[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]


      EXPLORING VA'S OVERSIGHT OF CONTRACT DISABILITY EXAMINATIONS

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

                                HEARING

                               BEFORE THE
                               
       SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

                                 OF THE

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

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                      THURSDAY, NOVEMBER 15, 2018

                               __________

                           Serial No. 115-81

                               __________

       Printed for the use of the Committee on Veterans' Affairs

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Available via the World Wide Web: http://www.govinfo.gov
        
                               __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
35-835                      WASHINGTON : 2019                     
          
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                     COMMITTEE ON VETERANS' AFFAIRS

                   DAVID P. ROE, Tennessee, Chairman

GUS M. BILIRAKIS, Florida, Vice-     TIM WALZ, Minnesota, Ranking 
    Chairman                             Member
MIKE COFFMAN, Colorado               MARK TAKANO, California
BILL FLORES, Texas                   JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American    ANN M. KUSTER, New Hampshire
    Samoa                            BETO O'ROURKE, Texas
MIKE BOST, Illinois                  KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine                J. LUIS CORREA, California
NEAL DUNN, Florida                   CONOR LAMB, Pennsylvania
JODEY ARRINGTON, Texas               ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana              SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto 
    Rico
BRIAN MAST, Florida
                       Jon Towers, Staff Director
                 Ray Kelley, Democratic Staff Director

       SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

                     MIKE BOST, Illinois, Chairman

MIKE COFFMAN, Colorado               ELIZABETH ESTY, Connecticut, 
AMATA RADEWAGEN, America Samoa           Ranking Member
JACK BERGMAN, Michigan               JULIA BROWNLEY, California
JIM BANKS, Indiana                   CONOR LAMB, Pennsylvania

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                            
                            
                            C O N T E N T S

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                      Thursday, November 15, 2018

                                                                   Page

Exploring VA's Oversight Of Contract Disability Examinations.....     1

                           OPENING STATEMENTS

Honorable Mike Bost, Chairman....................................     1
Honorable Elizabeth Esty, Ranking Member.........................     2
Honorable Phil Roe, Chairman, House Veterans Affairs Full 
  Committee......................................................     3

                               WITNESSES

Ms. Elizabeth H. Curda, Director, Education, Workforce, and 
  Income Security Team, U.S. Government Accountability Office....     5
    Prepared Statement...........................................    21

Ms. Margarita Devlin, Principal Deputy Under Secretary for 
  Benefits, Veterans Benefits Administration, U. S. Department of 
  Veterans Affairs...............................................     6
    Prepared Statement...........................................    25
        Accompanied by:

    Ms. Beth Murphy, Director, Compensation Service, Veterans 
        Benefits Administration, U. S. Department of Veterans 
        Affairs

    Ms. Mary Glenn, Deputy Director, Compensation Service, 
        Veterans Benefits Administration, U. S. Department of 
        Veterans Affairs

    Mr. Phillip W. Christy, Deputy Executive Director, Office of 
        Acquisition, Logistics, and Construction, U. S. 
        Department of Veterans Affairs

                        STATEMENT FOR THE RECORD

Veterans of Foreign Wars of The United States (VFW)..............    27

 
      EXPLORING VA'S OVERSIGHT OF CONTRACT DISABILITY EXAMINATIONS

                              ----------                              


                      Thursday, November 15, 2018

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                      Subcommittee on Disability Assistance
                                      and Memorial Affairs,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 10:30 a.m., in 
Room 334, Cannon House Office Building, Hon. Mike Bost 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Bost, Coffman, Radewagen, Esty, 
and Lamb.
    Also Present: Representative Roe.

            OPENING STATEMENT OF MIKE BOST, CHAIRMAN

    Mr. Bost. Good morning and welcome. This oversight hearing 
of the Subcommittee on Disability Assistance and Memorial 
Affairs will now come to order. Veterans who apply for 
compensation may receive a disability exam. The purpose of the 
examination is to determine if the veteran has a disability, 
the extent of the disability, and whether the disability is 
linked to his or her military service. In other words, the 
medical evaluation is a key part of the VA exam process, and we 
have an obligation to ensure that these exams are completed 
accurately and within a responsible amount of time.
    Some people may be surprised to learn that the disability 
exam may not be performed by the VA employee. In the past 
years, VA has been using independent vendors to carry out these 
exams. From January 1, 2017, to April 2018, contractors 
performed about 1 million exams, or about half of all 
disability exams.
    And in fiscal year 2017 and fiscal year 2018, VA actually 
paid contractors $639 million and $919 million, respectively. 
So given how important disability exams are, I was very 
concerned when the GAO recently released a report that found 
serious gaps in the way the VA is overseeing the contract 
examiners.
    As a businessman, I know that you have to stay on top of 
contractors to ensure that the program is working as well as it 
should. One of the biggest concerns is the -- and the most -- 
one of the biggest concerns, that most contractors are not 
meeting the VA's quality goal of 92 percent accuracy. In fact, 
GAO reports that quality scores for contracts rating -- ranging 
from only 62 percent to 92 percent. Of course, that raises the 
question of whether veterans are getting correct decisions if 
the exams are not accurate.
    GAO also says that VA does not have a way to verify whether 
or not contractors are taking the required training, which may 
explain why the quality of exams is so low. Now, that isn't to 
say that the vendors wouldn't welcome feedback on how they can 
improve service to veterans. I am almost -- but I am also 
frustrated that GAO found that the VBA could not accurately 
measure whether contractors are meeting timelessness goals.
    Providing exams within a reasonable time frame is very 
important to the compensation-claims process. Unnecessary 
delays in scheduling exams force veterans to wait longer for 
decisions and add to the backlog. According to VA, it did not 
have the staffing and IT needed to effectively oversee the 
program. I am concerned the VA chose to expand a potentially 
$6.8 billion program without having the necessary controls in 
place to hold the vendors accountable.
    The contract specifically -- hold on.
    The contract specifically -- financial incentives are 
penalties for the vendors based on their performance. However, 
last year, VA did not have the resources required to timely 
verify the contractors' invoices for accuracy, much less 
quality. It is unfair for veterans and taxpayers to pay the 
price of a potentially mismanaged program. That being said, we 
don't know what this is, in fact, a mismanaged program. The 
issue -- if this program is mismanaged, the issue is, the VA 
does not have the data that Congress needs to make such a 
determination.
    I know the VA set up an exam program office to improve 
oversight of contractors. I am interested in learning more 
about how this office will help improve contract exams, as well 
as getting an update on the VA's progress in implementing GAO's 
recommendations. Again, I want to thank everyone for being 
here.
    Now I would like to turn to our Ranking Member for any 
opening statements she might have. Ms. Esty?

      OPENING STATEMENT OF ELIZABETH ESTY, RANKING MEMBER

    Ms. Esty. Thank you, Chairman Bost. I want to thank you 
very much for calling this hearing today, and for taking the 
lead in requesting the GAO report, which is the basis of this 
oversight hearing of the VA's contract medical examination 
program.
    Well before I joined this Committee, I was involved with 
improving the medical evaluation system used by the VA to 
determine a fair level of compensation for veterans who are 
injured, or made ill as a result of their military service. I 
heard often from veterans in my home State of Connecticut that 
their lack of faith in the medical evaluations they received 
was a major reason why they filed appeals.
    In the past, veterans would tell me that the outside 
doctors who they saw for evaluation sometimes didn't appear to 
have the necessary understanding of their illness or injury to 
make a valid medical determination. And they also described 
that -- a feeling of being, frankly, pushed around by the 
bureaucracy. For example, people were sent from rural 
Connecticut to New York City for an exam which fit within the 
VA's mileage criteria, but didn't take into account the 
transportation difficulties for an elderly, World War II 
veteran in rural Connecticut to make it in the middle of winter 
for an exam.
    Others had the experience of having the three required 
notification phone calls, all received on the exact same day, 
to provide them notice of when their exam is. Again, those are 
the sorts of frustrations that we received.
    Over the last couple of years, VBA has worked to create a 
new system that veterans can have more faith in. In order to 
get the exams they need to support their claims, the use of 
outside contractors has increased to the point that about 50 
percent of all of the medical exams are being done by outside 
contractors at this point. We applaud the progress VBA has made 
in timeliness and efforts towards improved quality, and I 
invite the program directors here today to describe that 
progress, especially in timeliness. Nevertheless, the GAO 
findings that the training doctors are supposed to receive is 
not always verified independently, concerns me.
    I am also concerned about whether veterans travel 
reimbursements are being tracked and accounted for by VBA. This 
is a particular issue we have heard about involving contract 
exams, and whether those reimbursements actually ever reach the 
veterans as intended.
    And, of course, this Subcommittee is always concerned that 
the IT infrastructure necessary for this key element of the 
disability compensation claims process is up and functioning 
well.
    So while we all applaud VBA's progress, it is our job to 
ensure that the system is being managed to a standard that 
earns veterans' trust and doesn't leave them feeling as if they 
are a profit center for outside contractors. They should be 
treated as heroes. So, thank you to our witnesses for their 
commitment to veterans and for being here on this snowy 
morning, which we did not all anticipate. I look forward to 
hearing your testimony, and with that I yield back.
    Mr. Bost. Thank you.
    I also want to welcome Full Committee Chairman, Phil Roe, 
to this hearing. Chairman Roe, would you like to say a few 
words?

