an audit of RO processing of mail that pertains to claims 
adjudication and general mailroom operations. During the OIG audit, 
which is still ongoing, the OIG examined the mail-handling activities 
and triage areas in four ROs: Detroit, St. Louis, Waco, and St. 
Petersburg. While on-site in Detroit in September, the OIG audit team 
identified claims-related mail and original supporting documents that 
were placed in ``shred bins'' at the ROs, an action that was clearly 
unauthorized and inappropriate. The OIG informed local officials of the 
documents and asked for clarification
    On October 14, 2008, the OIG briefed VA leadership on its 
preliminary findings concerning the improper shredding of claims-
related mail and documents at the three ROs because they had not 
completed work at St. Petersburg. This was the OIG's first contact with 
VA that specifically dealt with the shredding of claims-related mail 
and documents. In its review of these four offices, the OIG found 45 
documents in shred bins that, if destroyed, could potentially affect a 
veteran's or other claimant's entitlement to benefits.
Immediate Actions In Response to the OIG Preliminary Report
    On the same day Veterans Benefits Administration (VBA) leadership 
was briefed by the OIG, we immediately ordered all ROs, as well as the 
Appeals Management Center and the Records Management Center, to cease 
all shredding activities. All facility directors were instructed to 
relocate all shred bins and shredding equipment to offices occupied by 
VBA management officials and to review the contents of all shred bins.
    The facility directors and their management teams inventoried all 
claims-related mail or original supporting documents found during this 
review. This effort identified 474 documents affecting benefit 
entitlement inappropriately placed in shred bins for disposal. These 
474 documents and the 45 documents identified by the OIG were found at 
41 of our 57 regional offices and centers, Appeals Management Center, 
and Records Management Center. No evidentiary documents were found in 
shred bins at the remaining 17 ROs. RO Directors certified in writing 
that no additional claims documents or copies of supporting claims 
documents were found among the materials in their shred bins.
    Collectively, the Columbia, St. Louis, and Cleveland ROs were 
responsible for more than half of the documents found. Employees at two 
of the three offices were investigated by VA and OIG for mishandling 
government documents. As a result of the investigation, an employee was 
removed from duty at the St. Louis RO on December 8, 2008, and an 
employee was removed from the Columbia RO on December 12.
    All 474 documents found in shred bins were analyzed to determine 
appropriate action. The documents requiring action were placed under 
control and processed as a top priority by the RO. As of February 20, 
2009, appropriate action on 415 of the 474 documents had been 
completed. Of the remaining 58 documents, 56 of the associated claims 
are currently under development and two are ready for decision.
8-Point Plan of Action

    In an effort to ensure this situation does not occur again, VBA 
developed an 8-point plan of action to strengthen our policies and 
procedures to safeguard veterans' paper records. In developing this 
plan, we worked closely with representatives of the six major veterans 
service organizations and received input from House Committee and 
Subcommittee staffs, as well as the staff of the Senate Veterans' 
Affairs Committee. This action plan implements tighter controls to 
protect veterans' applications and claims-related documents and ensures 
measures are in place to prevent future incidents of employees 
inappropriately discarding veterans' paperwork.

    1.  Records Control Team
    VBA created a Records Control Team to revise policies and 
procedures for the proper handling and shredding of documents. The Team 
convened the week of October 27, 2008, and provided a draft policy 
document on November 3, 2008. We continued to refine the policies, 
after receiving input from veterans service organizations and 
Congressional staffs through briefings conducted on three occasions. We 
finalized and implemented the new policies on November 14, 2008.

    2.  Training
    Even before we finalized our new policies, we provided special 
training to all VBA employees covering the proper handling and disposal 
of documents. All ROs certified to their Area Directors that all 
employees completed the training on November 3, 2008. Additionally, a 
separate training module on ethics was administered in December 2008 
via a national broadcast featuring the Under Secretary for Benefits.

    3.  Records Management Officers
    To strengthen oversight of our records management activities, our 
new policies establish a Records Management Officer position at every 
VBA facility. All facility shredding equipment and operations are now 
under the strict control of the facility Records Management Officer. 
Division Records Management Officers were also designated (as a 
collateral-duty assignment) to assist in carrying out the new policies 
and procedures. Standardized position descriptions for both positions 
were developed for nationwide implementation.

    4.  Two-Person Review of Documents to be Shredded
    Employees are now directed to date and initial all duplicate 
claims-related documents that have been identified as requiring 
shredding. The document or documents (including the claims folder, if 
necessary to establish the appropriateness of the disposal action) must 
be forwarded to the employee's Decision Review Management Officer for 
approval. This two-person review is required prior to the destruction 
of any claims-related document. Any documents deemed by the supervisor 
inappropriate for shredding will be returned to the employee for 
inclusion in the claims folder. If this occurs, the supervisor will 
ensure the employee immediately receives additional training.

    5.  Individual Employee Shredding Receptacles
    Every employee has a separate receptacle to contain all papers 
deemed appropriate for shredding. These receptacles are subject to 
review by supervisory personnel and the facility Records Management 
Officer.

    6.  Systematic Analyses of Operations
    All ROs and centers are now required to conduct regular systematic 
analyses of their records control procedures and activities, including 
their shredding procedures and controls.

    7.  Site-Visits
    Reviews of records management procedures, including checks of 
documents identified for shredding, have been integrated into RO 
oversight visits performed by all Headquarters program offices and area 
offices. ROs are subject to both announced and unannounced site visits.

    8.  Certification of Full Implementation Before Shredding 
Resumption
    The moratorium on shredding was lifted on December 31, 2008, after 
all facility directors certified to their area directors that the new 
policies have been fully implemented.
Special Temporary Procedures for Missing Documents
    We were greatly assisted by the veterans service organizations and 
Congressional staffs in developing special temporary claims handling 
procedures for veterans and claimants who assert VA did not process 
their claims because documents they previously submitted to VA to 
support a claim for benefits were shredded or otherwise improperly 
disposed. These special procedures for missing documents were 
officially released on November 14, 2008. Since November 14, 2008, 
there have been 335 instances of veterans or beneficiaries contacting 
VA to inquire about the status of their claims in relation to the 
shredding of VA documents.
    The special procedures consist of three key components:
    First, to assist claimants in establishing that an application or 
other claims document was previously submitted to VA, but was not 
properly acted upon by VA or retained in the veterans' claim record, VA 
will process duplicate claims documents and set effective dates for 
granted claims as though the claim was received on the date asserted by 
the claimant. These special temporary procedures cover any missing 
documents originally submitted by a veteran or other claimant during 
the 18-month period immediately preceding the date VA ceased all 
shredding activities, or between April 14, 2007 and October 14, 2008.
    Second, under these special procedures, VA will accept claims 
asserting previous submission of documents between April 14, 2007, and 
October 14, 2008, for 1 year (or from November 17, 2008, the date of 
public notice of temporary special claims handling procedures, to 
November 17, 2009).
    Third, effective dates prior to April 14, 2007, will be established 
in accordance with the facts and credible corroborating evidence 
presented by a veteran, and applicable laws and regulations. Claimants 
asserting that documents filed before April 14, 2007, are missing will 
be asked to submit any available evidence supporting the previous 
submission, such as a date-stamped copy of their claim, a dated 
transmittal or cover sheet from their representative, or confirmation 
from a deliverer of mail. We will also take steps to determine whether 
VA possesses any documentation to support the previous submission.
Communicating Our Actions
    I extend my sincere appreciation to the Senate and House Committee 
staffs and to the veterans service organizations for their input and 
counsel as we developed our action plan. We will need your continued 
support and that of the veterans service organizations as we work to 
ensure anyone potentially affected by this situation is assisted in 
filing a claim under these special procedures. At the time these new 
procedures were established, we placed information on our website and 
provided special training to all of our public contact employees. Our 
RO directors briefed local veterans service organization 
representatives and Congressional staffs, so that they could 
appropriately inform their members and constituents and refer anyone 
affected by this situation needing assistance.
    Veterans who are concerned that VA may not have all of their 
information are being advised to contact VA on our toll-free number, 1-
800-827-1000, or to send an inquiry through IRIS.VA.GOV. We 
electronically track documents for currently pending claims and can 
verify receipt of documents through our tracking system. If necessary, 
our representatives will review the veteran's claims file to verify 
receipt of applications and supporting evidence.
Electronic Document Retention and Paperless Claims Processing
    VBA is working in partnership with the Office of Information 
Technology to implement the Paperless Delivery of Veterans Benefits 
Initiative. The primary goal of the initiative is to improve service to 
veterans by transitioning our business model to be less reliant on the 
acquisition and storage of paper documents, and we are making good 
progress. As of August, all claims submitted through the Benefits 
Delivery at Discharge Program are processed in a paperless environment.
    VA has contracted with Electronic Data Systems (EDS) to serve as 
the Lead Systems Integrator (LSI) for this effort. fiscal year 2010 is 
our target year for release of the initial hardware and software in 
support of the large-scale expansion of the paperless initiative. The 
EDS effort is designed to provide enhanced paperless claims processing 
capabilities across VA.
    For example, these enhanced capabilities will allow veterans to 
submit benefit applications electronically and eliminate the need for 
VA to print the form for processing--there also exists the potential to 
submit supporting evidence for claims, further reducing the submission 
of paper to VA.
    We are learning from others who have been successful in integrating 
paperless technologies. On January 14 and 23, 2009, we visited the 
Social Security Administration (SSA) and received a demonstration of 
their imaging capabilities. SSA has been very helpful in sharing 
information about their business process transformation. We also 
visited United Services Automobile Association (USAA) Headquarters in 
San Antonio. USAA's use of today's technologies has helped to form our 
vision of how we need to serve and communicate with today's veterans. 
Control over all documentation is imperative, and while we recognize 
that paperless is not the panacea, the use of technology will allow VA 
to maintain electronic copies of documents, which cannot be shredded.
Date-of-Claim Reviews
    Mr. Chairman and Members of the Committee, you also requested a 
status on the proper date stamping of documents at ROs. I would first 
like to address the New York RO and the sequence of events that 
transpired. I would then like to discuss the actions taken by VBA to 
conduct a nationwide date-of-claim review.
VBA Site Visit Findings at the New York Regional Office
    A C&P site survey team conducted a routine site visit at the New 
York RO during the week of July 14, 2008. During their visit, it was 
discovered that 16 of 20 claims had an incorrect date of claim 
established in the electronic claims tracking program. The New York RO 
was establishing claims using an unsupported date of claim that was 
within 7 days of the date of claim rather than the actual date of 
receipt of the claim. As a result, the timeliness data for the New York 
RO was inaccurate. It is important to note that no veterans were 
impacted by these actions.
    The then-Assistant Director of the RO met with the Under Secretary 
of Benefits to discuss the findings of the C&P site survey team. 
Subsequently, C&P staff members conducted an on-site review of a 
statistically valid sample of 390 rating-related pending claims to 
assess data integrity at the RO. Of the 390 cases reviewed, 220 had an 
incorrect date of claim, representing a 56.4 percent error rate.
Actions Taken as a Result of the Findings
    The Eastern Area Director convened a group to review claims in 
other categories, specifically completed rating-related claims in FY 07 
and FY 08 and pending non-rating claims. Of the 386 cases reviewed, 
22.8 percent had errors in the date of claim established in the 
electronic claims tracking program. At the same time that the 386 case 
review was conducted, the Eastern Area Director convened an 
administrative investigative board (AIB) in the New York RO.
    The AIB was tasked to conduct a thorough and comprehensive 
investigation onsite in New York. The AIB interviewed approximately 35 
Veterans Service Center employees and supervisors with knowledge of or 
involvement in the date-of-claim discrepancies during the week of 
August 11, 2008. Based on the findings of the AIB, we took appropriate 
administrative action with six RO leaders involved with the inaccurate 
claim receipt dates.
Nationwie Date-of-Claim Review
    As a result of the findings at the New York RO, the Office of Field 
Operations and C&P Service conducted a full date-of-claim review. 
Beginning in November 2008, the C&P Quality Assurance Staff added date-
of-claim accuracy reviews to all STAR quality reviews. A comprehensive 
review of 385 claims from four ROs (St. Louis, Roanoke, Baltimore, and 
Seattle) was in December 2008.
    Concurrent with C&P Service's review of four ROs, the remaining 53 
ROs received a list of 385 rating and non-rating completed claims on 
December 2, 2008. Each RO was given 1 week to review each claim and 
determine if the appropriate date of claim was applied. The purpose of 
the review was to determine if ROs are using the proper date of claim, 
and if not, reasons for using an incorrect date of claim. The review 
also required each RO to determine whether any use of an improper date 
of claim was to the advantage of the RO.
Measures Taken to Ensure Proper Application of the Date of Claim
    The C&P Site Visit Staff will continue to conduct date-of-claim 
reviews during routine site visits. The OFO has worked with each Area 
Office to conduct additional unannounced site visits at ROs under their 
jurisdiction. Unannounced site visits will include a review of a sample 
of both pending and completed to ensure the integrity of the date of 
claim. The information documented from both C&P and Area Office site 
visits is provided to leadership at the RO level, as well as senior 
leadership in VBA. Based on the findings from on-going date-of-claim 
reviews, VBA will continue to provide training, guidance and reminders 
to the field on the importance of the proper date of claim.
    The Office of the Inspector General also conducted an audit of date 
of claim accuracy at ROs. The report, released February 27, 2009, 
contained three recommendations to improve the accuracy of the dates of 
claim receipt, including establishing goals for receipt-date accuracy 
and strengthening controls to provide greater assurance of reliable 
claims processing times. We concurred with all three recommendations 
and are taking action to implement the recommendations.
Rebuilding Claims Folders
    As long as VBA continues to establish and store paper claims 
folders, we will be vulnerable to misplacement or misfiling of records, 
damaged records, and occasionally losing files. VA has longstanding 
clear and specific guidelines covering lost folders and rebuilding 
folders. These procedures include step-by-step instructions of what 
needs to be completed and how those steps are documented. They are 
covered in VBA's C&P Manual, M21-MR, Subpart ii, Chapter 4, section D 
(Lost Folders). In this section, guidance is provided for lost folder 
searches, special requests for 24-hour searches and file number 
reconciliation and cancelation procedures.
Lost Folder Searches
    In this section of the Manual, clear guidance is provided for:

      General search procedures,
      Missing claims folders and deceased veterans' claims 
folders,
      Missing Notice of Death Folders, commonly used in 
survivor claims, and Dependents' Educational Assistance folders, and
      What to do once a folder is located.

    ROs are obligated to conduct an exhaustive search within their 
facilities before declaring a folder lost. The ROs coordinate with the 
Records Management Center to ensure that all appropriate facilities and 
divisions have searched for the record. When these searches are 
completed and responses properly documented, the RO is responsible for 
rebuilding the folder.
    The process of rebuilding folders includes replicating all evidence 
available to VA. If there is evidence pertinent to a pending claim that 
VA does not have, all development must be done again in order to obtain 
that evidence. In addition, VA is required to notify the veteran and 
his/her representative of the lost folder and ask him/her to provide 
any documents pertinent to successful rebuilding of that folder.
    If the original claims folder is subsequently located, the RO is 
obligated to combine the contents of both the claims folder and the 
rebuilt folder.
Month-of-Death Benefit for Suriving Spouses
    Public Law No. 104-275 amended section 5310 of title 38, United 
States Code, to provide that a compensation or pension payment issued 
for the month of a veteran's death shall be treated for all purposes as 
being payable to a surviving spouse. This change was effective for all 
deaths after December 31, 1996, unless the surviving spouse is granted 
death benefits. Due to problems implementing the change in law, some 
surviving spouses did not receive the veteran's compensation or pension 
benefit for the month of death.
Retroactive Month-of-Death Payments
    VA is currently identifying surviving spouses who may be entitled 
to retroactive month-of-date payments. On December 29, 2008, VA made 
payments to 10,800 surviving spouses. Additional surviving spouses have 
been identified, and payments to those spouses were made last week. 
This process will continue as we identify additional beneficiaries due 
the retroactive benefit.
Changes to Month-of-Death Processing
    Procedures are being revised to automatically issue the month-of-
death benefit immediately on processing the notice of death where VA 
knows of a surviving spouse. No application is required to make 
payment. We expect to issue the new procedures later this month.
    Our goal is to ensure accurate and consistent processing of all 
month of death benefits so that all deserving surviving spouses get the 
highest payment allowed for the month of death during their time of 
mourning.
Conclusion
    Mr. Chairman, I have worked for VA for 35 years. During that time, 
I worked with many dedicated employees who devoted their careers to 
serving veterans. The events I discussed about in this testimony, 
particularly the shredding of documents, go totally against the 
responsibilities we have as public servants. Veterans have lost trust 
in VA. That loss of trust is understandable, and winning back that 
trust will not be easy. We are committed to doing whatever we can to 
accomplish this.

