[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
UPDATE ON VA CONTRACTED EXAMS,
QUALITY REVIEW PROCESS, AND
SERVICE TO RURAL VETERANS
=======================================================================
HEARING
before the
SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
__________
THURSDAY, SEPTEMBER 19, 2019
__________
Serial No. 116-34
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via http://govinfo.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
40-990 WASHINGTON : 2022
COMMITTEE ON VETERANS' AFFAIRS
MARK TAKANO, California, Chairman
JULIA BROWNLEY, California DAVID P. ROE, Tennessee, Ranking
KATHLEEN M. RICE, New York Member
CONOR LAMB, Pennsylvania, Vice- GUS M. BILIRAKIS, Florida
Chairman AUMUA AMATA COLEMAN RADEWAGEN,
MIKE LEVIN, California American Samoa
MAX ROSE, New York MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia JACK BERGMAN, Michigan
SUSIE LEE, Nevada JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR., DANIEL MEUSER, Pennsylvania
California STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN, W. GREGORY STEUBE, Florida
Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York
Ray Kelley, Democratic Staff Director
Jon Towers, Republican Staff Director
SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS
ELAINE G. LURIA, Virginia, Chairwoman
GILBERT RAY CISNEROS, JR., MIKE BOST, Illinois Ranking Member
California GUS M. BILIRAKIS, Florida
GREGORIO KILILI CAMACHO SABLAN, STEVE WATKINS, Kansas
Northern Mariana Islands W. GREGORY STEUBE, Florida
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
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, SEPTEMBER 19, 2019
Page
OPENING STATEMENTS
Honorable Elaine G. Luria, Chairwoman............................ 1
Honorable Mike Bost, Ranking Member.............................. 3
Honorable Gregorio Kilili Camacho Sablan......................... 10
Honorable Gus M. Bilirakis....................................... 12
Honorable W. Gregory Steube...................................... 14
Honorable Gilbert Ray Cisneros, Jr............................... 19
WITNESSES
Ms. Mary Glenn, Deputy Director, Mandatory Disablity Exams
Program, Veterans Benefit Administration, U.S. Department of
Veterans Affairs............................................... 4
Ms. Elizabeth Curda, Director, Education, Workforce and Income
Security Issues, U.S. Goverment Accountability Office.......... 6
Mr. Rick Weidman, Excutive Director for Policy, Vietnam Veterans
of America..................................................... 21
Mr. Shane Liermann, National Legislative Director, Disabled
American Veterans.............................................. 23
Mr. Ken Wiseman, State Adjutant and Accredited VSO, Veterans of
Foreign Wars, Department of Virginia........................... 24
Ms. Kimberly Shalloo, Washington DC Liaison Chair, National
Association of County Veteran Service Officers................. 26
APPENDIX
Prepared Statements of Witnesses
Ms. Mary Glenn Prepared Statement................................ 35
Ms. Elizabeth Curda Prepared Statement........................... 38
Mr. Rick Weidman Prepared Statement.............................. 51
Mr. Shane Liermann Prepared Statement............................ 54
Mr. Ken Wiseman Prepared Statement............................... 59
Ms. Kimberly Shalloo Prepared Statement.......................... 61
The National Congress of American Indians Prepared Statement..... 72
Submissions For The Record
The American Federation of Goverment Employees, AFL-CIO.......... 77
Letter to Representative Steube from Bay Pines VA Office......... 79
UPDATE ON VA CONTRACTED EXAMS,
QUALITY REVIEW PROCESS, AND
SERVICES TO RURAL VETERANS
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THURSDAY, SEPTEMBER 19, 2019
U.S. House of Representatives
Subcommittee on Disability Assistance
and Memorial Affairs,
Committee on Veterans' Affairs,
Washington, DC.
The subcommittee met, pursuant to notice, at 10:30 a.m., in
room 210, House Visitors Center, Hon. Elaine Luria [chairwoman
of the subcommittee] presiding.
Present:Representatives Luria, Cisneros, Sablan, Allred,
Underwood, Bost, Bilirakis, and Steube.
OPENING STATEMENT OF ELAINE G. LURIA, CHAIRWOMAN
Ms. Luria. I call this oversight hearing to order.
Good morning and welcome to the subcommittee on disability
assistance and memorial affairs hearing. Without objection, the
chair is authorized to declare a recess at any time.
I would like to start today's hearing by asking any veteran
in the room to raise their hand.
[Laughter.]
Ms. Luria. I know that my colleagues join me in thanking
you for your service. We share the sense of dedication to
ensure that we never forget the sacrifice that our women and
men in uniform have made in service to our country.
The path to service connection starts with a claim for
benefits, and most often requires a VA exam, commonly known as
a compensation in pension or C&P exam. These exams are critical
to the success of a veteran's claim. They often provide the
missing link to service or give a medical assessment of the
severity of a disability. This information can be a deciding
factor whether a claim for service connection is granted or
disability evaluation is increased.
Because disability exams play a key part in enabling
veteran access to benefits, we are under a continuing
obligation to make sure they are completed correctly and in a
timely fashion.
In the recent years we have seen a spike in the number of
C&P exams outsourced to contract examiners. The work that
contract examiners perform continues to increase. In fact, GAO
highlights that the number of contracted exams has quadrupled
since 2012.
Currently, contractors carry out 64 percent of the exams,
up from 61 percent in May of this year and 53 percent in May of
last year.
While I welcome the increased capacity that contracted
examiners offer to veterans in rural areas, including veterans
who live in my home State of Virginia, quick expansion often
can come with growing pains.
Today we are following up on last November's hearing on
disability contract exams to ensure that the VA is making
progress on the GAO's recommendations. At the last hearing, VA
assured Congress it would approve its quality review process,
correct flaws in their software and IT programs, and ensure
contract examiners completed VA trainings. This is an
opportunity for the VA to tell us about the progress they have
made over the last 10 months and what work still needs to be
done.
Since the VA's recent improvements, veterans report a
general decrease in the amount of wait times for C&P exams, but
are concerned that cultural training is not appropriately
provided to contract examiners.
Veterans also report that locations of contract
examinations are not consistently vetted. One example provided
in written testimony by the National Association of County
Veteran Service Officers highlights a veteran's experience
where their C&P exam was conducted inside of a nail salon.
Another example cited to my staff highlighted that a
veteran with mobility issues had difficulty reaching their
appointment because the contract did not have a handicapped
access ramp.
My staff has also heard reports that contract examiners are
not consistently providing travel reimbursements to veterans.
This, too, is supported by a recent survey conducted by the
Disabled American Veterans who outline that as many as 40
percent of their service had offices reported that veterans
were not receiving travel reimbursements for the contracted
medical exams.
Numerous veterans service organizations, groups and
veterans report that expansion to access for benefits is a
priority. Our veterans who live in highly populated areas have
easier access to VA services than our veterans who live in
rural communities and in remote locations, including in tribal
lands.
I understand the new contract awarded in November 2018
restricted the geographical regions amongst venders in an
attempt to increase veteran access to examiners and evenly
distribute rural veterans amongst the contract vendors.
I look forward to hearing about the successes and
challenges with this initiative. It should be clear to everyone
that we simply cannot let distance be the barrier to a quality
and timely C&P exam.
The VA has made large strides in reducing wait times and
improving access to VA benefits. I applaud the VA for their
effort thus far. But more work to improve access must be done
in the realm of the contract examination process. I look
forward to hearing the testimony from the VA, GAO and from
veteran service organizations today. I welcome your ideas and
ask for your continued open and solution-driven communication.
With that, I would like to recognize Ranking Member Bost
for his opening comments.
OPENING STATEMENT OF MIKE BOST, RANKING MEMBER
Mr. Bost. Thank you, Chairman Luria, and thank you all for
being here today to discuss the Department of Veterans Affairs
issuing that veterans have access--ensuring that veterans have
access to a timely and accurate disability medical exams.
But I would also like to take a moment, if I can, to say a
special welcome to a friend and former chairman of the Veterans
Affairs' Committee, Jeff Miller, is who is here in the audience
with us today. Welcome.
The VA oversight of contract exams programs is important
because if a veteran does not receive adequate exam, the
veteran may not receive the benefits they deserve. This Fiscal
Year vendors have already completed 950,000 exams, or 64
percent of all disability exams at the cost of $876 million.
Given the size and cost of the contract exam program,
Congress has a responsibility to ensure that the contracts are
effectively serving veterans at a fair rate to taxpayers.
For those reasons, last November I immediately held a
subcommittee oversight hearing on contract exams after GAO
released a report that found VA was not collecting the data
necessary to monitor the contract exam program. I was troubled
that the VA could not determine whether the contractors were
meeting quality and timeline standards.
Moreover, the VA could not verify whether contract
examiners completed required training and whether it was
productive.
However, since the November 2018 hearing, I am pleased that
Secretary Wilke has started the process to better oversee the
contracts such as hiring a quality review team that can conduct
quality reviews monthly, and update IT systems to ensure that
the Department has accurate data on contract timeliness.
Today, I am looking forward to receiving an update on VA's
progress to implementing the GAO's recommendations. I am also
interested in learning how the VA can improve the accuracy of
the contract exams.
To perform these reviews, VA uses a checklist of 13
questions to assess whether the exam is satisfactory. However,
I am concerned that the checklist may not collect enough
information to identify the program-wide challenges. If the VA
cannot identify common errors and quickly update training
contract examiners, many may repeatedly provide inaccurate
medical opinions. VA has a responsibility to ensure that
contract examiners are sufficiently trained on the requirements
for disability exams. Our veterans deserve no less.
Additionally, I am worried about the veterans who live in
rural areas, may not have a VA or a contract examiner within a
reasonable distance. Many of these veterans have disabilities
that make it difficult for them to travel any long distance.
If a veteran is unable to travel to their exam, the VA may
not be able to gather the medical information necessary to
decide their claim. I am looking forward to learning how the VA
and the vendors are developing innovative ways to meet rural
veterans where they live.
Lastly, Congress approved the use of contract examiners to
allow VA to focus more of its resources on treating patients
and to expedite the scheduling of disability exams.
I would like to discuss how contract examiners have
streamlined VA's claim system while maintaining veteran
satisfaction with the process.
Again, I want to thank everyone for being here today.
With that, I yield back, Madam Chair.
Ms. Luria. Thank you.
For our first panel we have Ms. Mary Glenn, Deputy Director
of the Mandatory Disability Exams Program at the Veterans
Benefit Administration; and Ms. Elizabeth Curda, Director of
the Education Workforce and Income Security Issues for the
Government Accountability Office.
Thank you for being here today.
I would like to recognize Ms. Glenn first for 5 minutes.
STATEMENT OF MARY GLENN
Ms. Glenn. Good morning, Chair Luria, Ranking Member Bost,
and members of the committee. Thank you for the opportunity to
speak today on the Veterans Benefits Administration contract
medical disability examination program. Today I will provide an
update on how VBA is delivering contract examination services
to veterans in the United States and around the world.
When necessary to adjudicate disability compensation or
pension claims, VBA orders an examination and/or medical
opinion. This occurs when there is insufficient medical
evidence of record to decide the claim. Prior to 1998, all C&P
examinations were completed by the Veterans Health
Administration. As a result of Public Law 104-275, VBA uses
mandatory funds for examinations from non-VA sources.
In Fiscal Year 2017 the authority was expanded to allow
examinations across all states and territories, and to
international locations. The expansion has afforded VBA great
opportunity to complete a larger volume of examinations with
greater flexibility in a more efficient manner. The contracts
allow VBA to supplement VHA's capacity and have resulted in VBA
providing more timely benefit decisions.
In November 2018, VBA awarded new contracts for the United
States and aligned the contract districts from 5 to 4,
providing more even distribution of rural and urban areas
across the districts and increased vendor capacity by allowing
for 3 vendors to each district as opposed to only 2 in the
previous contract. Vendors are required to meet new quality
timeliness and customer service standards.
In addition to the 4 regional contracts, VBA has contracts
that provide examinations to service members going through the
pre-discharge program and to veterans residing overseas.
VBA has significantly expanded the international contract,
increasing from 25 overseas locations in Fiscal Year 2018 to 33
in Fiscal Year 2019.
In Fiscal Year 2018, VBA contract vendors were responsible
for 841,852 of the total 1.44 million examination requests
completed. Contract examination completions for Fiscal Year
2019 through August 2019 total 957,858.
VBA's administration of the MDE program employs numerous
quality, training and oversight elements to ensure that any
issues identified are addressed in a timely manner. VBA is
committed to ensuring that veterans are provided with high
quality disability examinations. Examination quality is
evaluated monthly with the results from the reviews used to
identify training needs and provide feedback to contractors
through monthly calls and reports.
The MDE quality assurance office became fully staffed in
January 2019 and has remained up to date on quality reviews
since that time.
To best serve veterans, contract examiners receive the same
training as VHA examiners in order to provide consistent
results and familiarize them with veteran specific needs.
The MDE program office utilizes multiple mechanisms as
efficiently oversee the contract examination program. VBA
combines the use of international systems and ancillary
contracts to better evaluate vendor performance. The MDE
program office uses ancillary contracts to administer financial
auditing, validate provider credentialing and provide customer
service survey results.
A third party credentialing vendor checks the contract
examiner medical credentials against multiple sources such as
State medical licensing boards and Federal sanctions data
bases.
Another contract audits financial activity associated with
vendor invoices and payments. Finally, the customer service
survey contracts allows all veterans who receive a contract
examination the opportunity to provide feedback regarding their
examination experience.
VBA designed an examination management system that provides
the capability to interface with multiple vendors' proprietary
systems. VBA continues to enhance EMS through a monthly
software release schedule. In the last year we have addressed
connectivity issues and enhanced system functionality to
improve oversight and visibility into vendor performance.
Veterans in the United States and its territories traveling
to C&P examinations are eligible for travel reimbursement.
Beneficiary travel payments are mailed to veterans by the
vendors immediately following their disability examination
appointments and are validated through VBA's third party
financial audit contract.
In summary, the MDE program is vital to the delivery of
timely and high quality claims decisions. VBA continues to
provide C&P examinations in those instances where VHA does not
have the capacity.
VBA appreciates the authority provided by Congress to
obtain contract examinations for veterans and transitioning
service members. Continuous oversight and enhancement of the
MDE program remain priorities as well as looking for
opportunities to streamline the examination process.
This concludes my testimony. I would be happy to answer any
questions from members of the committee.
[The Prepared Statement Of Mary Glenn Appears In The
Appendix]
Ms. Luria. Thank you, Ms. Glenn.
Ms. Curda, I would like to recognize you for 5 minutes.
STATEMENT OF ELIZABETH CURDA
Ms. Curda. Chair Luria, Ranking Member Bost and members of
the subcommittee, thank you for inviting me to update you on
VBA's progress implementing recommendations we made in 2018 to
improve 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. Since 2012, the number of
exams completed by contracted examiners has more than
quadrupled to about 958,000 and currently accounts for more
than half of all exams.
Following the issuance of our report, VBA awarded 12 new
contracts to private firms that are worth up to $6.8 billion
over 10 years.
Today, I will discuss VBA's progress implementing
recommendations we made in 2018 in 2 areas. First, the progress
VBA has made in assessing contractor performance in terms of
the quality and timeliness of contracted exams and, second, the
progress VBA has made in ensuring that its contracted examiners
are well trained.
Regarding the first area, we previously reported that VBA
lacked accurate and complete information on whether contractors
are meeting the agency's quality and timeliness targets. At the
time of our review VBA had not completed many of quality
reviews of the contracted exams due to an insufficient number
of staff.
In response, VBA officials told us they hired additional
quality review staff to complete the outstanding quality
reviews. For the new contracts, VBA officials said that they
have completed initial quality reviews, but have not yet
finalized them.
Further, we previously found that VBA could not accurately
assess the timeliness of the contracted exams. In our 2018
report we recommended that VBA develop and implement a plan for
using data from its new exam management system to accurately
access contractor timeliness, monitor time spent correcting
exams, and verify proper exam invoicing.