OPENING STATEMENT OF PHIL ROE, CHAIRMAN, HOUSE VETERANS AFFAIRS 
                         FULL COMMITTEE

    Mr. Roe. Thank you, Mr. Chairman and Ranking Member Esty, 
for holding the hearing, I appreciate that. And one of the 
priorities as Chairman of the House Committee on Veterans' 
Affairs is ensuring the Nation's veterans receive timely and 
accurate compensation decisions. Timely and accurate disability 
exams are a key input into those decisions.
    Some of you may not know that in 1996, Congress approved 
the use of contract examiners to allow VHA to focus more on its 
resources of treating patients and to expedite the scheduling 
of disability exams. And that is to be commended because the VA 
is short-staffed now. So I think that was probably a good move.
    As Chairman Bost pointed out in his statement, since 
Congress originally authorized the pilot program, the 
Department has dramatically expanded both the size and cost of 
the program. While it is important for VA to schedule 
examinations in a timely manner, it is equally important that 
contract examiners are rendering accurate and consistent 
medical opinions.
    For these reasons, when I first became -- came on as 
Chairman as of the Full Committee, I immediately requested that 
GAO investigate whether VA is effectively overseeing contract 
exams.
    When I reviewed the report, I was incredibly frustrated to 
learn that VA does not have procedures in place to monitor a 
program that is vital to providing the medical information 
needed to decide veteran claims. Moreover, of the last 2 fiscal 
years, the contract exam program cost almost $1.6 billion, and 
the VA cannot timely verify if contractors are charging the 
correct amount.
    As a physician, I know that my medical practice would not 
have succeeded if I were unaware of whether my patients were 
receiving quality and timely care. Unfortunately, VA hasn't 
been collecting information necessary to assess whether the 
contract exams are satisfactory, and to hold the vendors 
accountable if not.
    Congress needs this information to determine if the 
contract examiners are effectively serving veterans, and to 
ensure that the program is a wise use of taxpayer funding. 
Today I am interested in hearing how the VA is addressing the 
GAO's recommendations to improve how VA evaluates contractor 
performance.
    For example, GAO suggested that VA develop and implement a 
plan for how we use EMS to oversee the contractors. I am 
looking forward to hearing from VA about how the Department 
intends to use EMS in a way that will prevent -- will benefit 
veterans while holding vendors responsible for any delay or 
inadequate exams.
    Additionally, I am concerned by GAO's findings that VA does 
not monitor the adequacy of its training for medical examiners. 
If VA's training is not sufficient, then examiners may render 
an inaccurate medical opinion, which could result in a rater 
denying a veteran's claim.
    Ultimately, I am committed to ensuring that the men and 
women who served our country receive the benefits that they 
have earned, and I am looking forward to hearing from today's 
witnesses about ways to improve VA's oversight of contract 
exams.
    And, again, Chairman Bost, I appreciate you holding this 
hearing, and I yield back my time.
    Mr. Bost. Thank you, Mr. Chairman.
    I want to welcome all the witnesses who have joined us here 
this morning, and thank you for taking the time out of your day 
to be here. Joining us from the VA is Ms. Margarita Devlin, who 
is the Principal Deputy Under Secretary for Benefits. She is 
accompanied by Ms. Beth Murphy, the Director of Compensation 
Services for VBA. Also with Ms. Mary Glenn, the Deputy Director 
of Compensation Services for the VBA, and Mr. Phillip Christy, 
the Deputy Executive Director of the OALC.
    Also joining us today is Ms. Elizabeth Curdy -- Curda -- 
I'm sorry -- the Director of Education Workforce and Income 
Security Team for GAO.
    We want to welcome all of you, and I want to remind the 
witnesses that your complete written statement will be entered 
into the hearing record. I want to make sure -- Ms. Curdy -- or 
Curda, I have done that twice to you, I apologize -- you are 
now recognized for 5 minutes.

                STATEMENT OF ELIZABETH H. CURDA

    Ms. Curda. Chairman Bost, Ranking Member Esty, and Members 
of the Subcommittee, thank you for inviting me to discuss GAO's 
findings on VBA's oversight of its contracted examiners.
    In addition to VHA physicians, VBA relies on private 
physicians via contracts to examine veterans who claim benefits 
for a service-connected disability. Between 2012 and 2017, the 
number of exams completed by contracted examiners more than 
tripled to about 600,000, and currently accounts for about half 
of all exams. All told, VBA awarded five private firms 
contracts that are worth up to $6.8 billion over 5 years.
    Today, I will highlight the findings and recommendations 
from our recently issued report in three areas: First, what is 
known about the quality and timeliness of VBA contracted exams; 
second, the extent to which VBA monitors contractors' 
performance; and, third, how VBA ensures that its contractors 
provide qualified and well-trained examiners.
    Regarding the first area, VBA lacks accurate and complete 
information on whether contractors are meeting the agency's 
quality and timeliness targets. As of last summer, VBA staff 
had not completed reviews of the quality of the contracted 
exams for the latter half of 2017. Of those that VBA had 
completed, the agency reported that almost all contractors 
missed VBA's quality target of 92 percent in the first half of 
calendar year 2017, with scores ranging from 62 to 92 percent.
    Further, VBA could not accurately assess the timeliness of 
the contracted exams. Per the contracts, VBA should measure 
timeliness as the amount of time it takes for a contractor to 
complete and submit the initial exam report, and exclude any 
time taken to make corrections. However, VBA systems did not 
accurately capture the date that corrected exams were initially 
reported.
    Although the timeliness data could not be used to assess 
contractor compliance, we analyzed the data on all contracted 
exams completed between February 2017 and January 2018, 
including the corrected ones. We found that about half of the 
exams completed were done within the general 20-day target, 
while the other half exceeded 20 days, and 12 percent took more 
than twice as long to complete.
    VBA officials told us they planned to hire additional staff 
by the end of fiscal year 2018 to complete the remaining 
quality reviews. In addition, VBA officials said their new 
information system would more accurately track contractor 
timeliness. However, at the time of our review, the system was 
not yet producing accurate data.
    Regarding the second area, on monitoring contractors, VBA 
identified and addressed some contractor issues, such as delays 
in completing specific exams. However, VBA lacked adequate data 
and plans for overseeing contractors' overall performance. For 
example, without sufficient quality and timeliness information, 
VBA could not apply financial penalties for exams needing 
correction or for contractor performance that did not meet 
timeliness or quality targets.
    Further, VBA has not conducted any comprehensive analyses 
that would allow it to identify and address higher-level trends 
and program-wide challenges. For example, such analyses could 
identify challenges in conducting exams across different 
contractors, geographic regions, exam types, or other relevant 
factors.
    To address these issues, we recommended that VBA develop 
and implement a plan for using data from the new exam 
management system to regularly monitor contractor performance. 
We also recommended that VBA regularly assess aggregate 
performance data, higher-level trends and program-wide 
challenges. VA agreed with these recommendations.
    Finally, regarding examiner qualifications, we found VBA 
had systems in place to check that examiners had proper 
credentials, such as licenses, to perform exams. However, VBA 
lacked information it needed to verify that contracted 
examiners had taken required training. Instead, the 
contractor's self-reported this information.
    VBA also lacked plans to evaluate the quality of the 
training it provided to examiners, to ensure that they are able 
to provide high quality exams and reports. This is particularly 
problematic given the low-quality scores VBA gave to many of 
the contractors.
    To address this, we recommended that VBA implement a way to 
verify that contracted examiners have completed required 
training. We also recommended VBA assess the effectiveness of 
its training and make improvements as needed. VA agreed with 
our recommendations.
    In summary, we found that several gaps in the information 
VBA needs to effectively manage and oversee contract 
performance. As VA continues to rely on contracted examiners, 
it is important that the agency is well-positioned to carry out 
effective oversight of contractors to help ensure that veterans 
receive high quality and timely exams and contractors are paid 
correctly.
    This concludes my prepared statement, and I will be happy 
to address the Subcommittee's questions.

    [The prepared statement of Ms. Curda appears in the 
Appendix]

    Mr. Bost. Thank you, Ms. Curda.
    Ms. Devlin, this is your first time testifying before the 
Subcommittee. We thank you for being here, and you are 
recognized for 5 minutes.

                 STATEMENT OF MARGARITA DEVLIN

    Ms. Devlin. Good morning. Thank you, Chairman Bost and 
Ranking Member Esty, and Members of the Committee. We 
appreciate the opportunity to come and speak to you about our 
contract medical disability examination program, or MDE. I 
would like to take a moment to just provide an overview of our 
MDE program. VBA requests a disability exam or a medical 
opinion when necessary to adjudicate a disability claim for 
disability or pension, commonly referred to as C&P exams.
    For a decade, VA relied only on VHA to provide these exams. 
Then in 1996, as you mentioned, Congress provided VA the 
authority to contract exams using the mandatory fund. VA began 
using this authority in 1998, which was originally limited to 
10 regional offices. After 16 years, the statutory authority 
was extended to 12 regional offices in fiscal year 2015 and in 
2016, as many regional offices as the Secretary deemed 
necessary, starting in fiscal year 2017.
    Claims processors at VBA's 56 regional offices now can use 
an online tool, enabled by real-time data, to assess by exam 
type if VHA has the capacity to conduct the exam, and if not, 
to direct that exam to a contract vendor.
    VBA's current contract is structured in five districts 
across the continental United States, with two vendors per 
district. There is also an overseas contract -- or overseas 
district served by one vendor, and an additional district with 
one vendor serving our transitioning servicemembers who go 
through our pre-discharge program such as benefits delivery at 
discharge, or BDD, and integrated disability evaluation system, 
or IDES.
    VBA's contract vendors have also begun conducting exams for 
incarcerated veterans where the prison systems will allow us 
in. Over 1.3 million veterans or servicemembers received C&P 
exams in fiscal year 2017, with vendors fulfilling more than 45 
percent of those requests. For fiscal year 2018, vendors 
performed nearly 60 percent of the 1.4 million exam requests 
completed. This included more than 14,000 veterans and 
servicemembers overseas, where VHA has no footprint and our 
contract vendors are the only method to provide this service.
    The total cost over the last 2 fiscal years for contract 
vendor exams, including the ancillary support contracts, were 
approximately $765 million in fiscal year 2017, and $896 
million in fiscal year 2018. Each exam request can contain one 
or more disability benefits questionnaires, or DBQs. The 
average number the DBQs per exam request is between three and 
four.
    After the award of VBA's contract in 2016, there were 
multiple protests and an appeal of the award in the five 
continental U.S. districts, followed by contractual ramp-up 
time periods. Based on these events, the evaluation period for 
Districts 1 through 5, did not begin until September 27th, of 
2017. To ensure seamless service to veterans, VBA relied on a 
series of bridge contracts as necessary to avoid any gap in 
service. VBA anticipates continuing to use these bridge 
contracts until December of 2018.
    Execution of the current MDE contracts was impacted by many 
unforeseen challenges, including the award protests I just 
mentioned, one nonperforming vendor who is no longer working 
under contract for VBA, and system limitations for managing 
exam requests. These issues have since been resolved.
    Also VBA worked with our industry partners to modify the 
contracts more than a hundred times to enhance service delivery 
to veterans and servicemembers.
    VBA concurs with the recommendations in the report released 
this week by the Government Accountability Office. As stated in 
the report, GAO reviewed timeliness and quality data through 
February of 2018. The GAO findings validate the issues VBA was 
already working on, and VBA has already implemented many 
improvements. For example, our exam management system is fully 
operational, and we are on track to finish all of our quality 
reviews.
    Also, I am pleased to announce that the contracting officer 
is sending out today, for signature and award, the new 
contracts for Districts 1 through 5, with updated terms based 
on all the lessons we have learned and our current business 
needs.
    VBA appreciates the authority provided by Congress to 
obtain contract exams to supplement VHA's capabilities. The MDE 
program enabled VBA to obtain the necessary evidence in 
deciding 1.4 million disability rating claims in fiscal year 
2018, in an average of under a hundred days processing time 
with 95 percent quality. This would not have been possible if 
we had to rely only on VHA's capacity.
    VBA is committed to continuous improvement of the MDE 
program. We know how important it is to get this right for 
veterans.
    Mr. Chairman and Ranking Member, this concludes my 
statement. My colleagues and I welcome any questions that you 
have.