                                 
               Statement of Susan R. Frasier, Albany, NY

    Today's hearing on VA document tampering in veterans claims is long 
overdue. I welcome and thank you for this opportunity to tell you my 
story, Mr. Chairman.
    I am here to announce and allege to you today that I am the victim 
of a VA remand order fraud scheme that has been allowed to go on for 
entire decades in my comp and pen disability claim.
    I have literally spent years trying to report this fraud scheme to 
VA authorities, and to this very minute not one of those reports have 
been processed, acknowledged, or remedied by any office with the VA 
agency.
    Remand order fraud is largely perpetrated by the Board of Veterans' 
Appeals at Washington, DC, and is premised upon a falsified and trashed 
comp case coming out of VA Regional Office at New York City.
    I was discharged from the Army in 1972, and a few months later in 
December, I entered the VA Hospital system as an inpatient here in 
Washington, DC, for the very first time. I have been in both the VA 
Hospital system and the VA comp and pen disability system since then, 
now totaling 37 years. To this very day I have no VA disability 
benefits, not even a zero percent rating, and I am nearly 60 years old 
now. I have spent my entire adult life in the system since age 22.
    I have been under the jurisdiction of the VA Regional Office in New 
York City since the year 1977. New York is my home State and I am under 
the medical care of the VA Hospital in Albany, NY. For the record, 
please know that I am crippled with a confirmed muscular disease and I 
walk with a crutch and wear prosthetics on my legs.
    I was declared disabled by the Social Security Administration in 
1993 which was backdated to the year 1991, and that disability claim 
was supported in part by written statements and papers from VA hospital 
practitioners handling my medical care at that time.
    In 1996, I was diagnosed with a crippling muscular disease. 
Although that diagnosis was not the high point of my life, it 
absolutely did bring much needed answers about my entire medical 
history up to that point. For years I had suffered with one symptom at 
a time, and this new 1996 diagnosis had brought some closure to 
explaining what those chain of symptoms were all about. That was good 
news for me, but it was bad news for those who had been falsifying my 
VA ruling papers up until then.
    My medical history dated back to my Army active duty days in 1970, 
1971, and 1972 and are permanently fixed in my Army hospital files 
although the VA Raters have blocked those hospital records for years.
    At the time of my muscular diagnosis, I had compiled all of the VA 
diagnostic tests, biopsy surgery results, and related VA practitioner 
papers through a Privacy Act request, and then submitted them as 
updates into my then 24-year-old VA comp and pen case. Since that year, 
1996, I repeatedly sent those practitioner papers into VA Regional 
Office in New York City several and many more times thereafter. I 
flatly reject the idea that the VA comp and pen system does not have 
these papers because they do have them X 10.
    The 1996 diagnosis for my muscular disease basically confirmed the 
very first medical theories that had been submitted to the VA all the 
way back to the year 1972 in my case. However, while I thought the 
diagnosis would finally pave the way for my swift VA disability 
adjudication, what happened next was anything EXCEPT a rating in my 
favor.
    I found myself on the receiving end of a perpetual and infinite 
revolving door of Remand Orders and fake ruling papers coming first 
from VARO New York City, then by the Board of Veterans' Appeals in 
Washington, DC.
    I am caught up in a kind of Remand Order hell of which there is no 
escape.
    Let's start with the fact that the Page 1 Issues list of the fake 
and phony remand orders, are not showing exactly what my VA comp claims 
are for.
    I am, for sure, submitting to the VA concisely named and numbered 
VA medical diagnostic codes under the 38 CFR Part 4 tables. What I am 
getting back from the VA Raters is a vague translated version of those 
codes followed by the word ``disorder.''
    Please know and understand that I am almost 60 years old now and 
all of my medical conditions are fully diagnosed by regular VA doctors. 
When a person spends 2 full months in the VA Critical Care Ward with 
abdominal tube life support after a life threatening surgery, I think 
it's a given that VA doctors along the way would have likely told me 
what my diagnosis is. They did, but I am finding out now there is no 
rational way possible to file those medical diagnostic codes into the 
VA disability system and STILL get a truthful and accurate law finding 
in return that determines me to be service connected disabled. The VA 
Raters are just not going to have it that I already know the medical 
titles of my diagnosis results. It's their plan to keep on writing this 
case as if they alone can determine my diagnosis.
    The better part of all of my medical conditions are diagnosed as a 
result of surgeries. Very often, those VA surgery reports are only 1 
page long in computer format. For as many times as I have cited the VA 
diagnostic codes under 38 CFR Part 4 and filed them with the 1-page 
surgery reports from the VA, then that's as many times as I continue to 
get a denial on the claim by VA Raters and for no apparent reason. The 
VA Raters appear to be of the idea that I am asking THEM for THEIR 
``opinion'' about what my diagnosis is. I am not. If I am diagnosed by 
licensed VA practitioners then why in the world would I ever turn 
around and ask an incompetent and illiterate VA Rater for their 
``opinion'' on those findings? It makes no sense. I submit these 
entries as declarations and not as a ``request'' for their opinion. My 
only obligation in disability claims is to submit proofing papers of 
what licensed doctors have already determined.
    Note that VA Raters at the VA Regional Office in New York City, and 
Board of Veterans' Appeals judges, are not medical practitioners either 
licensed or unlicensed. Most all of my modern day diagnosis are 
perfectly matched to my Army hospital records from active duty.
    For an example of how the VA Raters alter the statement of my 
medical conditions, take 38 CFR Part 4 diagnostic tables, Code 7308 for 
instance. VA Raters change this and alter it into ``gastrointestinal 
disorder.'' It's important to understand what's happening here, as 
small as it may first appear to be.
    While that by itself seems harmless enough, what the VA Raters are 
doing by this sleight of hand is basically concealing the fact that I 
am already diagnosed by licensed medical doctors. They are making it 
falsely appear on the Page 1 Issues section of the fake remand orders, 
as if I have never been diagnosed at all by any doctor and that some 
kind of ``mystery'' lurks in my disability case. No such ``mystery'' 
exists and it stands to reason that what I am saying here is true.
    After they create this false illusion on paper that there is some 
kind of ``mystery'' in my case, then here comes a truckload of ``law'' 
excuses for why a remand order is the only solution to the ``mystery''. 
This is fake, this is phony, this is a deceptive practice and it is a 
fraud scheme. I am here to blow the whistle on the matter and to ask 
Congress to put a decisive end to all of it. When I submit a claim for 
Code #7308, then Code 7308 is exactly what I expect to see on my ruling 
papers when I receive them back from Raters. Anything else is a 
deliberate falsification for remand order purposes.
    After the Page 1 ISSUES section is falsified in this way, then the 
entire following 15 pages after that are wrong, bungled, misapplied, 
and misinterpreted and the entire ruling ends up not even worth the 
paper that it's written on. I've had enough and I'm here to ask 
Congress to end this practice.
    What is taking place in my VA disability case is the ongoing 
refusal of VA Raters to read my diagnostic papers, compare them to my 
Army Hospital records, and then pay the claim. Instead I am getting 
phony remand orders for papers which are already in the C File, and all 
kinds of fake and phony overtures which suggests I am NOT fully 
diagnosed. I am for sure, and all they are doing is ignoring or 
concealing the proofing papers for delay purposes.
    My Army hospital papers are blocked in every single review by the 
VA Raters as relentless abuses of the new and material evidence rule 
under 38 CFR Part 3.156. It seems to me that a full repeal of this 
regulation would put a swift end to these abuses.
    In 1999, I received my first bungled Remand Order from the Board of 
Veterans' Appeals here in Washington, DC, which was for doctors who 
were known to be dead; and for places where I had never been treated 
at; and for other information that was already submitted in my C-File. 
I knew for sure then that the VA was jerking me around on my disability 
case.
    It took from 1999 to 2008 for me to get to the Board of Veterans' 
Appeals a second time. I came to the hearing in person on May 21, 2008, 
at 2:00 p.m. I welcome a subpoena by any investigator who would like to 
obtain the video of that hearing because a picture is worth a thousand 
words. The BVA Judge was completely lost on the case and he conducted 
the hearing without ever having read any of the case papers. He didn't 
know what questions to ask and he didn't comprehend the REAL case that 
I was talking about in front of him.
    Also, it just so happens that I am in possession of part of my VA 
C-File at home which is dated in 2004, but nearly 1/3 of the box was 
missing in the version that was brought out for my inspection at the 
BVA Hearing in May of 2008. So I knew from that moment there would be a 
chance for a bungled ruling yet again but I was hoping for the best.
    In August, I received the second fake and phony remand order from 
BVA, once again completely incorrectly showing a falsified ISSUES list 
on the Page 1 of the ruling. He went on and on talking about my PTSD 
claim, when in fact, no PTSD claim from me was ever submitted for that 
appeal, nor was it argued at the hearing, nor was any evidence 
submitted in the papers for that appeal. Basically he was assessing a 
PTSD condition on paper that was nowhere sitting before him. It was all 
his own fabrication in the ruling and he was in it by himself. This is 
why the hearing video would be important to see because there is no 
match between what actually went on at the BVA hearing and the 
resulting and absurd 15-page falsified ruling which came out later in 
August.
    Incredibly, he ``remanded'' the case for more papers on the PTSD 
not realizing the HUGE mistake he had made. Within approximately 5 days 
of the fake remand order, I submitted a Motion for Reconsideration and 
to Vacate the remand order, which was well within the 120-day allotted 
time for such a Motion.
    In October, he issued a second fake and phony ruling, first 
removing the falsified PTSD entry but then leaving behind the other 5 
or 6 remaining falsified entries as ``Issues.'' All of the Issues were 
altered and reworded to NOT coincide with the evidences I had submitted 
on the appeal.
    I can tell you with certainty, that it's my considered opinion 
after receiving these fake papers, that the Board of Veterans' Appeals 
is not even reading C-Files. They are just reaching in the box and 
grabbing a handful of papers and making up whatever story they can 
concoct for the sake of issuing a fake remand order for delay purposes 
to not pay the claim.
    There is nobody who is more evidenced than I am with Army hospital 
records, an A-1 physical rating upon my entry into the military, VA 
hospital records spanning 37 years by VA doctors, and yet after all of 
THAT, the Board of Veterans' Appeals STILL cannot get it right in my 
case. I have concluded that these events are deliberate and not a 
mistake, and that even when handed the papers they are claiming to 
need, then it's STILL not enough to pay the case. This is nuts.
    As you know, Veterans cannot receive free lawyer assistance on 
disability claims until we enter the Court of Veterans Appeals. After 
receiving the second falsified BVA Remand Order, I then filed my court 
papers and began the search for lawyer representation.
    It was here that the value and purpose of issuing fake remand 
orders began to reveal itself. I came upon a veterans lawyer in 
Washington who was found to be harboring and protecting the fake remand 
orders coming from the BVA. While trying to solicit his services for 
the case, it all came out that he only and exclusively reviewed what 
the BVA said in cases and NOT what the client (veteran) side of the 
case was. In other words, the client is never represented, only the VA 
is represented to the client by this particular lawyer. This is a 
second fundamental piece to the remand order fraud which is the full 
wall of silence and protection coming from the veterans lawyer 
community, and includes the VSOs.
    The national veterans claim backlog grew to nearly 800,000 at one 
point last year and yet Congress has not really connected the dots that 
it happened on their watch. So this self-admitted, one-sided case 
review to only consider the VA's side of a case is the next big reveal 
that came to bear as I was trying to get help in the fake remand order 
scheme.
    Allegedly the Veterans Pro Bono Consortium is receiving Federal 
funding from the Court of Veterans Appeals to represent veterans before 
the court, and yet this very same Consortium has taken an advance 
position that all remand orders issued by the BVA are true, valid, and 
legitimate which quite frankly, is a breach and violation of the 
standing Bar Associations doctrine that lawyers must review cases on 
their individual merits. Case in a box and McClaims are not valid law 
practices by most law firms, but here it is alive and well inside the 
national veterans claims arena.
    It seems that VA remand orders generally, no matter how falsified, 
or how bungled, or how misstated on the details of the case by the BVA 
Rater, do have the final result of blocking the veterans from accessing 
the free lawyers for representation at the Court of Veterans Appeals. I 
was rejected across the board by all lawyers for representation in my 
case, for no other reason that I had a remand order--no matter how 
trashed and falsified. I was effectively boycotted.
    It was also found that the Court of Veterans Appeals is refusing to 
even accept or hear remand orders of any kind, no matter how trashed, 
falsified, or misstated by the BVA Raters. Again, the Court presumes 
all remand orders to be true, valid, and legitimate and their authority 
does not remain open for the possibility of VA driven fraud schemes or 
deliberately falsified documents.
    At the Court of Veterans Appeals on February 9th, the VA agency 
filed a Motion to Dismiss my appeal followed immediately by a Motion 
for a Stay in contemplation for a dismissal. The Court Clerk, without 
any judicial review and just 15 minutes apart after the VA had filed 
their motions in Washington, went ahead and granted the VA's motion. 
This is in clear violation of constitutional Due Process and is a 
breach of the ex parte proceeding rule under 38 USCA.
    I assert to you today that I am fully entitled to a right of Notice 
in my case and the right of responsive pleading. Ex parte proceedings 
are prohibited in all Federal courts, but here it is alive and well at 
the Court of Veterans Appeals.
    This is all out legal malpractice at the Court, and it shows that 
the entire veterans claims system at every level, is self absorbed, out 
of control, and having it's way with the sick and injured of our 
Nation.
    This story gets even worse. After all of that, in November of 2008 
and right while my trashed VA case was being bounced around between the 
BVA and Court, the very man who was falsifying my ruling documents at 
the VARO level out of New York City was included in a mass firing which 
made newspaper headlines. In a small way I felt vindicated, but my 
filed complaints on this guy, which to this very day still remains 
unprocessed at the VA.
    The VA Inspector General, for the entirety of the 1990s and into 
the 2000 decade now, had repeatedly refused to accept my complaints 
that the VARO in New York City was deliberately falsifying my ruling 
documents. I was given a rejection form letter saying that the IG did 
not process filings, related to veterans claims. In January of 2008, I 
alternately filed 2 different VA Civil Rights complaints on the very 
guy who eventually was fired or suspended out of New York City. Those 
Civil Rights complaints have also never been processed by the VA in 
Washington to this day. Walls of silence, lockouts, boycotts, and 
refusals to assist: these are the common trends and practices of what I 
have been getting out of the national veterans claims system for my 
case. No help, just excuses and ex parte decisions at the Court.
    Also during this time, a national scandal has broken out involving 
other VA regional offices shredding documents that were submitted by 
Veterans for their disability claims. It is my suspicion, and partly 
why I am here today, to allege that these shredded documents may be 
attached to the much larger crimes of VA-caused remand order fraud. 
What the VA gets away with at one location, often creeps into other 
locations. Remand order fraud is the perfect VA crime because one has 
to be incredibly smart to even discover it.
    There is, for sure, a legislative void in this issue of remand 
orders. Veterans are never notified by any VA publication whatsoever, 
that remand orders are NOT appealable at the Court of Veterans Appeals. 
[says the Veterans Pro Bono Consortium]
    I have been forced to sit through (for years at a time) fake ruling 
orders for medical conditions I had never applied for, and for evidence 
papers which were separated and confused by the VA and then misapplied 
to the wrong medical conditions among other things. I've had every 
dirty rotten trick in the book played on me in the ruling papers of my 
case.
    And let's talk a minute about the misuse and abuse of ``comp and 
pen exams.'' There is NO comp and pen doctor under the sun who is going 
to read my 37-year-old C File, spanning several boxes of medical and 
surgical files from 1972 to 2009, and then do this all in a matter of a 
1-hour VA exam. This is perhaps one of the most wasteful, overly 
abused, and malpractice burdens of all which VA Raters are putting upon 
lifelong backlogged cases.
    Understand that I will not consent to a ``comp and pen exam'' 
because nothing at all other than more of the same, will come out of 
such a scenario. It's bungled now, and I will just get more bungled out 
of a comp and pen exam. What can a ``comp and pen'' exam show in 1 hour 
that my VA licensed doctors haven't seen in 37 years? This question 
deserves a serious answer.
    How many decades will I be forced to sit through a pile of fake and 
phony remand orders before some official police authority comes to my 
rescue?
    How elderly must I be before my VA Hospital papers are compared to 
my Army Hospital papers to show once and for all that I am truly a 
service connected disability case?
    If I never receive another ``final order'' in my case again, then 
does this mean that I can also never file an appeal at the Court of 
Veterans' Appeals again? And is it for sure, the true intent of 
Congress to have NO appeal process whatsoever for fake and phony remand 
orders which are issued by the criminal agendas at the Board of 
Veterans' Appeals? When does a lifetime remand order become ``final'' 
for appeal purposes, and are there no possible conditional scenarios 
where remand orders are FORFEITED by reason of VA abuse?
    What do BVA Raters think they are competing with exactly, when they 
put veterans through lifelong overkill process, when at the very same 
time, those veterans are holding full diagnosis papers from surgery 
outcomes?? Clearly, the Board of Veterans' Appeals does NOT understand 
it's role in disability claims. Since when is the BVA empowered to not 
accept surgery findings from licensed hospital practitioners as 
rational proofing of a disability claim?
    At what point over a lifetime is the veteran given a golden 
parachute to go directly to the VA pay order and to stop the flow of 
remands?
    These are all fair questions to know.
    There needs to be more clarity in police authority at the VA so 
that those of us who are crime victims can speedily report corruption 
to the authorities and not receive some ridiculous rejection form from 
the VA Inspector Generals Office saying they have no jurisdiction in 
matters related to veterans claims.
    And what exactly is the true meaning of patient abuse and patient 
exploitation in the VA disability process--because I can make a very 
good case right now that I have been through both in the name of 
pursuing my disability benefits from the Army?
    As a lifelong backlogged case in the VA disability system, I hope 
this Committee can rescue me and others like me who are hopelessly 
trapped in this VA process from hell.
    I will be glad to meet with any Federal prosecutor who would like 
to seriously pursue a conviction at the VA as I have the worlds biggest 
stockpile of papers showing VA Raters gone amuck. Bring on the 
handcuffs I say, and shame on the lawyers who have been protecting 
them.
    In conclusion, if you look at the list of broken pieces that I just 
finished describing, then there really is too much here to be 
considered a ``coincidence'': false ruling documents, altered medical 
conditions, boycotting lawyers, case rigging at the appeals Court, and 
suspended police action not processing reports. It certainly sounds 
like a crisis to me!
    Thanking you today Mr. Chairman.