VBA officials have told us they are now able to correctly
measure contractor timeliness in completing initial exams and
in making corrections. However, as of September 2019, VBA
reported that it has not yet been able to fully implement its
plan for using the new system to calculate contractor
timeliness versus targets.
Lacking quarterly performance reports with official quality
and timeliness scores, VBA has not yet administered financial
bonuses or penalties linked to performance per the contracts.
In addition, ongoing technical issues have prevented VBA
from implementing an automated invoicing system that it plans
to use to validate the accuracy of contractors invoices. As a
result, according to VBA it still cannot ensure that
contractors are properly discounting exams that had to be
corrected.
VBA stated that it has completed testing of its invoice
system and will provide an updated target completion date in
October.
Due to these ongoing systems issues, VBA has not yet used
its contractor exam data to examine contractor performance
trends and program-wide challenges as we have recommended. VBA
stated that as it improves its systems it will be able to
implement this recommendation, but did not provide a specific
date.
In the second area of examiner training, VBA has made some
progress. We previously found that VBA lacked information it
needed to verify that contract examiners had taken required
training. Instead, the contractors self-reported this
information.
VBA also lacked plans to evaluate the quality of the
training it provided to examiners. This was particularly
problematic given the low quality scores many of the
contractors had at the time of our review.
We recommended that VBA implement a way to verify that
contracted examiners have completed required training and to
evaluate the quality of the training. In response, VBA started
conducting random audits of contractor training records. In
addition, VBA is in the process of developing a centralized
training system to collect information on all training
completed by contract examiners and to obtain participant
feedback on each course.
VBA stated that it expects the new system will be fully
implemented by the end of Fiscal Year 2020, and that it will
continue random audits until full implementation.
In summary, the VBA has taken steps to address the problems
with contractor oversight we identified in 2018, but has not
yet fully implemented our recommendations. As VA increasingly
relies on contracted examiners, it is important that the agency
is well positioned to carry out effective oversight to 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 Elizabeth Curda Appears In The
Appendix]
Ms. Luria. Thank you, Ms. Curda.
We will now begin with questions. I recognize myself for 5
minutes.
I would like to start with Ms. Glenn, and thank you again
for your time today. I would like to revisit the issue raised
in last year's GAO report regarding the quality review process.
I understand that VA's quality review team previously had a
backlog that made it difficult, if not impossible, for VA to
award incentives or penalties to contract vendors for
performance.
Have you worked through the backlog and are you up to date
on issuing these incentives and penalties?
Ms. Glenn. Yes, ma'am. We have worked through the backlog
as of January 2019 when we became fully staffed on the quality
review program. We actually caught up that month of January
2019 and we have remained caught up since that time.
For the new contracts that we just awarded in November,
they had a 6 month ramp up period. We are doing quality reviews
and we are caught up on quality reviews for the ramp up period,
and we are now evaluating the quality reviews for the first
period of performance, which started in June. That is a quarter
of performance, so June, July and August. We are in the process
of completing the quality reviews for that quarter. They should
be completed in the next month and a half or so.
Ms. Luria. Great. Well, we will look forward to being able
to see the results of those quality reviews.
Is there any data to show whether a veteran is more or less
likely to have their claim denied if it was performed by a VA
C&P examiner versus a contract examiner?
Ms. Glenn. We do not have any data like that. However, we
are very open to our veterans and we listen to them, and we
have completely revised the training program. Well, actually,
we created a training program for our medical providers. They
have to take all training that any VHA C&P provider has to
take. We have also expanded that and created training for them
for military culture, for any kind of court decision that comes
down that changes the way we look at the medical system, and--
--
Ms. Luria. Do you have a comprehensive----
Ms. Glenn.--revision----
Ms. Luria.--system in place in order to track the
completion of that training?
Ms. Glenn. Right. We do not yet have that. We are working
very closely to get a talent management system that we can use
for all the providers. Right now as Ms. Curda eluded to, we are
doing random audits of the completion from the vendors. We are
able to go into the vendor system----
Ms. Luria. Is there any quality control you use for
completion of the training? Is someone required to take an
exam----
Ms. Glenn. Yes.
Ms. Luria.--or have a certification----
Ms. Glenn. Yes.
Ms. Luria.--based off the training?
Ms. Glenn. Yes, they are.
Ms. Luria. But you don't have a mechanism to track right
now whether that has been done?
Ms. Glenn. We do. We go into the vendor's training systems.
We have access into their training systems. We pull the data
ourselves.
Ms. Luria. Do you have examples of providers who have been
rejected because they either failed to do the training or
failed to pass the required exams related to the training?
Ms. Glenn. The last audit we did everyone was in
compliance.
Ms. Luria.: I would also like for you to address issues
raised by veterans who State that they have attended VA
contract exams in places that didn't really seem appropriate
for exams, such as a nail salon or behind a sandwich shop.
Can you explain to me the vetting process for these
contract providers and how we can catch things like this before
a veteran goes to that location?
Ms. Glenn. Right. All of the vendor locations are supposed
to be ADA compliant. That is required by the contract. When
we----
Ms. Luria. The contractor is required to physically verify
that before they start using a provider?
Ms. Glenn. Yes, ma'am.
Ms. Luria. What happens----
Ms. Glenn. So----
Ms. Luria.--what kind of penalty for the contractor exists
when we discover there are cases where that was not true?
Ms. Glenn. If we find out that they are using somewhere
that is not ADA compliant, we will tell them to cease and
desist immediately. They will no longer use that provider or
that facility.
Ms. Luria. I will continue and yield to Mr. Bost for 5
minutes. Thanks.
Mr. Bost. Thank you, Madam Chair.
Ms. Glenn, and this is important that we get this on the
record so we know for future reference. Can you explain, you
know, how the VA has used how you are using the lessons learned
from the MSLA incident and past failure to quickly respond to
the developing situation with VetFed or any other potential
underperforming vendor so that the veterans do not receive
inadequate or delayed exams?
Can you explain exactly what you are doing to make sure
that that doesn't happen or----
Ms. Glenn. Right. So----
Mr. Bost.--cover this problem?
Ms. Glenn.--3 things come to mind. One is the fact that we
changed the contract so that we changed the areas so that we
had a more even distribution of rural and urban areas. We have
staffed up our quality review program. We are giving monthly
training and quality calls to all the vendors on a regular
basis. We are there to answer their questions and take care of
any training issues immediately.
The third thing is we have looked at our EMS program and we
are tracking the data much more closely. We are able to get
more data. We are able to have a much broader range of data
points than we have ever had before. This is a new system, and
we are able to look at it and catch immediately when we see
that there is a problem.
Mr. Bost. Do you feel like you are ahead of the VetFed
problem right now so that you can make sure that it does not
develop like the other one did into such a large situation that
it causes the veterans to suffer and then the program as a
whole to look bad?
Ms. Glenn. Right. We are looking at all of our vendors very
closely during this first period of performance. We have been
looking at them since the beginning of the ramp up period so
that we can catch any kind of problems and make adjustments in
their training and anything that we can do to assist them to
make sure that they are serving veterans properly.
Mr. Bost. Thank you.
Ms. Curda, is the GAO confident that the information
captured in the EMS will allow VA to determine if contractors
are meeting performance targets?
Ms. Curda. VA has told us that they have corrected many of
the problems with the EMS system. However, we still haven't
really heard an answer about whether the system can produce the
timeliness information that is required under the contracts.
I think it can be determined maybe with some work arounds,
but I don't know that the system right now can produce that
information as readily as would be desired.
Mr. Bost. Okay. Then I am going to check and go with you,
Ms. Glenn, and can you give us detailed plans you have to
capture the EMS to evaluate performance----
Ms. Glenn. Right.
Mr. Bost.--where you see this going that you can meet the
requirements that are set forth by GAO?
Ms. Glenn. Yes. Absolutely.
We are looking at the current provider performance
standards. We are listening to our VSO partners. We are
listening to veterans. We want to make sure that we do not in
any way disadvantage veterans in order to have these
performance standards met. We are looking at the new data
points that we are able to see now with our EMS system. We are
seeing a lot of the underpinnings of the system that we
previously could not see, which we have already talked about
with the back and forth between the vendor and the claims
processor and the answering questions and asking questions.
We are taking all that into consideration as well as
meeting with our VSOs to make sure that we have our performance
set at the right level.
We also now have the ability to move examination requests
quickly from one vendor to another. So if we see a problem, we
are able to do that overnight.
Mr. Bost. Thank you.
I am going to kind of shift gears here just for the last
minute or so.
Ms. Glenn, what feedback has the VA received from veterans,
particularly rural veterans, about the experiences that they
have received from the mobile medical clinics?
Ms. Glenn. Right. Most of the veterans that we have talked
to that have had an examination through the mobile clinics have
been very, very pleased. We were just in a claims clinic in
North Carolina this past weekend. We were able to see about 80
veterans during the claims clinic through our mobile clinics.
80 veterans in that area were able to walk in and get an
examination that day.
Mr. Bost. It is probably much better than a nail salon.
[Laughter.]
Ms. Glenn. Yes, sir.
Mr. Bost. Just guessing.
Ms. Glenn. Yes, sir.
Mr. Bost. With that I will yield back. Thank you.
Ms. Luria. Thank you.
I now recognize Mr. Sablan for 5 minutes.
Mr. Sablan. Thank you, Madam Chair. Thank you for holding
today's hearing. Good morning, Ms. Glenn and Ms. Curda.
I think I can honestly say that there is--all of us in this
room want nothing but to say that all of our veterans are
getting the benefits they deserve fully and no one falls down
out of the crack.
There are 2 cycles that I have been in this committee also.
I have observed that in one way or another VA has not lived up
to its obligations for our veterans.
In a hearing yesterday after 2 years with a software
program they still can't determine how many actually--how many
employees there are with VA, and how many positions are vacant,
and how many are being recruited, and how many are resigning,
and how many are relocating.
Again, today I come from a place where there is--when I got
in there was no VA existence, period. Then a fee-based clinic
conductor was hired. We have VA assistance, but our veterans
are going, flying to destinations to get examinations for--to
be determined eligible for benefits.
In your opening testimony, Ms. Glenn, mentioned that VA
reimburses veterans from the territories, yes?
Ms. Glenn. Yes, sir. That is correct.
Mr. Sablan. Yes. So how does the process work? How
efficient is it to get because these are not wealthy people. To
fly to say, Hawaii, would cost you at least $1,000, plus hotel,
plus transportation to go to Tripler or things like that.
How efficient is the process to reimburse these veterans?
Ms. Glenn. Yes, sir. The process is laid out to be very
efficient. After the veteran reports for the examination, they
check with the veteran to confirm that the contractor has the
veteran's correct mailing address. The veteran, once the
veteran confirms the mailing address, they should receive a
beneficiary travel check within a couple of weeks.
Mr. Sablan. A couple of weeks, Okay, because veterans come
and ask me for help on getting their reimbursements.
May I ask, Ms. Glenn, if you would provide me with a paper
or any document explaining the process that veterans so I could
share it with them, you know, when they come visit me?
Ms. Glenn. Yes, sir. We would be happy to look into that
for you and get back to you----
Mr. Sablan. Thank you.
Ms. Glenn.--and your staff.
Mr. Sablan. Are you aware if there are instances when
veterans don't get reimbursed on time?
Ms. Glenn. I have recently heard that there are instances
like that. We have been speaking----
Mr. Sablan. How much? How many in the terms of percentage?
Ms. Glenn. Actually, my staff has not received any
complaints. But I have heard anecdotally that there have been
problems. We would be happy to work with anybody out there if
they are having a problem getting their beneficiary travel
check, and make sure that that is rectified immediately.
Mr. Sablan. Right.
Just like, you know, some of the responses you gave GAO
that you would do something in 2 years, and here we are 2 years
later and you still don't have a plan as promised. I am not
here to be critical in any way. I want nothing more but for you
to be successful in your duties and your responsibilities. That
is the way we need to serve our veterans.
You are not. The Department is not successful with its
mission, and we need to work harder to try to find a way to get
the Department, get the different agencies to be successful so
that our veterans would be served with the benefits and we give
them the benefits they deserve.
My time is up. Thank you.
Ms. Luria. Thank you, Mr. Sablan.
I would like to follow up with a question. In this example
where someone is having to get an exam in the Northern Mariana
Islands, is there a provider there, a contract provider there
who they can see?
Ms. Glenn. There is a contract provider there who is
capable of doing some types of examinations.
Ms. Luria. If that is not within their scope they have to
fly somewhere else?
Ms. Glenn. They do have to fly somewhere else.
Ms. Luria. They are getting reimbursed, so they have to
have the money first just to get the exam? Is that----
Ms. Glenn. Yes. At this----
Ms. Luria. And you----
Ms. Glenn.--point in time, yes.
Ms. Luria. What if they can't afford it?
Ms. Glenn. If we are notified about it, we can certainly
work with the vendor and work something out for them.
Ms. Luria. To potentially receive advance travel?
Ms. Glenn. Yes, to potentially get them to where they need
to be for the examination, either that or bring a provider in
to that area to be able to examine them on the spot.
Ms. Luria. Okay. I mean, this seems like incredibly
burdensome for someone who lives in a remote area where there
is not a choice or an available provider. I would like to know
that you followed up with Mr. Sablan so that he can have that
information for his constituents who, you know, would have to
pay out of pocket just to go get an exam which seems
unreasonable.
If someone is driving 50 miles, I think that is not an
unreasonable expectation. They could do that and then get
reimbursed. To travel from Northern Mariana to Hawaii is quite
a burden. I would like to know more about that.
Ms. Glenn. Okay. Certainly.
Ms. Luria. Thank you.
Mr. Bost, do you have any followup on this?
Okay. I would like to recognize Mr. Bilirakis for 5
minutes.
Mr. Bilirakis. Thank you, Madam Chair. I appreciate it very
much, and I thank you for your testimony.
Ms. Glenn, GAO recommended the VA assess whether its
training for examiners is effective. Is VA performing any error
trend analysis, such as consistency studies, to determine if
VA's training has improved the quality of exams?
Ms. Glenn. Yes, sir. My quality team does error trend
analysis on every sample that they look at. That's one of the
reasons that we provide monthly--we have monthly quality calls
with the vendors, and we notify them if we see anything that is
potentially problematic immediately. We provide additional
training for them on those quality calls.
Mr. Bilirakis. Okay. Very good.
Also, Ms. Glenn, VBA's quality review checklist does not
include criteria for frequent exam errors. For example, we have
received information that medical examiners commonly fail to
consider the impact of flare-ups on range of motion for
musculoskeletal conditions. I messed that one up.
Is VA planning to update its quality review process to
include additional criteria based on the DBQ completed?
Ms. Glenn. Yes, sir. We are always reevaluating our quality
assurance process. But I will tell you that we recently did
training on exactly the issue that you're talking about to all
of our vendors. That should resolve some of the problems that
have been seen in the past.
Mr. Bilirakis. Okay. We are going to followup with that
then.
Ms. Curda, what are the main obstacles remaining for VA to
implement your recommendations on improving its oversight of
contractor training?
Ms. Curda. Well, I think first they need to work out the
kinks in EMS so that they can produce the required timeliness
information so they can hold the contractors accountable per
the terms of the contract. I think they are up to date on the
quality reviews. We were waiting on the first quarter of
performance under the new contract.
There are also technical issues with the invoicing
verification system. Right now if a contractor produces an
inadequate exam, it has to be sent back to be fixed. Under the
terms of the contract, those exams are supposed to be charged
at 50 percent of the cost and the contractor submits an invoice
reflecting that discount.
VBA, until the system is in place, will not have a way to
verify if that invoicing has been done correctly and that the
government is being charged correctly.
We also feel like--I think we mentioned this last year; VBA
needs to do some planning around how to use all this
performance information that it is now collecting. They appear
to have a lot more information than they had last year. The
information may be better than what they had last year, but
there--we have not yet seen a plan for how they plan to use all
this information to identify trends across the contractors,
across regions, to dig into the data and do analysis and use
that information to take corrective actions.