    [The prepared statement of Ms. Devlin appears in the 
Appendix]

    Mr. Bost. Thank you. And you hit that right on 5 -- for 
this, your first time, you hit it right on 5 minutes. That was 
really good. But I am going to start with questioning. I am 
going to allow myself 5 minutes if I can.
    Ms. Curda, please provide your perspective on the extent to 
which VBA was adequately prepared to manage and oversee the 
contract exam program once the contracts were put into place in 
the summer of 2017.
    Ms. Curda. Overall, we found that VBA was not prepared to 
manage the contractors and provide adequate oversight at the 
time. Early on, we found that some contractors did not have the 
capacity to do the exams that were assigned to them and had to 
be reassigned.
    There were, as I mentioned earlier, some problems with the 
quality of the exams, and the systems that VBA was using at the 
time could not provide accurate timeliness information which is 
necessary to execute and monitor the contracts.
    And some of the causal factors I mentioned in my oral 
statement, that there were inadequate number of staff in the 
program management office to oversee the contracts, both in 
terms of quality reviewers and contractor-officer 
representatives. And as I mentioned, the system at the time was 
not producing accurate timeliness data.
    Mr. Bost. Ms. Devlin, has VA exercised any physical -- 
fiscal incentives or penalties to contractors based on their 
quality or timeliness performance?
    Ms. Devlin. We have not.
    Mr. Bost. Okay. Can you tell us if there are any new plans 
in place -- first off, why not?
    Ms. Devlin. I will defer to our acquisition colleague here 
to answer that.
    Mr. Christy. Hi, good morning. To pick up that, the one 
contractor that did not perform, we did go through a settlement 
to mitigate the nonperformance there, but no incentives or de-
incentives were made. We did do the settlement to make sure 
that the work that needed to be done, that they did not do, was 
picked up by the other contractors. And they were required to 
pay that -- that amount to make sure that that work could be 
done. Once those other contractors picked up, the contractor 
did not perform, was just, through the settlement, no more work 
was provided to them, and that contract ended for them.
    Mr. Bost. So, Mr. Christy or Ms. Devlin, either one, so 
what are we -- what are our plans in the future to make sure 
that we actually have penalties and have those things in place 
to make sure they are doing the timeliness and all of the 
things that are required under the contract?
    Mr. Christy. I will answer from the procurement side very 
specifically. So both the current contracts and the ones that 
are being awarded this morning, have incentives and de-
incentives in them for timeliness and quality. The procurement 
vehicle itself, the contract has that built into it. I will 
defer now to the program, and I think they are going to talk to 
you about the things that have gotten better and improved over 
the last year, and I think that has been a good teaming 
arrangement, actually, between industry, program, and the 
procurement folks.
    Go ahead and I will let you finish that good-news story 
there.
    Ms. Devlin. Yes, thank you for the question. First of all, 
we are almost caught up on our quality reviews and have 
submitted many of them to the acquisition office for review. 
Secondly, I would like to point out that while we had not 
submitted those reports at the time of the GAO report, we had 
been conducting reviews and having feedback sessions with our 
contractors on a regular basis. We issue memorandum with 
guidance memos on a routine basis, based on lessons learned, 
based on the quality reviews that we have done.
    In addition, with the new contract, we were able to staff 
up our business office to the 17 people. We have got two left 
to get on board so that we can conduct our quality reviews in a 
timely manner and get any feedback to the contracting office as 
quickly as we can.
    Mr. Bost. Just real quick, because I am going to run out of 
time, I am afraid, but what are you doing as far as, from here 
on out, to do the proper audits, to make sure that we know and 
you know that the contractor is doing everything they are 
supposed to be doing?
    Ms. Devlin. We actually have another contract that comes in 
and does invoice audits as well. And in addition to those -- 
because we are now staffed appropriately to conduct the quality 
reviews, we will do those quality reviews in a timely manner 
and get them to the contracting office and then take any 
actions, both related to incentives or disincentives, in a 
timely manner. And I would like to, if it is okay, allow my 
colleagues to elaborate.
    Ms. Murphy. Sir, I just wanted to add that our new exam 
management system, EMS, which is now functional, has that 
automatic invoicing, auditing, built in, so that we are able to 
do a better job going forward, validating the invoices.
    Mr. Bost. I am out of time, so I am going to go ahead and 
yield to the Ranking Member, 5 minutes.
    Ms. Esty. Thank you, and I want to thank the witnesses for 
joining us here today.
    Quick question for Ms. Devlin. Do you feel, with 17 full-
time equivalents who are now about to be on boarded, will that 
be a sufficient number to do the kind of oversight and review 
that we need? Do you believe that is a sufficient number?
    Ms. Devlin. Yes. Based on our estimates, we believe it is.
    Ms. Esty. All right. I think we will be revisiting that in, 
you know, 6 months' time to verify if, in fact, it is, because 
we all want to be providing the resources necessary, and if 
that proves not to be, then we need to know that and not wait 
for another GAO report.
    I am interested about, I am looking at the testimony that 
we received today about concerns about this process. So I want 
to know if the VSOs are part of that feedback loop. There ought 
to be continuous improvement in this process on both timeliness 
and quality. And the people on the front lines, you have 17 
full-time equivalents who are supervising the program. We have 
thousands, probably tens of thousands of VSOs around the 
country. They can, and should be, eyes and ears about what is 
going on. How are they involved with you in ensuring that you 
are getting on-the-ground feedback about timeliness and 
quality?
    Ms. Devlin. That is a great question. We collaborate with 
our VSO partners regularly, and on this topic, as well as other 
topics, we have quarterly training sessions with our VSOs where 
we talk to them about various initiatives. And we have talked 
to them about the MDE program in particular, to make sure that 
we are explaining to them where we are in the process and to 
get feedback from them about what they are hearing on the 
ground.
    In addition to the quarterly training sessions, we have 
regular meetings with the Under Secretary for Benefits and 
VSOs, as well as other meetings at the staff level.
    Ms. Esty. Thank you. I want to, again, because, to 
highlight from the written testimony today, the VFW listed five 
major concerns they are still seeing: late notification of 
exams, and I mentioned that; lack of options for veterans to 
reschedule exams, that can be important, depending on health, 
transportation, weather; lack of availability of adequate 
examiners within a reasonable distance from the veteran; no 
adequate review of the veteran's claim filed prior to the exam. 
I can tell you personally I have heard about that from folks in 
my district, that they did not get a review sufficiently ahead 
of time; and inadequate time for providers due to the volume 
and the pressure and turnaround time.
    So those are the specific issues we are concerned about, 
and that goes to the totality of the experience. I have a 
specific question, though, on the ``20-day within the system, 
30-day outside of the system'' timeliness criteria. We want it 
to be timely, but even more important, it has to be accurate. 
If it is not accurate, people are going to file claims, and 
they should. That will slow down the whole system, gum up the 
works, cost money, and lead, most importantly, to veterans not 
trusting the results.
    So what do you -- do you feel that those are reasonable 
time goals? And if not, you know, how are we going to make a 
determination? Because we are hearing someone anecdotally, I 
can say, I am hearing from VSOs, they do not want to be a slave 
to that 20- or 30-day time period. So I want to make sure we 
are not measuring the wrong metrics and losing something more 
important, which is faith and quality in the system.
    Ms. Devlin. Thank you for that question. I would like to 
start and then allow my colleagues to elaborate. We take 
quality very seriously. And as I indicated, our disability 
claims quality is at 95 percent for the end of the fiscal year, 
and, of course, the disability exams are part of that process. 
So I feel confident in the quality of our disability-claims 
decisions.
    With respect to the quality of the exams, I did want to 
point out that when we review for quality, we review a 
combination of technical accuracy and administrative accuracy. 
So when you look at the statistics provided in the GAO report, 
I would just like to point out that some of that includes 
errors based on administrative procedures.
    For example, if the provider failed to put their license 
number on the DBQ, or on the report, or if they failed to check 
a box of something that is administrative and not related to 
the disability exam itself, those are counted as errors as well 
and will be reflected in the scores. We do take quality very, 
very seriously. I will allow my colleagues to discuss the 20-
day time frame.
    Ms. Murphy. I did want to elaborate on a couple of the 
points she made. I saw in the VFW testimony, I am pleased to 
say that they are hearing frequent positive comments about the 
contract, and it is important to note, they are a key piece of 
our oversight. They are partners with us. Mary and I meet with 
them regularly, and we always emphasize that it is important 
that if they hear individual, specific situations of the nature 
you described, we want to hear about that. And they do funnel 
those to us and we follow-up on every single one.
    As far as the timeliness goals, I understand your concern, 
and we share that concern. We want to make sure we are doing, 
not only a timely job, but also a quality job. Because that is 
what is important, and that is how we best serve veterans. We 
have taken that into account.
    I think another thing that is important to going forward is 
that under this new contract, we have done the research and the 
homework, done the analysis, including with VHA partners, on 
how better to balance rural and urban areas within the 
districts, which will enable the vendors to set up a healthier 
infrastructure footprint, and then that can help them meet the 
timeliness measures as well.
    Ms. Esty. Thank you, and I am over time.
    Thank you.
    Mr. Bost. Thank you.
    Chairman Roe?
    Mr. Roe. Thank you, Mr. Chairman.
    To follow along with what Ms. Esty was talking about, I 
would like to know how you -- if I am doing the disability 
claim for VA, how do you train me? And then how do you assess 
that I am doing a quality exam?
    Ms. Glenn. Yes, sir. We use the same training methods that 
VHA does. We use the same training materials that they do. We 
also have an additional training --
    Mr. Roe. I mean, do I do an online class? Do you come to my 
office? Or what do you do?
    Ms. Glenn. It has been somewhat of both of those things. We 
have used train-the-trainer method where we pulled the vendors' 
training officers together in one location and trained them. We 
have online materials that they use. So we use whatever 
training method works and makes sense for whatever the topic 
is.
    Mr. Roe. And then to measure the quality, how do you do 
that? And I agree with Ms. Devlin, if you miss checking a box, 
that is not really an issue about the quality exam that you 
gave. And I do understand why you need -- the VA needs help to 
evaluate 1.4 million claims. You just don't have the internal 
capacity to do that, I don't think. You barely have the -- I 
mean, 35 percent of the health care the VA provides outside 
now. I know they don't have the capacity to see all those 
patients in addition.
    Ms. Glenn. So, sir, when we do our quality reviews, if you 
are talking about how do we maintain quality for --
    Mr. Roe. How would you evaluate me, to know that I am 
providing quality care?
    Ms. Glenn. When we do our quality reviews, if we notice 
that there is one specific doctor or one specific vendor that 