                                 
  Statement of Master Sergeant Kurt Priessman, USAF (Ret.) Vernon, TX

    Honorable Chairmen and Members, I thank you for inviting me to 
testify before the joint session of the Subcommittees on Disability 
Assistance and Memorial Affairs and Oversight and Investigations today. 
I come before this esteemed body as a citizen, as a military retiree 
and former civil servant, as a disabled Vietnam Veteran and bearer of 
the Order of the Silver Rose, and as the proud father of an active duty 
military member. My name is Kurt Priessman, MSgt, USAF (Ret) from 
Vernon, Texas. I have previously provided testimony to this 
Subcommittee on the subject of the Backlog and the Claims Processing 
System.
    I thank Mr. Larry Scott of VAWatchdog.org, whose published articles 
and information provided Veterans with the ability to determine from 
internal sources that the Veterans Administrations Office of Inspector 
General found evidence of spoliation and tampering of Veterans claims. 
Accordingly, when the Department of Veterans Affairs, Veterans Benefits 
Administration generated FAST Letter 08-41, they admitted that 
something was seriously amiss with Veterans records and thus with 
rating decisions at Regional Service Centers across the country.
    On behalf of all Veterans, we ask these Committees to comprehend 
the nature of these events and understand that Veterans are not willing 
to pass them off to be forgotten. These findings are egregious and are 
widespread. The following amnesty period, while not well known, 
definitively showed that these were not misdeeds of a few ``bad 
apples''; they are not symptoms, they are the results of efforts by 
senior management and supervisors to ``meet a quota'' set by a very 
poor work credit system. This system must end immediately.
    Veterans wonder why the VAOIG Report was not forthcoming, and now, 
when finally it is published, will put almost no credence in its 
findings unless the Report puts the responsibility on what Veterans 
across the country believe is an extension of the ``deny, deny, until 
they die'' mentality of senior Department and Veterans Benefits 
Administration officials. Their trust, if there was any left, will not 
be restored by the testimony of these officials before these 
Subcommittees.
    And so it is that Veterans across this Nation are asking you, our 
elected representatives, to do more than ask piercing questions, to do 
more than accept pre-prepared excuses, to do more than write off the 
truth as ``anecdotal stories''. You must begin to accept that the 
disability claims system is so severely broken that it must be 
simplified. Professor Linda Bilmes of the Harvard School of Business 
and a Presidential Advisor made a brilliant suggestion in previous 
testimony as did several members of the most recent hearing of the 
improvement of the Appeals Process. But please know that to do nothing 
denigrates Veterans and their families, their service to the country, 
and this esteemed body. I sincerely ask you to consider that what you 
are experiencing here is an affront by the Department, not only to the 
Congress, but to all Veterans of the United States of America.
    Veterans ask you to consider what has really happened since 
Chairman Filner's Roundtable Discussion on Wednesday, November 19, 
2008, and Admiral Dunne's mea culpa.
    As an example, this Veteran filed a claim on November 25, 2008, in 
accordance with the FAST Letter concerning the adjudication of a 
decision in which ``the claim was considered by VA based on an 
incomplete record because the supporting evidence or information was 
not added to the record.''
    This Veteran received no acknowledgement, there was no indication 
of a need for a ``Report of Contact'' (Step1); there were no requests 
for any documentation (Step 2a), there was no VCAA letter as specified 
(Step 2b); nor was there anything from the Regional Service Center 
complying with Step 2c. The Veteran finally received an acknowledgement 
on February 18, 2009, after asking through the Inquiry Routing 
Information System (IRIS) on January 27, 2009, again on February 6, 
2009, and finally on February 11, 2009.
    What begs to be answered is what exactly has been done at Regional 
Service Centers?
    What are Veterans really facing with regards to the implementation 
of this letter?
    Are Veterans really being given the benefit of the doubt concerning 
lost, shredded, withheld, and spoliated documents or is the Department 
doing something else?
    I personally asked a senior representative of the Disability 
Compensation and Pension Branch here in Washington if there was 
forthcoming guidance, and his honest answer was, ``I haven't seen 
anything on the subject floating around these halls''.
    And so I am forced to ask:
    Are the Regional Service Centers in receipt of changes in M21-1MR? 
If so, why are there no published updates available to Veterans, their 
Advocates, or their Veterans Service Officers?
    Are any of these procedures published in the Federal Register? 
While promised, there are none anyone has seen.
    Do Veterans know what they are to do, what they should expect from 
the VBA and when? It is not at all likely. Or using the phraseology of 
the VA ``It is more likely than not'' that the VBA continues its 
``modus operandi'' of keeping the Veteran wondering what, when, and how 
their claims should be filed and how they will be handled?
    In conclusion, I believe this is standard operating procedure by 
the Department, as is non-compliance with most of its own regulations. 
I request that the Sub-Committees recommend to the Chairman of the 
House Veterans Committee and to the full Congress legislation that:
    1.  simplifies the claims process;
    2.  precludes ``negotiation'' of the findings of a VAOIG Report;
    3.  codifies the FAST letter;
    4.  places spoliation of Veteran documentation as an area of 
concern, and
    5.  adopts a no tolerance policy and sets forth disciplinary 
procedures in regulation that requires termination of anyone found 
responsible for spoliating, shredding, or withholding any claim 
document without exception.
    Thank you all for your patience in this critical matter.

                                 
                                                      Cohocton, NY.
                                                  February 15, 2008
Secretary Eric Shinseki
Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

Re: XC 24 884 978

Dear Secretary Shinseki,

    In spite of the VA Fast Letter #08-41 dated November 14, 2008, and 
the Inspector General's audit, and in spite of the pending hearing set 
for February 25th by the Subcommittee on Disability Assistance and 
Memorial Affairs regarding the ``October Incident'' the Veterans 
Administration has again destroyed my probative medical evidence.
    In defiance of the terms of a September 2008 BVA remand, which for 
the first time acknowledged my three independent medical opinions that 
support my claim and also references other documentation I had sent to 
VA as probative evidence--the decision I just received from the AMC, 
which was mailed to me from the Seattle VARO (the claim originated at 
Buffalo VARO where I filed it in February 2003, 6 years ago) this 
decision shows that my evidence has been destroyed again by the 
Veterans Administration.
    I have enclosed copies of 53 tracking slips from USPS since Feb 
2003 that proves that I not only sent this evidence in, I also sent it 
directly to Donna Terrill Director VA Buffalo, directly to Terry Draper 
DRO Buffalo, to Former Deputy Secretary Mansfield (April 2008) (whose 
office in turn submitted it again to the Buffalo RO) and as you can see 
these were numerous submissions of considerable evidence. I am a 
volunteer veterans disability advocate and I certainly know what is 
probative evidence and what is not redundant nor accumulative evidence. 
I also am aware of all VA case law and regulations that assure a 
claimant's evidence will be properly considered.
    Since this involves so much evidence and even subsequent 
submissions of it all again, in my case, I can hardly accept any notion 
that it has somehow all been misplaced or lost. It has been destroyed 
by the Veteran's administration, most recently under the jurisdiction 
and auspices of the AMC.
    Since my most critical evidence from 1995 to 1997 was destroyed by 
the Buffalo VA and only by calling the Strategic Health Team at VACO 
did I have it finally properly addressed, when I faxed it directly to 
them-this too adds credibility to my charge that the Veterans 
Administration has again destroyed my evidence. Also I have two CUE 
claims filed in 2004 that the Buffalo VARO has ignored and probably 
destroyed my extensive legal evidence on as well, since they never have 
acknowledged this legal evidence at all.
    The Neurologist, Dr. Hamid Rabiee, had prepared a VA MRI report on 
the veteran when he was employed at the VA and was treating my husband 
at the Syracuse VAMC. His IMO statement of 2004 incorporated into the 
first IMO from Dr. Bash was based on his own medical entries in the VA 
clinical records when he himself had treated the veteran. Dr. Craig C. 
Bash based his opinions of November 2004 and August 2006 on many other 
medical points to include his experience in reading ``thousand's'' of 
MRIs of diabetics and he gave full medical rationale for his 
conclusions. My IMO opinions fully outweigh the expertise of a 
physician's assistant who opined on this claim recently without the 
entire record and evidence.
    I have submitted to VA, as well as evidence from the actual VACO 
report of malpractice dated July 1997, a prior Internal VA Review that 
supports this claim that VA said never existed at all but I have sent 
the VA a copy of it, EEOC testimony, the veterans complete autopsy, 
Corning College Voc Rehab Accommodation request info, VA, as employer 
of the veteran-accommodation request info, SSA records, and countless 
medical abstracts I sent that are SPECIFIC in every way to the claim, 
the Veterans Administration-most recently under the auspices and 
jurisdiction of the AMC, has chosen to destroy that evidence and to 
completely violate the conditions of the BVA remand. The BVA remand 
also told me that I could send in more evidence and additional argument 
for proper resolve. I did--the AMC received this packet of evidence and 
argument on October 3rd, 2008. That too has been destroyed by the AMC.
    You have inherited problems that will continue to get worse. The IG 
audit is not public and so far only the online veterans communities are 
fully aware of the ``October Incident.'' The VA has not implemented any 
viable scenario at all to support the statements in the Fast Letter 
#08-41.
    I want the AMC to call a CUE on itself, to realize they have made a 
clear and unmistakable error to my detriment by not acknowledging my 
extensive and probative evidence. I want a decision under Relative 
Equipoise because my medical evidence far outweighs the VA's and comes 
from medical doctors who have the expertise to make a valid opinion and 
who also considered the clinical record and other evidentiary documents 
properly. Also my competent lay evidence and abstracts are pertinent 
and probative to this claim I want ALL of my evidence considered.

            Respectfully,

                                                   Berta M. Simmons
                              Surviving Spouse of Rodney F. Simmons
    Enclosures: copy 53 USPS tracking slips
    Copies being sent to:
    Inspector General VA
    Congressman Hall House Subcommittee Disability/Memorial Affairs
    Congressman Filner House VAC
    Subcommittee Investigations and Oversight VA
    Arthur Russo, Director Appeals Management Center-VA
                   MATERIAL SUBMITTED FOR THE RECORD

         Veterans Affairs Probe: Records Found in Shredder Bin
                      Employee Under Investigation
                       Thursday, November 6, 2008
                            By Chuck Crumbo
                          [email protected]

    Veterans Affairs officials are investigating why 95 records were 
erroneously dumped in a shredder bin at the VA office in Columbia.
    An unidentified employee at the Columbia office is under 
investigation for mishandling the documents, which include new benefits 
claims and other personal files, VA officials said.
    ``I can't discuss in detail what action may be taken against an 
employee in this instance until the investigation is complete,'' VA 
press secretary Alison Aikele said Wednesday.
    In South Carolina, the possible destruction of benefit claims could 
affect some of the State's 413,000 veterans. The shredding probe 
involves the VA's benefits offices, not the hospitals.
    So far, few veterans suspect they might have a problem resulting 
from their benefit claim being erroneously shredded.
    ``We don't know how many, we don't know why it happened,'' said 
Rodney Burne, quartermaster of the Veterans of Foreign Wars S.C. 
department. ``It will be interesting to find out.''
    The documents slated for destruction were found in the shredder bin 
Oct. 3 as part of the agency's inspector general's review of how 
veterans records and claims are handled.
    The probe discovered 41 of the VA's 57 regional offices, including 
Columbia, had 500 records wrongly slated for shredding. The VA further 
determined that half of those records were found in shredder bins at 
the Columbia office and at two other offices, St. Louis and Cleveland.
    Forty-six of the records--or about half--discovered in the shredder 
bin at the Columbia office were either new claims for benefits or 
supporting documents.
    Other claims included burial and death benefits, notices of 
clients' disagreements with VA rulings, and documents for education 
benefits.
    The House Veterans' Affairs Committee, whose Membership includes 
U.S. Rep. Henry Brown, R-S.C., plans to look into the issue in mid-
November, an aide said. ``We're going to have a roundtable 
discussion,'' the aide said, explaining the session would not be as 
formal as a Committee hearing.
    Officials from the VA as well as representatives of veterans 
service organizations will be invited to the discussion, she added.
    Brown called the reports ``troubling,'' and added ``there is never 
any excuse for the shredding of documents especially when they 
jeopardize the benefits our veterans are entitled to.''
    Brown said the incident ``shows how important it is for the VA to 
focus on modernizing its information technology systems and 
establishing clear safeguards.''
    The shredding issue was first reported by vawatchdog.org, a Web 
site run by Army veteran Larry Scott, of Vancouver, Wash.
    Scott learned records were erroneously dumped in shredder bins at 
the VA's Detroit office. VA investigators discovered Detroit was just 
part of the problem, so they ordered all 57 offices to check their 
shredder bins.
    The fact that the Columbia office would have the most records in 
the shredder bin wasn't a surprise, Scott said.
    The Columbia office has a reputation as a ``troubled office,'' 
meaning it has a low clearance rate of veterans claims.
    In 2005, the VA reported Columbia had the third-highest remand rate 
of the agency's 57 regional offices. A remand is a benefit case that, 
once appealed, must be redone.
    The VA said 50.1 percent of 3,095 cases filed with the Columbia 
office had to be remanded. The agencywide average was 44.3 percent.
    Scott doubted Oct. 3 was the only time documents were erroneously 
headed for the shredder.
    The mishandled documents add fuel to many veterans' suspicions that 
the agency's policy is to frustrate a vet's effort to process a claim, 
Scott said.
    ``The expression is: `Delay, deny and hope that I die,''' Scott 
said.
    Millions of documents are routinely shredded by VA offices without 
incident, Aikele said.
    Shredding is done to protect the veterans' privacy. It is supposed 
to be done after documents have been copied, she added.
    ``They're just not tossed in the garbage,'' Aikele said.
    Reach Crumbo at (803) 771-8503.