I think as Ms. Glenn said, they are certainly doing this on
a monthly basis, just looking at the quality information. Now
they have timeliness information. They should have better
veteran satisfaction information coming in, and doing some
analysis on all of this information in combination would give
them some insights that they could then use to proactively
address contractor issues.
Mr. Bilirakis. Thank you very much.
Ms. Glenn, how does VBA know that it has fully resolved the
initial technical issues with the exam management system and
exam requests getting ``stuck''?
Ms. Glenn. Yes, sir. That is no longer an issue. We have
worked very closely with our IT partners. As I said in my
opening statement, they are doing monthly updates now to our
system. We are no longer seeing cases getting stuck. The cases
that were stuck have been moved forward and are no longer being
delayed, and most have been processed.
Mr. Bilirakis. Okay. How recent was that where we don't
have cases getting stuck?
Ms. Glenn. It's been a----
Mr. Bilirakis. Give me a timeline.
Ms. Glenn.--continuous process since last summer. Every
update that happened unstopped more cases, solved more defects.
And then it was just a process where we would go and correct
additional defects, and then the next month correct more
defects.
It has been a process since last summer, but we are now at
a good place.
Mr. Bilirakis. All right. I see my time has expired. Thank
you very much for the answers and we will follow up. I
appreciate it very much. Madam Chair, I yield back.
Ms. Luria. Thank you.
I now recognize Mr. Steube for 5 minutes.
Mr. Steube. Thank you, Madam Chair.
Ms. Glenn, so are you over the appeals process as well or
just the C&P examinations?
Ms. Glenn. I am just over the C&P examinations.
Mr. Steube. Okay. I will keep my comments related to that.
I represent Southwest Florida. A lot of my district is very
rural. Most of--well, everybody in my district has to go to Bay
Pines, which they have to travel some distance to get to Bay
Pines. Many veterans are told when they have to go for their
C&P examination that they have to plan to be there the whole
day. You need to be there at 08 or 07, which for people in
Sarasota, Hardy, Desoto, Highlands Glades, Okeechobee Counties
is going to be like a 3 to 4 hour drive. You are getting up at
like 3, 2, 3 in the morning to get there by 07, 08. Then they
are being told that they have to be there the entire day for--
plan the entire day for their C&P exams.
Most working age adults obviously don't have the ability to
take off work during a Monday and Friday for an entire day just
to go and get an examination for 30 or 45 minutes.
Can you explain to me why our veterans are being told that
and expected to be there the entire day?
Ms. Glenn. I can't speak for what--if they are going to the
Bay Pines VA Medical Center, I can't speak to what their
process is. I just look at--I am just over the contract medical
examinations that are administered by VBA. We do not tell--I
don't believe our vendors tell people that. They give them the
time of the appointment and then just ask them to be at the
specific address at that time.
Mr. Steube. Well, they are being told that because I have
been told that just as early as a couple of months ago. My
appeal has been going through the process for now 10 years, 8
to 9 to 10 years. I had a C&P exam at Bay Pines and I will tell
you my story and then I will ask for why this is happening to
our veterans because it is not just happening to me. It is
happening to people in my district.
I received the letter for my C&P exam. So here is the
letter from my C&P exam from Bay Pines, from the VA. The date
of the letter is June 24, 2019, and then in the letter where it
says, ``If the C&P office does not receive your call to
schedule appointments for the examination by the identified
date above''--which the identified date above is Monday, June
24th, which is the date of this letter, so I don't know how you
are going to be able to respond on the date of the letter to
that date. Then there is a handwritten time in there. I
received this on July 3rd, which then the next day is July 4th
which is obviously a holiday and nobody is working. I had 1 day
to call this office.
I called the office and I was told--I called the number on
the letter for the C&P exam. I am going to ask to enter this
letter into the record so that you can have a copy of it and
the committee has a copy of it to just see what I have
experienced, and I am sure other veterans are experiencing the
same thing.
When I called the lady to set up the appointment she said
she had one day available, which, again, I don't know how
working age males can find one day in their schedule that they
are going to go on that day and have to take off work for that
day and not get paid for that day. She said I had 1 day. I had
to be there at 07 or 08, and she told me on the phone that I
had to plan to be there all day. I asked her why would I have
to be there for the entire day just for an examination. She
said that is what the regulations require us to do.
This is what--I see your head shaking behind you, but like
this is what was told to me by your VA. Okay. I said, well, I
am not available on that date, and I didn't tell her I was a
Congressman. I just told her I wasn't in town that day.
She said, Okay, this is what you are going to have to do.
You are going to have to--because there are no other dates
available in this 30-day window, you are going to have to call
me back in 2 weeks, and she gave me the phone number. I wrote
it down for you so you have it. You are going to have to call
back in 2 weeks because we are going to have to send your
packet back to the regional office and you have to wait 2 weeks
until the regional office then does whatever they do, and then
call back 2 weeks later. Then you have to request from the
regional office that they send your packet back to this person
that I am talking to and then wait 2 weeks to then set up a new
appointment, and then they are going to tell you a 1 day and
then you have to be there all day.
Can you explain to me how the--I mean, what is happening
is a veteran like myself, whether I was in Congress or not, if
I was still not in Congress and just a lawyer or just a plumber
or an electrician, I can't take off a day off work to drive 2
hours for a 30 minute appointment.
Explain to me how--because what most veterans are going to
do, they are going to say, especially my generation of veterans
are going to be like, screw it. It is not worth me going up
there, taking a day off work, to lose the money from going a
day off work, to go up there and deal with this and sit there
because that is going to do because I can explain--I don't have
much time left. Hopefully, the chair will give me a little
leeway here; but to sit there all day for a 30-minute
examination.
Can you explain to me why our veterans are being treated in
this manner?
Ms. Glenn. Yes, sir. Just to be clear, that was--I am sorry
you had that experience. We don't want any of our veterans to
be disadvantaged when they have to go to their C&P examination.
I will be happy to take the information that you provide
and go to my colleagues in VHA and see if they can provide you
with the information that you are requesting.
Mr. Steube. Okay. Since my time is--oh, thank you. Can you
please provide me that by--I mean, how long do you think it
will give you that information of whoever is in charge of that
program and whoever I can talk to as to--because Bay Pines is a
big hospital.
Ms. Glenn. Right.
Mr. Steube. It has a big service area. If it is happening
to me, I can guarantee you it is happening to every veteran
that is having to go to a C&P exam.
Let me back up a little bit further. My case was one of the
cases that was stuck. For 2 years I haven't heard anything from
the VA. Occasionally you get a letter and then nothing for the
last year or so.
I had to reach out like what is going on because I have had
this appeal going on for 9 or 10 years, what is going on and
why--like what is the next step, like tell me what the next
step is. And then so somehow it got dislodged from being stuck
in the ether, wherever it was stuck in the ether, and then it
was like, oh, you need a C&P exam. I am like, well, I just had
a C&P exam like 2 years ago, what is wrong with that. Well, the
time has elapsed from--you need another one, which is what
precipitated the letter, which then I had 1 day to respond to
the letter and then the 1 day that they give me to show up I am
not available. And then it has to go back to the regional
office to come back to this.
I mean, it is just--it is ridiculous. I mean, it is
ridiculous that we are putting our veterans through this type
of rigmarole because what they are going to do is say, you know
what, it is just not worth going through this to have to go
through all these hoops to deal with this.
Ms. Glenn. Right.
Mr. Steube. I would like to know who in the VA--I had a
meeting with Secretary Wilke supposedly today or yesterday. He
canceled. So I want to know who it is I need to talk to in the
VA to make sure that veterans, at least in the State of
Florida, are not having to deal with these issues. I don't have
time to talk about all the other issues as it relates to the
appeal and C&P process. That is just one little piece that just
happened this past summer.
There is a lot of issues that need to be discussed. I hope
this committee--I mean, you are a veteran. A lot of us are
veterans. I hope that we really address these issues to make
sure that our veterans aren't going through the things that I
personally went through at least in our country.
I would very much appreciate the information of who I need
to talk to to remedy these issues.
Thank you, Madam Chair.
Ms. Luria. Well, thank you, Mr. Steube, for sharing your
personal experiences. And without objection the material that
Mr. Steube presented will be entered in the record.
[The Letter To Representative Steube From The Bay Pines Va
Office Appears In The Submissions for the Record]
Ms. Luria. I would like to start a second round of
questioning, so if you do have further things that you would
like to have, you will have time again to do that.
So I recognize myself again for 5 minutes, and this time I
have some questions for Ms. Curda.
In our district in Coastal Virginia, I represent over
90,000 veterans in the Second congressional District. And I am
concerned with the VA's slow walk toward conducting thorough
oversight of these contracted exams as I think our veterans
deserve the highest level of quality service.
Do you think from your assessments at GAO that the VA needs
more full-time equivalent, more personnel in order to complete
the evaluation necessary to give us a good pulse on the
evaluations process?
Ms. Curda. We did not conclude in our work last year, I
mean, other than the issue with the quality reviews, that
staffing was a significant factor in addressing the oversight
issues. I think that we would recommend that the VBA take the
time to plan what it needs to do with all this information to
be able to provide the oversight, and then use that plan to
then align all of its systems and performance information to be
able to provide the oversight that they should do.
Ms. Luria. Okay. Thank you.
And, Ms. Glenn, we had the opportunity to meet yesterday
and you did reference a previous staffing shortage. But it
seems as though you are within 1 position of having all of
those filled.
Are there any additional resources that you would need in
your role to be able to provide this thorough analysis or is it
a question of taking the new data that you have access to and
then working on metrics?
Ms. Glenn. Yes, ma'am. I will say we are always looking at
our resources and what our capability is, and trying to take
advantage of every bit of resources that we have so that we can
better serve veterans.
I would say at this point, as we spoke, we are still
analyzing all of our data, and when we are finished doing that
I will be happy to meet with you and your staff and let you
know.
Ms. Luria. Great. Well, we look forward to that.
One of the other topics we talked about is cancelations. So
do you feel that you have the appropriate IT systems to be able
to capture data relative to cancellations and how that impacts
the performance both for the contractors and then for the
satisfaction of the veterans?
Ms. Glenn. Yes, ma'am. We do at this point. As I said, this
is all new data. This EMS system was a new system that we built
based on our specifications, and it is able to go into the
proprietary systems of all of our vendors and pull the data out
of there. That is something brand new that we have never had
the ability to do before.
Ms. Luria. Okay. Likewise we would like to be able to
understand, you know, the conclusions that you can draw from
that data once you have had time to analyze it.
Lastly, the enactment of Blue Water Navy Veterans Act is
pending here in January. And I would like you to explain how
that will affect the need for claims exams, and is the VA, and
specifically in your capacity as providing contract C&P exams,
are you prepared for that role out and a significant jump in
claims relative to the Blue Water Navy Veterans Act?
Ms. Glenn. Yes, ma'am. We have been preparing for that for
several months now. We do feel that we will be able to meet the
surge in exams that we expect in January.
We have been planning on a daily basis all of compensation
service in order to meet the needs for our Blue Water Navy
veterans.
Ms. Luria. When you say that, is that specifically internal
to your organization? Do you also feel that confidence within
the contractors and their capacity to----
Ms. Glenn. Yes, ma'am.
Ms. Luria.--take on additional exams?
Ms. Glenn. Yes, ma'am. We have notified them as soon as we
found out that the act had passed, and we notified them to
expect a surge when it went into effect in January.
Ms. Luria. Thank you.
I recognize Mr. Bost for 5 minutes.
Mr. Bost. Thank you.
Thank you, Madam Chair.
Okay. Ms. Glenn, I'm going to go back to the rural area.
This is, I think, something that we need to expand on and get
on the record.
Can you give us detailed plans what the VA plans is to
provide rural veterans with the claim clinics? You know, what
is the overall design that you are looking at, what are some
unique ideas that you are coming up with to--because that is a
real issue out there. I know there is an extreme case like we
heard about a while ago because that would be the extreme case.
There are rural areas all over that we can see that the
problem of long-time travel to VA or to even a clinic would be
tough.
Ms. Glenn. Yes, sir. We are always looking to improve our
outreach to rural veterans. We are reaching out to them through
these claims clinics which are typically held by the regional
offices within that State. As soon as we hear that there will
be a claims clinic, we notify our vendors and ask them if they
would be willing to participate. Thus far they have been more
than willing.
They have large recreational vehicles that they have
stripped down and turned into traveling doctors' offices,
mobile clinics, so to speak, and they are able to travel to
these rural areas and provide different types of examinations,
psychiatric exams, audiological exams, general medical type
musculoskeletal exams, any type of exam that can be done within
an examination room.
As I eluded to earlier, we had a claims clinic this past
weekend in North Carolina. We had 2 vendors there and they were
able to see a total of 80 veterans.
Mr. Bost. That is because the vendors have the capability
to do this under existing rules?
Ms. Glenn. Yes, sir. They have the ability. They also have
the ability to move medical doctors across State lines so that
they can--if they see that there is an issue in a rural area,
they can travel one of their provider physicians across State
lines in order to perform examinations.
Mr. Bost. Then the next question, because I think you
touched on it a little bit, but how is it that we are able to
reach out to our veterans that may be in the rural area,
educate them that this is available to them?
Ms. Glenn. Yes, sir. We work very closely with the regional
offices in each State in order to make sure that they are
advertising the claims clinics and the availability of our
vendors when they are there.
The other thing that our vendors are doing is they are
doing some Telehealth exams now so that the veteran really
doesn't have to travel far beyond the borders of their home.
They are also looking at what we call ACE exams, which are
acceptable clinical evidence examinations, where in some
certain specific instances the doctor is able to review the
veteran's claims folder and make a determination without
needing an examination.
We are actually promoting that the vendors use the ACE
exams and the Telehealth exams so that the veteran is not
disadvantaged in any way.
Mr. Bost. Okay. I am going to kind of shift gears here
right quick. I want to ask Ms. Glenn again. Okay. I understand
the VA has not yet produced quality timeliness and quality
reports that summarize each contractor's performance under the
new contracts.
Does EMS have automated functionality to generate
timeliness reports or is the VBA still employing manual work
arounds to kind of get this information?
Ms. Glenn. Right. We have all this new data now. We are
analyzing it. We expect that once we have determined that we
are using the right performance measures that EMS will be able
to provide us with reports automatically. That is what it was
built for and that is what we want it to do. We just need to
make sure that it is measuring the correct number, the correct
performance measures.
Mr. Bost. When do we think that we as a committee would be
able to receive that information, you would have that
information available so that we can compare notes and
understand what we are trying to do is being done correctly or
where the holes are so we can try to work through that?
Ms. Glenn. Yes, sir. As soon as we have worked through
that, and my staff is actively working on it today, we will let
you know and I will be happy to come back and speak to you
again.
Mr. Bost. Are these measures, that information, required in
the contract by those--that each individual provider has to be
able to get that information back to it?
Ms. Glenn. It is required in the contract that we notify
the provider. That is part of their performance. The overall
quality timeliness and customer survey satisfaction, that is
all of the 3 things that they are measured on and that is in
the contract.
Mr. Bost. Okay. Thank you.
And, Madam Chair, I yield back.
Ms. Luria. Thank you.
And I now recognize Mr. Cisneros for 5 minutes.
Mr. Cisneros. Thank you, Madam Chairwoman. Thank you both
for being here.
Ms. Glenn, thank you for being here. I wanted to bring to
your attention a constituent of mine, Alberto Gonzalez, a Gulf
War veteran. He came to my office in Fullerton seeking help
with a claim for compensation and pension. The VA had referred
him out to a physician contractor with third party vendors,
VetFed, for an examination earlier this year.
During the course of the evaluation the physician's office
made a coding error whereby they incorrectly indicated Mr.
Gonzalez was employed during the time of the examination. In
fact, Mr. Gonzalez had been unable to sustain gainful
employment since February 2018 due to the condition for which
he was being evaluated for.