continues to have problems -- and this is something that we do 
track -- we notify the vendors and --
    Mr. Roe. Well, what is a problem? That is where I don't -- 
when you say that, what does that mean?
    Ms. Glenn. That they did not fill out the form correctly.
    Mr. Roe. Okay.
    Ms. Glenn. They gave inadequate information, that the DBQ, 
the disability benefits questionnaire that they completed was 
not adequate for rating purposes.
    Mr. Roe. Okay. The other thing, I guess, once again, we are 
back to IT, and anecdotally, as Ms. Esty was talking about, I 
ran into a man on Veterans Day -- you run into a lot of 
veterans on Veterans Day, but this fellow was asked to go get a 
hearing exam 2 hours' drive up into southwest Virginia for his 
disability claim, when we have one of the best hearing 
departments right there in Johnson City at Mountain Home 
Medical Center. He finally got it fixed where he didn't have to 
drive essentially 4 hours to get this disability. Those are the 
kind of things, I think, that people also get upset about, is 
when they know they can have the exam right there if they can, 
instead of going 2 hours.
    And I think if I were a veteran, and I were given the 
option, hey, you can wait a month to get seen here locally, or 
you can drive in 2 weeks, 2 hours one way, I would just wait 
the couple of weeks. I hadn't been able to hear for 30 years, 
so why would I care about 2 more weeks? So those are the kind 
of commonsense things, I think, that we need to do.
    The other question I want to ask -- and this is one that 
goes to, not just this particular part of VA, but we had a 
hearing yesterday, we are going to have another one on the GI 
bill later today -- is that, why would you expand this to all -
- other than I understand the need to get these done -- to all 
56 ROs when you didn't have the IT to evaluate what GAO said? 
Why would you expand a program until you had the systems in 
place to adequately see if I am doing it in a timely fashion 
and I am doing quality work? Why would you do that?
    Ms. Murphy. So, great question, sir. Mary and I came on to 
this program in about the middle of 2016, and the plans were in 
place for the IT infrastructure and the program requirements 
going forward. There was a protest to the original award. It 
happened in March 2016, and it was over a year that we were on 
a stop-work order. During that time frame, we were anticipating 
that the system would be built out and we would be testing with 
those vendors. That stop-work order hindered our ability to 
work with these vendors to test adequately and get the system 
on track on time. So, there were some delays for that reason.
    We have ramped up, worked with those vendors, who have been 
great partners to us, and we are in place now, going forward, 
to be able to use that system effectively.
    Mr. Roe. So you think you can monitor what you need --
    Ms. Murphy. Yes, we can.
    Mr. Roe. -- to monitor going forward? Okay.
    Ms. Murphy. Yes, sir.
    Mr. Roe. And I heard also that you feel like, by the end of 
the year, you will have the staff and the IT. So as Ms. Esty 
said, 6 months from now, we have this hearing again, we are not 
going to hear the same thing again. Am I -- I want that on 
record, we are correct in hearing that?
    Ms. Devlin. That is correct.
    Mr. Roe. Okay. I yield back.
    Mr. Bost. Mr. Lamb, you are recognized for 5 minutes.
    Mr. Lamb. Thank you, Mr. Chairman.
    This is a question, I think, for anyone from the VA. In 
Pittsburgh, Pennsylvania, near where I am from, our VBA is a 
primary site for processing claims from overseas. And I was 
just hoping you could fill me in a little bit on how monitoring 
and overseeing the contractors for contracts that do overseas 
claims might be different, or any of the specific issues you 
have seen there.
    Ms. Glenn. We do work very closely with the vendor who has 
the overseas contract, and as far as the monitoring goes, they 
are still held to quality and timeliness standards, which are 
written into the contract. We also receive feedback from our 
VSO partners and from the Pittsburgh regional office, as well 
as anybody else who comes to VA and has a problem.
    As far as I know, our overseas operations have been in 
place, and, in fact, we added six more additional sites in 
fiscal year 2019.
    Ms. Murphy. And, Congressman, if I could add, it just so 
happens, about 10 years ago, I was director of the Pittsburgh 
regional office, and I know firsthand the struggles that we had 
at that time in getting exams done overseas. We would work with 
VHA, embassies, State Department, to try to get some solution 
for exams overseas and it was very difficult.
    Last year, we did about 7,000, almost 8,000 exams, through 
the contract for overseas veterans, and this year, it has been 
about 14,000. So it really is a solution we have never had 
before.
    Mr. Lamb. So the -- you are saying that the use of 
contractors recently has made that easier for the overseas --
    Ms. Murphy. Absolutely.
    Mr. Lamb. Okay.
    Ms. Murphy. The timeliness has improved. We are not 
struggling and looking for alternative solutions, like next-
best solutions. We are actually being examined by people who 
know how to do these exams.
    Mr. Lamb. Do you -- and this is -- Ms. Curda, too, you can 
answer this. I don't know who would know, but have you noticed, 
is there any -- is the performance of the contractors doing 
overseas examinations any better or worse when it comes to 
quality and timeliness? Was that something you all looked at?
    Ms. Curda. In terms of timeliness at the time of our 
review, there were similar issues as the other domestic 
districts. On the qualitiness -- I am sorry -- quality part of 
it -- yeah, they had slightly higher scores.
    Mr. Lamb. Okay. Now, when it comes to having VA doctors do 
the exams, you know, in a community like ours, we are lucky to 
have two VA hospitals that are in pretty close proximity to a 
lot of people. So that would be kind of the best option. Would 
you agree that the VA doctors, because of their skills, their 
training, their experience, and also just their awareness of 
veteran culture and personality and the experience, would you 
agree that they tend to be a better option than the contractors 
themselves?
    Ms. Murphy. I think with 8,000 examiners on the contract 
side, and with several hundred or a thousand on the VHA side, 
that is difficult to answer, just as a generality. I know that 
VHA is very committed in its mission, and our vendors are 
committed in their mission as well. We use the same training 
materials, as Mary said earlier. We do consult with VHA 
regularly to help with our exams. So there is a good 
partnership there.
    Mr. Lamb. As far as making sure that the contractors have 
the same kind of cultural awareness as the VA doctors, are they 
VA doctors that are providing the training, or have you 
contracted out the training as well?
    Ms. Glenn. One of the pieces that is different for the -- 
the vendor training as opposed to VHA training is, we provide 
and we have the vendors familiarize all of their subcontractors 
with VA culture, with our benefits. They go through a whole 
training program about VA benefits and the importance of 
serving veterans and how we are all committed to making sure 
that veterans get accurate and timely examinations in order for 
their claims to be processed.
    Mr. Lamb. Okay. But my question is, who is training the 
person who does the exam? Is it a VA doctor? Or is a contractor 
doing the training of another contractor?
    Ms. Glenn. The contractor is doing a training with another 
contractor, usually, using VA materials.
    Mr. Lamb. Okay, thank you.
    Mr. Chairman, I yield back.
    Ms. Murphy. And if I could add, very specifically, we 
expanded our contract in the last year so that vendors could 
help do medical opinions for Camp Lejeune contaminated water 
cases. We specifically had the VHA folks come with us and train 
the examiners for those vendors.
    Mr. Bost. The gentleman yields back. Thank you.
    Mr. Coffman?
    Mr. Coffman. Thank you, Mr. Chairman.
    And I think, Ms. Murphy, you said that there were plans in 
place with an effective date for the implementation of these 
contracts. But you also said that -- that you all knew prior to 
that implementation date that the IT system wasn't ready. Then 
why did you all go forward with this?
    Ms. Murphy. So that was a little before my time. I am not 
up to speed on all of the decisions and the analysis that 
happened ahead of time. I can only speak to what Mary and I 
observed when we took our positions, and going forward. We made 
sure that every twist and turn that hit us, with the protests, 
with the systems, with the staffing, that we addressed that and 
moved forward.
    Mr. Coffman. Ms. Curda, could you answer that? I mean, why 
did they move forward when the IT system wasn't ready?
    Ms. Curda. I don't have an explanation because, you know, 
we got our information from Beth. She wasn't there, so we don't 
know prior to that.
    Mr. Coffman. Can anybody answer that question?
    Ms. Murphy. I think, to the best of my knowledge, it was 
the fact that there was a plan in place, that they would 
synchronize their release of the original contract with the 
system. And then because of the protests and the stop-work 
orders, we couldn't engage with the contractors for building 
that out and testing, it delayed things by about a year.
    And then once the protests and appeal period were over, we 
are into June 2017. Then we had the ramp-up of 90 days for the 
new vendors. It was the beginning of fiscal year 2018 before we 
were up and ready to start measuring.
    Mr. Coffman. It still makes no sense. It still absolutely 
makes no sense. When you didn't have the systems -- the 
adequate systems in place, that brought us to this situation 
today, that you still moved forward. And nobody can answer, 
really, give an adequate answer as to why.
    Ms. Murphy. Well, I think it is important to remember that 
VHA did not have the internal capacity to do these exams in a 
timely manner. We are here to serve veterans in a timely and 
quality way, and these contracts have been in place for 20 
years. We had experience with this, and we were working through 
the ramp-up the best we could. There were a lot of lessons 
learned during that ramp-up period of this new contract. And 
the protests are behind us, the systems are in place, the 
staffing is in place. We are well-poised to do this 
appropriately going forward.
    Mr. Coffman. Well, you haven't done it appropriately yet.
    I yield back.
    Mr. Bost. Thank you.
    Ms. Radewagen?
    Mrs. Radewagen. Thank you, Mr. Chairman. I have a question 
for Ms. Devlin.
    As you know, VA has been using contract exams since 1998. 
Now, I realize that you only came on board in 2016, but do you 
have any idea why VA waited until 2016 to establish a contract 
exam office?
    Ms. Devlin. Thank you. I actually have been in the VA for 
23 years, but in my current position since May of this year. I 
cannot answer to the decisions going back multiple years. What 
I can tell you, though, is that it was only, I believe, in 
2017, that we received the authority to conduct contract exams 
in all regional offices. Up until then, it was merely a pilot 
program.
    And I also want to kind of put some context around the IT 
system. When developing an IT system that is going to be used 
with contractors, of any type, we would build, with our IT 
folks, the preliminary product, but the key ingredient is 
enabling the contract vendor, through their IT systems, to 
connect to ours. The only way to fully, sort of, complete the 
system is to have contract vendors in place who help us test. 
And so that was the delay that was described by Ms. Murphy as 
to why we didn't have the systems in place. We had the 
preliminary IT development complete, but the inability to 
interact with our vendors to do the testing did not enable us 
to finish that last step.
    Mrs. Radewagen. So when EMS was deployed, it was not fully 
interoperable with the contractors' IT systems?
    Ms. Devlin. That is correct.
    Mrs. Radewagen. How many claims were affected by this 
issue? Ms. Devlin?
    Ms. Devlin. As I understand it, no claims were affected 
directly. Any exams that did not go to the contract vendor 
correctly were pulled back and manually reassigned to another 
contract vendor. The system was basically getting exam requests 
stuck when we first deployed, and we were manually unsticking 
those exam requests so that the veteran did not suffer, because 
the exam would still be completed, and they would get their 
rating decision completed.
    Mrs. Radewagen. So what short- and long-term steps are you 