                                 

                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                                    Washington, DC.
                                                      March 4, 2009

Michael Walcoff
Deputy Under Secretary for Benefits
Veterans Benefit Administration
U.S. Department of Veterans' Affairs
810 Vermont Ave., N.W.
Washington, DC 20420

Dear Mr. Walcoff:

    In reference to our House Committee on Veterans' Affairs Joint 
Subcommittees on Disability Assistance and Memorial Affairs and 
Oversight and Investigations Hearing on ``Document Tampering and 
Mishandling at the Veterans Benefits Administration'' on March 3, 2009, 
I would appreciate it if you could answer the enclosed hearing 
questions as soon as possible.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your response to 
Ms. Megan Williams by fax at (202) 225-2034. If you have any questions, 
please call my office at (202) 225-2315.

            Sincerely,

                                                    Ann Kirkpatrick
                                                             Member

                               __________

              Questions from Rep. Ann Kirkpatrick, Member
                  House Committee on Veterans' Affairs
       Subcommittee on Disability Assistance and Memorial Affairs
    Hearing on ``Document Tampering and Mishandling at the Veterans 
                       Benefits Administration``
                             March 3, 2009

    Question 1: During today's hearing, we discussed claims documents 
that were improperly shredded. This raises an important background 
question: Why are documents pertaining to an open claim shredded at 
all?
    Response: Many of the documents identified for shredding are 
duplicate copies of electronic records printed from VA systems. VBA 
allows duplicate copies of electronic records printed from VA systems 
or documents that have no impact on a pending claim, or have no 
historical value to be shredded. However, duplicate documents that are 
submitted by Veterans and other claimants are returned to the 
claimants. Retaining duplicate or irrelevant documents in claims 
folders unnecessarily increases folder size and impacts the records 
review time required to process claims.
    Question 2: The restriction of needing two signatures before any 
document can be shredded seems very inefficient. Has anyone explored 
the possibility of scanning and saving each document that is shredded, 
so that the scanned records can be used as an auditing tool and 
documents can be easily recovered in a worst-case scenario?
    Response: The protection of Veterans' paperwork is of the utmost 
importance to VBA. We are committed to ensuring that we have systems in 
place to safeguard all Veterans' records and that employees are held 
accountable. We believe the procedures we put in place for protecting 
Veterans' paperwork are necessary in order to regain Veterans' 
confidence and trust in VBA's handling of their documents. The 
established procedures ensure only documents with no record value are 
slated for destruction. We agree that we must leverage today's 
technologies to protect Veterans' information and support claims 
processing. We are working aggressively to achieve our goal of 
paperless claims processing by 2012.

                                 

                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                                    Washington, DC.
                                                     March 25, 2009

Kerry Baker
Assistant National Legislative Director
Disabled American Veterans
807 Maine Avenue, SW
Washington, DC.

Dear Mr. Baker:

    Thank you for testifying at the House Committee on Veterans' 
Affairs' Subcommittees on Disability Assistance and Memorial Affairs 
Oversight and Investigations hearing on ``Document Tampering and 
Mishandling at the Veterans Benefits Administration '' held on March 3, 
2009. I would greatly appreciate if you would provide answers to the 
enclosed follow-up hearing questions by Friday, April 24, 2009.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all Full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your response to 
Ms. Megan Williams by fax at (202) 225-2034. If you have any questions, 
please call (202) 225-3608.

            Sincerely,

                                                       John J. Hall
                                                           Chairman

                               __________

                 UNITED STATES HOUSE OF REPRESENTATIVES
                     COMMITTEE ON VETERANS' AFFAIRS
       SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS
 March 3, 2009, Oversight Hearing on Document Tampering and Mishandling

  Response to Questions for the Record from Chairman John J. Hall to 
                              Kerry Baker

    Queston 1: What would DAV agree to be a reasonable time for VA to 
undertake to implement the IT system and Imaging Centers you described 
in your statement?
    Response: From our understanding, the VA has already sought 
information from contractors regarding potential projects such as the 
DAV's proposed image scanning center. For example, the Social Security 
Administration uses such a contractor for that very purpose.
    Therefore, current technology not only exists, but is in use. 
Acknowledging this, it actually hinges upon the priority placed on the 
issue of fully electronic records. If the agency were to consider this 
one of its highest priorities, we believe that such an undertaking 
could begin within the next 12 months.
    The VA has stated that they plan on being completely paperless by 
2012. However, we do not fully understand the mechanism for success 
behind this goal, i.e., an image scanning center or some other form of 
electronic media. Nonetheless, we believe that 12 months is sufficient 
to begin this undertaking, whether it is utilized at a test facility 
first, only on new claims coming into the system, at the appellate 
stage, etc.
    Question 2: VA says that it is allowing a ``relaxed claims 
submission'' period for claimants who fall within the 18 month period 
leading up to the discovery of the shredding. Do you have any reason to 
believe that the shredding could have been going on longer than that 
based on the feedback from DAV service officers over the years? Have 
any veterans expressed concern that they had claims that were denied 
before the 18 month window because VA did not consider information that 
the veterans, in fact, provided.
    Response: This question is very difficult to answer with certainty. 
As a former Service Office Supervisor, I can state that there has been 
many occasion wherein evidence never made it to the claims file, 
ultimately leaving the claimant no choice but to resubmit the evidence. 
Therefore, as it pertains to the question, shredding could have been 
going on longer than the 18 month window. However, such mishaps could 
just as easily be the result of incompetence; it's impossible to know.
    Regarding the second part of the question, the DAV has not had any 
significant number of claimants state that their claims were denied 
because VA failed to possess and then consider all pertinent evidence. 
We actually anticipated more than has surfaced.
    Question 3: In her testimony, VA's Assistant Inspector General for 
Audit tells us that so-called mail amnesties in Detroit and New York 
uncovered 16 thousand pieces of mail and other documents that had not 
been processed. Have you ever heard of these mail amnesties? How often 
do veterans tell you that they have submitted paperwork, and how well 
does VA deal with these situations.
    Response: This is a first. We had never heard of mail amnesties. We 
do hear from claimants often wherein they indicate that evidence was 
submitted but that VA doesn't have the evidence. Until now, these 
situations were not handled well. The VA claimant was usually forced to 
produce more copies of the evidence unless the claimant could prove 
that VA received the evidence. It can be very frustrating in cases 
where the veteran or widow submits their only copy of the evidence.
    Question 4: You indicate in your testimony that you are aware of 
the document handling procedures now in place. Do you believe this new 
process is sufficient to protect veterans' claims until the IT solution 
is complete, or do you still have concerns with potential mishandling 
of records?
    Response: I do believe it is sufficient to safeguard the records, 
but at a price. It's time consuming and burdensome. It will likely slow 
down production on claims' decisions. The DAV believes a better 
approach is to pass legislation that mandates criminal punishment for 
VA employees who maliciously destroy evidence. Criminal prosecution is 
a large deterrent, one that appears to be very effective in preventing 
fraudulent claims. It does not work as a deterrent for destroying 
evidence because title 38 does not mandate such prosecution for VA 
employees.

                                 

                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                                    Washington, DC.
                                                     March 25, 2009

Mr. Ronald Abrams
Joint Executive Director
National Veterans Legal Services Program
1600 K Street, NW, Suite 500
Washington, DC 20006

Dear Mr. Abrams:

    Thank you for testifying at the House Committee on Veterans' 
Affairs' Subcommittee on Disability Assistance and Memorial Affairs and 
the Subcommittee on Oversight and Investigations hearing on ``Document 
Tampering and Mishandling at the Veterans Benefits Administration '' 
held on March 3, 2009. I would greatly appreciate if you would provide 
answers to the enclosed follow-up hearing questions by Friday, April 
24, 2009.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all Full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your response to 
Ms. Megan Williams by fax at (202) 225-2034. If you have any questions, 
please call (202) 225-3608.

            Sincerely,

                                                       John J. Hall
                                                           Chairman

                               __________

                   Response From Ronald B. Abrams for
        Question From the House Committee on Veterans' Affairs,
       Subcommittee on Disability Assistance and Memorial Affairs
            Hearing on ``Document Tampering and Mishandling
               at the Veterans Benefits Administration''
                             March 3, 2009

    Question 1: Do you believe that Congress should not consider any 
proposals to modernize the VBA disability claims processing system that 
would infringe or eliminate any of the veteran's current procedural 
rights? Are there any circumstances in which you would support such 
action?
    Response: Congress should not avoid considering a proposal simply 
because it would infringe or eliminate a veteran's procedural rights. 
NVLSP would support a set of changes, assuming that there are 
comprehensive changes to the claims adjudication process, that, as a 
whole, benefit veterans and other claimants. NVLSP believes that the 
best way to improve VBA and to make things better for veterans seeking 
VA disability benefits is to implement comprehensive--not piecemeal 
change. If NVLSP believed that a set of changes would benefit claimants 
as a whole, NVLSP could well support the changes even though some 
rights of the claimants would be curtailed.
    Question 2: I am very interested, and I agree with your 
streamlining suggestions regarding hearing loss and PTSD criteria. 
However, I often hear that this will open the system to much more 
waste, fraud and abuse by veterans. What do you think of that 
possibility and what would you do to mitigate it from happening? What 
has been the response from VA to your streamlining suggestion?
    Response: Abuse probably exists in any disability system. That 
said, we do not believe that the changes proposed by NVLSP would cause 
much more, if any, fraud, waste and abuse. We say this because having 
the VA presume that veterans were exposed to acoustic trauma, or that a 
veteran who served in a combat zone is telling the truth when he or she 
describes a traumatic incident to support a claim for PTSD, only 
establishes the in-service incident, not the diagnosis. Also, in many 
instances medical experts can catch those who are attempting to abuse 
the system.
    For example, if the VA was required to presume that veterans were 
exposed to acoustic trauma, only one element of the three required to 
establish service connection would be presumed. (See Caluza v. Brown, 7 
Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) (table). 
Obviously a presumption in favor of only one of the three elements does 
not guarantee the grant of service connection. Also, it does not mean 
that all veterans who have a current hearing loss will obtain service 
connection. This is true because these claimants will still have to 
establish that they suffer from hearing loss consistent with acoustic 
trauma and obtain a medical opinion that the current hearing loss is 
linked to the acoustic trauma in service.
    It should be noted that there are tests that can, in many 
instances, identify hearing loss that has been caused by acoustic 
trauma. According to the attached 2002 position paper issued by the 
American College of Occupational and Environmental Medicine, ``[i]n 
early noise-induced hearing loss, the average hearing thresholds at 
500, 1000, and 2000 Hz are better than the average at 3000, 4000, and 
6000, and the hearing level at 8000 Hz is usually better than the 
deepest part of the ``notch.'' This ``notching'' is in contrast to age-
related hearing loss, which also produces high frequency hearing loss, 
but in a down-sloping pattern without recovery at 8000 Hz.'' This means 
the VA, in many cases, should be able to differentiate old-age hearing 
loss from noise induced hearing loss.
PTSD:
    Please note that veterans seeking service connection for PTSD 
cannot be service connected unless they have been diagnosed with PTSD 
and the current PTSD is linked to a traumatic event in service by a 
medical expert. Therefore, while those who served in a combat zone may 
be presumed to have been exposed to a stressor, to win disability 
benefits, these veterans would still have to be diagnosed with PTSD and 
then have the PTSD linked to service.
    According to the VA Clinicians Guide ``[A]t times, the examiner may 
have questions about the degree of distortion or fabrication in the 
interview. The clinical picture of PTSD is relatively easy to fabricate 
on a superficial level but very difficult to fabricate in depth. Thus, 
the more detailed the history taking, the greater the validity'' 
(Clinicians Guide, Chapter 14, par. 14.10). Therefore, if the VA 
examination is properly conducted there should be little fraud, waste 
or abuse.
    Question 3: When you have participated in quality reviews with The 
American Legion, what do you do when you see that a folder has been 
mishandled.
    Response: When The American Legion quality review team identifies 
an error it is first brought to the attention of VA regional office 
(RO) officials, time permitting. The RO officials then have a 
opportunity to defend their decision or correct the error while the 
team is still at the RO. Then the Legion prepares a report that is sent 
to RO for additional review and comment. Again, the RO has a chance to 
correct any errors identified by the Legion. Also, while these reviews 
are ongoing Legion service officers may be obtaining new evidence or 
filing new claims which were generated by the quality review. 
Eventually, a final report is issued and a copy of the report is sent 
to both the VA and to Congress.
    Question 4: What other mishandling issues do you see at the 
regional offices on a regular basis? How are veterans claims impacted 
by improper handling.
    Response: NVLSP finds that, in general, the most serious problem at 
the regional offices is that VA adjudicators fail to take the time to 
assist the claimant by attempting to obtain the evidence necessary to 
substantiate the claim and therefore adjudicate the claim before the 
necessary evidentiary development has taken place. These inadequately 
developed and adjudicated claims clog the system because many of those 
unfairly denied file appeals which eventually force the VARO and the 
BVA to unnecessarily spend far too much time reviewing the case, 
sending the case back for proper development, and then adjudicating the 
claim once more. If the VA would take the time to adjudicate claims 
correctly in the first instance, in the long run VA workload would be 
substantially lessened and, more importantly, veterans would be better 
served.
    The frustration level of veterans confused by these premature 
adjudications cannot be underestimated. Some just drop out and others 
suffer emotional and financial stress. There are far too many veterans 
who have been unfairly denied. Also, there are too many veterans who 
have not been afforded fair process.
    Based on our participation in Legion quality reviews and based on 
our review of thousands of BVA denials, NVLSP has noticed the following 
major error patterns:
    1.  denials that are premature because the regional office (RO) 
inadequately developed the claim or because the RO relied on inadequate 
medical information;
    2.  improper denials of disability claims for Post Traumatic Stress 
Disorder;
    3.  assigning disability ratings for service-connected mental 
conditions, joint disabilities, and diabetes that are lower than the 
rating warranted by proper application of the VA rating schedule; and
    4.  failure to adjudicate claims for secondary service connection 
and for individual unemployability that are reasonably raised by the 
record.