As a result of the error, there has been substantial delay
in Mr. Gonzalez receiving the benefits for which he was
entitled, with several months passing before my office was able
to help him obtain a letter from the physician to correct the
misinformation.
Now Mr. Gonzalez is forced to drive all the way to San
Diego regional office for a non-appeal hearing to present the
correction letter, which is a one and a half hour drive from
his home in Fullerton, California.
For Mr. Gonzalez, this has been an added stressor for
himself and his family, and a burden on his time. In a letter
to me Mr. Gonzalez stated, I feel guilty that I have had to put
a strain on my children's resources. I am one of the lucky ones
that has a strong, loving, supportive family.
Mr. Gonzalez's situation is but one example and I fear that
we do not have a clear understanding of the full extent of the
situation. As the GAO raised in their testimony, this is a
serious concern for the VBA. It does not have information on
whether training effectively prepares examiners to conduct the
high quality exams.
Ms. Glenn, my question is, what training is involved to
ensure that third party contractors are fully listing and
coding appropriately in the VA system so that a veteran's life
isn't put on hold?
Ms. Glenn. Yes, sir. All of our contracted, subcontracted
physicians and medical providers have to go through the same
training that VHA C&P examiners have to go through.
We also have additional training that we have developed for
military culture awareness and any kind of court decision or
any kind of other training that we feel is necessary based on
trend analysis during quality reviews. We hold monthly calls
with all of our vendors in order to go over what we're finding
with their quality reviews.
I am very sorry that your constituent is having that issue,
and if you would like to provide us with the information I
would be happy to go back and see what I can do.
Mr. Cisneros. We will do that.
Why is it so hard to correct if there is an error made? Why
does it take so long to make a correction to where this--why
can't it be just done very simply?
Ms. Glenn. Yes, sir. It should be done very simply and I am
not quite sure, you know, what happened in that specific case.
But it should not be the problem that you indicated that it
was.
Mr. Cisneros. All right. I yield back the balance of my
time.
Ms. Luria. Thank you, Mr. Cisneros, and thank you all for
appearing today and answering questions.
I would like to now invite Panel Number 2 to the witness
table. As you change places I will make an introduction of
those who will be joining us on panel 2.
We have Mr. Rick Weidman, Executive Director for Policy
from the Vietnam Veterans of America; Ms. Kimberly Shalloo,
Washington D.C. Liaison Chair of the National Association of
County Veteran Service Officers; Mr. Shane Liermann, Deputy
National Legislative Director of the Disabled American
Veterans; and Mr. Ken Wiseman, State Adjutant and Accredited
VSO for the Department of Virginia Veterans of Foreign Wars.
I will just give everyone a minute to get settled and then
we will continue.
[Pause]
Ms. Luria. I especially want to thank Mr. Wiseman today for
joining us from my home State of Virginia. We will start with
Mr. Rick Weidman. I will recognize you for 5 minutes.
STATEMENT OF RICK WEIDMANN
Mr. Weidman. This is the first time a Member of Congress
has recognized me for my age, I think, by putting me first. I
am almost always last at these hearings, Ms. Luria.
First, at VVA, we thank you for holding this hearing and we
are grateful to you for inviting us to share our thoughts and
observations.
This is an important issue for Vietnam veterans because our
average age is 73. That is a mean average age, and it was 73.0
this past June. Folks are frankly in the fourth quarter and not
just us, but people who serve us like the VA, whether on the
health side or the benefits side, need to step up their game,
also, and get into a 2-minute drill.
The extension by 6 months of the Blue Water Navy claims has
particularly upset us, but also our colleagues who deal with
Blue Water Navy folks because how many of those people are
going to die between and now July 1 and January 1. The claim
dies with the veteran as we all know. And so if they don't
adjudicate it now, even if it is a direct medical claim, not a
presumptive, it doesn't happen. They have frozen all of them.
The point is here on whether on that or on other claims. We
did not support the appeal management and improvement act,
Modernization Improvement Act, and the reason when people ask
me is, well, it neither improved nor modernized the system.
That is why we did not support it. And we need to go back to
letting the previous system of the Court making decisions and
then that decision being binding on the original claim process.
That needs to happen before we are ever going to straighten out
this system.
In regard to Blue Water Navy, they claim they will be
scheduled as early as early October, but that still doesn't cut
it in terms of moving those claims through in a timely manner,
which are necessary.
I will skip right to some of our observations and
communications about what we believe is the heart of the
matter. As much has been made about training, and we believe
that is true, that the problem is no cognitive based tests.
That is not just for the people who are the medical examiners
to fill out the claim. They don't do cognitive based testing
of--everybody who touches a claim ought to go through the same
type of a test.
A number of years ago, and I am glad the former chairman is
in the room because he charged us with coming up, a group of
VSOs, and we came back with just such a plan. It would be VSOs
plus county and State people, but also VA people and even
attorneys would have to take that exam. And people said, well,
you can't make attorneys take an exam. I said, really. Do you
know you can't practice Maritime law without passing the
Maritime bar? You can't practice aviation law unless you pass
the aviation bar, and on and on and on. So we could require
that of folks.
In this case the question, central question for us is
adequacy of the exam and the accuracy of the judgment. And in
many cases folks just aren't trained in the wounds entries and
illnesses that result from military service.
Some of the technical things that has to do with scheduling
is currently the date that the exam is ordered is not entered
into the VBMS computer system so that our folks, our benefits
counselors, can know that it went in there and to work with the
veteran to make sure that he or she has transportation to get
to that exam. That should be an easy thing to do, but it is not
being done.
We have suggested it, by the way, directly to VBA in their
monthly meetings.
We also recommend that all exam notification letters to the
veteran clearly State that it is possible to reschedule the
exam and how to do so. Right now it just threatens people,
except one. LHI's letter says, to reschedule this exam contact
LHI at least 1 business day prior to your scheduled appointment
to determine if you are eligible.
That last phrase means to most vets, well, I must not be
eligible because they would have called me before. And so what
they do is discourage anybody from reaching out.
The third recommendation is that all contractors are
trained to speak with an accredited veterans service agent just
like the rest of the VA people are trained to do in order to
represent the best interest of our clients. VVA recommends that
all exam requests generated by VBA contain a date of request on
the form to increase accountability and transparency. Currently
they don't. You have no idea how long it languished, much less
the letter that is generated until it gets to the veteran.
We strongly urge the subcommittee to dive deeper into the
quality issue. The quality assurance and you will notice that
all of the testimony about trying to address the previous GAO
report is all insider baseball. It is all about bureaucratic
things. Well, we have adequately staffed up. Okay. How has that
improved the actual quality of the exam, and the accuracy of
the exam?
Many times, the truth is in the exam itself. From what
people tell us, it is clear during the medical exam that the
examiner, the contract examiner, has never even looked into
your previous medical history. A lot of the claims,
particularly of Gulf War claims and other things, become
apparent only by looking at the things over time, which is only
contained in the medical record.
I am out of time. I do thank you and look forward to
discussing with you and your colleagues as well as staff some
of the changes that we think are due.
Thank you very much, Madam Chairman.
Ms. Luria. Thank you, Mr. Weidman. I will now recognize Mr.
Liermann for 5 minutes.
[The Prepared Statement Of Rick Weidman Appears In The
Appendix]
STATEMENT OF SHANE LIERMANN
Mr. Liermann. Thank you, Madam Chair, Ranking Member Bost
and members of the subcommittee. On behalf of DAV's more than 1
million members, we thank you for the opportunity to present
our views at today's hearing.
In order for veterans to receive their earned benefits, a
claim seeking service connection for specific conditions must
be established with the VA. In many cases, the VA exam is the
lynchpin to establish or deny the claimed benefit, thus
demanding quality and timely VA and VA contract exams.
Starting in Fiscal Year 2017, the disability contract exam
program was expanded to all VA regional offices. Also in Fiscal
Year 2017 1.3 million veterans received VA exams of which 45
percent were provided by VA contractors at a cost of $765
million.
In Fiscal Year 2018 1.4 million veterans received VA exams
of which nearly 60 percent were provided by VA contractors at a
cost of nearly $900 million.
In the June 2019 OIG report, inadequate oversight of the
contracted disability exam cancelations, they determined that
VA exam cancelations increased by 74 percent in Fiscal Year
2017. The staggering increase in exam cancelations is
disturbing and DAV is concerned that veterans are being
negatively impacted.
If a contractor reports a cancelation reason, such as a
veteran was a no show for an exam, the case will be decided
based on the evidence of record without the benefit of medical
evidence from a completed exam. If this leads to a denial and
the veteran then disputes it, the veteran must now submit a
supplemental claim to have the exam rescheduled which will
cause further delays and add new claims to the pending process.
One factor that may be contributing to the increase in exam
cancelations is the contractually required 20 day time period
for exam completion. Contractors are not allowing veterans to
schedule or reschedule exams that may place them outside of the
20 day time period.
Madam Chair, recently we solicited feedback from our 65 DAV
national service offices around the country. Almost 70 percent
reported that contractors canceled exams even when veterans
were willing and able to report. More than 80 percent reported
that veterans whose exams were canceled were unable to
reschedule with the contract examiner.
Given the recent increases in contract exam cancelations
and the number of veterans involved, we recommend that VBA
track all canceled VA contract exams with specific reasons for
the cancelations and provide a quarterly report to congress, as
well as requiring all existing and future VA exam contracts to
add canceled exam as a performance measure.
Cancelled VA contract exams need to be closely monitored as
part of the ongoing quality reviews as these can have
detrimental effects for all veterans, but specifically rural
veterans as their access to VA or VA contract exams is even
much more limited.
For example, our office in North Dakota reported that there
are only 2 contract examiners available to veterans, requiring
them to drive over 70 miles and, in some instances, veterans
are being asked to travel 3 to 4 hours one way for a VA
contract examination.
Enacted in 2016, Public Law 114-315 allows a VA contracted
physician to conduct an exam at any location in any State.
However, this only includes physicians. We recommend this law
be amended to include other licensed healthcare professionals
such as nurse practitioners and clinical psychologists that VA
currently accepts as VA examiners.
Access to VA healthcare for rural veterans is challenging,
but providing VA exams to receive their earned benefits
accurately and timely should not be.
In closing, the contract exam process should serve the
needs and best interests of the men and women made ill or
injured by their service. The VA contract exam process should
not be designed to serve solely the requirements of the
contract.
Madam Chair, this concludes my testimony. I would be
pleased to answer any questions you or members of the
subcommittee may have.
[The Prepared Statement Of Shane Liermann Appears In The
Appendix]
Ms. Luria. Thank you, Mr. Liermann.
I now recognize Mr. Wiseman for 5 minutes.
STATEMENT OF KEN WISEMAN
Mr. Wiseman. Thank you, Madam Chair, and Ranking Member
Bost, members of the subcommittee. We appreciate the
opportunity to testify today on the important matter of what
veterans living in rural areas face when attending C&P exams as
part of their VA disability claims.
The C&P exam is a vital part of this process for
determining if a veteran has a condition that is service
connected and in determining the severity of the condition. As
an accredited veteran service officer and a veteran myself, I
know the C&P exam is a major phase of completing the disability
claim, but it is a process which can be improved and rural
veterans would benefit.
The VFW provided testimony on contracted exams to this
subcommittee this past November and we highlighted 5 major
areas which I can report that all of those are only worsened by
the fact that a veteran lives in a rural area.
I also want to note that just yesterday VA has reached out
to the VFW to have a conversation about these appointments.
The shortage of examiners is something that the VA is known
to have. However, there are ways to solve this. One of the
nurses who cares for me at the Salem VA Medical Center reported
to me that after 19 years she will be retiring. However, she
clearly stated she wanted to continue working part-time, but VA
regulations prohibit this.
Considering that our Nation has a shortage of medical
professionals, why would we want to turn away dedicated,
experienced people who could help fill critical gaps like C&P
exams? This could help solve the problem that rural veterans
face.
Veterans also complain about the distance that they travel
for an appointment. I represent a veteran who is unable to
drive long distances and his daughter drives him. VA recently
granted his claim for Type II diabetes associated with Agent
Orange. However, his experience with the C&P exam was absurd
and is one we can use to highlight ways to fix this system.
His daughter takes off from work so she can drive the
veteran to the appointment. The appointment that was for the
exam was deemed as incomplete by VA and the veteran was forced
to return to that doctor for another exam. The veteran reported
both exams collectively lasted less than 60 minutes and the
trip was 8 hours of driving for the two exams. That only gives
a negative taste of the VA to the veteran.
I often hear from veterans that their VA doctor, who works
for the Veterans Health Administration, VHA, has diagnosed him
with having a condition, but they still must go through a C&P
exam administered by the Veterans Benefits Administration, VBA.
Why can't the evidence found in a VHA exam suffice for a
claim submitted through the VBA? I certainly understand that
the responsibility of the VHA doctors who treat a condition,
not necessarily evaluate in accordance with regulations.
However, there would be fewer C&P exams if VBA first asked
the treating physician to complete a C&P exam. VBA already
pulls the evidence from the veteran's record as part of the
normal claims process. It is actually questioned right on the
exam or, excuse me, right on the claims application.
Continuing on this issue, I would like to point to the
types of conditions that veterans file for that are conditions
which are diagnosed with a simple blood test. The veteran I
mentioned having diabetes lives less than 30 minutes from a VA
clinic and could have reported there for the blood draw needed
to diagnose his diabetes.
Further, his private doctor could have provided the
evidence obtained through a blood test, and this highlights the
VFW's long-standing position supporting greater use of private
medical evidence in the claims process. Repetitive work that
only re-diagnoses a condition is something that needs to end.
Any portion of the C&P exam which requires a veteran to be
visually seen by an examiner is an opportunity to use
Telehealth, especially for rural veterans. The VFW praises VA
for the work they have done to expand options and is a proud
partner in one of the latest projects, advancing Telehealth to
local access stations better known as Project ATLAS. ATLAS uses
buildings zoned by the VFW and American Legion posts to provide
locations for Telehealth based appointments. There is no reason
we can't do the same for C&P exams.
Partnerships with other Federal agencies and medical
schools like the VA has made in the past would be another
option for these exams.
Finally, the VA and its third party contractors that
provide many C&P exams need to offer more flexibility for
veterans in completing their exams. VA has tightened its
timelines to complete the exam and this only exasperates
unnecessary travel and burdens for rural veterans.
Veterans understand the need for the exam as part of the
claims process and are more than willing to wait another week
if necessary if it means a shorter drive. In my written
testimony I noted the difficulties veterans face in
rescheduling C&P exams. VA needs to include flexibility for
rescheduling as this only leaves advocates like me to clean up
the mess through unnecessary supplemental claims and appeals.
While I have offered several options to improve this
system, I want to be explicitly clear about one important
issue. There is no support in my testimony for the lowering of
the burden of proof needed for the VA to grant a claim, and the
integrity in the exam process is something that the VFW has
long supported. Accuracy being sacrificed for speed would only
ensure a veteran gets the wrong answer faster and that is not
the answer.
In closing and on behalf of those veterans who live in
small towns and wide open spaces across our great nation, I ask
Congress to work to improve the process by which a veteran is
examined for their VA disability claims. Where a veteran lives
should not be a burden they are forced to shoulder in this
process.
This concludes my testimony and I welcome any questions
that the subcommittee has. And we are very happy to have one of
Virginia's own as the subcommittee chair.
Thank you.
[The Prepared Statement Of Ken Wiseman Appears In The
Appendix]
Ms. Luria. Well, thank you, Mr. Wiseman. Thanks for your
testimony. You were right on 5 minutes, so perfect.
I now recognize Ms. Kimberly Shalloo for 5 minutes.
STATEMENT OF KIMBERLY SHALLOO
Ms. Shalloo. Thank you. Chairwoman Luria, Ranking Member
Bost, and distinguished members of the committee, my name is
Kim Shalloo. I serve as a county veteran service officer in
Monmouth County, New Jersey, and as the Washington Liaison for
the National Association of County Veteran Service officers, or
NACVSO. It is my honor to testify before this committee about
the effectiveness of contracted VA C&P exams.