taking to ensure that exams are not getting stuck in EMS? You 
may have partially answered it already, but -- Ms. Devlin?
    Ms. Devlin. We have made multiple fixes to the system with 
our IT partners. In fact, all of the fixes to the system that 
have been completed to date have tested well, and we have been 
able to point forward, assure that no other exams will be 
stuck. Those problems have been fixed. We still have a few 
exams in the system that we are manually rerouting, but point 
forward, the system is now fixed.
    Mrs. Radewagen. Thank you, Mr. Chairman.
    I yield back.
    Mr. Bost. Thank you.
    We are going to go a second round of questioning, because 
there are some things I feel like we really need to get to, 
that need to be on record, and vitally important to this issue. 
And so I want to tell the Members that if they have other 
questions, that they will get that the other time.
    Let me go back, when we were talking about the audit and 
what could be done. And Mr. Christy, this is specifically to 
you. What resources is realistically available to the VA and if 
the VA finds that, as a result of the audit, the Department was 
overcharged, given that those at the MSLA invoices have already 
been paid, what are the options to draw back on that 
overpayment if they are there?
    Mr. Christy. Right. And so with these audits, the fact 
pattern will kind of -- really kind of tell a story, and with 
our legal counsel we will look at that. It is kind of a -- a 
tough situation to give you exact details without actually 
having the facts, so that we can work through that with our 
legal counsel.
    As we talked about yesterday, as the reports are now 
starting to come in and we start looking at that data, I think 
there will be challenges on the government side for the work 
that was already paid for in the previous submittals, but there 
are remedies there that we could explore. But we are still 
trying to adjudicate that data.
    Mr. Bost. And that is the problem when we are all asking 
the questions and why we are -- and I know it happened before 
you were there, I understand that. But there is three things -- 
two things, really, that are vitally important. One is, three, 
the timeliness and the quality of the exam. But also, we have a 
fiduciary duty, and that fiduciary duty, it falls, falls, falls 
on you. And that is, that if all of a sudden we continue to let 
a train run down the track without the ability to implement the 
drawbacks and/or audit of those people who are private 
contractors providing a service, and now we are, all of a 
sudden, coming back later, and the legal problem we are going 
to have to try to get back the money that the taxpayers gave, 
and gave probably in a situation where the people weren't doing 
their job correctly.
    Mr. Christy. This will be a challenge. The good news, as I 
have mentioned, as was mentioned this morning, new awards are 
literally taking place this morning. The new EMS system and the 
hiring and the oversight, myself and Mary had very strong 
conversations the last few days about the new contracts being 
awarded this morning, and the oversight of that. And to the 
six-month leap forward when we come back here and present the 
data that went on record here earlier, we all believe we are in 
a really good spot going forward. I can't pull back what 
happened, and there will be challenges from the data that we 
get, if it is not favorable --
    Mr. Bost. And the problem we all have, as Members of 
Congress, is the fact that we go back and talk to our 
constituents, and then we have to answer to them, for where our 
levels of bureaucracy have failed, where they should have never 
been put in the position where they were going to fail in the 
first place, when they told us they could do it.
    My hope is, Ms. Devlin, when we come back, that in 6 
months, your statement is correct, and that this will be 
operating correctly. With that, I am going to yield to Ranking 
Member Ms. Esty for 5 more minutes.
    Ms. Esty. Thank you very much. So two things I want to 
actually start where my friend, Chairman Bost, ended. I want 
clarity on what is different now. Number 1, we have got a 
better oversight system in place with the exam management 
system, right, with EMS, we have got that in place. But I want 
clarity, and I think that sounds like you, Mr. Christy. Is the 
language different in the new contracts that specifically 
provides for authority and/or for authority for either claw 
back or withholding until we guarantee? Is the language 
different than it was in previous contracts?
    Mr. Christy. So the procurement vehicles that are in place 
today, and being awarded today, are very similar in nature. 
There are some nuances maybe on percentages for the incentives 
and decentives. A lot of this is going to come back to the 
programmatics of making sure that we have the proper oversight 
that was not at its best in the previous versions of these 
contracts. And so, I am going to ask help from the program when 
we talk about the guarantees on EMS.
    I know, from my perspective in the procurement world, we 
have the CORs that all have been appointed, properly trained, 
the right level of talent and skill set, and the follow-on 
people that support those CORs are in place from a procurement, 
contracting perspective. Those are ready to go, signed. Before 
the awards were even made, that was all in place. I will 
default a little bit back to EMS and the staffing levels to the 
VBA here.
    Ms. Esty. All right, so then what I am hearing is, this was 
not an issue of not having authority on the contracts. This was 
an issue of not having the data, or not having the data in a 
timely fashion that put you in a position to have enforcement.
    So what we want to know is, will you now have the data? 
Will you now be getting it in a timely fashion so that you can 
guarantee that that oversight is happening sufficiently rapidly 
that you can put a stop to payments if it turns out people are 
failing -- grotesquely failing on timeliness, or failing on 
quality? Is that -- what I am hearing is, you are saying, yes, 
but I want that on the record, that you are saying, yes, you 
believe you will now have the data to make timely 
determinations to activate the clauses that were already there 
in the contracts which you chose not to activate, because it 
was so far late in time, is what I am hearing, and you needed 
that money to get them to pay somebody else to do the work they 
didn't do? Is that correct?
    Ms. Devlin. I will answer for that. So, yes, ma'am, to your 
question about are we equipped now to perform the oversight 
that we need to perform, we are. We have the exam management 
system, which is functional and ready to provide us all the 
data we need. We are now also staffed. We have our last two 
people reporting soon, to get the full 17 staff in the office, 
so that we can conduct quality reviews in a timely manner, and 
get them turned into the acquisition professionals, so that if 
action is necessary with our contractors, they can take those 
actions accordingly.
    The other thing I just wanted to, again, reiterate for the 
record, is that our quality reviews and the feedback that we 
have been giving to our contractors does not reflect any 
egregious issues that we haven't been able to -- any small 
issues that we have been able to deal with, as Mary Glenn 
indicated, we have been able to deal with on the spot. But we 
do have all the -- everything in place with this new contract, 
to start fresh with all the data that we need and all the 
oversight capabilities. And if I have missed anything, Ms. 
Murphy will add.
    Ms. Murphy. I do want to add that the quality review piece 
that we have talked about is part of a larger staff of 84, who 
are dedicated to this mission. Among our comp service staff, 
who are all very talented, these are some of the hardest 
working folks, and the highly manual reporting and redirecting 
of work and monitoring that was caused by our nonperforming 
vendor last year, in four of our five districts in the U.S., 
was very challenging. It was unexpectedly taking more bandwidth 
to manage this from the staff we had than we anticipated.
    Ms. Esty. All right, well, thank you. It is important to 
get that on the record so we all have the same understanding of 
what the challenges were and the same assurance going forward.
    The last thing I want to flag, which I mentioned in my 
opening, was about the travel reimbursements, and so that 
people understand there is a different travel reimbursement 
system that is used for contract exams. And I think it is 
important -- four of the five of you were at the table with me 
yesterday in my office. I think it is very important that you 
put in place a system to verify that when contractors receive 
reimbursement for the VA, for having paid travel 
reimbursements, we need to guarantee they have actually sent 
those travel reimbursements to the veterans. And, anecdotally, 
we are hearing they are not always getting that.
    So that is -- again, that is part of that feedback, to make 
sure they are not getting paid for something they haven't 
actually done. So we look forward to hearing that down the 
road, what system you have in place to track that. Thank you.
    Mr. Bost. It is my understanding, Mr. Coffman, you don't 
have any more questions.
    Ms. Radewagen, you are recognized.
    Mrs. Radewagen. I thank you, Mr. Chairman.
    Ms. Devlin, I want to come back to you. You didn't really 
answer my question, and that is -- let me just rephrase it -- 
how many cases got stuck in EMS?
    Ms. Devlin. I don't have that exact number off the top of 
my head, but I will ask if Ms. Glenn has that exact number.
    Ms. Glenn. Yes, ma'am. We had about 45,000 cases get stuck 
in EMS at some point. We are now down to half a day's work in 
the EMS, and we are manually working those every day. And we 
expect to have that cleaned up by the next version of EMS that 
goes forward in December.
    Ms. Murphy. And, ma'am, if I could add, the period of time 
was around March, April, until around July, August, so there 
was that time period, and these cases -- these exam requests, 
as they tried to move forward to the vendor, and the reports 
coming back, they would hang up at different junctures; some 
for a day, some for several days, several weeks. And as Mary 
mentioned, we had patches and fixes that helped move those 
forward in batches. We are also doing it manually, and we are 
down to just a handful now.
    Mrs. Radewagen. Thank you, Mr. Chairman. I yield back.
    Mr. Bost. With that, thank you to the witnesses for 
participating in the hearing, and with that, I will also yield 
to the Ranking Member for any closing statement that she might 
have.
    Ms. Esty. Again, I want to thank the Chairman for convening 
this hearing today. I want to thank GAO for their work in 
allowing us to do our sworn duty to be oversight, both as 
responsibility to the taxpayers, and to the veterans who 
deserve to have a timely, appropriate, and careful, quality 
treatment. So, again, I want to thank you for appearing today 
and our shared commitment to continue to do better.
    And, again, whatever those metrics are -- and metrics are 
important -- this shouldn't be the ceiling for what we are 
doing for our veterans. It needs to be the floor. And we need 
to be continuously improving what we are doing, finding ways to 
do it faster, cheaper, better, on behalf of veterans. So please 
understand, if what we are doing in terms of metrics, or 
something else, is impeding our effort to get closer to the 
kind of care that our veterans deserve, we need to hear from 
you. Don't wait for us to ask. Assume that is a constant 
request -- what can we be doing smarter, better, more 
efficiently for taxpayers, and serving our veterans better. And 
you are better positioned to know that, as our partners at the 
VSO are.
    So let's not lock in the technology, the practices of past; 
let's continue to look for better ways to do that. And with 
that, again, I want to thank my friend, the Chairman, and thank 
all of you for joining us here today.
    Mr. Bost. So I want to thank everyone for being here, both 
the witnesses and the Members, and as earlier had been said, 
the complete, written statements of today's witnesses will be 
entered into the hearing records. I ask unanimous consent that 
all Members have 5 legislative days to revise and extend their 
remarks and include extraneous material.
    I also ask unanimous consent that the statement for the 
record submitted by the Veterans of Foreign Wars of the United 
States be included in the record. Hearing no objection, so 
ordered. This hearing is now adjourned.