                               __________

                               ATTACHMENT
      AMERICAN COLLEGE OF OCCUPATIONAL AND ENVIRONMENTAL MEDICINE

    ACOEM is the pre-eminent organization of physicians who champion 
the health and safety of workers, workplaces, and environments.
Noise-induced Hearing Loss

  Copyright  2002 American College of Occupational and Environmental 
                                Medicine
    Since the publication in 1989 of an earlier position statement by 
the American College of Occupational and Environmental Medicine 
(ACOEM), \1-\ noise-induced hearing loss remains one of the most 
prevalent occupational conditions, partly due to the fact that noise is 
one of the most pervasive occupational hazards found in a wide range of 
industries. ACOEM believes that occupational clinicians need to become 
increasingly proficient in the early detection and prevention of noise-
induced hearing loss. This requires clarification of current best 
practices, as well as additional research into certain aspects of 
noise-induced hearing loss that remain poorly understood.
---------------------------------------------------------------------------
    \1\ ACOM Noise and Hearing Conservation Committee. Occupational 
noise-induced hearing loss. JOM. 1989;31(12):996.
---------------------------------------------------------------------------
    Based on current knowledge, and to promote improved surveillance 
and research for this condition, ACOEM proposes the following update of 
previous position statements regarding the distinguishing features of 
occupational noise-induced hearing loss.
Definition
    Occupational noise-induced hearing loss, as opposed to occupational 
acoustic trauma, is hearing loss that develops slowly over a long 
period of time (several years) as the result of exposure to continuous 
or intermittent loud noise. Occupational acoustic trauma is a sudden 
change in hearing as a result of a single exposure to a sudden burst of 
sound, such as an explosive blast. The diagnosis of noise-induced 
hearing loss is made clinically by a medical professional and should 
include a study of the noise exposure history.
Characteristics
    The principal characteristics of occupational noise-induced hearing 
loss are as follows:
      It is always sensorineural, affecting hair cells in the 
inner ear.
      Since most noise exposures are symmetric, the hearing 
loss is typically bilateral.
      Typically, the first sign of hearing loss due to noise 
exposure is a ``notching'' of the audiogram at 3000, 4000, or 6000 Hz, 
with recovery at 8000 Hertz (Hz). \2\ The exact location of the notch 
depends on multiple factors including the frequency of the damaging 
noise and the length of the ear canal. Therefore, in early noise-
induced hearing loss, the average hearing thresholds at 500, 1000, and 
2000 Hz are better than the average at 3000, 4000, and 6000, and the 
hearing level at 8000 Hz is usually better than the deepest part of the 
``notch.'' This ``notching'' is in contrast to age-related hearing 
loss, which also produces high frequency hearing loss, but in a down-
sloping pattern without recovery at 8000 Hz. \3\
---------------------------------------------------------------------------
    \2\ McBride DI, Williams S. Audiometric notch as a sign of noise 
induced hearing loss. Occup Environ Med. 2001;58(1):46-51.
    \3\ Coles RR, Lutman ME, Buffin JT. Guidelines on the diagnosis of 
noise-induced hearing loss for medicolegal purposes. Clini 
Otolaryngology Allied Sci. 2000;25(4):264-73.
---------------------------------------------------------------------------
      Noise exposure alone usually does not produce a loss 
greater than 75 decibels (dB) in high frequencies, and 40 dB in lower 
frequencies. However, individuals with superimposed age-related losses 
may have hearing threshold levels in excess of these values.
      The rate of hearing loss due to chronic noise exposure is 
greatest during the first 10-15 years of exposure, and decreases as the 
hearing threshold increases. This is in contrast to age-related loss, 
which accelerates over time.
      Most scientific evidence indicates that previously noise-
exposed ears are not more sensitive to future noise exposure and that 
hearing loss due to noise does not progress (in excess of what would be 
expected from the addition of age-related threshold shifts) once the 
exposure to noise is discontinued. \4\
---------------------------------------------------------------------------
    \4\ Rosenhall U, Pedersen K, Svanborg A. Presbycusis and noise-
induced hearing loss. Ear & Hearing. 1990;11(4):257-63.
---------------------------------------------------------------------------
      In obtaining a history of noise exposure, the clinician 
should keep in mind that the risk of noise-induced hearing loss is 
considered to increase significantly with chronic exposures above 85 
dBA for an 8-hour time-weighted average (TWA). In general, continuous 
noise exposure over the years is more damaging than interrupted 
exposure to noise which permits the ear to have a rest period. However, 
short exposures to very high levels of noise in occupations such as 
construction or firefighting may produce significant 
loss,5, 6 and measures to estimate the health effects of 
such intermittent noise are lacking. When the noise exposure history 
indicates the use of hearing protective devices, the clinician should 
also keep in mind that the real world attenuation provided by hearing 
protectors may vary widely between individuals. \7\
---------------------------------------------------------------------------
    \5\ Lusk SL, Kerr MJ, Kauffman SA. Use of hearing protection and 
perceptions of noise exposure and hearing loss among construction 
workers. Amer Indust Hygiene Asso J. 1998;59(7):466-70.
    \6\ Tubbs RL. Noise and hearing loss in firefighting. Occup Med. 
1995;10(4):843-56.
    \7\ Berger EH, et al. Development of a new standard laboratory 
protocol for estimating the field attenuation of hearing protection 
devices. Part III. The validity of using subject-fit data. J Acoustical 
Soc Amer. 1998;103(2):665-72.
---------------------------------------------------------------------------
The Occupational Physician as Professonal Supervisor of a Hearing 
        Conservation Program
    ACOEM believes that occupational physicians can play a critical 
role in the prevention of noise-induced hearing loss by serving as 
professional supervisors of hearing conservation programs. The Council 
on Accreditation of Occupational Hearing Conservation (CAOHC) offers a 
course for professional supervisors.
    The responsibilities of such a supervisor include supervision of an 
audiometric technician, review of problem audiograms and determination 
of whether there is a need for additional evaluation, determining the 
work-relatedness of a threshold shift, revision of an audiometric 
baseline, and evaluation of the effectiveness of the hearing 
conservation program. \8\ The professional supervisor should be an 
advocate for the ``hearing health'' of noise-exposed persons, and work 
to ensure that noise exposures are minimized both at work and during 
recreational activities, through avoidance of excessive noise and 
proper use of hearing protection when necessary.
---------------------------------------------------------------------------
    \8\ OSHA. 1910.95 CFR Occupational Noise Exposure: Hearing 
Conservation Amendment (Final Rule). Fed Reg. 1983;48:9738-9785.
---------------------------------------------------------------------------
Additional Considerations in the Evaluation of the Worker with 
        Suspected Noise-induced Hearing Loss
    Clinicians evaluating cases of possible noise-induced hearing loss 
should keep in mind the following clinical concerns:

      While noise-induced hearing loss is typically bilateral, 
asymmetric sources of noise such as sirens or gunshots can produce 
asymmetric loss. When evaluating cases of asymmetric loss, referral to 
rule out a retro-cochlear lesion is first warranted before attributing 
the loss to noise.
      Co-exposure to ototoxic agents such as solvents, heavy 
metals, and tobacco smoke may act in synergy with noise to cause 
hearing loss. \9\ However, the role of such cofactors--as well as the 
role of cardiovascular disease, diabetes, and neurodegenerative 
diseases--remains poorly understood. Individual susceptibility to the 
auditory effects of noise varies widely, but the biological basis for 
this also remains unclear. \10\
---------------------------------------------------------------------------
    \9\ Morata TC. Assessing occupational hearing loss: beyond noise 
exposures. Scand Audiology. Supplementum. 1998;48:111-6.
    \10\ Ward WD. Endogenous factors related to susceptibility to 
damage from noise. Occup Med. 1995;10(3):561-75.
---------------------------------------------------------------------------
      Over a period of years of prolonged noise exposure, 
hearing loss due to noise expands to involve additional frequencies. 
This, together with the effects of aging, may reduce the prominence of 
the ``notch.'' Therefore, in older individuals, the effects of noise 
may be difficult to distinguish from presbycusis without access to 
previous audiograms. \11\
---------------------------------------------------------------------------
    \11\ Consensus conference. Noise and hearing loss. JAMA. 
1990;263(23):3185-90.
---------------------------------------------------------------------------
      Individuals with noise-induced hearing loss may 
experience significant morbidity due to hearing loss, concomitant 
tinnitus, and impaired speech discrimination. On the job, such hearing 
loss can impact worker communication and safety. Other conditions 
associated with hearing loss may be depression, social isolation, \12\ 
and increased risk of accidents. \13\ Workers with evidence of hearing 
loss require an individualized approach that takes into account the 
need to communicate safely and effectively, and the need for protection 
from additional damage due to noise.
---------------------------------------------------------------------------
    \12\ Hetu R, Getty L, Quoc HT. Impact of occupational hearing loss 
on the lives of workers. Occup Med. 1995;10(3):495-512.
    \13\ Zwerling C, et al., Occupational injuries among older workers 
with visual, auditory, and other impairments. A validation study. JOEM. 
1998;40(8):720-3.
---------------------------------------------------------------------------
      Since the loss of hearing due to noise is not reversible, 
early detection and intervention is critical to improving prevention of 
this condition. A 10 dB confirmed threshold shift from baseline in pure 
tone average at 2000, 3000, and 4000 Hz (OSHA standard threshold 
shift), while not necessarily resulting in significant impairment, is 
an important early indicator of permanent hearing loss. Therefore, 
individuals in hearing conservation programs who exhibit such 10 dB 
threshold shifts on serial audiometric testing should be carefully 
evaluated and counseled regarding avoidance of noise and correct use of 
personal hearing protection.
      Age correction of audiograms is a method of age 
standardization allowing comparisons of hearing loss rates between 
populations. Applying age correction to the surveillance audiograms of 
a noise-exposed population results in fewer confirmed 10 dB shifts 
being reported. Therefore, when applying age correction to the 
audiometric results of an individual who has experienced a threshold 
shift, the clinician should consider whether in that individual a 
preventable noise component of hearing loss is playing a role.
Research Priorities
    In an effort to shed light on some of the gaps in the current 
knowledge, ACOEM proposes the establishment of a research agenda for 
noise-induced hearing loss, and recommends research be conducted in the 
following areas:

      the relationship between specific noise exposures and 
risk of hearing loss, including impact noise, fluctuating noise, and 
noise at different frequencies, in order to improve protective exposure 
guidelines for noise exposure;
      early indicators of hearing loss, including the use of 
emerging audiologic technology such as otoacoustic emissions;
      the role of cofactors in hearing loss, including 
solvents, metals, vibration, heat, and carbon monoxide;
      the biology of noise-induced hearing loss, including the 
role of antioxidant compounds in prevention and recovery and whether 
noise damage continues to progress after noise exposure stops;
      individual susceptibility to noise-induced hearing loss, 
including the molecular basis for such susceptibility;
      the relationship of noise-induced hearing loss to other 
medical conditions, including cardiovascular disease, diabetes, and 
neurodegenerative diseases including age-related hearing loss;
      the impact of noise-induced hearing loss on individuals 
and their families and the development of rehabilitation strategies to 
maximize function and minimize disability;
      the behavioral aspects of noise avoidance and protection, 
including the effectiveness of training programs for hearing loss 
prevention.
Evaluation of the Effectiveness of a Hearing Conservation Program
    To date, there is no universally accepted method of evaluating the 
effectiveness of a hearing conservation program. Hearing conservation 
programs include aspects of administrative controls, engineering 
controls, audiometric surveillance, and training. Occupational 
physicians can actively participate with employers in improving all 
these aspects of hearing conservation programs through ongoing 
evaluation of program outcomes and processes.
Acknowledgements
    This ACOEM statement was developed by the ACOEM Noise and Hearing 
Conservation Committee under the auspices of the Council on Scientific 
Affairs. It was peer-reviewed by the Committee and Council and approved 
by the ACOEM Board of Directors on October 27, 2002.

                                 
                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                                    Washington, DC.
                                                     March 25, 2009

Kathryn Witt
Co-Chair, Government Relations Committee
Gold Star Wives of America, Inc.
200 N. Glebe Road, Suite 425
Arlington, VA 22203

Dear Ms. Witt:

    Thank you for testifying at the House Committee on Veterans' 
Affairs' Subcommittees on Disability Assistance and Memorial Affairs 
and Oversight and Investigations hearing on ``Document Tampering and 
Mishandling at the Veterans Benefits Administration'' held on March 3, 
2009. I would greatly appreciate if you would provide answers to the 
enclosed follow-up hearing questions by Friday, April 24, 2009.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all Full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your response to 
Ms. Megan Williams by fax at (202) 225-2034. If you have any questions, 
please call (202) 225-3608.

            Sincerely,

                                                       John J. Hall
                                                           Chairman

                               __________

         Questions for the House Committee on Veterans' Affairs
      Subcommittees on Disability Assistance and Memorial Affairs
                    and Oversight and Investigations
         Hearing on ``Document Tampering and Mishandling at the
                   Veterans Benefits Administration''
                             March 3, 2009

    Question 1: In your experiences with your membership, has VA been 
successful in contacting widows and families to reinstate the month of 
death payments?
    Response: When this issue was first made public, I sent messages 
out on the Gold Star Wives message boards informing those who receive 
information from the message boards of the circumstances. This message 
included the special phone number that the VA provided to answer 
questions from survivors.
    I recently posted an inquiry on our message boards asking our 
members to respond to this question. GSW has approximately 11,000 
members and approximately 1000 of them are sent messages through our 
message boards.
    I received 32 responses, but most of those who responded were 
widows of those who died on active duty or widows of those who died 
before January 1, 1997, when the law went into effect. One response was 
from a widow who had received the death payment, three of those 
responses were from widows who were probably eligible for the death 
payment but did not remember whether or not they had received it, one 
lady who had called the VA but never received a response and one 
response was from a lady who the VA says has received the death payment 
but she has no record of receiving it.
    I provided the VA contact information to those who might be 
eligible so they could check with the VA.
    Based on the responses I received and the lack of complaints, I 
believe that VA has done a good job of contacting survivors who are 
eligible for the Death Payment but have never received it.
    Question 2: In your testimony your recommend that the VA acquire a 
computer system to scan in claims and backup documents. As you know, an 
IT focused system would take time to set up. Even now, as the VA works 
toward a paperless system for claims, this is still a long way from 
being operational. In the meantime, do you have any suggestions for how 
VA should proceed to ensure that claims and documents are properly 
handled and processed?
    Response: My suggestion would be that a manual tracking system be 
created.
    All claims and supporting documentation should be date stamped as 
they are received, assigned a tracking number, logged into some sort of 
a database (list is technically a database), those who work on the 
files should sign for each and every claim they handle. When they are 
finished processing the claim, the claim should be returned to whoever 
is controlling the claims database and logged back into the database as 
completed. The claims could then be taken to the file room and signed 
for by file room personnel.
    If the claims processor needs to obtain further information on a 
particular claim, the claim file should be placed in a central suspense 
file according to the date that an answer is required. The suspended 
files should be checked daily by the supervisor to ensure that claims 
are processed properly and in a timely fashion.
    When the additional information is received, the supervisor should 
return the additional paperwork and the original claim to the person 
who initially worked on the claim.
    (Claims should never be put in an employee's desk drawer. There 
should be a secure central place to store claims that an employee is 
working on overnight or over a weekend.)
    Any documentation provided as a part of the claim should be 
maintained with the claim even if the documentation is redundant or not 
needed. Once the claim is processed a true copy of any original 
documents should be made and the originals returned to the person who 
initiated the claim.
    I would suggest that a PC database using Access or similar computer 
software be stabled to log in and track claims processing. A PC 
database and data entry system could be created by a programmer 
familiar with Access in a very short time.
    I think it would help to reduce the backlog if ``cut and dried'' 
claims were processed separately. For example, a claim for DIC with all 
the appropriate documentation could be assigned to a newer employee and 
the more complex claims assigned to a senior, experienced employee.
    Please understand that I have not seen how the VA claims processing 
system works at even one regional office. The suggested tracking and 
processing system is based on one used by the Army in the seventies and 
early 1980's before computers were common in the workplace. A computer 
system can be programmed to enforce these rules but a manual system 
depends on each employee's willingness to participate.
    Question 3: In your testimony you spoke about the new Office of 
Survivors Assistance and referred to several initiatives that have been 
instituted to assist survivors. In your opinion, should this be an 
office survivors can go to for help if they believe relevant documents 
have been lost or mishandled? If so how do you envision this office 
handling this responsibility? Also if so, do you think this office as 
currently planned by VA will be able to handle this function?
    Response: The VA Office of Survivors Assistance was not created to 
accommodate this function and is not staffed to accomplish this 
function. Complaints about document tampering and mishandling of 
documentation and claims should be first addressed to the VA Regional 
Office that processed the original claim and documentation. The 
Director of each Regional Office should have an employee who is 
responsible directly to the Director assigned to handle such problems 
and complaints. If this employee is not able to resolve the issue, then 
the survivor should be referred to the VA Inspector General's office.
    The Office of Survivors Assistance is located in Washington, DC. 
The person who initially pursues these issues would probably need to be 
co-located at the Regional Office which processed the claim or 
documentation.
                                                    Kathryn A. Witt
                                                           Co-Chair
                                     Government Relations Committee
                                         Gold Star Wives of America

                                 

                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                                    Washington, DC.
                                                     March 25, 2009

Marilyn Park
Legislative Representative
American Federation of Government Employees, AFL-CIO
80 F Street, NW
Washington DC 20001

Dear Ms. Park:

    Thank you for testifying at the House Committee on Veterans' 
Affairs' Subcommittees on Disability Assistance and Memorial Affairs 
Oversight and Investigations hearing on ``Document Tampering and 
Mishandling at the Veterans Benefits Administration'' held on March 3, 
2009. I would greatly appreciate if you would provide answers to the 
enclosed follow-up hearing questions by Friday, April 24, 2009.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all Full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your response to 
Ms. Megan Williams by fax at (202) 225-2034. If you have any questions, 
please call (202) 225-3608.