NACVSO is comprised of nearly 2,000 county, city, tribal
and State government employees from 33 states who work to
ensure an estimated 10 million veterans receive the veterans
that they have earned through their sacrifice and service to
this country.
CVSO has helped veterans constituents and their families
navigate benefits and resources to assist them in their daily
lives. Our daily interactions allow our members to develop an
unfiltered scope of the issues at the community level. I hope
my testimony will given the committee a frontline perspective
as to the current State of C&P exams and how it relates to the
overall claim process.
In preparation for today's hearing we surveyed our members
so that we could help the committee better understand the
impact contracted C&P exams have on veteran experience with the
benefit claim process.
We also wanted the committee to understand our members'
experience with contracted exams in contrast to those performed
by the VA. We asked our members a series of questions which are
detailed in our written testimony. The survey went out to
nearly 2,000 members and in 24 hours we had captured responses
from nearly 15 percent of our members representing a cross-
section of urban, suburban and rural America.
Our CVSO members do not report a significant difference in
the timeliness or accuracy of C&P exams performed by
contractors or VA providers regardless of their location. CVSOs
also believe the decision to contract C&P exams has been
positive overall for the veteran community. The proximity of
exams tends to be much more closer for rural veterans leading
to an increase in attendance rate.
While our analysis is still very preliminary, our results
suggest there could be still some significant improvements to
the process. Several of our VSOs, particularly those in rural
areas, feel that the use of contracted examiners has led to an
increase in decisions leading to appeals. This means VA needs a
better quality review process for their contracted examiners.
Currently, the VA assigns examiners to cases, but the
agency only monitors whether the exam was returned in a timely
manner. According to our feedback from our members, this lack
of oversight has lead to veterans receiving exam notifications
the day before an exam and, in some cases, after the exam date
has already passed. Due to the contractors' inability to
reschedule exams, veterans often end up in the appeals process.
We have also heard numerous anecdotes about veterans who
were examined in inappropriate locations as mentioned. For
example, that one veteran in Florida who drove to the address
listed on his packet for his exam. Upon arrival, the veteran
found himself very confused. He was at a nail salon. And while
the nail salon was ADA compliant, it still was a nail salon.
In spite of his confusion, he decided to walk into the
facility and asked if he was at the correct location. The staff
member said indeed he was at the right place and directed to
him a back office where his examiner evaluated his claimed
disabilities.
Thus, we believe the following recommendations, if
implemented, would help jumpstart the reform process.
First, develop a report that outlines the effectiveness of
contracted exams from VBAs perspective, evaluating not only
timeliness, but also the rate of appeals generated and rate of
overturned cases.
Second, implement a yearly review process of contract and
VA examiners so that the agency can determine which clinicians
are performing well and which ones need improvement.
Lastly, create a mechanism for veterans so that they can
reschedule their C&P exams. This will ensure veterans will be
able to make their appointments in case they receive a late
notice.
Chairwoman Luria, Ranking Member Bost, and distinguished
members of the committee, on behalf of NACVSO and its members
we thank you for including us in this hearing, and I look
forward to answering any questions that you may have.
[The Prepared Statement Of Kimberly Shalloo Appears In The
Appendix]
Ms. Luria. Thank you, Ms. Shalloo, and thanks to all of our
witnesses for appearing today and sharing your observations for
working with veterans in our community and being such strong
advocates.
I will start with a question for Mr. Wiseman, and want to
say thank you, again. I'm very happy to have a veteran, a
fellow Virginian here with us on the panel today.
As you know, the Second District, the district that I
represent includes the eastern shore----
Mr. Wiseman. Yes.
Ms. Luria.--which is, you know, a remote area and has
geographic challenges, including a very long and expensive
bridge tunnel to get across to where most of the----
Mr. Wiseman. Yes.
Ms. Luria.--medical providers are in the Hampton VA.
For those in areas like the eastern shore and you said
Salem, you know, there are quite long distances between where
people live and those facilities. The distances between their
residences and the nearest care providers, many of the veterans
residing in these areas, such as where you live or in North
Hampton or Accomack Counties have difficulty accessing VA
healthcare facilities that would normally conduct these C&P
exams.
Can you provide an example of the importance the contract
examiner services provide in assisting those in rural areas? Do
you have cases where you----
Mr. Wiseman. Yes. Madam----
Ms. Luria.--have actually dealt with----
Mr. Wiseman. Yes, Madam Chair. We have a VFW post in
Accomack County. It is around the corner from the Wal-Mart and
the Bojangles. When you live in areas like that, you are not
going to cross that bridge unless you absolutely have to. When
we have doctors who are willing to take on claims in that area,
it is very important.
My example is the current VFW post commander of that
Accomack County post, he is wheelchair bound. It is very
difficult for him to get around and go distances. And so having
that facility near him, the doctor near him where he was able
to go get his examinations was extremely important.
However, because his claim was complex, he had to have
multiple C&P exams and only one could be in that area. He had
to go to other--he actually had to go down to Hampton VA for
the rest of it.
Yes, it mitigated part of it. But we need better.
Ms. Luria. The next part of my question I had written down
ahead of time which was, you know, asking you for
recommendations. I really do appreciate the fact that you came
with some recommendations that I think are very insightful and,
you know, 3 of those that I wrote down and I plan to look into
as well is your comments about contract physicians, but what
other types of level of certification of medical professionals
could be included in that to increase the access.
The comment about part-time employment.
Mr. Wiseman. Yes.
Ms. Luria. I think that gets back to our full committee
hearing from yesterday where we talked about not only hiring
and retention, but if there is an opportunity for retention of
someone on a part-time basis, I'm not familiar with the
regulations that currently prohibit that. But it does seem like
a way to expand the number of providers.
Then I have also heard from, you know, veterans in rural
areas that Telehealth is very beneficial. I would like to be
able to explore, you know, if there's ways to use that in
providing these types of exams as well.
Thanks for your thoughtful testimony.
Mr. Wiseman. Thank you.
Ms. Luria. I would also like to ask a question of Ms.
Shalloo. Thank you for being here.
You focused on the rescheduling, and we have heard that as,
you know, a habitual problem. You know, my colleague, Mr.
Steube, gave an example about the scheduling process and some
of the challenges regarding that, and have also come to
understand that there is a 20-day timeline. If the contractor
falls outside of that 20 days they can be penalized for
fulfillment of the contract.
From your observation, what type of system would work
better? How could we communicate better to veterans that they
have the option to request rescheduling these appointments and
just, you know, make this a more transparent process so that we
can, you know, both meet the intent of the 20 days because,
obviously, that was, you know, found as a benchmark to be
timely, but sometimes, you know, timely is not as advantageous
as distance or quality of the exam. Giving the veterans a
choice in that process and actually giving them an option that
they can schedule an exam that they can actually get to.
Ms. Shalloo. Yes. Thank you.
One of the examples that we have often received is that a
veteran who is willing and able as previously mentioned is
contacted while in transit to the appointment. That the
appointment has been cancelled, whether that be for the
contracted provider not being present or some other reason that
it is just cancelled and they will have to speak with, in our
case their veteran service officer to reschedule, which means--
in full disclosure it means that we are going to file a
supplemental claim stating that the veteran was unable to make
it and we'll detail in that process, you know, unable to make
it as the contractor did call and cancel while the veteran was
in route.
One of the things that through the AMA that we lost was
that ability to ask for a reconsideration. It was an easier
process than the current supplemental claim asking for a
rescheduled exam. And no law is perfect and we look to find a
way for VA to find a stop gap measure to fill that space where
the reconsideration was.
Often times if the veteran is not available on that
specific date, it is a failure to report, an FTR, and that
right in that--the contracted examiner doing that forwards that
to VA and the VA is decided based on the evidence in record,
which there might not be enough to grant. That becomes a
denial.
Some sort of mechanism, even when a veteran is getting a
C&P exam through VA it is a phone call, it is a discussion. It
is not a letter saying, this is when you must report, and there
is no--and, yes, it is often done on Day 18, Day 19, and it is
without--it is outside of their purview to extend that.
Yes, you know, a conversation as opposed to a demand I
think would be a great start. Yes, LHI does offer the
opportunity to call in, but the other providers, this is your
date, please report.
Ms. Luria. Well, thank you for sharing that. I recall going
through the process of separating and this evaluation process
myself. The tone in the letters that I received definitely made
me think like you have to be there at this date and this time.
And, you know, I simply couldn't do that for some of the
appointments and I was able to call and make changes, but I
would say that you're--it is not apparent that that is a
possibility. And I, you know, don't know which of the service
providers actually was contracted for the exams that I did.
But I did go through the C&P exam process. I did go to
providers in town and I feel like I had good quality exams when
I was there. I was satisfied with my result. But, again, I did
experience the scheduling conflict and I would like that to be
more transparent for people.
I would now recognize Mr. Bost for 5 minutes.
Mr. Bost. Thank you, Madam Chair.
I have got a question for the whole panel, and it is a 2
part question, kind of. Okay. I want to know how for rural
areas what is the recommendation of each of your organizations
to make it to where they can provide the exams better, Okay,
and provide them when we deal with rural areas because, I mean,
we are--they are trying to do the mobile vans. They are trying
to do all of that. I know it sounds very, very terrible that it
happened in a nail salon. Okay. But let me put a disclaimer
here.
My wife and I own a beauty salon. I would not, you know,
say that that would be the proper place. But then the question
is, if the front was a nail salon, quite often in our small
communities where we could provide these services, there might
be an adjacent room that would be appropriate for an exam and
then it would give the appearance that it was a nail salon. I
don't think it is a good idea. Okay.
When we are trying to provide the closest and best exam
that we can for people who have chose to live and/or move back
home to a place that is as rural as many of my areas are. So I
am asking for you to give suggestions, how do we work with the
VA to--and the contract examiners to say, Okay, these are the
criteria we set and that way we can really provide for all of
them, the best possible.
I will start.
Mr. Weidman. Telehealth is a great way and while we had
always favored Telehealth, I personally had that experience
where they had thought I had had a stroke back in January and
transported me to the Washington VA. My neurologist stayed in
the room, but the specialist, there's a specialist, at least 2
on duty someplace in the VA system 24/7, and talked to the
specialist who was at DeBakey VA Hospital in Houston. They had
me hooked up to all the monitors and a big screen, so I might
as well have been in the same room.
The point is this. Even very rural communities usually have
some kind of medical facility, and that kind of thing could
happen out of that medical facility, including having people
hooked up to the medical gear.
It seems to us that that is the way to go. While we were in
favor of the contracting out in the beginning, what we really
favor is filling those 50,000 vacancies that VHA has with those
clinicians and then doing it and pulling it back in-house.
Mr. Liermann. You know, a lot of areas, especially when
you're talking rural, there is going to be a lot of limitations
for all sorts of resources. I think one of the big ones, too,
is time. Growing up on a farm out in the middle of nowhere you
don't always have the time to do things because you have other
requirements that you have to fulfill.
I think one thing we really need to look at when it comes
to rural veterans is maybe extend it from 20 to 30 days. Give
them that opportunity to reschedule that contract exam in a way
that still gives them the option to get it done without it
being not rescheduled and now they have to start all over
again.
The other portion I would like to talk about again is they
were talking about the mobile claims clinics and how they can
go to certain locations and do a claim clinic. Well, why can't
we have a compensation exam mobile clinic to where we know
there is a group of veterans in this area that all need C&P
exams, why can't we set up a clinic like that in a lot of these
regions to where we can use some of the local medical
facilities that are there.
If we amend Public Law 114-315, not only can you take
physicians across State lines, but now you can bring in
resources that the contractors may have such as clinical
psychologists, nurse practitioners, that can help fill those
gaps and provide those exams in a much more expedient manner
instead of waiting or rescheduling or driving 4 hours to get an
exam.
Mr. Wiseman. Mr. Ranking Member, I have to agree with my
colleague from VVA, the Telehealth option is there. That is why
ATLAS is so amazing. If you go to Lee County, Virginia, it's in
the far southwest corner, one of my State officers live there.
They don't have a hospital. They have got veteran organizations
who have buildings. If we had Telehealth abilities, like, for
instance, mental health, we are doing a great job at VA
treating for mental health. Why can't we do the C&P exam for
mental health, you know, in a bigger spread of more and more
appointments because you can go to those places.
We have got that ability. Partnering with the VSO is
something that the VA has always been able to do. Let's do it
more.
Ms. Shalloo. Yes, sir.
65 percent of our members of CVSOs are in rural areas where
we all have offices with doors providing privacy. Yes, we look
to partner with VA and why can't we work out some sort of
arrangement where VA enters into agreements with County Veteran
Service Officers to provide C&P exams onsite where the veteran
is already familiar with and can attend.
Thank you.
Mr. Bost. Thank you all very much. My time is expired.
Ms. Luria. Mr. Bost, would you like more time to continue
questioning?
Okay. Well, I want to say thank you again to all of our
witnesses for coming today and continue this ongoing dialog. It
is great to have those--both those of you from the VSO
community who deal with our veterans in communities, especially
rural communities, as well as representatives from the VBA and
the GAO to join us today. I think it's an important question
that we need to continue to address, and it is good to have
many voices and many different sources of input into help
improving the services that we are providing to our veterans.
With the growing number of disability exams performed by
contractors, it is crucial that we ensure that these exams are
performed accurately and in a timely manner. And VA's oversight
of contract vendors is key to making sure that each veteran
receives excellent and convenient care, and exam results enable
quick adjudication by VA raters.
It is clear that we still have some work to do. I am
hopeful in the future that VA will continue to improve the
contract exam program to guarantee better results for veterans
and their families. I am also looking forward to understanding
what we can learn from some of the data that we have begun to
collect recently.
Thank you again for appearing today and thank you for
being engaged in this important discussion.
Mr. Bost, would you like to make any closing remarks?
Mr. Bost. Just once again, thank you for being here. We are
going to continue to work on this issue. We want the VA to
bring their information back as quick as possible when that
data is complete.
Thank you.
Ms. Luria. Well, all members are advised that they have 5
legislative days to revise and extend their remarks, and
include any extraneous material.
The hearing is adjourned. Thank you.
[The Prepared Statement Of The National Congress Of
American Indians (NCAI) Appears In The Appendix]
[Whereupon, at 12:09 p.m., the subcommittee was adjourned.]
=======================================================================
A P P E N D I X
=======================================================================
Prepared Statements of Witnesses
----------
Prepared Statement of Mary Glenn
Good morning, Chairwoman Luria, Ranking Member Bost, and Members of
the Committee. Thank you for the opportunity to speak today on the
Veterans Benefits Administration (VBA) Contract Medical Disability
Examination (MDE) Program. Today, I will provide an update on how VBA
is delivering contract examination services to Veterans in the United
States and around the world. I will also discuss beneficiary travel
reimbursement and highlight some of VBA's oversight functions of the
program to include quality and training.
statutory authority
When necessary to adjudicate disability compensation and 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. 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 Veterans Affairs 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 Fiscal Year
2016, and to as many ROs as the Secretary considered appropriate
beginning in Fiscal Year 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 have enabled VBA to provide more timely benefits
decisions. Additionally, the contracts enable VBA to request
examinations for Veterans and Servicemembers in overseas locations,
which was not an option previously provided through any source.
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
During Fiscal Year 2019, VBA has made considerable improvements in
the MDE Program. In November 2018, VBA awarded new contracts for the
United States and realigned the contract districts from five to four in
order to provide more equal distribution of rural and urban areas
across the districts. The new contracts also increased vendor capacity
by allowing for three vendors in each district as opposed to only two
in the previous contract. Vendors are required to meet new quality,
timeliness, and customer service standards, and face stiffer penalties
and disincentives if standards are not met. Specifically, the quality
performance metric is as follows:
82 percent: 3-months following ramp-up period (June 2019-
August 2019)
87 percent: 2d 3-month period following ramp-up period
(Sept-Nov 2019)
92 percent: 6 months after ramp-up period (November 2019
forward)
The timeliness standard requires vendors to ensure that 75 percent-
85 percent of their inventory is completed within 20 days for C&P exams
in regions 1-4. Vendors are also required to maintain a customer
service satisfaction score of 90 percent to 94 percent.