    [Whereupon, at 11:32 a.m., the Subcommittee was adjourned.


                            A P P E N D I X

                              ----------                              

                 Prepared Statement of Elizabeth Curda
VA DISABILITY EXAMS

Improved Oversight of Contracted Examiners Needed

    Chairman Bost, Ranking Member Esty, and Members of the 
Subcommittee:

    I am pleased to be here today to discuss the Veterans Benefits 
Administration's (VBA) oversight of disability medical exam 
contractors. \1\ As you know, VBA relies on medical evidence to help 
determine a veteran's eligibility for disability compensation. To 
obtain such evidence, VBA staff may request that the veteran undergo a 
disability medical exam through the Veterans Health Administration 
(VHA) or contracted examiners. Over the past several years, VBA has 
used contractors to conduct an increasing number of these disability 
medical exams. From fiscal year 2012 through 2017, the number of these 
exams completed by VBA contractors more than tripled. According to the 
Department of Veterans Affairs (VA), it has increased its reliance on 
contractors to help avoid delays in the disability claims process 
related to completion of these exams.
---------------------------------------------------------------------------
    \1\ In this statement, we refer to examinations as exams.
---------------------------------------------------------------------------
    In 2016, VBA awarded 12 exam contracts to five private firms, which 
cover disability medical exams conducted both in the United States and 
overseas. These contracts are worth up to $6.8 billion and can last up 
to 5 years. VA reported that in fiscal year 2017 the agency spent $765 
million on disability medical exams conducted by these VBA contractors. 
VBA contracted examiners completed about 1 million disability medical 
exams from January 1, 2017 to April 2018, which is about half of these 
type of exams during this time.
    VBA's exam contracts outline quality and timeliness targets that 
are used to assess contractor performance and may also be used to 
determine financial incentives, among other things. VBA established an 
exam program office in 2016 to manage and oversee contractors, monitor 
their performance, and ensure that they meet contract requirements. VBA 
also has an office dedicated to completing quality reviews of 
contractors' exam reports, which the exam program office uses to assess 
contractor performance against quality targets outlined in the 
contracts. According to agency officials, in part, because VBA wanted 
to update performance measures for its contractors, VA re-solicited 
contracts in May 2018 for exams conducted in the United States.
    My remarks today are based on our October 2018 report on VBA's 
oversight of disability medical exam contractors. \2\ This testimony 
addresses: (1) what is known about the quality and timeliness of VBA 
contracted exams; (2) the extent to which VBA monitors contractors' 
performance to ensure that they provide high quality and timely exams; 
and (3) how VBA ensures that its contractors provide qualified and 
well-trained examiners. I will highlight several key actions we 
recommended in our October 2018 report that VA can take to better 
oversee its contracted examiners.
---------------------------------------------------------------------------
    \2\ GAO, VA DISABILITY EXAMS: Improved Performance Analysis and 
Training Oversight Needed for Contracted Exams, GAO 19 13 (Washington 
D.C., Oct. 12, 2018).
---------------------------------------------------------------------------
    For our report, we reviewed and analyzed VBA data on the quality 
and timeliness of exam reports completed from January 2017 to February 
2018. We also reviewed relevant federal laws, regulations, selected 
provisions of selected contract documents, and VA guidance. We 
interviewed VA, VHA, and VBA officials; each of the five contractors; a 
private firm that performs audits of VBA contracted examiners' 
licenses; and three national veterans service organizations. More 
detailed information on our scope and methodology is available in our 
issued report. We conducted the work on which this statement is based 
in accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives.

VBA Has Limited Information on Contractor Quality and Timeliness

    VBA has limited information on whether contractors who conduct 
disability medical exams are meeting the agency's quality and 
timeliness targets. For example, as of late-June 2018, VBA was behind 
in completing quality reviews for exams that were completed in the 
second half of 2017. For those reviews that VBA did complete, the 
agency reported that almost all contractors missed VBA's quality target 
of 92 percent in the first half of calendar year 2017, with scores 
ranging from 62-92 percent. \3\ VBA officials said the primary reason 
for the delays in completing quality reviews and related quarterly 
performance reports was a lack of quality review staff; however, VBA 
recently hired more staff to address these delays.
---------------------------------------------------------------------------
    \3\ According to VBA documents, for each quality score, VBA 
estimated the percentage of exam reports with no errors with a margin 
of error of up to 5 percentage points at the 95 percent confidence 
level.
---------------------------------------------------------------------------
    VBA officials also acknowledged that they did not have accurate 
information on whether contractors were completing veterans' exams in a 
timely manner as outlined in the contracts. VBA measures timeliness as 
the number of days between the date the contractor accepts an exam 
request and the date the contractor initially sends the completed exam 
report to VBA. \4\ The exam management system VBA used until spring 
2018 did not always retain the initial exam completion date, 
specifically when VBA sent an initial exam report back to a contractor 
for clarification or correction. In such cases, VBA's system maintained 
only the most recent date an exam report was sent back to VBA. In such 
a situation, according to agency officials, VBA would not always be 
able to accurately assess a contractor's timeliness as outlined in the 
contracts. Further, if VBA were to use the data to assess timeliness 
against the contracts' targets, it could lead to a contractor's 
timeliness score being inaccurately calculated-appearing to take longer 
for initial exam completion. In spring 2018, VBA implemented a new 
system designed to capture all of this information, but officials 
stated that the agency was still working to resolve unexpected 
technical issues with the new system.
---------------------------------------------------------------------------
    \4\ The contracts signed in 2016 included differing information 
regarding the start date of the timeliness measure. One provision of 
those contracts referred to the start date as the date VBA submits the 
exam request to the contractor. VBA later clarified that it uses the 
date the contractor accepts the exam request as the start date and that 
it revised its timeliness measure accordingly in contract modifications 
signed in December 2017 and January 2018.
---------------------------------------------------------------------------
    While VBA's data does not allow it to reliably assess contractor 
performance against the timeliness targets in the contracts, the data 
can be used in other ways. For example, we analyzed data for exams 
completed between February 2017 and January 2018 to get a general sense 
of how long it took contractors to complete exams (across all 
contractors rather than for individual contractors)-including any time 
to correct or clarify exam reports. \5\ To put our analysis into 
context, we calculated the percentage of exams that were completed 
within VBA's timeliness targets of 20 days for most exams completed in 
the United States and 30 days for overseas exams or exams requested 
through special programs. \6\ Our analysis showed that just over half 
of the exams completed were done within these general targets; however, 
some exams took twice as long to complete. \7\
---------------------------------------------------------------------------
    \5\ According to the contracts, contractors are not expected to 
complete all exams within the timeliness target, but rather they should 
meet the timeliness target on average in a given quarter. As such, the 
results of our analysis should not be interpreted as reflecting 
contractor compliance with timeliness targets under the contracts.
    \6\ Special programs include programs for servicemembers, such as 
Benefits Delivery at Discharge and Integrated Disability Evaluation 
System. VBA officials stated that exams for special programs may take 
longer because veterans who are transitioning from military service may 
not be readily available for exams. Similarly, they said it may take 
longer to schedule exams with veterans living overseas.
    \7\ For disability medical exams conducted in the United States, 
306,479 out of 575,739 exams were completed within 20 days while 12 
percent took more than 40 days to complete. For disability medical 
exams conducted overseas or for special programs, 39,132 out of 70,266 
exams were completed within 30 days.

VBA Identified Some Contractor Issues, but Lacked Adequate Oversight of 
---------------------------------------------------------------------------
    Contractors' Performance

    VBA identified some contractor performance problems, such as 
contractor delays in completing specific exams, challenges meeting the 
demand for exams, and providing timely exam reports. Nonetheless, the 
incomplete quality and timeliness information that I already mentioned 
highlight VBA's inability to adequately oversee contracted examiners 
and also contribute to other challenges managing the contracts. For 
example, we reported that, according to VBA officials, VBA had not 
completed all quarterly performance reports, which are key components 
to effectively assessing contractor performance against VBA quality and 
timeliness targets outlined in the contracts. These delays also 
affected VBA's ability to allocate exam requests across contractors and 
administer potential financial incentives across contractors. More 
specifically, the contracts state that VBA can use performance data to 
help determine how to allocate exams within specified areas in the 
United States that have two contractors. However, VBA could not do this 
because complete performance data were unavailable. Rather, VBA 
officials told us that they allocated exams based on contractor 
workload. \8\ Further, the contracts outline how VBA can use 
performance data to administer financial incentives linked to 
performance targets. However, because of its delays in completing 
quality reviews and the lack of reliable data on contractor timeliness, 
VA had not yet administered these incentives at the time of our review.
---------------------------------------------------------------------------
    \8\ For exams performed in the United States, two contractors share 
the workload within specific VBA geographic areas. As stated in the 
contracts, VBA can determine how to allocate some exams between the two 
contractors based on each contractor's performance, and its capacity to 
conduct exams.
---------------------------------------------------------------------------
    VBA officials also acknowledged that they were unable to track 
exams that needed corrections or clarifications, which is needed to 
determine if VBA should reduce payment to a contractor. The current 
version of the contracts require that contractors correct these exams 
within a certain number of days and bill VBA for these exams at half 
price. However, we found that VBA did not know if contractors met 
either of these requirements due to the lack of complete and reliable 
information on these exams.
    VBA's new exam management system, implemented in spring 2018, was 
designed to capture information that allows VBA to track whether 
contractors are properly discounting their invoices for corrected or 
clarified exams, and should also provide accurate data on exam 
timeliness. However, because not all contractors had complete 
functionality with the new system, VBA officials said the agency still 
did not have complete data. While officials said they are addressing 
these issues, VBA has not documented how it will ensure the data in the 
new system are accurate or how it will use the data to track the 
timeliness and billing of corrected or clarified exam reports. VBA's 
lack of accurate information is inconsistent with standards for 
internal control for the federal government regarding the use of 
quality information to achieve key objectives. \9\ Creating plans to 
verify that exam data are accurate can help VBA ensure it pays 
contractors the correct amount for corrected or clarified exams, and 
accurately measures contractor timeliness.
---------------------------------------------------------------------------
    \9\ GAO, Standards for Internal Control in the Federal Government, 
GAO 14 704G (Washington, D.C.: Sept. 10, 2014), principle 13.
---------------------------------------------------------------------------
    VBA has also not conducted comprehensive analyses of performance 
data that would allow it to identify and address higher-level trends 
and program-wide challenges across contractors, geographic regions, 
exam types, or other relevant factors. Agency officials told us they 
had no plans to conduct such analyses. Federal internal control 
standards state that management should establish and operate monitoring 
activities and evaluate the results of those activities. \10\ Without 
plans to conduct comprehensive performance analyses, VBA is limited in 
its ability to determine if the contract exam program is achieving its 
quality and timeliness goals in a cost effective manner.
---------------------------------------------------------------------------
    \10\ GAO 14 704G, principle 16.
---------------------------------------------------------------------------
    To address these issues, we recommended that VBA develop and 
implement a plan for using data from the new exam management system to 
oversee contractors. We also recommended that VBA regularly monitor and 
assess aggregate performance data and trends over time to identify 
higher-level trends and program-wide challenges. VA agreed with these 
recommendations.