            Sincerely,

                                                       John J. Hall
                                                           Chairman

                               __________

        Questions from the House Committee on Veterans' Affairs
      Subcommittees on Disability Assistance and Memorial Affairs
                    and Oversight and Investigations
    Hearing on ``Document Tampering and Mishandling at the Veterans 
                       Benefits Administration''
                             March 3, 2009

    Question 1(a): What process is used to determine if an employee has 
intentionally engaged in improper shredding?
    Response: As best I can tell, it is made by interviewing the 
involved employee and the nature of the allegations, and to what level 
a document was improperly shredded.
    Question 1(b): Who makes the decision?
    Response: Decisions are made initially by local officials who, at 
some point, may defer to the jurisdiction of OIG if there is reason to 
believe that the improper activity has criminal implications.
    Question 1(c): When does central office get involved and what 
guidance do they provide?
    Response: As far as I know, the director is required to notify CO 
on all allegations in a report and CO may drive the boat on what to do, 
but the director could influence that decision. If there is a suspicion 
of impropriety at some point in time OIG may be called in to 
investigate any investigation resulting from improper document 
handling. But more generally, AFGE has no idea when CO becomes involved 
in this process or what guidance CO may relay to local managers either 
in a general sense or in any particular instance since such information 
is generally not shared with AFGE. However, when documents are found 
that have been misplaced there are some stringent reporting and 
tracking requirements concerning how those documents are ultimately 
routed to the proper location, and how any claim(s) attendant to those 
documents are ultimately resolved. VBA officials would be better suited 
to detail those requirements.
    Question 1(d): What is the evidentiary standard for employee 
misconduct?
    Response: It seems like very little evidence is required to allege 
employee misconduct, as we have seen in an internal case where a 
reprimand was issued and sustained with little direct evidence, only 
hearsay.
    More generally, the evidentiary standard for employee 
``misconduct'' depends on the nature of the alleged misconduct and the 
forum of any dispute concerning the alleged misconduct. Clearly, if 
there are criminal charges brought by OIG as a result of improper 
document handling, those allegations would be resolved in a court of 
competent jurisdiction and the standard of proof would be beyond a 
reasonable doubt.
    If the alleged misconduct is used as the basis for an adverse or 
disciplinary action having impact on employment, the standard of proof 
is, for the most part, whatever the Agency decisionmaker feels is 
appropriate. AFGE has little recourse in such matters at the Agency 
level, and ordinarily has to seek the intervention of an arbitrator or 
other appropriate labor relations dispute mechanism to ensure that 
Agency decisions concerning allegations of misconduct are not arbitrary 
and capricious.
    Question 2(a): Were employees properly trained or made aware of the 
VA's policy on shredding documents outlined in the M-21-1b previous 
before the news report?
    Response: No way, very little information was given at first and 
when information was given, it was confusing and hard to follow. 
Employees were most certainly not trained or specifically advised of 
any particular policy on the shredding or proper handling of documents 
prior to news reports of improper document handling
    Question 2(b): What does the AFGE think of the VA's new policy on 
shredding?
    Response: Unfortunately, it seems to be a waste of time and 
manpower. Nothing is really accomplished. It seems to be an 
overreaction, rather than a real solution, and fails to address the 
root of the problem. The VBA is overworked and the offices are 
understaffed. The shredding incidents were a direct result of VA's 
focus on production, not on quality or creating a fair workplace.
    More generally, AFGE's position is that all relevant documents 
pertaining to veterans' claims must be preserved and properly addressed 
in each and every instance. VA's new ``policy'' on shredding, however, 
does little to ensure such an outcome since it provides no real 
guidance concerning what documents have evidentiary value, and 
employees have not been adequately trained concerning why some 
documents have evidentiary value.
    Ultimately, the shredding ``crisis'' that recently came to light is 
the product of several misguided policies. First, VA's historical 
insistence of quantity over quality in the claims process and a refusal 
to sacrifice short-term productivity for the long-term gains in 
productivity and quality by properly and effectively training employees 
led to some ignorant, but not malicious, decisions concerning the 
handling of particular documents.
    Second, unrealistic, arbitrary and capricious production standards 
imposed upon employees actually provided them with incentives to take 
any shortcut available to meet their performance standards in order to 
keep their jobs.
    Third, VA created a culture of productivity over quality, and 
management turned a blind eye toward any deficiencies in the claims 
process (including improper handling of documents) so long as 
productivity goals were being met or exceeded.
    Finally, VA engineered a claims process (specifically, the ``CPI 
model'') that minimized accountability of individual employees and made 
them responsible only for minute and discrete actions in the claims 
process, thereby virtually ensuring that defects at any stage of the 
process could go unnoticed and unaddressed with no specific employee 
being held accountable for mistakes, and no employees being trained 
concerning how to correct recurrent mistakes.
    Question 3(a): In your testimony, you discussed further 
investigation into the efficacy of VBA's brokering policies and 
suggested soliciting input from frontline employees and their 
representatives. What advice would you give VBA in improving the claims 
processing system?
    Response: AFGE suggests that Congress mandate that an independent 
investigation be undertaken concerning the efficacy and cost-
effectiveness of VBA's brokering policies. Our members almost uniformly 
report the impression that brokering cases from one Regional Office to 
another decreases the quality of work product, results in needless 
duplication of effort, often delays proper adjudication of claims, and 
presents unnecessary opportunities for losing or misplacing important 
documents.
    AFGE has anecdotal evidence that most VBA managers, including 
Regional Office Directors, have serious reservations about the wisdom 
of brokering of cases. Moreover, VBA recently contracted with Booz 
Allen Hamilton to develop strategies to improve the claims process and 
their preliminary findings seem to indicate that the more a claims file 
is moved from one place or person to another within a Regional Office, 
the greater the likelihood of loss of documents, delay in proper 
development of evidence, and improper resolution of claims. Incredibly, 
when AFGE asked VBA management during a briefing on the Booz Allen 
Hamilton findings whether any consideration had been given to the 
implication of those findings vis-a-vis brokering of cases between 
Regional Offices, management was unwilling to consider that larger 
implication.
    Question 3(b): What advice would you give VBA in improving the 
claims processing system?
    Response: The VBA claims process can be improved by increasing 
accountability for claims processors and making them jointly 
responsible for the ultimate product of their joint efforts. VBA should 
either abandon or seriously modify the CPI (Claims Processing 
Initiative) that was initiated approximately 8 years ago and that is 
responsible, at least in part, for the diminished quality and 
increasing claims backlog that VBA faces today. AFGE notes that Booz 
Allen Hamilton seems to have reached a similar conclusion, and that VBA 
plans to pilot a test of an improved claims processing model at several 
locations in the near future. AFGE respectfully requests that Congress 
inquire directly of VBA concerning the import of this pilot project and 
the findings which drove it, since AFGE's requests to management for 
further information are too often met with inaction.
    Question 4: You refer to VBA's policy on brokering cases as an 
``assembly line'' approach to developing and adjudicating claims. 
Furthermore, in your testimony you are critical of a new brokering 
process using newly created Appeals Resource Centers. In your opinion, 
how could VBA implement a new system that would adequately address the 
concerns you have raised in your testimony?
    Response: First, AFGE believes that Appeals Resource Centers 
represent the highest evolution of the folly VBA's brokering policies. 
These Centers are designed to accept and process claims in various 
stages of the appeals process and return them to the Regional Offices 
with original jurisdiction over the claims upon completion by a Rating 
Specialist of a Rating Decision, Statement of the Case, or Supplemental 
Statement of the Case. In effect, Appeals Resource Centers have the 
perverse impact of utilizing VBA's most highly experienced, trained and 
skilled adjudicatory personnel--Decision Review Officers--to develop 
evidence so that less experienced Rating Specialist can render a 
decision based upon that evidence.
    Appeals Resource Center brokering guidelines are so stringent that 
they require Decision Review Officers or highly paid managers to waste 
an inordinate amount of time locating cases that can be brokered. If 
the Rating Specialist at an Appeals Resource Center determines that a 
favorable decision is not warranted, they prepare a Statement of the 
Case, or Supplemental Statement of the Case and the file is returned to 
the Regional Office of original jurisdiction over the claim for 
certification to the Board of Veterans' Appeals as necessary. 
Unfortunately, that certification must in most instances be done by a 
Decision Review Officer at the Regional Office of original jurisdiction 
who then has to review the entire claims file yet again, determine 
whether the action taken by the Appeals Resource Center Rating 
Specialist was correct and, if not, correct any and all underlying 
substantive errors prior to certifying that the case is ready for 
review by the Board of Veterans' Appeals.
    For example, our members report instances where a Decision Review 
Officer has conceded a veteran's combat stressor and ordered a 
posttraumatic stress disorder examination which confirms the veteran 
has posttraumatic stress disorder related to his verified military 
experiences, only to have that case returned from an Appeals Resource 
Center with a determination from a Rating Specialist that no in service 
stressor has been verified and a denial of service connection for 
posttraumatic stress disorder. Incredibly, Appeals Resource Centers are 
given credit for processing that claim, even though their actions have 
added nothing substantive to the process and done nothing to resolve 
the case.
    AFGE made numerous attempts to influence VBA's decisionmaking 
process concerning the creation of Appeals Resource Centers and was 
rebuffed in every instance. With no substantive input from AFGE or 
frontline employees, Appeals Resource Centers have been created and 
staffed in Waco, Texas, and Seattle, Washington with an enormous 
obligation of full time employees that could have been more effectively 
used at individual Regional Offices.
    VBA has a burgeoning appeals caseload in large part due to VBA 
management's insistence on utilizing fewer Rating Specialists to create 
more low quality decisions (i.e. emphasis on quantity over quality). 
Instead of attempting to address the burgeoning appeals caseload by 
consolidating the processing of appeals at Appeals Resource Centers, 
VBA should be required to devote more personnel at each Regional Office 
to resolving appeals, and provide Rating Specialists at Regional 
Offices with sufficient time, training, and incentive to properly 
develop and decide cases in the first instance, thereby avoiding 
unnecessary appeals from veterans.
    VBA management has a non-working model regarding the utility of 
centralizing processing of appeals in the form of the Appeal Management 
Center (AMC) in Washington, DC, which process appeals that have been 
remanded after review by the Board of Veterans' Appeals. Despite the 
fact that AMC actions are in large part directed by the Board of 
Veterans' Appeals, AMC has been historically ineffective in its charge. 
Incredibly, despite empirical evidence that appeals consolidation is 
not effective, anecdotal knowledge that brokering of cases in general 
is a bad policy, and growing independent evidence that the more a case 
changes hands the less efficient the claims process becomes, VBA 
management decided to further centralize appeals processing by creating 
Appeals Resource Centers.
    At best, Appeals Resource Centers will merely serve to shift the 
burden of appeals processing to the Board of Veterans' Appeals and 
ultimately back to the AMC. They are the latest product of a mistaken 
policy hastily brought into existence in the absence of any 
justification concerning its effectiveness. At the very least, Congress 
should require an independent study to determined how many man-hours 
are ultimately saved or wasted by brokering cases.

                                 

                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                                    Washington, DC.
                                                     March 25, 2009

Belinda Finn
Assistant Inspector General for Auditing
Office of Inspector General
U.S. Department of Veterans Affairs
801 I Street, NW, Room 1110
Washington, DC 20005

Dear Ms. Finn:

    Thank you for testifying at the House Committee on Veterans' 
Affairs' Subcommittee on Disability Assistance and Memorial Affairs and 
the Subcommittee on Oversight and Investigations hearing on ``Document 
Tampering and Mishandling at the Veterans Benefits Administration '' 
held on March 3, 2009. I would greatly appreciate if you would provide 
answers to the enclosed follow-up hearing questions by Friday, April 
24, 2009.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all Full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your response to 
Ms. Megan Williams by fax at (202) 225-2034. If you have any questions, 
please call (202) 225-3608.

            Sincerely,

                                                       John J. Hall
                                                           Chairman

                               __________


                                U.S. Department of Veterans Affairs
                                                  Inspector General
                                                    Washington, DC.
                                                     April 23, 2009

The Honorable John J. Hall
Chairman, Subcommittee on Disability
Assistance and Memorial Affairs
Committee on Veterans' Affairs
United States House of Representatives
Washington, DC 20515

Dear Mr. Chairman:

    This is in response to your March 25, 2009, letter to Ms. Belinda 
Finn, Assistant Inspector General for Auditing, following the March 3, 
2009, hearing on Document Tampering and Mishandling at the Veterans 
Benefits Administration. Enclosed are Ms. Finn's responses to the 
additional hearing questions.
    Thank you for your interest in the Department of Veterans Affairs.

            Sincerely,

                                                    GEORGE J. OPFER
Enclosure

        Questions from the House Committee on Veterans' Affairs
    Subcommittees on Disability Assistance and Memorial Affairs and
           Oversight and Investigations, Hearing on Document
   Tampering and Mishandling at the Veterans Benefits Administration
                             March 3, 2009