VBA understands the challenges of serving Veterans living in rural
areas where access to medical services are limited. To reduce travel
beyond the contractual 50-and 100-mile requirement, VBA has authorized
higher pricing within the contract that covers the Midwest, as this
region has fewer medical resources and more rural locations. To improve
the accessibility of medical examinations within rural locations,
vendors have invested in mobile clinics. The mobile clinics have
allowed vendors to conduct examinations in support of claims clinics
and other outreach events to provide services in support of disability
claims. Vendors deploy mobile clinics around the country, as needed.
pre-discharge and overseas contract examinations
In addition to the four regional contracts, VBA also has a contract
that provides examinations to Servicemembers going through the Pre-
Discharge program and Veterans residing overseas. VBA contracts provide
the first opportunity to serve Veterans living overseas. VBA has
significantly expanded the International contract, increasing the total
number of overseas locations from 25 locations in Fiscal Year 2018 to
33 locations in Fiscal Year 2019. VBA's overseas exam contract is
operationally responsible for scheduling examinations for overseas
Veterans, which also includes examinations for Benefits Delivery at
Discharge and Integrated Disability Evaluation System. VBA continues to
explore expanding coverage in international locations.
performance
In Fiscal Year 2018, vendors completed 841,852 examination requests
of the total 1.44 million examination requests. VBA contract vendors
completed 14,448 overseas examination requests in Fiscal Year 2018 and
have completed 11,441 through August 2019. Also, through the end of
August 2019, Pre-Discharge examination completions total 59,013. In
summary, completions for all contracts through end of month August 2019
total 957,838.
Quality, Training, and Oversight
VBA's administration of the MDE Program employs numerous quality,
training, and oversight elements to ensure that any issues identified
are addressed in a timely manner.
quality
VBA is committed to ensuring that Veterans are provided with high-
quality disability examinations. Examination quality is evaluated on a
quarterly basis by applying quality assessment criteria to a
statistically valid sample of examination reports. The results from the
quality reviews are used to identify training needs and provide
feedback to contractors. VBA utilizes various feedback mechanisms such
as monthly phone calls, quarterly meetings, memos, etc., to improve
quality. Quality reviews are conducted by Quality Analysts with the
assistance of Medical Officers. At the beginning of this fiscal year,
the office responsible for quality reviews became fully staffed with 17
Quality Analysts. This has allowed VBA to stay up-to-date on quality
reviews and identify issues for improvement more readily.
training
In order to best serve Veterans, contract examiners receive the
same training required for VHA examiners in order to provide consistent
results and to familiarize them with Veteran-specific needs. Contract
examiners receive privacy training to ensure all Veteran medical
information is protected under the Health Insurance Portability and
Accountability Act. VBA has recently expanded the office responsible
for developing, delivering, and tracking training for contract
providers.
Since filling these positions earlier this year, VBA has conducted
an initial validation of provider training requirements and developed
an approach for future, ongoing training validation. VBA develops ad
hoc training modules when we identify error trends in our quality
reviews or when program requirements require a change. Most recently,
training has been developed and delivered to vendors on topics
including Military Culture, Supplemental Gulf War Illnesses,
Musculoskeletal Exams, and Audiological and Mental Health examinations.
VBA has also investigated options to improve delivery and tracking of
training requirements and is in the process of implementing the Talent
Management System for all vendor providers.
oversight
Oversight of the contract exam program is critical to ensuring that
Veterans claims are completed accurately and timely. The MDE Program
utilizes multiple mechanisms to effectively oversee the contract exam
program. Using internal systems and ancillary contracts, we can
effectively evaluate vendor performance. VBA has created a formal
oversight mechanism to strengthen the overall performance and integrity
of the MDE Program. The MDE Program coordinates access to MDE systems
and provides training to assist field users with understanding and
utilizing the contract examination process. My staff works proactively
with the contract vendors to investigate and take appropriate action on
any concerns reported about an examination experience.
The ancillary contracts administer financial auditing, provider
credentialing validation, and customer service survey results. The
third-party credentialing vendor reviews the contract examiner medical
license credentials. In this regard, provider licensing information is
checked against multiple sources, such as State Medical Licensing
Boards and Federal Sanctions data bases. This allows VBA to identify,
among other things, any revoked licenses or past disciplinary actions
of providers. Finally, a separate contract audits financial activity
associated with vendor invoices and payments. The financial audits
provide detailed insight and validation of payments made to all MDE
vendors to validate the accuracy of invoicing. The customer service
survey contract provides feedback regarding the Veteran experience
during vendor examinations. All vendors are currently achieving an
overall customer satisfaction score of 90 percent or better.
exam management system (ems)
VBA designed an examination management system that provides the
capability to interface with multiple vendor proprietary systems. VBA
continues to make significant progress in the enhancement of the EMS
system. Through collaboration with VA's Office of Information and
Technology, additional resources were committed to support a monthly
software release schedule that was implemented to address system
defects and new functionality. These releases were prioritized to
minimize impact to claims processing timeliness. In the last year, we
have addressed connectivity issues and enhanced system functionality to
improve oversight and visibility into vendor performance.
beneficiary travel
Veterans in the United States and its territories traveling to
authorized health care facilities for scheduled examinations are
eligible for travel reimbursement. Beneficiary travel payments are
mailed to Veterans immediately following their disability examination
appointments. Payments are based on the distance between the Veteran's
address of record and the examination site. Upon issuance of the
beneficiary travel payment, vendors invoice VBA for the amount paid to
the Veteran. If a Veteran does not endorse the beneficiary travel
payment, vendors issue credits back to VBA for the amount previously
invoiced. Beneficiary travel payments are validated through VBA's 3d
party financial audit contract.
conclusion
In summary, the MDE Program is vital to the delivery of timely and
high-quality claims decisions. VBA continues to expand the capacity to
perform contract examinations both in the United States and overseas,
while maintaining the flexibility to send examinations to VHA based on
timeliness specifications. In the last year, VBA has significantly
improved MDE Programs operations by right-sizing staffs that oversee
the MDE Program and realigning stateside operations from five districts
to four regions. VBA has enhanced collaboration between Veterans,
Veterans Service Organizations, ROs, and contract exam vendors with the
MDE staff through the design of its corporate mailbox. The mailbox
provides an internal mechanism to communicate challenges with the
vendors, program or process issues, as well as customer service
complaints. The VBA program office utilizes the information received to
improve vendor performance and to provide support to field offices.
VBA appreciates the authority provided by Congress to obtain
contract examinations for Veterans and transitioning Servicemembers.
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.
______
Prepared Statement of Elizabeth Curda
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
______
Prepared Statement of Rick Weidman
Good afternoon Chairwoman Luria, Acting Ranking Member Bost, and
other Representatives of this distinguished subcommittee. On behalf of
the VVA National President, as well as the members of Vietnam Veterans
of America (VVA), I thank you for affording VVA the opportunity to
testify today regarding the Department of Veterans' Affairs (VA)
contracted Compensation and Pension examinations (hereafter ``exams'').
VA Compensation and Pension Exams are an often-necessary step in a
veteran's disability compensation claim. Obtaining a timely and
accurate exam helps to ensure that the claim is correctly decided the
first time. This prevents veterans from entering an often multi-year
long appeal process to obtain a final and just decision. Given that the
VHA has more than 50,000 clinical vacancies, VA simply lacks the
capacity and person-power to conduct all necessary exams in-house. As
such, VVA supports VA's efforts to utilize contractors as an option to
help veterans obtain timely and quality exams for disability
compensation purposes.
Nevertheless, VA may delegate authority, but VA may not delegate
responsibility. VA must still be held accountable for ensuring that all
aspects of the exam process handled by contractors are conducted with
the highest level of quality, accuracy, and transparency. Veterans
should not be bullied or threatened into attending an exam they simply
cannot make. Veterans should not be penalized for not attending an exam
that they just learned about the day before. Veterans should not be
forced to appeal an erroneous denied claim due to the examiner's
incompetence, failure to review the veteran's medical records, or
inability to complete the form.
Under the Appeals Modernization Act, there is an often unspoken but
ever-present-emphasis on speed at the expense of quality. This emphasis
on speed has permeated the contract exam world in all aspects of the
exam process--from scheduling an exam to the exam itself. At the end of
the day, a focus on speed with little emphasis on accuracy and quality
only hurts veterans.
The average age of a Vietnam veteran today is 73 years old.
Pursuant to the Blue Water Navy Vietnam Veterans Act of 2019 (hereafter
``BWN Act''), countless more veterans and family members will be
entitled to disability compensation benefits due to them under the law.
As early as October 2019, VA has assured us that exams will be
scheduled for veterans who are entitled to benefits under the BWN Act.
The issues surrounding scheduling exams disproportionately impacts
older veterans who need to arrange for transportation to and from the
testing site, homeless veterans who have limited phone access,
incarcerated veterans, and veterans who live in rural areas who must
travel long distances to get to and from an exam site. VVA urges VA to
swiftly prioritize the issues outlined in this testimony, especially in
light of the increase in exam requests likely to occur for Vietnam-era
veterans.
i. inadequate advanced notice of scheduled exams and contractors
pressuring veterans to not reschedule or told their claim will be
denied.
Contractors often do not give veterans sufficient advanced notice
to attend the exam. If the veteran does not attend the exam, it is
common for the contractor to report to VBA that the veteran was a ``no
show'' and the claim is often automatically denied. In one instance,
for example, the veteran was notified of a September 18, 2019 scheduled
exam in a letter dated September 10, 2019. By the time the veteran gets
the letter, he will only have a couple of days to arrange his schedule
to attend this exam. This is the norm. A couple of days advanced notice
is often insufficient for veterans that need to arrange for
transportation or request a day off from work.
VVA also knows of cases where veterans were being pressured to not
reschedule their exam by contractors or being told that if they do not
choose the alternative appointment time given, VA will deny the claim.
This is unacceptable, especially for veterans that may need to have
several weeks advanced notice to be able to coordinate transportation
to and from the exam site.
The pressure from contractors to schedule these exams expeditiously
is troubling. Veterans should be given sufficient advanced notice of
scheduled exams, and when they call to reschedule, they should be given
options to schedule it at a time that is convenient for them and
without fear of retribution. What timeliness requirements are set by
VBA to the contractors where the contractors feel the need to pressure
and bully veterans into attending exams that they are unable to attend?
ii. communication issues between contractors and veterans, and between
the contractors and vba.
Communication between veterans and the contract exam agencies can
be improved, as well as between the contractors and VBA. An egregious
communication issue happened recently when a 96-year-old World War II
veteran who lives in an assisted living facility was not notified that
his exam had been cancelled by the contractor. In this case, the World
War II veteran was required to coordinate transportation to and from
the testing site, and when the veteran arrived at the exam site, the
doctor was not there. It was not until our accredited service officer
inquired with VA as to why the exam did not happen that the veteran
found out that the exam had been cancelled. No one bothered to notify
the veteran in advance of his exam that it had been cancelled.
In another example, VVA recently observed a veteran being scheduled
for two exams on the same day by the same contractor, but at different
testing facilities with less than 3 hours between scheduled exams.
Depending on how long the first exam lasts, it may be physically
impossible for the veteran to attend both scheduled exams on the same
day. VVA also knows of a recent case where the veteran notified the
contractor that she was unable to attend the scheduled exam, and the
contractor notified VBA that the exam was ``unable to be scheduled.''
In response, VBA issued a decision that denied the claims, citing that
the veteran failed to show up for the scheduled exam. This is wrong.
Notwithstanding the example scheduling issues detailed above, VVA
strongly urges VA to prioritize increasing communication and
information to the veteran in the following ways:
1. VVA recommends that all exam requests and exam notifications
sent to the veteran by the contractor be timely uploaded to
VBMS. Exam notification letters, in particular, are not always
uploaded to VBMS. This would be helpful for veteran service
representatives to help ensure that veterans are able to attend
scheduled exams, and if not, to help the veteran reschedule the
exam. If the exam notification letter is not included in VBMS,
the veteran service representative will have no way of knowing
when an exam is scheduled. Requiring this information be
uploaded in VBMS will also increase transparency and
accountability on the part of the contractors.
2. VVA recommends that all exam notification letters to the
veteran clearly State that it is possible to reschedule the
exam and how to do so. For example, VES's letter does not State
anywhere on the letter that it is possible to reschedule or how
to reschedule the appointment. This is problematic. As another
example, LHI's letter indicates the following: ``To reschedule
this appointment, contact LHI at least one business day prior
to your scheduled appointment to determine if you are
eligible.'' Although it is helpful for the letter to indicate
that it is possible to reschedule the exam, by stating ``to
determine if you are eligible'' indicates that it may not be
possible to reschedule the exam and may deter a veteran from
calling. Often the veteran is notified only a couple of days
prior to the scheduled exam and it is not uncommon for the
veteran to need to reschedule due to the short-notice.
3. VVA recommends that all contractors are trained to speak
with an accredited service representative on behalf of a
veteran as is done when accredited service representatives
interact with VBA employees. VVA service representatives report
that contractors refuse to speak with them regarding a veteran
we represent. As such, service representatives are unable to
assist a veteran in rescheduling an exam with the contractor.
4. VVA recommends that all exam requests generated by VBA
contain a date of request on the form to increase
accountability and transparency. Although there is the date in
VBMS when the form was allegedly uploaded, the exam request
form itself does not have a date on it as to when it was
generated and sent over to the contractor. Because the VBMS
date can easily be changed or inaccurate, VVA recommends the
date of the request to be added to the exam request form
itself.
iii. exam quality is lacking.
In addition to implementing policies and procedures to ensure that
the veteran will be able to attend the exam, it is also important to
ensure that the exam itself is of sufficient quality to render an
accurate decision for the veteran. The October 2018 GAO report
indicated that VBA did not verify if examiners completed the training,
nor did VBA collect any information to assess the training
effectiveness in preparing examiners. VVA is eager to learn whether VBA
has indeed developed a robust training program that has been tested for
effectiveness. What are the results? VVA believes that a quality
assurance program that is not publicly available for review, including
the specific metrics used, makes it as if the program does not exist at
all.
VVA also strongly urges this subcommittee to dive deeper into the
quality score and metrics being reported by VBA and to not be satisfied
with a simple number. What exact metrics are being developed to
determine if an exam is accurate? What feedback loops and training is
conducted when quality scores are not of a certain standard? Have the
quality and performance data been used to identify and implement
program-wide changes? How can we have a quality score of 92 percent,
but still see a large number of appeals based upon an inadequate exam?
Too often has VVA seen ``accuracy'' scores produced by VBA as a way to
appease Congress in not questioning the sudden and dramatic increased
pace by which claims are being adjudicated.
VVA understands that it is not an easy task to produce an adequate
and thorough exam for compensation purposes. This is an area where
continual training, monitoring, and feedback to the examiners must be
an integral part of the quality control process to ensure that exams
meet the legal minimum standards. The quality of exams can always be
improved--it is just a matter of determining what aspect of the exams
VA wishes to improve in any given moment. A static number reporting
``accuracy'' is insufficient and helps no one.
In addition to developing a robust and dynamic quality assurance
program for exam contractors, VVA also urges VA to implement a
competency-based test for all VA employees that touch a disability
benefits claim--contract examiners, VHA examiners, raters, coaches, VA
managers, and even veteran service representatives and private
attorneys. VA benefits disability law is a specialized field that
requires particularized knowledge and competencies. For contract
examiners in particular, if VA is confident in its training
effectiveness, it should not have a problem with implementing a test to
ensure its contractors are equipped to issue adequate and comprehensive
exams.