VBA Uses An Auditor to Verify Contracted Examiner Licenses, but Does 
    Not Verify Training Completion or Collect Information on 
    Effectiveness

    VBA uses a third-party auditor to verify that all active contracted 
examiners have a current, valid, and unrestricted medical license in 
the state where they examined a veteran. However, VBA relies on 
contractors to verify that their examiners complete required VA 
training, and agency and contractor officials told us that VBA does not 
review contractors' self-reported training reports for accuracy or 
request supporting documentation, such as training certificates, from 
contractors. The contractors, rather than VBA, access the contractor 
training systems to verify that examiners have completed the required 
training before they are approved to conduct exams. VBA officials said 
that they plan to enhance monitoring of examiner training by spot 
checking training records and by developing a new system that will 
allow the agency to certify that examiners have completed required 
training. However, at the time of our review, VBA had not provided 
details or documentation on these planned checks or this system. 
Without plans to verify that training has been completed, VBA risks 
using contracted examiners who are unaware of the agency's process for 
conducting exams and reporting the results, which could lead to poor-
quality exams that need to be redone and delays for veterans.
    VBA also does not collect information from contractors or examiners 
to help determine if required training effectively prepares examiners 
to conduct high quality exams and complete exam reports. Given that VBA 
plans to award new contracts soon, the number of contracted examiners 
who are new to VA processes may increase. Thus, collecting and 
assessing regular feedback on training from contractors and examiners 
could help VBA determine if training effectively prepares examiners or 
if additional training courses are needed across contractors or for 
specific exam types.
    To help ensure that examiners are completing training and that the 
training is effective, we recommended that VBA document and implement a 
plan and processes to verify that contracted examiners have completed 
required training, as well as collect information from contractors or 
examiners on training and use this information to assess training and 
make improvements as needed. VA agreed with our recommendations.
    Chairman Bost, Ranking Member Esty, and Members of the 
Subcommittee, this concludes my prepared statement. I would be happy to 
answer any questions you or other members of the subcommittee may have 
at this time.

GAO Contact and Staff Acknowledgments

    For questions about this statement, please contact Elizabeth Curda, 
Director, Education Workforce, and Income Security at (202) 512-7215 or 
[email protected]. Contact points for our Offices of Congressional 
Relations and Public Affairs may be found on the last page of this 
statement. In addition to the contact above, Nyree Ryder Tee (Assistant 
Director); Teresa Heger (Analyst-in-Charge); Sherwin Chapman; Alex 
Galuten; Justin Gordinas; and Greg Whitney made key contributions to 
this testimony. Other staff who made key contributions to the report 
cited in the testimony are identified in the source product.

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                                 -------
                 Prepared Statement of Margarita Devlin
    Good afternoon, Chairman Bost, Ranking Member Esty, and Members of 
the Committee. We are here today to speak on VBA's Contract Medical 
Disability Examination (MDE) Program. Accompanying me is Beth Murphy, 
Executive Director of Compensation Service, Mary Glenn, Deputy Director 
of the Contract Examination Program Office, and Phillip Christy, Deputy 
Executive Director, Office of Acquisition, Logistics, and Construction. 
I will provide an overview of the MDE Program including operational 
aspects of working with the contract vendors and Veterans Benefits 
Administration (VBA) oversight of the program.

Statutory Authority

    When necessary to adjudicate disability compensation or pension 
(C&P) claims, VBA orders an examination and/or medical opinion. This 
occurs when there is insufficient medical evidence of record to decide 
the claim (See 38 United States Code  5103A). Prior to 1996, 
VA ordered C&P examinations exclusively through the Veterans Health 
Administration (VHA). As a result of Public Law (P.L.) 104-275, the 
Secretary of VA was authorized to contract through VBA using mandatory 
funds for examinations from non-VA sources. VBA began utilizing 
contract vendors to complete examinations in 1998, with the authority 
limited to 10 regional offices (RO) requesting examinations through 
contract.
    P.L. 113-235 authorized the Secretary to expand the use of contract 
examinations to 12 ROs in Fiscal Year (FY) 2015, 15 ROs in FY 2016, and 
to as many ROs as the Secretary considered appropriate beginning in FY 
2017. The expansion has afforded VBA a greater opportunity to complete 
a larger volume of examinations with greater flexibility in a more 
efficient manner. The contracts supplement VHA capacity and has enabled 
VBA to provide more timely benefits decisions. Additionally, the 
contract enables VBA to request exams for Veterans and Servicemembers 
in overseas locations, which was not an option previously provided 
through any examination.
    Through these statutory authorities, all 56 ROs now have the 
flexibility to request an examination or medical opinion from VHA 
facilities or designated contract providers closest to where the 
Veteran lives or receives regular medical treatment. Claims processors 
at ROs use an online tool enabled by real-time VHA examiner 
availability data and by examination type to determine whether VHA has 
the internal capacity to complete an examination request or whether to 
direct the examination request to a contract vendor.

Contract Vendors

    As of October 1, 2016, VBA manages all VA contracts with vendors 
that provide examinations in support of disability claims. VBA 
currently maintains 10 contracts with 4 primary vendors across the 7 
contracting districts. These vendors provide examinations nationally 
and internationally to both Veterans and certain transitioning 
Servicemembers going through the Benefits Delivery at Discharge (BDD) 
and Integrated Disability Evaluation System (IDES) pre-discharge 
programs. The current VBA contracting coverage by district is, as 
follows:

 
------------------------------------------------------------------------
     Districts                              Areas
------------------------------------------------------------------------
1 - North Atlantic  CT, DC, DE, MA, MD, ME, NC, NH, NJ, NY, PA, RI, VA,
                                                           VT and WV
------------------------------------------------------------------------
 2 - Southeast                                                     AL, FL, GA, KY, SC, and TN
------------------------------------------------------------------------
   3 - Midwest                                                 IA, IL, IN, KS, MI, MN, MO, ND, NE, OH, SD and WI
------------------------------------------------------------------------
4 - Continental                                             AR, CO, LA,
------------------------------------------------------------------------
   5 - Pacific                AK, AZ, CA, HI, ID, NM, NV, OR, and WA
------------------------------------------------------------------------
  6 - National      Providence Disability Rating Activity Site (DRAS),
 Mission (IDES,       Winston-Salem RAS and CPS, Seattle DRAS, Salt Lake
           BDD)                           City RAS and San Diego CPS
------------------------------------------------------------------------
7 - International   C&P, BDD, IDES within American Samoa, Australia,
                        Canada, Costa Rica, Germany, Guam, the Inuit
                     Islands, Italy, Japan, Mexico, Northern Mariana
                    Islands, Panama, Puerto Rico, Philippines, South
                      Korea, Spain, Thailand, United Kingdom, and US
                                                      Virgin Islands
------------------------------------------------------------------------

    In FY 2017, vendors completed 623,810 of the total 1.36 million 
examination requests. In FY 2018, vendors completed 841,852 examination 
requests of the total 1.44 million examination requests. During this 
same timeframe, VBA contract vendors exclusively completed 14,448 
overseas examination requests compared to 7,873 in FY 2017. The 
performance standards for completion of an examination request by 
contract vendors (measured from date of request until return of 
completed examination report(s)) is currently 20 days nationally and 30 
days for pre-discharge and international cases. The total costs over 
the last two fiscal years for MDE contracts, including ancillary 
contracts, were approximately $765 million in FY 2017 and $896 million 
in FY 2018.
    After the award of VBA's current contract in March 2016, there were 
multiple protests and appeal of the award, followed by contractual 
ramp-up periods for the vendors. To ensure seamless service to Veterans 
during protest periods, VBA relied on a series of bridge contracts. 
These bridge contracts have enabled VBA to extend existing contracts in 
a short term and noncompetitive manner to avoid a gap in service. VBA 
anticipates these bridge contracts will continue through December 2018.
    Going forward, VBA is focused on enhancing the MDE Program by 
rightsizing the Program Office staffing, expanding international 
coverage, such as the recently-added locations of Bahrain, Belgium, 
Denmark, Dominican Republic, Netherlands, and Poland, and by awarding a 
new contract with terms informed by our experience since 2016. Some of 
the key lessons learned during this period are the need to better 
balance between rural and urban areas within district lines and the 
need for expanded capacity and additional skill sets in the MDE Program 
Office for purposes of training and quality assurance.

Administration and Oversight

    VBA's administration of the MDE Program employs numerous training, 
quality assurance and oversight elements to ensure that any issues 
identified are addressed in a timely manner. Contract examiners receive 
the same training required for VHA examiners, including privacy 
training, to ensure all Veteran medical information is protected under 
the Health Insurance Portability and Accountability Act. The MDE 
Program Office is currently hiring staff to design and track updated 
training for the primary vendors and thousands of subcontractors.
    Likewise, VBA has expanded the staff that assesses the quality of 
completed contract examination reports and provides feedback to the 
vendors. Although quality reviews for FY 2018 have not yet been 
finalized, VBA anticipates that the new contract terms will enhance our 
ability to provide timely feedback as we deploy training to the vendors 
who conduct and document exams and to the VBA claims processors who 
make exam requests.
    VBA uses several ancillary contracts to strengthen the overall 
performance and integrity of the MDE program. One contract administers 
customer service surveys on all vendor examinations completed as a 
feedback mechanism and to provide Veterans an avenue to report concerns 
about a vendor examination experience. Another contract checks and 
validates contract examiner medical license credentials, including 
looking for past disciplinary actions. Finally, an additional contract 
assists with auditing financial activities on vendor invoices and 
payments. Through feedback mechanisms afforded by these ancillary 
contracts, VBA can take immediate action to address contract 
examination issues, such as if a license has been revoked or if a 
Veteran reports a concern related to an examination from a contract 
vendor.
    Overall, the MDE Program Office staff monitors contractor 
performance and compliance, timeliness, quality, financial management, 
and customer satisfaction related to program directives. The staff 
coordinates access to all MDE systems and provides training to assist 
field users with understanding and utilizing the contract examination 
process. Staff proactively works with the contract vendors to 
investigate and take appropriate action on any concerns reported about 
an examination experience.

Examination Management System

    In March 2018, VBA deployed its Examination Management System 
(EMS). Through integration with the Veterans Benefits Management System 
(VBMS), EMS streamlines examination scheduling requests and improves 
tracking and timeliness of examinations. VBMS integration provides bi-
directional system communication; automated system updates; responses; 
handling and improved reporting.
    Following the deployment of EMS, several defects impacting the exam 
request process-and in turn, claims processing timeliness-were 
identified. During this time, VBA worked closely within the agency and 
with contract vendors to address the issues. Updates in software 
releases have resolved most of the defects, and the remaining system 
enhancements should be addressed by the end of first quarter in FY 
2019.