    Question 1: The Committee understands that the VA Office of 
Inspector General (OIG) is still in the process of creating a Benefits 
Inspection Division and will be developing a standardized protocol. Can 
this protocol be shared with House Committee on Veterans' Affairs staff 
before it is implemented? If not currently available, can it be?
    Answer: We have contacted Committee staff to arrange a briefing on 
the Benefits Inspection Program. We plan to focus on five areas during 
the initial reviews: claims processing, data integrity, management 
controls, information security, and public contact. We anticipate 
reevaluating the protocols after we have completed several reviews and 
refining the protocols as needed.
    Question 2: During the hearing we discussed the appropriateness and 
effectiveness of a 4-year cycle for inspections and the resources it 
would take to enhance that process. Can you provide a description of 
what would be a more ideal model and cycle time along with the 
resources it would require?
    Answer: Funding included in the OIG's fiscal year 2009 
appropriations to conduct VA Regional Offices (VARO) inspections 
supported the establishment of 10 full-time equivalents (FTE) 
positions. This allows for the completion of 12 inspections annually 
and all 57 VAROs within a 5-year period. To accelerate the schedule and 
complete all 57 VAROs within 3 years, we would need an additional 10 
professional FTEs at the cost of $2.25 million for salaries, expenses, 
and travel.
    Question 3: Will the VA OIG conduct an additional review to 
determine whether entries in Control of Veterans Records System 
(COVERS) and Veterans Appeals Control and Locator System (VACOLS) 
accurately reflect the dates that written responses and appeals are 
received from veterans?
    Answer: While both COVERS and VACOLS provide tracking capabilities 
for the Veterans Benefits Administration (VBA) neither system tracks 
specific veteran correspondence. COVERS is an application that tracks 
the location of folders within, and between, VBA field stations. VACOLS 
is the shared automated database created by the Board of Veterans' 
Appeals (BVA) for tracking and controlling veterans' appeals. VACOLS 
also tracks and monitors productivity, quality, and pending workloads.
    We do not have any immediate plans to review the accuracy of dates 
related to written responses and appeals from veterans as reflected in 
VBA's systems. However, an ongoing audit of COVERS will evaluate VBA 
procedures and controls to track and locate claims folders. We will 
provide the Committee with our findings and recommendations upon 
publication of our report, which is expected in September 2009. 
Further, the Benefits Inspection Division will review the integrity of 
data in VACOLS and other automated systems at individual VAROs.
    Question 4: Could the problems that we are discussing be addressed 
by information technology systems? We know that VA's claims processing 
system is paper-based. In your opinion, if VA created an electronic 
claims process, could these sorts of problem be prevented?
    Response: The incidents of inappropriate shredding of certain 
claim-related documents by VAROs nationwide, as uncovered both by the 
OIG and by VBA itself, highlight a critical weakness to the paper 
claims process, which a paperless environment would largely address. 
However, VBA moving to a paperless system would not in and of itself 
fully address incidents of the purposeful mishandling of claim-related 
documents by VBA employees. Moreover, as long as many documents are 
received in hard copy form by VBA before being entered into an 
electronic system, the risk of mishandling or losing documents will 
still exist.
    Question 5: Will the VA OIG investigate further the mail amnesty 
issue it identified in Detroit and assess the utility of this practice 
and why it occurs? What did the OIG find out about the significance of 
the records found and why they were unprocessed?
    Answer: We do not plan to review the Detroit amnesty further 
although we will be alert to mail-handling procedures in future reviews 
and the Benefits Inspection Division will review VARO mail-handling 
procedures and destruction of documents procedures during VARO 
inspections. VBA senior managers have advised that there will be no 
future mail amnesty periods due to the strengthening of new records 
management procedures.
    We conducted limited follow-up on the amnesty issue at the Detroit 
VARO. We reviewed VBA reports on the results of the Detroit amnesty in 
July 2007 which indicated that records found were significant, 
including 700 claims that had not been established and 2,700 pieces of 
medical evidence or medical records. During interviews with the OIG, 
Detroit VARO staff indicated that productivity goals may encourage 
employees to process certain types of documents at the expense of 
others, which could provide the motivation to hide and/or destroy some 
documents.
    Question 6: With regard to date changing, did the OIG attempt to 
find out whether other RO employees in addition to the Senior Veterans 
Service Representative (SVSR) in Boston understood their directive from 
management was to make the VA look on time? Does the OIG know how this 
came to be the impression of the employee?
    Answer: Yes, we did attempt to find out if other VARO employees 
believed that they had to make VA look good. We interviewed 13 other 
VARO Boston employees and none of them reported the impression that 
they were supposed to change claim dates to make the VA look on time. 
In addition, our review of documentation in 355 claims folders found no 
indications that any other employees had the same understanding as the 
SVSR. The SVSR did not tell us why he felt he had to help the Veterans' 
Service Center (VSC) achieve the ``goal to make numbers meet.''
    Question 6(a): Did OIG confine its investigation of date changes to 
initial claim applications? Does it plan to check notice of 
disagreements (NODS), Statements In Support of Claims, Evidence 
Submissions, and VA9 filing?
    Answer: During our Review of VA Regional Office Compensation and 
Pension Claim Receipt Dates (Report No. 09-00189-81, February 27, 
2009), we reviewed both rating and non-rating claims. Rating claims 
include initial and reopened compensation and pension claims. Non-
rating claims include administrative types of claims such as dependency 
change, notice of death, claims for veteran burial benefits, and 
initial death pension claims.
    The Benefits Inspection Division will be using a protocol to review 
the integrity of VACOLS. This includes steps to review the processing 
of NODS and VA Form 9 (used to initiate an appeal to BVA).
    Question 6(b): Besides the four Regional Offices cited in your 
report, does the OIG intend to investigate and provide reports on other 
VAROs regarding date changing?
    Answer: Yes. Given the challenges VBA has faced with data 
integrity, we will continue to include review claim date accuracy 
during ongoing and future audits. In addition, the Benefits Inspection 
Division will review claim date accuracy during VARO inspections.
    Question 7: Does the OIG intend to conduct further investigation 
and/or produce additional reports on shredding of documents, misdating 
of claims and other document mishandling? What does the OIG intend to 
do to further investigate whether these problems are systemic?
    Answer: While we do not plan any reviews focused solely on 
shredding of documents, misdating of claims, and other document 
mishandling, we will continue to monitor corrective actions at the 
VAROs during our VARO inspections and other VBA audit work. We will 
also continue to evaluate controls that could be potentially 
circumvented by VARO staff to ensure that veterans' claims and records 
are promptly processed and appropriately protected.
    Question 8: In your testimony, you inform that the Detroit VA 
Regional Office instituted a records amnesty and discovered 16,000 
records. Are you aware of how many other amnesties were instituted in 
VA Regional Offices in 2007 and 2008?
    Answer: We interviewed representatives from all four VBA Area 
Offices. The Eastern and Southern Area Offices confirmed that they were 
aware of amnesties that occurred within their areas in the past. We 
also learned of the amnesty that occurred at the New York City VARO in 
December 2008 that recovered 717 documents from VARO employees. VBA 
senior managers have advised that there will be no future mail amnesty 
periods due to the strengthening of new records management procedures.
    Question 9: Did the OIG attempt to find out why employees from the 
Boston VARO, also believed that that they understood that their 
obligation was to make VA appear as if it was timely processing claims 
when in fact it was not?
    Answer: Only one Boston VARO employee stated he entered inaccurate 
claim receipt dates in VBA's automated computer system because he had a 
``general impression'' of responsibility to help the VSC achieve the 
``goal to make numbers meet.'' That employee did not say why he felt 
that way. The employee's supervisor told us that he had never 
instructed staff to use inaccurate claim receipt dates in VBA's 
automated computer system. In addition, no other employees interviewed 
stated that they used inaccurate claim receipt dates.

                                 

                                     Committee on Veterans' Affairs
         Subcommittee on Disability Assistance and Memorial Affairs
                                                    Washington, DC.
                                                     March 25, 2009

Michael Walcoff
Deputy Under Secretary for Benefits
Veterans Benefits Administration
U.S. Department of Veterans Affairs
Washington, DC 20420

Dear Mr. Walcoff:

    Thank you for testifying at the House Committee on Veterans' 
Affairs' Subcommittees on Disability Assistance and Memorial Affairs 
Oversight and Investigations hearing on ``Document Tampering and 
Mishandling at the Veterans Benefits Administration'' held on March 3, 
2009. I would greatly appreciate if you would provide answers to the 
enclosed follow-up hearing questions by Friday, April 24, 2009.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for material for all Full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively on letter size paper, 
single-spaced. In addition, please restate the question in its entirety 
before the answer.
    Due to the delay in receiving mail, please provide your response to 
Ms. Megan Williams by fax at (202) 225-2034. If you have any questions, 
please call (202) 225-3608.

            Sincerely,

                                                       John J. Hall
                                                           Chairman

                               __________

                        Questions for the Record
                      Hon. John J. Hall, Chairman
        Disability Assistance and Memorial Affairs Subcommittee
                  House Committee on Veterans' Affairs
                             March 3, 2009
      Document Tampering and Mishandling at the Veterans Benefits 
                             Administration

    Question 1: Please provide the VBA 90-day review findings/report on 
its new shredding policy to the House Committee on Veterans' Affairs 
when it is completed.
    Response: On March 8, 2009, the Office of Field Operations 
requested feedback from each regional office (RO) on the effectiveness 
of the new shredding procedures. The ROs identified a few issues and 
recommended additional training be provided to RO employees on those 
issues. They also indicated that the new procedures were working, but 
were labor intensive. We will conduct another review after 180 days.
    Question 2: How many employees in each RO who had been processing 
claims are now assigned instead to monitoring shredding? Is the VBA 
using new hires for this activity or are you drawing from the existing 
workforce?
    Response: To ensure adherence to the established policies and 
guidelines, the Veterans Benefit Administration (VBA) created two 
positions to oversee the management of Veterans' records, the records 
management officer (RMO) and the division records management officer 
(DRMO). Each RO is required to have one full-time RMO; larger regional 
offices may have more than one. The DRMO is a collateral-duty 
assignment with one DRMO assigned to approximately 15-20 employees. The 
DMRO reviews all paper identified by the employees for shredding. On 
December 31, 2008, all ROs certified that all RMOs and DRMOs were in 
place.
    Most of the RMO positions were filled with existing VBA employees. 
The majority of those selected for the RMO positions were not claims 
processors. ROs were authorized new full time employees to replace 
losses created by filling the RMO position.
    Question 3: During the Hearing Mr. Walcoff indicated that sending 
files through the mail is not the primary way that files are lost. 
Please identify the primary way that files are lost?
    Response: The Department of Veterans Affairs (VA) does not track 
the reasons that caused a folder to be missing, nor does VA know in all 
cases what exactly happened to a folder unless it is subsequently 
located. We do know that claims folders are misplaced due to a number 
of reasons, including:

      Folder lost when transferred between locations, including 
VA medical centers, the Board of Veterans' Appeals, etc.
      Folder status not updated in the VBA folder tracking 
system, control of Veterans records system (COVERS).
      Folder misfiled and not in numerical order in file bank.
      Folder sent back to wrong RO by outside facility.