Unfortunately, it is still common to hear about cases when
veterans' claims files are not being reviewed by the examiner, or the
examiner does not have adequate time to examine the veteran during the
scheduled exam. Veterans also report that during the exam, it appears
as of the examiner did not review anything in the claims file prior to
the exam. An exam that is riddled with errors and that does not
accurately and comprehensively assess a veteran's disability for
compensation purposes is a waste of time, waste of money, and is
ultimately a disservice to our veterans. We can do better than that.
conclusion
VVA is supportive of the use of contract exams in theory. However,
the push by VA for the contractors to meet certain timeliness
objectives results in not delivering the necessary resources and
support to veterans as well as compromising on the quality of exams.
Veterans should be given more advanced notice of scheduled exams and
the ability to reschedule an appointment if necessary. Veterans should
not be bullied into attending an exam out of fear that their claims
will be denied, and veterans should be provided clear instructions as
to how to reschedule an exam.
Consideration into the needs of older veterans, such as sufficient
time to arrange for transportation to and from an exam site and
scheduling challenges for veterans with limited phone use is strongly
encouraged. Homeless veterans and incarcerated veterans should not be
penalized and prevented from obtaining an adequate exam.
Finally, quality should not be an afterthought. Timeliness at the
expense of quality is not a win for veterans as an inadequate exam will
just result in a multi-year appeal battle to obtain benefits that the
veteran is entitled to under the law. VVA calls upon VA to require
competency-based testing for all individuals that touch a benefits
claims file, including contract examiners. Additionally, VVA urges VA
to develop a dynamic quality assurance program that does not focus on a
static ``accuracy'' number, but rather, focuses on continually
identifying and implementing ways to improve the overall quality of
exams.
On behalf of our membership, I ask that you enter our full
statement for the record and we thank you for the opportunity to
testify and I will be honored to answer any questions the subcommittee
may have regarding our testimony presented before you today.
vietnam veterans of america funding statement september 19, 2019
The national organization Vietnam Veterans of America (VVA) is a
non-profit veterans' membership organization registered as a 501(c)
(19) with the Internal Revenue Service. VVA is also appropriately
registered with the Secretary of the Senate and the Clerk of the House
of Representatives in compliance with the Lobbying Disclosure Act of
1995.
VVA is not currently in receipt of any Federal grant or contract,
other than the routine allocation of office space and associated
resources in VA Regional Offices for outreach and direct services
through its Veterans Benefits Program (Service Representatives). This
is also true of the previous two fiscal years.
For further information, contact: Executive Director for Policy and
Government Affairs, Vietnam Veterans of America, (301) 585-4000,
extension 127
rick weidman
Richard F. ``Rick'' Weidman serves as Executive Director for Policy
& Government Affairs on the National Staff of Vietnam Veterans of
America (VVA). As such, he is the primary spokesperson for VVA in
Washington. He served as a 1-A-O Army Medical Corpsman during the
Vietnam War, including service with Company C, 23rd Med, AMERICAL
Division, located in I Corps of Vietnam in 1969.
Mr. Weidman was part of the staff of VVA from 1979 to 1987, and
from 1998 to the present, serving variously as Membership Services
Director, Agency Liaison, Director of Government Relations, and now
Executive Director for Policy & Government Affairs. He left VVA to
serve in the Administration of Governor Mario M. Cuomo (NY) as
statewide director of veterans' employment & training (State Veterans
Programs Administrator) for the New York State Department of Labor from
1987 to 1995.
Rick has served as Consultant on Legislative Affairs to the
National Coalition for Homeless Veterans (NCHV), and served at various
times on the VA Readadjustment Advisory Committee, as a consumer
liaison on the Secretary's Advisory Committee on Serious Mental Illness
at VA, the Secretary of Labor's Advisory Committee on Veterans
Employment & Training, the President's Committee on Employment of
Persons with Disabilities--Subcommittee on Disabled Veterans, Advisory
Committee on veterans' entrepreneurship at the Small Business
Administration, and numerous other advocacy posts in veteran affairs.
Weidman has been honored with awards for his work in veterans'
employment at the local, State and national levels many times over the
last forty years. He is currently Chairman of the Veterans
Entrepreneurship Task Force (VET-Force), which is the consortium of
most of the major veterans' service organizations and military service
organizations regarding expanding opportunities for veterans,
particularly disabled veterans to create, own, and successfully operate
their own small business.
Mr. Weidman was an instructor and administrator at Johnson State
College (Vermont) in the 1970's, where he was also active in community
and veterans affairs. He attended Colgate University (B.A., 1967), and
did graduate studies at the University of Vermont.
He is married and has four children.
______
Prepared Statement of Shane L. Liermann
Chairwoman Luria, Ranking Member Bost, and Members of the
Subcommittee:
Thank you for inviting DAV (Disabled American Veterans) to testify
at today's hearing on Department of Veterans Affairs (VA) Contracted
Exams, Quality Review Process, and Service to Rural Veterans.
DAV is a congressionally chartered national veterans' service
organization of more than one million wartime veterans, all of whom
were injured or made ill while serving on behalf of this Nation.
To fulfill our service mission to America's injured and ill
veterans and the families who care for them, DAV directly employs a
corps of more than 260 National Service Officers (NSOs), all of whom
are themselves wartime service-connected disabled veterans, at every VA
regional office (VARO) as well as other VA facilities throughout the
Nation. Together with our chapter, department, transition and county
veteran service officers, DAV has over 4,000 accredited representatives
on the front lines providing free claims and appeals services to our
Nation's veterans, their families and survivors.
We represent over one million veterans and survivors, making DAV
the largest veterans' service organization (VSO) providing claims
assistance. This provides us with an expert understanding and direct
knowledge in navigating the VA claims and appeals process. Recently, we
reached out to our 260 DAV National Service Officers for their feedback
and veterans' perceptions regarding VA contract exams.
Based on our collective experience, our testimony will discuss the
impact of VA examinations, VA contract exam oversight and quality
reviews, the service to rural veterans, and the feedback from our
service officers.
the impact of va examinations
In order for veterans to receive their earned benefits, a claim
must be established with the VA seeking service connection for specific
conditions. Those claims are developed and adjudicated by the Veterans
Benefits Administration (VBA). In Fiscal Year (FY) 2018, VBA decided
1.4 million disability claims in an average of less than 100 days with
95 percent quality.
As a part of the development process, a VA veterans' service
representative (VSR) determines if a VA exam is required for the
specific claimed condition. The VA Compensation and Pension (C&P)
examination process is a vital part of the claims process as it can be
determinative of the existence of a current condition, or if the
veteran's illness or injury is related to their active military service
or specifically, the severity of that condition.
VBA has created a new tool that provides the VSR, in real time,
with information to determine whether the Veterans Health
Administration (VHA) has the internal capacity to conduct the C&P exam.
When VHA has the capacity, the exam request is then sent to the VA
medical center nearest the veteran to schedule the exam. If VHA does
not have the capacity, the exam request is sent to the Medical
Disability Examination (MDE) program to be assigned to a VA contractor.
If the request is accepted by the contractor, they contact the veteran
to schedule the exam with a contract medical exam provider.
In many cases, the VA exam is the linchpin to establish or deny a
claimed benefit. However, if a veteran fails to appear for exam or it
is cancelled and not rescheduled, this can result in denial of
benefits. For example, if a scheduled examination is not completed, it
will be returned to VBA for review by a VSR to determine if the case is
ready to rate. It is then assigned to a rating veterans' service
representative (RVSR) for review and a decision. In this instance, the
case would be decided based on the evidence of record without the
benefit of medical evidence from a completed exam, which will usually
result in a denial of the claimed benefit.
In other instances, a missed or cancelled exam can lead to a
reduction of benefits. A re-examination or routine future examination
(RFE) will be requested whenever VA determines there is a need to
verify either the continued existence or the current severity of a
disability. Veterans for whom reexaminations have been authorized and
scheduled are required to report for such reexaminations. If a veteran
does not report for the exam or it is cancelled and not rescheduled,
VBA will issue a decision proposing to reduce the disability in
question.
VA C&P exams are of a unique importance and missed or cancelled
exams can negatively impact a veteran's claim and disability rating. If
a negative decision is rendered based on a missed or cancelled exam,
the veteran cannot simply request to reschedule the exam. At this
point, the veteran is required to submit a supplemental claim
requesting a new exam for the claimed conditions, thus requiring
additional time, development, and a new scheduled exam for a new VA
rating decision.
va contract exams
Starting in 1996, as part of a pilot program, VA was authorized to
complete disability exams from non-VA medical sources to increase its
capacity and improve timeliness, but stipulated no more than ten VA
Regional Offices (VAROs) could participate. These contract exams,
originally managed by the VHA, later to be called the Disability Exam
Management (DEM) contract exams, were expanded from ten to 15 VAROs
between 2014 and 2016.
In 2016, VHA officially transferred to VBA the national
compensation and pension disability exam contract and program
management. VA established VBA's Medical Disability Examination (MDE)
program to manage and oversee contractors, monitor their performance,
and ensure that they meet contract requirements, while enhancing the
prompt delivery of disability benefits claims and improve the
disability exam experience for veterans. The disability contract exam
program was also expanded to allow all VAROs access to use the
mandatory contract exam program starting in Fiscal Year 2017.
The contracts for the vendor-provided VA examinations require a
specialized focus on three areas: quality, timeliness and customer
satisfaction. The examiners for the vendors are required to complete
the same training as provided to VHA examiners. In reference to the
timeliness, the contract exams are required to be completed within 20
days generally, or within 30 days for specialized exam requests outside
of the vendor's network.
The use of VA contract exams has vastly increased since October
2016. In Fiscal Year 2017, 1.3 million veterans received C&P
examinations, of which 45 percent were provided by VA contractors at a
cost of $765 million and in Fiscal Year 2018, 1.4 million veterans
received VA C&P exams, of which, nearly 60 percent were provided by VA
contractors at a cost of $896 million. This increased reliance on VA
contract exams, in addition to the importance of a VA examination for a
veteran's claim, requires close monitoring and oversight of the VA
contract exam program.
october 2018 government accountability office report
In its report, VA Disability Exams ``Improved Performance Analysis
and Training Oversight Needed for Contracted Exams,'' GAO found the
following: VBA reported contractors missed exam quality targets and VBA
could not accurately measure performance on timeliness targets; delayed
quality reviews and performance reports and data limitations hinder
VBA's monitoring of contractors; VBA's data limitations hinder its
ability to oversee certain contract provisions, and VBA has not
conducted comprehensive performance analysis; auditor verifies
contracted examiner licenses, but VBA does not verify training
completion or collect information on training effectiveness. The
report's recommendations are listed below:
1. The Under Secretary for Benefits should develop and
implement a plan for how VBA will use data from the new exam
management system to oversee contractors, including how it will
capture accurate data on the status of exams and use it to (1)
assess contractor timeliness, (2) monitor time spent correcting
inadequate and insufficient exams, and (3) verify proper exam
invoicing.
2. The Under Secretary for Benefits should regularly monitor
and assess aggregate performance data and trends over time to
identify higher level trends and program-wide challenges.
3. The Under Secretary for Benefits should document and
implement a plan and processes to verify that contracted
examiners have completed required training.
4. The Under Secretary for Benefits should collect information
from contractors or examiners on training and use this
information to assess training and make improvements as needed.
november 2018 disability assistance and memorial affairs subcommittee
hearing
In November 2018 at the House Veterans' Affairs Subcommittee on
Disability Assistance and Memorial Affairs hearing, Exploring VA's
Oversight of Contract Disability Examinations,'' VBA acknowledged the
problems outlined by the GAO report and concurred with it.
VBA noted its electronic management system (EMS) for managing, data
capturing, and overseeing the contract vendors was fully operational.
The staffing of MDE was noted to be at 17 FTEE and VBA noted it was
sufficient to maintain the program and provide proper quality review of
the contract vendors and examinations.
At the hearing, VBA announced that the new vendor contracts had
been awarded. The contracts contain required standards based on
performance measures:
The quality standard is a 92 performance rating after 6
months.
The timeliness standard is 75 to 85 percent of the
inventory exam requests must be within 20 days for C&P exams.
The customer satisfaction standard is a 90 to 94 percent
rating, which is a new standard on all contracts.
The contracts also contain financial incentives as well financial
disincentives concerning the standards set for quality, timeliness and
customer satisfaction.
Subsequent to the hearing, it was announced that the new MDE
program contracts were awarded to the following contractors: Logistics
Health Inc. (LHI); QTC Medical Services Inc. (QTC); Veterans Evaluation
Services (VES); VetFed Resources Inc. (VetFed).
june 2019 office of inspector general report
In June 2019, OIG released its report, ``Inadequate Oversight of
Contracted Disability Exam Cancellations.'' This report was based on
essentially the same time period as the 2018 GAO report and identified
similar issues with the oversight of the VA contract examination
process.
The OIG report did include a new concern not specifically addressed
by the GAO report; disability exam cancellations. The number of
contracted exam requests has increased since 2017. The contracting
officer overseeing the MDE contracts stated that VBA anticipated these
numbers would continue to increase as the overall volume of claims was
expected to rise.
Claims processors requested 1,342,123 DBQ exams from November 1,
2017 through April 30, 2018--an approximate 19 percent increase over
the previous 6-month period (May 1, 2017 through October 31, 2017). The
OIG team determined that during these same timeframes, cancellations
increased by 74 percent.
If a contractor reports a cancellation reason, such as a veteran
was a no-show for an exam, the case will be decided based on the
evidence of record without the benefit of medical evidence from a
completed exam. This type of situation usually leads to a denial of the
benefits sought. As we previously noted, if VBA issues an adverse
decision as the result of an improper exam cancellation and the veteran
then disputes it, the veteran must submit a supplemental claim to have
the exam rescheduled, which will cause further delays.
One factor that may be contributing to the increase in exam
cancellations, is the contractually required 20-day time period for
exam completion. As we will reveal further in the testimony,
contractors are not allowing veterans to reschedule exams that may
place them outside of the 20-day time period. Of further concern is
that contractors struggling to meet this standard may be improperly
canceling exams to protect their reported timeliness.
Another factor that may be adding to the increased exam
cancellation may be a contractor's pursuit of the additional incentives
for timeliness. To be eligible for incentives for timeliness, the other
standards must also be met. The new contracts contain financial
incentives that allow for a 5-percent bonus if the examinations are
completed in 15 days or less. A 5-percent bonus, when considered with
$896 million spent on VA contract exams last fiscal year, could be
motivation to find means to reduce exam timeliness for financial gain.
recommendations
Given the recent increases in contracted disability exam
cancellations and the number of veterans involved, we are greatly
concerned over improperly cancelled examinations and the impact on
veterans trying to establish service-connected disabilities and
increased evaluations and thus make the following recommendations:
Require VBA, through the MDE, to track all cancelled VA
contract exams with specific reasons for the cancellations and provide
a quarterly report to Congress.
Require all existing and future VA exam contracts to add
cancelled exams as a performance measure with a base standard and
incentives as well as disincentives.
Cancelled VA contract exams need to be closely monitored as part of
the ongoing quality reviews as these can have detrimental effects for
all veterans but specifically rural veterans, as their access to VA or
VA contract exams is much more limited.
service to rural veterans
For rural veterans, improperly cancelled exams have an even more
profound effect given the limited number of health care resources and
the large geographical distances between veterans and basic levels of
health care. VHA recognizes the challenges of providing accessible care
to rural veterans and currently allocates 32 percent of its health care
budget to rural veteran care.
In rural areas, basic levels of health care or preventative care
may not be available to support long-term health and well-being.
Compared to urban areas, rural communities tend to have higher poverty
rates, more elderly residents, residents with poorer health, and fewer
physician practices, hospitals and other health delivery resources.
As noted by the VHA Office of Rural Health, there are 4.7 million
rural and highly rural veterans with 2.8 million enrolled in VHA. Rural
veterans experience rural health care challenges that are intensified
by combat-related injuries and illnesses.