Conclusion

    In summary, the MDE Program is vital to the delivery of timely and 
high-quality claims decisions. Utilizing contract vendors for C&P exams 
provides more flexibility by having vendors use a fluid mix of brick 
and mortar, and subcontractor footprints to deliver their products. 
Additionally, these contract exams enable VBA to reach some rural areas 
and individuals overseas in contrast to the limited options in rural 
areas and has no option overseas.
    VBA appreciates the authority provided by Congress to obtain 
contract examinations for Veterans and transitioning Servicemembers as 
a supplement to VHA's capabilities and for the first time to have a 
viable solution to providing examinations internationally. Continuous 
oversight and enhancement of the MDE Program remain priorities as well 
as looking for opportunities to further streamline the examination 
process.
    This concludes my testimony. I would be happy to address any 
questions from Members of the Committee.

                                 -------
                       Statements For The Record

          VETERANS OF FOREIGN WARS OF THE UNITED STATES (VFW)
STATEMENT OF MICHAEL FIGLIOLI, DEPUTY DIRECTOR
NATIONAL VETERANS SERVICE

    Chairman Bost, Ranking Member Esty, and members of the 
Subcommittee, on behalf of the Veterans of Foreign Wars of the United 
States (VFW) and its Auxiliary, thank you for the opportunity to 
provide our comments on the Department of Veterans Affairs' (VA) 
oversight of contract disability examinations (CDEs).
    Over the last 20 years, VA has more frequently contracted with 
private health care providers as a way to provide sound medical 
opinions with the intent to quickly and accurately adjudicate veterans' 
disability benefit claims. This contracted system has proven to be 
beneficial to both veterans seeking benefits and VA in ensuring 
veterans can receive timely and correct benefit decisions. The VFW 
fully supports VA's efforts to provide veterans with contract 
disability examination options for a variety of reasons. The most 
significant of which is that we believe, and veterans confirm, that 
private providers can furnish a largely objective opinion in evaluating 
a veteran's claimed medical condition.
    Moreover, we hear frequent positive comments about contract exams 
and the outcomes for veterans. Unfortunately, since VA executed its 
latest contract for disability examinations in 2016 and extended work 
to two new vendors, Logistics Health, Inc. (LHI) and MSLA, a Medical 
Corporation, the VFW has seen new problems emerge which impelled us to 
join our partners in the veterans service organization community to 
call for a hearing so that this subcommittee can better assess the 
situation.
    Under the most recent contract, VA instituted new, incredibly rigid 
timelines for contractors to complete exams and return records to VA. 
Though the recent Government Accountability Office (GAO) report notes 
that VA allows 20 days for vendors to conduct routine exams, in reality 
the vendors tell the VFW that this leaves them a window of only about 
one business week in which to conduct the exams. This is an 
unreasonable expectation. These standards in no way reflect the needs 
of the veteran, nor are they favorable to VA which has a well-
documented shortage of examiners at both the full-time employee and 
contract levels. When we ask VA about these timelines, the usual 
response is that VA believes veterans want their benefits completed 
quickly. We concur. However, VA cannot sacrifice accuracy and a 
positive customer experience for the sake of speed. It does not matter 
how quickly a veteran receives a rating decision from VA if the 
decision is wrong.
    Since 2016--and amid multiple disputes about the validity of VA's 
contract; extensions of bridge contracts; termination of one of VA's 
new vendors; and the solicitation of new bids--the VFW has seen a 
growing list of problems with VA's contract exam system. This summer, 
in light of these problems, we asked VA for a report on quality for the 
current contract examination system. After dragging its feet for more 
than a month, VA finally replied that they could not share this 
information unless the VFW filed a Freedom of Information Act request. 
After reviewing the GAO report, the VFW believes that the leadership of 
the Mandatory Disability Exam Office did not want to admit that they 
had not completed a quality review report for any period in 2018. With 
all of these factors affecting veterans' access to accurate and timely 
benefits, this hearing comes at a very critical time.
    The VFW can summarize the problems we have seen with the current 
contract exam system as follows:

    - Late notification of exams.

    - Lack of options for veterans to reschedule exams.

    - Lack of availability of adequate examiners with reasonable 
distance to the veteran.

    - No adequate review of a veteran's claim file prior to the exam.

    - Inadequate time with provider due to volume and turnaround.

Late Notification of Exams

    The VFW has learned from our field staff and locally in the 
Military District of Washington about dozens of instances where 
veterans were not notified in a timely manner that VA had scheduled 
exams. In one example from Georgia, the veteran was contacted by VA's 
vendor, LHI, on a Thursday afternoon for an exam scheduled on Monday 
morning. When the veteran tried to reschedule with LHI, he was guilted 
into rearranging his schedule for the Monday appointment and 
essentially forced into calling out of work and rearranging other 
health care appointments out of fear that his benefits would be 
adversely affected. When the VFW reviewed the veteran's claim file, we 
noticed that not only had VA sent the exam request to LHI less than a 
week before the exam was scheduled, VA also failed to include accurate 
contact information for the veteran, which was readily available in the 
veteran's records.
    Under the old contract, veterans were afforded more time to get 
their affairs in order to attend contract exams. Even the legacy 
contractors have complained to the VFW that the new contract makes it 
harder for veterans to attend exams, resulting in higher no-shows and 
returned exam requests to VA, either further delaying delivery of 
earned benefits, or worse, resulting in erroneous denial of benefits.

Lack of Options to Reschedule

    Given the new compressed timeline, we hear from veterans that if 
they cannot make the appointments assigned to them by the contractor, 
they are offered only three options: attend your appointment regardless 
of conflicts; be reported as a no-show and VA will likely deny your 
benefits; or have the contractor return the appointment request to VA 
as a cancellation with the hope that VA issues another exam request 
soon. Each of these options is bad for veterans. Under the old 
contract, the legacy contractors were reasonably flexible with 
veterans, ensuring exams could be completed in a matter of weeks. The 
VFW received very few complaints before 2016, and even collected 
positive stories about the contract exam experience.
    Unfortunately, under the new contract, we have seen negative 
outcomes for veterans and some potentially concerning business 
practices when it comes to rescheduling or cancellation requests. The 
most glaring example of this came from a veteran in Maryland who is 
assisted by the VFW staff here in Washington, D.C. According to the 
veteran's claim file, VA ordered a series of exams from LHI on October 
17, 2018. On October 18, 2018, the veteran was listed in the Veterans 
Benefits Management System as a no-show for her exams. This obviously 
caught our attention and we contacted the veteran to learn what 
happened. The veteran told us that she was called by LHI on October 18, 
and asked if she could reschedule. LHI told her she could not, and they 
would have to return the exam request to VA. Veterans seeking benefits 
should not have to be concerned about contractor penalties due to their 
inability to properly notify them or obtain a timely exam.
    In spite of this, what concerns the VFW most about this situation 
is that the veteran was reported as a no-show. Our understanding of the 
contract is that this means that LHI is still paid for the exam, even 
though no exam was ever completed. Again, VA's contract exams office 
has not been transparent with the VFW on contract exam issues, so we 
have no way to verify this, other than posing it as an assumption to 
the subcommittee in this forum. Regardless, at the very least it seems 
that contractors are incentivized to cut corners in an effort to meet 
VA's unreasonable expectations.

Lack of Availability of Examiners

    Another persistent issue we have heard from offices around the 
country is that to meet the timeliness goals of the contract, each of 
the contractors is forced to schedule veterans wherever they can find 
an available doctor. This leads to unreasonable travel times and 
unrealistic appointment expectations for veterans.
    In Arkansas, one elderly veteran was scheduled for a contract exam 
in Oklahoma, more than three hours away from his home. In Washington 
state, another veteran in the Seattle area was scheduled for an exam 
more than three hours away in Oregon. In Washington, D.C., we have seen 
veterans sent to Gettysburg, Pa., for exams.
    Another glaring example came from California, where a San 
Francisco-area veteran was scheduled for one exam at 3:30 p.m., more 
than 20 miles outside of the city, with a second exam scheduled at 4:15 
p.m. back in San Francisco, making it logistically impossible for the 
veteran to attend both.
    Fortunately, in each of these cases, the VFW's service officers 
have caught these unreasonable requests and worked with VA to resolve 
the issue. However, we must question the structure of a contract that 
forces a vendor to make these kinds of decisions.

No Adequate Review of Claim File/Inadequate Time with Provider

    The VFW believes the final two issues are linked. We continue to 
hear concerns about the adequacy of a contract examiner's review of the 
veteran's claim file and the time that veterans receive with providers. 
These have been issues that the VFW has raised prior to the 2016 
contract, but these problems persist, and we believe they have been 
exacerbated by the new timeliness requirements of the contract.
    When contract providers fill out Disability Benefit Questionnaires 
(DBQs) for veterans, they must verify whether or not they have fully 
reviewed the veteran's file. They usually affirm that they have and 
then go on to render an opinion. However, we have learned that the 
vendor selects which specific files to share with a provider ahead of 
the exam, meaning they likely never fully review the file. We have also 
heard reports that some contract providers solely rely on the 
claimant's pre-exam worksheet to evaluate the historic record of a 
condition, rather than the official claim file documents. To the VFW, 
both scenarios render the exam unacceptable and inadequate.
    Next, we have also heard conflicting information from veterans 
about the time spent with providers and the attention given to their 
issues. We hear anecdotes that veterans see providers for only a matter 
of minutes and that certain required measurements or evaluations are 
never actually conducted, though they are reported as such on the DBQ. 
We have no way to verify this independently, but the volume of 
complaints that we hear from our service officers in the field and 
directly from veterans once again force us to raise this issue with 
this subcommittee.
    The VFW does support and believe in the contract disability 
examination concept. We have seen it work. In Wisconsin, we continue to 
see very positive outcomes for veterans, and our service officer even 
reports that when it comes to accuracy, he believes contract exams more 
closely match the veteran's reported experience than exams conducted 
internally by VA. This reinforces the VFW's core belief that 
unaffiliated third parties are well suited to render objective 
opinions. However, even Wisconsin reports that they have seen 
scheduling problems for veterans they serve. We are very concerned that 
VA is not adequately tracking quality and customer experience for its 
contractors, meaning there is no real way for VA to monitor the 
efficacy of the contract for the veterans they serve. This is why we 
are left to resort to anecdotes and trends that we see around the 
country for our clients.
    VA has a unique opportunity now as it seeks to enter into a new 
contract for CDEs. The new contract must factor in veteran experience, 
measure quality outcomes, and report transparently on these outcomes. 
Without this, we will continue to see erroneous denials, reported no-
shows, and contractors cutting corners to try and meet unrealistic 
objectives.

                                 [all]