    Question 3(a): Please inform the Committee on how many files are 
lost annually between different VBA offices and/or medical centers?
    Response: VA does not have information in our data systems on the 
dates misplaced folders are rebuilt so we are unable to provide the 
number of files lost annually. Many folders that are identified as 
missing or rebuilt are subsequently located.
    Question 3(b): What is done to rebuild and reconstruct files? Whose 
duty is it to rebuild and reconstruct files lost by VA?
    Response: VBA is responsible for rebuilding the claims folder and 
makes exhaustive attempts to locate missing claims folders. If all 
attempts fail, VBA creates a rebuilt folder and attempts to obtain 
pertinent information to support the claim from the Veteran, Records 
Management Center, and/or Veterans Service Organization (VSO) that 
assisted with the original claim. The first step in rebuilding a claims 
folder is gathering all available electronic records, including claim 
documents and Veteran information stored in VBA applications and 
electronic medical records from the Veterans Health Administration. If 
critical evidence such as a Veteran's service or medical records is 
lost, VA requests alternative documents to support the claim for 
benefits. For example, VA can request a search of military unit sick 
logs, morning reports, or Surgeon General Office reports for records of 
military hospitalization. Additionally, VA will ask the Veteran for any 
alternative records that may contain some evidence to support the claim 
for benefits. Such evidence may include statements from other 
servicemembers, letters written during service, photographs taken 
during service, State or local accident reports, private medical 
reports, prescription records, or insurance examination records.
    Question 3(c): How do lost files and documents impact claims 
adjudication?
    Response: VA tries to minimize the impact on claims adjudication as 
much as possible. If all attempts to obtain pertinent evidence fail, as 
mentioned in 3 (b), service connection can often be established without 
complete service or medical records. Pursuant to 38 C.F.R. Sec. 3.102, 
a broad interpretation of the law is applied, and any reasonable doubt 
is resolved in favor of the Veteran. There are also several 
disabilities for which a statutory or regulatory presumption of service 
connection is available for certain Veterans (e.g., in-country Vietnam 
service, former prisoner of war status). Even in the absence of any 
medical evidence establishing a connection between the disabilities and 
military service, the disabilities can be service connected if the 
criteria for invoking the presumption are satisfied. The goal of VA 
remains to ensure that Veterans receive the benefits to which they are 
entitled as soon as possible.
    Question 4: How are files tracked and a document chain of custody 
or responsibility established?
    Response: VA uses COVERS to track the location of claims folders 
within and between offices. VA uses the VETSNET corporate applications, 
share, and modern award processing-development (MAP-D) to track 
individual documents requested, received and associated with a claims 
folder. All three systems create an audit trail by maintaining a record 
of the individuals who took actions on each case. Guidelines on 
maintaining audit trails on documents and tracking claims folders are 
included in our administrative procedures and claims adjudication 
manuals, as well as user's guides for the specific applications.
    Question 5: As a result of this experience with shredding and the 
difficulty the VAOIG had in tracking claims, will VBA institute a 
consistent policy of tracking a claim to an individual employee?
    Response: VA uses several computer applications to record the 
location of a claims folder, the status of a claim, and the documents 
received regarding the claim. Each of these applications records the 
individual who received a claim folder, established a claim, updated 
the status of a claim, and developed or took adjudicative action on a 
claim.
    Question 6: What are the consequences to employees when a file is 
lost under their control? What about the managers? How is their 
performance measured when folders or documents go missing from their 
control? Do they still receive bonuses?
    Response: If a claims folder or document is intentionally destroyed 
by an employee, punishment up to removal from their position is 
authorized. This applies to both employees as well as managers in VBA. 
An employee or manager may also be subject to criminal sanctions, 
including imprisonment and fines, under title 18, United States Code, 
if he or she willfully and unlawfully destroys such files.
    Veteran service representative (VSR)/rating Veterans service 
representative (RVSR) performance standards include an element on 
workload management. Failure to properly follow COVERS procedures, as 
well as misplacing or losing documents, can affect the employee's 
performance evaluation under this element. A less than satisfactory 
rating in the workload management element results in a lower overall 
performance evaluation. Since bonuses are based on performance, a less 
than fully satisfactory evaluation will not result in a performance 
bonus.
    Question 7: It sounds like your new policy has VA waiting for 
veterans to self-identify if they think their documents were lost or 
destroyed. How will veterans know that they were affected by these 
errors? Have you contacted the veterans or other claimants whose 
documents were found in the shredder bins and informed them of what has 
happened?
    Response: VA notified Veterans and other claimants or beneficiaries 
of the policy by issuing news releases, meeting with VSOs, and posting 
a special questions and answers page on the VBA Web site. VA analyzed 
all of the documents found in shredder bins to determine appropriate 
action, but did not contact claimants whose documents were found 
because all documents requiring action were placed under control and 
processed with top priority.
    Question 8: What criteria did VA use in selecting the members of 
the Records Control Team (RCT), and what are their responsibilities?
    Response: Members of the records control team (RCT) were employees 
with extensive experience in the handling of Veterans' records and 
government forms. All employees were knowledgeable of Records Control 
Schedule Veterans Benefits-1, Parts 1 and 2, MP-4 Part X, Records 
Control Schedule--Budget and Finance, VA Directive 6371, Destruction of 
Temporary Paper Records, VBA's existing directives and guidance in 
managing records and forms. The RCT members were instructed to review 
existing materials, provide revisions to the existing directives and 
policies, and strengthen procedures for the proper handling and 
shredding of documents determined to be appropriate for disposal.
    Question 9: How did VA notify veterans about the 18 month amnesty 
for possible shredded documents? Do you believe this was sufficient? 
What other outreach actions are being planned by the department?
    Response: On October 16, 2008, VA issued a news release to 
initially notify the public of the document-shredding incident. On 
November 17, 2008, VA issued a second news release, which provided more 
information about the incident and directed inquiries to VA's toll-free 
number and Web site. Reuters (PRNewswire-USNewswire) and a number of 
military and Veteran organizations also covered this information. 
Additionally, VA worked with the six largest VSOs in developing special 
temporary procedures for processing claims from Veterans, family 
members, and survivors whose applications for financial benefits from 
VA may have been mishandled by VA personnel. In turn, these VSOs 
conveyed the information to Veterans. At this time, VA does not plan 
any additional outreach actions.
    Question 10: Please further elaborate on VA's response to the 
claims made by the AFGE during the hearing that the current policy for 
shredding documents only provides incentives for employees to keep 
extraneous material in the claim file?
    Response: The recently established policies and procedures do not, 
in any way, encourage employees to maintain extraneous paper documents 
in claims records. Past policy on folder maintenance, in which 
employees are responsible for removing duplicate copies of documents 
unless they contain notations of record value and removing documents if 
they have served their purpose and have no record value (i.e., routing 
slips, diary slips, etc.), remains in effect.
    Question 11: How does the new document handling procedure as 
identified by VA in October 2008 to the Committee, impact claims 
processing--i.e., is it making it more efficient? Has the VA assessed 
the adequacy of the VBA's document handling and chain of custody 
procedures to prevent document tampering and destruction as outlined 
under the M-21-1s. Please describe this process for the Committee. Does 
it intend to maintain these procedures (as identified under the M-21-
1s) and how do these correlate to the newly implemented procedures?
    Response: The new document handling procedures require additional 
steps for VBA employees to properly dispose of documents. The 
additional administrative time has a slight impact on claims 
processing, but is necessary to regain the public's trust and ensure 
accountability of our staff. Access to shredders, shredder bins, or 
other methods of document destruction is strictly controlled and 
limited to authorized individuals. VBA also added two positions, the 
RMO and DRMO, to ensure the management and safeguarding of veterans' 
records.
    The new procedures build on the standards currently established in 
the manuals and the records control schedule (RCS) and add an 
additional layer of document review to ensure proper policy 
enforcement. The policy changes include the plan of action discussed 
with the Committee on March 3, 2009, and the release of VBA Letter 20-
0863, VBA Policy on Management of Veterans' and other Governmental 
Paper Records. Special training covering the proper handling and 
disposal of documents was provided to all VBA employees in November 
2008. This training provides additional clarification of what documents 
employees can remove from a claims folder and properly eliminate. VBA 
Letter 20-08-63 was revised on March 13, 2009, to provide additional 
guidance for the maintenance, review, and appropriate destruction of 
paper records.
    To ensure these procedures are adhered to in all offices, regional 
office directors must conduct an annual review of their stations' 
control procedures to access compliance with VA new document handling 
procedures.
    Question 12: Does VA intend to examine whether its current system 
for processing claims emphasizes quantity at the expense of quality--
despite VA's contention that its current employee evaluation system 
ostensibly measures quality?
    Response: Current individual performance standards for claims 
processing employees equally weigh production and quality. VBA has 
recently established a workgroup to review the VSR performance 
standards. The workgroup is developing a new standard to align 
individual performance with organizational goals. The instructions to 
the workgroup directed them to ensure that quality be weighed equally 
to production.
    Question 13: Please inform the Committee of any recent pilot(s) 
that VA intends to conduct that deviates from the CPI Model of claims 
processing, particularly at the Little Rock, Arkansas RO?
    Response: VBA recently partnered with the Booz Allen Hamilton 
consulting group in a study aimed at assessing the claims development 
process. Booz Allen Hamilton developed process and organization 
recommendations to streamline the claims flow, reduce cycle time, and 
improve quality. The group submitted a model which represented a 
holistic approach to claims processing, incorporating fundamental 
process and organizational improvements. This model, by focusing on 
claim flow and eliminating or reducing non-value-added activity, 
predicts a reduced claim processing cycle time. In addition, it is 
anticipated that this model will reduce claims folder moves, which will 
also improve quality by eliminating opportunities for errors.
    VBA plans to pilot this concept at the Little Rock RO in the third 
quarter of fiscal year (FY) 2009. Booz Allen Hamilton is currently 
working with VBA to develop a pilot plan that outlines the purpose, 
scope, level of effort, timing, schedule, milestones, and deliverables 
associated with implementing this pilot to support a team-based claims 
processing concept. In addition, this pilot will also capture claims 
processing requirements relevant to the paperless initiative 
(documenting lessons learned and best practices to support additional 
pilot activities and/or future implementation activities).
    Question 14: What do you do when the claimant has a return-receipt-
requested slip, but the RO cannot find the information? How do veterans 
know that all of the records that they submitted were actually 
reviewed? What is VA doing to ensure that our Nation's veterans can 
have some confidence that claims that have been denied were at least 
denied on the basis of a complete record?
    Response: Upon accepting evidence or applications in person from 
claimants, VA employees will prepare a document receipt register on 
which the name and claim number of the individual(s) from whom 
documents were received, the date, the general type of evidence 
received, such as applications, medical evidence, financial evidence, 
dependency documents, or other, and the name of the employee who 
received the documents are recorded. These registers may be paper or 
electronic. When possible, VA employees provide a photocopy of the 
evidence or claim to the individual from whom it is received. If a 
claimant presents VA with the document receipt slip and the evidence or 
application cannot be found, we will accept the receipt as submission 
of the claim/evidence.
    VA is committed to the preservation and appropriate handling of all 
documents submitted by claimants and their representatives. VA 
developed special procedures to assist Veterans and their families to 
determine if evidence was previously submitted, but was not properly 
acted upon and retained in the Veteran's records. Veterans and others 
who are concerned about missing documents may contact VA on our toll-
free number, 1-800-827-1000, or send an e-mail inquiry through 
[email protected]. Claimants may also review their claims folder at the local 
VA regional office. VA electronically tracks documents for currently 
pending claims and can verify receipt of any document through our 
tracking system. VA also retains all claims applications and supporting 
documents in the veteran's claims file. Public contact representatives 
will review all VA's record systems to verify receipt of applications 
and supporting evidence.
    VBA rating decisions include a listing of all evidence considered 
in conjunction with the decision. VA is required by law to include a 
summary of the evidence considered in any decision denying a benefit. 
In addition, as required by section 221(b) of Public Law 110-389, VA 
established a pilot program at 10 ROs in December 2008 that provides 
Veterans with an easy-to-read checklist that lists the information or 
evidence that claimants must submit to support their claims.
    Question 15: During the hearing of March 3, 2009, the AFGE 
testified that many new hires are being fired during their probationary 
period. Please provide the total number of new hires brought on for 
production purposes and the number of new hires who are fired during 
their probationary period. Please explain how this impacts the 
processing of disability claims.
    Response: VBA recently conducted a review of the attrition rates of 
probationary employees in the VSR and RVSR job categories. Our analysis 
shows that VBA does not terminate a high number of employees during 
their probationary period.
      FY 2007
        1,367 claims processors hired
        12 (1 percent) terminated
        49 (3.6 percent) resigned
      FY 2008
        1,785 claims processors hired
        37 (2 percent) terminated
        110 (6 percent) resigned
      FY 2009 (through February)
        327 claims processors hired
        5 (1.5 percent) terminated
        6 (1.8 percent) resigned
    VBA strives to recruit and select candidates for claims processing 
positions who meet the experience, knowledge, skill, and ability 
requirements necessary to successfully perform in these positions. 
Claims processing is complex, and the type of work involved is not a 
good fit for every candidate selected. VA makes every effort to provide 
probationary employees with the opportunity to develop and demonstrate 
their proficiency. However, if after full and fair consideration, it 
becomes apparent an employee's performance and/or conduct is not 
suitable for satisfactory work, VBA will exercise its right to 
terminate employment during the probationary period in compliance with 
all rules and guidelines set by the Office of Personnel Management and 
in adherence with all negotiated labor agreements.
    Question 16: The VAOIG recently issued a report that indicated that 
the VBA does not conduct quality assurance reviews on brokered claims. 
How does VBA track the custody of brokered claims internally? How does 
the VBA intend to track the quality of brokered claims?
    Response: VBA tracks custody of brokered claims through the use of 
COVERS and spreadsheets. To separately sample brokered work apart from 
work sampled for national quality review from the regional offices, 
systems and procedural enhancements were necessary. Additional 
resources were also needed to support the expansion. VBA will begin 
sampling the work completed from 10 designated brokered sites during 
the third quarter of FY 2009. Current systematic technical accuracy 
review (STAR), rating-related sampling and review procedures will be 
employed with the brokered work. Brokered work accuracy reports will be 
generated in addition to the existing STAR accuracy reports.
    Question 17: In VA's oral testimony, it mentioned a lead systems 
integrator (contractor) as well as a contractor with which VA is 
working with on business transformation.
    Please identify the lead systems integrator and the business 
transformation contractors respectively. Please describe the role of 
each of these entities in helping VA reach its key performance measures 
and strategic goals as outlined in the latest Performance and 
Accountability Report.
    Response: Lead system integrator contractor (LSIC) awarded 
September 30, 2008, to Electronic Data Systems (EDS). The LSIC is 
responsible for the overarching technology design for VA's paperless 
delivery of Veterans benefits Initiative (paperless initiative). The 
LSIC is responsible for assisting VA with defining the system that will 
support paperless claims processing and benefits delivery. This 
includes eliciting and documenting business requirements and producing 
specifications for the technical architecture to serve as the 
engineering blueprint for the envisioned system. The LSIC is also 
responsible for communicating the vision for the technical system and 
assisting VA in procurement of application developer contractors to 
build the system components, install and integrate components into the 
overall system, as well as test, operate, maintain, and transition the 
system solution to VA. In developing the overall program, the LSIC will 
segment the activities into separate releases, which will be 
competitively contracted by VA. The LSIC will assist VA and manage the 
execution of these application development contracts to meet overall 
program objectives.
    Business transformation contractor (BTC) awarded February 12, 2009, 
to Booz Allen Hamilton. The BTC contractor will assist VBA in business 
process re-engineering, organizational change management, workforce 
planning and organizational learning strategies to ensure VBA is well-
positioned to take best advantage of the technology solutions being 
developed by the LSIC. In addition, the BTC will assist VBA in 
determining and documenting appropriate and measurable performance 
metrics to be achieved by the overall technology and business process 
transformation envisioned as part of the initiative. These metrics will 
be aligned with, and supportive of, those measures outlined in the 
annual Performance and Accountability Report. The BTC and LSIC, as well 
as VBA's strategic program management partner, MITRE Corp., are 
integral members of the cross-functional implementation team. These 
industry leaders provide the requisite expertise to support VA in 
achieving its vision of a world-class benefits delivery system for our 
Nation's Veterans and their families.
    Question 18(a): In December, you gave us a month-of-death action 
plan that showed by February 2009, VA would have identified retroactive 
beneficiaries and determined payment procedures. Where are you in that 
process? Has VETSNET been updated?
    Response: VA has identified over 260,000 surviving spouses who 
received the month-of-death benefit. On December 29, 2008, VA 
identified and made payments to 10,856 surviving spouses. On March 2, 
2009, VA made additional payments to 35,669 surviving spouses. VA 
continues to mine data to identify any surviving spouses who did not 
receive the month-of-death payment. An interim process for automating 
these payments will be deployed within the next 60 days, with a 
permanent solution to follow in 2010.
    Question 18(b): What has been done to determine how VA will handle 
the disbursement of the benefit if the surviving spouse has 
subsequently died as well?
    Will the benefit go to the estate?
    Response: A January 2009 VA General Counsel precedent opinion 1-
2009 held that the month-of-death payments are not payable to the 
estates of deceased spouses who would have been entitled to retroactive 
month-of-death payments but for their death prior to receipt.
    Question 19: In their testimony, the Disabled American Veterans 
suggested that Imaging Centers be established. Has the VA explored this 
option further or developed budget projections?
    Response: VBA currently conducts scanning and indexing activities 
at each of the three pension management centers to support pension 
claims processing. In addition to pension work, the St. Paul Pension 
Management Center is also performing limited scanning services for the 
paperless disability evaluation system pilot for claims originating 
from the National Capital Region. Additionally, VBA uses contract 
services to perform scanning activities in support of paperless 
benefits delivery at discharge claims processing.
    As part of the development of the paperless initiative, several 
options for document scanning are being evaluated. Among the options to 
be evaluated are mail processing centers, including scanning and 
indexing operations. VBA continues to develop a strategy that 
incorporates industry best practices for the receipt and imaging of 
incoming mail. VBA is in the process of establishing a business 
transformation lab (BTL) at the Providence RO to allow the organization 
to leverage lessons learned in our current scanning operations as well 
as to test new concepts and processes that will be enabled by the 
implementation of the new technology platform being developed by the 
LSIC. The BTL will enable the organization to continue to define how 
scanning and indexing, as well as other business process improvements, 
should be conducted as we move forward with the implementation of the 
paperless initiative.
    Question 20: At the hearing we discussed mail amnesty periods. Can 
you provide more details and background on this practice and the scope 
of its use in processing claims? Do you feel that mail amnesty is 
crucial to the process of getting the correct paperwork back in the 
system? What kind of controls are going to be put in place to ensure 
that documents/paperwork is being processed and not shredded, destroyed 
or otherwise mishandled--that they will be used to properly and fairly 
adjudicate claims?
    Response: ``Mail amnesty'' was used in rare instances to ensure all 
mail was properly associated with Veterans' claims for benefits no 
matter how long they were pending. Employees were granted ``amnesty'' 
to bring mail located at their desks to a centralized location. The new 
procedures implemented require employees to keep all mail out in the 
open. Periodic checks of an employee's work area are conducted to 
ensure there is no mail in cabinets or desk drawers. With the new 
procedures in place, there is no need for future mail amnesty.
    Question 21: During the hearing, Gold Star Wives suggested that VA 
actually call survivors when needing to retrieve funds. Has VA explored 
this possibility and what was the conclusion?
    Response: VA's electronic records include the name of the surviving 
spouse only if the Veteran received additional benefits for them. Also, 
VA's electronic records do not always contain the Veteran's telephone 
number.
    Currently, after VA receives information about the death of a 
Veteran beneficiary, VA's Debt Management Center promptly sends notice 
to the Veteran's estate about the need to return funds sent or 
deposited in the Veteran's name. In keeping with Department of Treasury 
procedures, some banks also automatically return payments issued to a 
deceased beneficiary.
    In order to conform to 38 U.S.C. Sec. 5310 and Treasury procedures, 
VBA plans to pay the full month-of-death benefit in the name of the 
surviving spouse for the month in which the Veteran died. VBA is 
developing system changes to ensure all next of kin, regardless of debt 
status, automatically receive notification providing information on 
entitlement to month-of-death benefits for surviving spouses as well as 
emphasizing the need to return funds issued in the Veteran's name.
    Question 22: What have you done to ensure that STAR takes into 
account the types of document handling errors? Will STAR evaluate each 
RO for how long it takes to get mail under control?
    Response: STAR's primary focus is to evaluate the accuracy of the 
decision made on a Veteran's claim, and as such, is outcome-oriented. 
STAR has not traditionally focused on internal VBA work management 
processes or timeliness, but in October 2008, the STAR process was 
expanded to include a review of accuracy of the date of claim 
established for work control purposes. This review is accomplished for 
every case sampled for national quality review.
    As part of VBA's quality assurance oversight program, VBA conducts 
site visits of ROs to ensure compliance and consistency. As a part of 
these site visits, the team conducts audits of employees' desks to 
ensure compliance with the safeguarding of Veterans' records. They also 
conduct random reviews of mail processing to ensure appropriate 
handling. Another integral part of the site visit is extensive analysis 
and assessment of the average time it takes the RO to place mail under 
control. For any problems identified, the team makes recommendations 
for correction and improvement.
    Question 23: VA has noted that STAR is not necessarily reviewing a 
valid sample of cases. What is being done to improve your quality 
oversight program particularly as outlined in P.L. 110-389?
    Response: STAR sampling for rating-related work from all ROs and 
work performed at the three pension management centers was increased 
during FY 2008 to achieve a statistically valid sample at a 95 percent 
confidence level with a 5 percent margin of error. Prior to that, STAR 
sampling was at a 90 percent confidence level with a slightly higher 
margin of error. As mentioned previously, STAR sampling will be further 
expanded in FY 2009 to include work completed at 10 brokered sites.
    As outlined in section 224 of Public Law 110-389, VBA has 
contracted with an independent third party to assess the VBA quality 
assurance program to include validation of the purpose and methodology 
of all aspects of the program, and to identify potential new 
efficiencies and improved analysis and review techniques.
    Question 24: When did VA first know about the Detroit Mail Amnesty 
and the over 16,000 documents that were turned in back in July 2007? 
When did VA notify Congress about the Detroit mail amnesty? What, if 
any, was the cause of delay in transmitting this information to 
Congress?
    Response: Shortly after arriving on station, the Detroit RO 
Director identified an issue in the length of time it was taking to 
associate mail with claims folders. As a result, the Director 
designated a ``mail amnesty'' period in July 2007 to improve internal 
controls over claims-related mail. This was a one-time action to 
establish an office-wide inventory of all opened mail not attached to a 
claims folder. Although 15,677 pieces of mail were reviewed, 
approximately 9,000 required no additional action except to be filed in 
the claims folder. Since this was a one-time action by the Detroit RO 
to improve mail control, VBA did not notify Congress.

                                 

                                U.S. Department of Veterans Affairs
                                        Office of Inspector General
                                                    Washington, DC.
                                                     March 26, 2009

Hon. John J. Hall
Chairman, Subcommittee on Disability
Assistance and Memorial Affairs
Committee on Veterans' Affairs
United States House of Representatives
Washington, DC 20515

Dear Mr. Chairman:

    This is in response to your request for additional information for 
the record on the resources needed to allow for the review of VA 
Regional Offices (VARO) on a 3-year cycle at the March 3, 2009, hearing 
on document tampering and mishandling at the Department of Veterans 
Affairs before your Subcommittee and the Subcommittee on Oversight and 
Investigations.
    Funding included in the Office of Inspector General's (OIG) fiscal 
year 2009 appropriations to conduct VARO inspections supported the 
establishment of 10 full-time equivalents (FTE) positions. This allows 
for the completion of 12 inspections annually and all 57 VAROs within a 
5-year period. To accelerate the schedule and complete all 57 VAROs 
within 3 years, we would need an additional 10 professional FTEs at the 
cost of $2.25 million for salaries, expenses, and travel.
    We thank you for your interest in the OIG's work and look forward 
to working with you in the future. This information has also been 
provided to Congressman Doug Lamborn, Ranking Republican Member, 
Subcommittee on Disability Assistance and Memorial Affairs; Congressman 
Harry E. Mitchell, Chairman, Subcommittee on Oversight and 
Investigations; and Congressman David P. Roe, Ranking Republican 
Member, Subcommittee on Oversight and Investigations.

            Sincerely,

                                                    GEORGE J. OPFER
                                                  Inspector General

    [An identical letter was sent to Hon. Harry E. Mitchell, Chairman, 
Subcommittee on Oversight and Investigations, Hon. Doug Lamborn, 
Ranking Republican Member, Subcommittee on Disability Assistance and 
Memorial Affairs, and Hon. David P. Roe, Ranking Republican Member, 
Subcommittee on Oversight and Investigations, Committee on Veterans' 
Affairs.]

                                  
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