VA's Annual Benefits Report for Fiscal Year 2018 shows the most
prevalent service-connected disabilities of new compensation recipients
were three different neurological disabilities, hearing loss, and post-
traumatic stress disorder. These all have special requirements for
testing for VA examinations which may not be readily available in rural
and highly rural areas. As noted above, rural communities have fewer
physicians available; this, coupled with the most prevalent service-
connected disabilities of new compensation recipients in 2018, clearly
places rural veterans at a disadvantage to receiving timely VA
examinations from qualified health care professionals even when
utilizing VA contract exams more frequently.
Enacted in 2016, Public Law 114-315, section 109, ``Improvements To
Authority For Performance Of Medical Disabilities Examinations By
Contract Physicians,'' notes that a physician may conduct an
examination pursuant to a contract, at any location in any State, the
District of Columbia, or a Commonwealth, territory, or possession of
the United States, so long as the examination is within the scope of
the authorized duties under such contract. A physician is defined as
one who has a current unrestricted license to practice the health care
profession of physician.
The above public law allows contract exam vendors to provide
examining physicians to rural areas that may not have examining
physicians available in their State or territory. This also provides
MDE with more options to get VA contract exams in areas with potential
backlogs of scheduled exams and limited resources. However, the law
speaks only to physicians and psychiatrists; however it does not
include other licensed health care professionals such as nurse
practitioners, clinical psychologists, and other clinical health care
professionals that are qualified to conduct VA examinations.
recommendation
Rural and highly rural veterans are in areas with limited medical
and health care resources. Thus, providing them with timely and quality
VA contract examinations for their VA claims can be challenging and all
avenues to provide them the same options as veterans in urban areas are
a necessity and we make the following recommendation:
Amend Public Law 114-315, section 109, to include
licensed health care professionals such as nurse practitioners,
clinical psychologists, and other clinical health care professionals,
to conduct VA contract examinations at any location in any State, in
the same manner as physicians. This should include all non-physician
health care professionals that the VA currently accepts as examiners.
As we will discuss below, our feedback from our National Service
Officers provides us with an insight to the VA contract exam issues
facing veterans and specifically rural veterans. Our office in North
Dakota reported that there are only two contact examiners available to
them, requiring them to drive over 70 miles and in some instances,
veterans are being asked to travel over 3 hours one way for a VA
contract examination.
Access to VA health care for rural veterans is challenging, but
receiving VA C&P examinations to receive their earned compensation
benefits should not be. This recommendation will enhance the MDE and
contract vendors to provide timely and quality examinations to the men
and who served and reside in rural and highly rural locations.
feedback from dav's national service officers
Finally, we recently solicited feedback from our 260 DAV National
Service Officers at over 60 locations throughout the country regarding
VA contract exams over the last 6 months. The feedback yielded the
following information:
Almost 70 percent of our NSO offices reported that
contractors cancelled exams when veterans were willing and able to
report for the exam and more than 80 percent reported that veterans
whose exams were cancelled were unable to reschedule with the
contractors. Also of importance is that 75 percent of NSO offices
reported that it was easier to reschedule exams with VA examiners;
while just 12.5 percent said it was easier with contractors.
This is consistent with contractors not being willing to
schedule or reschedule outside of the 20-day period. While we
understand that is part of the requirements of the contracts,
this is not providing service to veterans but providing service
to the contractual obligations.
NSO offices reported that the No. 1 complaint from
veterans regarding contractor exams by far was that felt the exams were
not thorough (43 percent); next was that examiners were not
knowledgeable (20 percent) about the veteran's claim at the time of the
exam.
While these two complaints may not speak to the actual quality
and thoroughness of the VA contract exams, as required by VA;
they do speak to the perception of veterans about the quality
and satisfaction of VA contract exams.
Approximately 40 percent of NSO offices reported that
some veterans were not receiving beneficiary travel pay after their
contract exams.
In conclusion, VA disability exams are essential for substantiating
veterans' disability claims. If VHA does not have the capacity for the
exams, then VA contract exams must fill in the gaps. Due to the
increased quantity of VA contract exams and their impact on disability
claims, it is imperative that VA conduct monitoring for quality and
timeliness. Improperly cancelled exams can cause preventable delays and
denials in awarding earned benefits to, regardless of where they
reside. We need to ensure that the VA contract examination process
serves the needs and best interests of the men and women made ill or
injured by their service, and not that the VA contract examination
process serves only the obligations and requirements of the contracts.
Madame Chair, this concludes my testimony on behalf of DAV. I would
be happy to answer any questions you or other members of the
Subcommittee may have.
______
Prepared Statement of Kenneth Wiseman
Chairwoman Luria, Ranking Member Bost, and members of the
subcommittee, I thank you for the chance to testify today on the
important matter of what veterans living in rural areas face when
attending Compensation and Pension (C&P) exams as part of their VA
disability claims.
The C&P exam is a vital part of the process for determining if a
veteran has a condition that is service-connected and in determining
the severity of the condition. The integrity of those exams should be
protected, and this important tool will continue to be part of the
process, but it should not be a burden to the veteran. As an accredited
Veterans Service Officer, I discuss these exams with every veteran I
represent before the exams happen so the veteran understands what to
expect and I also hear from those veterans what their experience was
with the exam. Further, I have personally sat through several exams
related to the many claims I have submitted resulting in the VA
disability rating I have. The C&P exam is a major phase of completing a
VA disability claim, but it is a process which can be improved.
The VFW provided testimony on contracted exams to this subcommittee
on November 15, 2018. In that testimony, the VFW highlighted five major
issues and I can report that those issues are only worsened by the fact
that a veteran lives in a rural area.
A shortage of examiners, both full-time and contracted, is
something the VA is known to have. However, there are ways to solve
this. I was at a medical appointment last Friday and the usual nurse I
see when I check in informed me that she will be retiring after 19
years with VA. She asked me, knowing what I do for the VFW, what she
could do to stay involved at the VA and continue to help veterans. She
added something that shocked me when she stated that she would be happy
to continue working part-time but that she was told VA rules prohibit
part-time work. Considering the shortage of medical professionals in
our Nation today, why would we want to turn away those who could fill
critical gaps in areas like C&P exams. As rural veterans wait for an
appointment, this could be an option to help solve the problem.
Veterans also complain about the distance they travel for an
appointment. I represent a veteran who is unable to drive long
distances and his daughter drives him. VA recently granted his claim
for Type 2 Diabetes associated with Agent Orange. However, his
experience with C&P exams is one that is both absurd and one which we
can use to highlight ways to fix this system.
His C&P exam was a 4-hour drive, roundtrip, and driving that
distance is not something he and his wife can easily do at their age.
Their daughter would take off from work for an entire day so she could
drive them. The exam was deemed incomplete by the VA and the veteran
was forced to return to that doctor for another exam. The veteran
reported to me that both exams lasted less than 30 minutes each. Eight
hours of driving for less than 60 minutes with the doctor is not the
best use of VA resources and it only serves as a negative experience
for the veteran.
I often hear from veterans that their VA doctor, who works for the
Veterans Health Administration (VHA), has diagnosed them having a
condition but they must still go through a C&P exam administered by the
Veterans Benefits Administration (VBA). If VA professes that there is
only one VA and that all parts are working together to provide the best
care and experience for the veteran, why can not the evidence found in
a VHA exam suffice for a claim submitted through VBA? I certainly
understand that the responsibility of the VHA doctor is to treat the
condition-not necessarily evaluate the current extent of a disability
within the perimeters of the VA Rating Schedule for Disabilities.
However, in lieu of forcing veterans to drive ridiculous distances to
C&P exams, I believe it would be more practical for VBA to first
request that a VHA treating physician complete the required disability
benefits questionnaires. This could perhaps eliminate the need for a
veteran to ever appear for an evaluative exam, should the treating
physician have the ability to provide the necessary information to
adjudicate the claim. VBA already pulls the medical records cited as
evidence from VHA and this could be an additional use of those records
that would provide a positive impact in this process.
Continuing on this issue, I would point to the types of conditions
that veterans file for that are conditions diagnosed with a simple
blood test. The veteran I mentioned lives less than 30 minutes from a
VA clinic and could have reported there for the blood draw needed to
diagnose his diabetes. Further, his private doctor could have provided
evidence obtained through a blood test and this highlights the VFW's
long-standing position supporting greater use of private medical
evidence in the claims process. Repetitive work that only re-diagnoses
a condition is something that needs to end and would make the claims
process easier for all veterans, including those living in rural areas.
Any portion of a C&P exam which requires the veteran to be visually
seen by an examiner is an opportunity to use telehealth--especially for
rural veterans. The VFW praises VA for the work they have done to
expand options and is a proud partner in one of the latest VA projects,
Advancing Telehealth to Local Access Stations, better known as Project
ATLAS. ATLAS uses the buildings owned by VFW and American Legion Posts
to provide locations for telehealth based medical appointments. There
is no reason VA cannot use telehealth for C&P exams. The veteran I
mentioned who received a grant for his claim for Diabetes could have
experienced a much shorter drive if the VA had telehealth options for
the exam. The use of telehealth would be especially useful in the case
of C&P exams where there is no need for lab work or x-rays, and no need
to physically touch a veteran. I want to especially highlight the
ability of VA to use telehealth in the area of mental health claims as
they are extensively using it for the treatment of mental health
conditions. Veterans already using telehealth would see much less
distance travelled and some, who use telehealth from the comfort of
their home, would see travel for an exam eliminated entirely.
VA has partnered with other Federal agencies in the past to help
veterans by using the doctors in those other agencies to provide care.
For example, VA partnered with the Indian Health Service to provide
care for American Indian and Alaska Native veterans. Partnerships like
this could be repeated for C&P exams.
An additional option for VA would be to bring on more partners who
could provide the exams. We continue to see the VA as a teaching
hospital which is something the VFW applauds. This effort exists in
many ways with medical schools and nursing programs partnering directly
with the VA to place their students. Partnering with medical schools to
provide C&P appointments would be a great option.
Finally, VA and its third party contractors that provide many C&P
exams need to offer more flexibility for veterans in completing their
exams. The VFW is well aware that VA tightened its timelines to
complete exams under its most recent contracts. This time crunch only
exacerbates unnecessary travel burdens for rural veterans. Like I
mentioned before, the reason rural veterans have to travel so far for
C&P exams is because the contractors cannot find sufficient capacity to
conduct the exams in highly rural areas. Veterans understand that many
times VA cannot grant a claim without a current exam, but in working
with veterans, waiting another week for an exam is perfectly
reasonable, if it means they can conduct the exam close to home.
Moreover, VA's current contracts also allow veterans only one
opportunity to reschedule. If a veteran needs multiple exams, they can
still only reschedule one of these exams. Otherwise, the contractor
reports to VA that the veteran was unwilling to report for an exam.
This is unreasonable, and only leave advocates like me to clean up the
mess through unnecessary supplemental claims and appeals. VA's
contracts must reflect the actual needs and expectations of veterans.
The current contracts do not.
However, while I have offered several options to improve this
system, I want to be explicitly clear on one important issue: There is
no support in my testimony for lowering the burden of proof needed for
VA to grant a claim. The exams must maintain the level of integrity
that the VFW has long supported having but there must be new options
which mitigate the long drives and long waits experienced by a veteran.
Accuracy being sacrificed for speed would only ensure a veteran gets
the wrong decision faster and that is never the answer.
In closing and on behalf of those veterans living in small towns
and wide-open spaces across this great nation, I ask that Congress work
to improve the process by which a veteran is examined for their VA
disability claims. Where a veteran lives should not serve as a burden
they are forced to shoulder in this process. This concludes my
testimony and I welcome any questions the Subcommittee may have. Thank
you for the opportunity to testify.
information required by rule xi2(g)(4) of the house of representatives
Pursuant to Rule XI2(g)(4) of the House of Representatives, the VFW
has not received any Federal grants in Fiscal Year 2018, nor has it
received any Federal grants in the two previous Fiscal Years.
The VFW has not received payments or contracts from any foreign
governments in the current year or preceding two calendar years.
______
Prepared Statement of Kimberly Shalloo
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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Prepared Statement of the National Congress of American Indians
On behalf of the National Congress of American Indians (NCAI), we
are pleased to submit a written Statement for the Record to the House
Committee on Veterans' Affairs, Subcommittee on Disability Assistance
and Memorial Affairs on the topic of the Department of Veterans Affairs
(VA) compensation & pension (C&P) exam process. NCAI is the oldest and
largest organization composed of American Indian and Alaska Native (AI/
AN) tribal nations and their citizens. NCAI has always held tribal
citizens that serve in the U.S. Armed Forces in the highest esteem. We
are grateful for the Committee's intention to better fulfill the
Federal Government's commitment to provide for the well-being of AI/AN
veterans when they return home.
i. background
AI/ANs have a long history of distinguished service to this
country. Per capita, AI/ANs serve at a higher rate in the Armed Forces
than any other group of Americans and have served in all the Nation's
wars since the Revolutionary War. In fact, AI/AN veterans served in
several wars before they were even recognized as U.S. citizens. Despite
this esteemed service, AI/AN veterans have lower personal incomes,
higher unemployment rates, and are more likely to lack health insurance
than other veterans.
Additionally, national data indicate that AI/AN veterans are more
rural (38.8 percent) compared to the U.S. veteran population nationwide
(26.2 percent).i Veterans who live in rural settings have
lower health-related quality of life than their urban counterparts.
NCAI would like to share with you some barriers rural AI/AN veterans
face when completing a C&P exam. These challenges include issues
associated with transportation infrastructure and options, cultural
competency, and the often-confusing VA system. We also provide
recommendations as to how Congress can help improve the process for AI/
AN veterans.
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i https://www.ihs.gov/california/tasks/sites/default/
assets/File/PDMtg-2013-NativeAmericanVeterans-King.pdf
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ii. issues with scheduling a va compensation and pension exam
AI/AN veterans often find the initial claims process for disability
compensation and pensions confusing, intimidating, and have
difficulties navigating VA's bureaucratic system. AI/AN veterans have
also expressed an underlying feeling of prejudice, discrimination, and
stereotyping that discourages them from seeking the VA benefits they
earned through their service.
Moreover, 35.4 percent of Americans residing on tribal lands lacked
access to fixed broadband services, compared to 7.7 percent of all
Americans.ii This lack of access to high-speed internet
makes it more difficult to start the claims process, communicate
effectively with a VA medical center or VA partner, and upload
treatment information or other evidence necessary for a claim's full
and proper consideration.
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ii U.S. Government Accountability Office, Broadband
Internet: FCC's Data OverState Access on Tribal Lands, GAO-18-630
(Washington, DC, 2015), https://www.gao.gov/assets/700/694386.pdf.
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iii. issues with transportation to a compensation and pension exam
Once a C&P exam is actually scheduled, many AI/AN veterans living
in rural areas experience difficulties traveling to the appointment
because of the long distance between reservation lands and the C&P exam
location, as well as the conditions of roads in Indian Country.
According to the most recent National Tribal Transportation
Facility Inventory (NTTFI), there are approximately 161,000 miles of
roads and trails in Indian Country eligible for Federal funding. Of
those, tribal nations own and maintain 13,650 miles of roads and
trails, of which only 1,000 (or 7.3 percent) are paved (the other
12,650 miles are gravel, earth, or primitive). Of the 29,400 miles
owned and maintained by the Bureau of Indian Affairs (BIA), 75 percent
are gravel, earth, or primitive. Altogether, the 42,000 miles of roads
in Indian Country are still among the most underdeveloped, unsafe, and
poorly maintained road networks in the Nation, even though they are the
primary means of access to tribal communities by Native and non-Native
residents and visitors.
The lack of access to comprehensive transit services also makes
traveling to C&P exams and VA services difficult for AI/AN veterans.
AI/AN veterans from across the country have shared their stories of how
they have overcome these challenges, which include hitchhiking, biking,
or even walking miles to reach bus service or a transit stop in order
to attend a C&P exam.
These transportation and transit challenges are known to cause AI/
AN veterans to miss their C&P exams. The consequence is that the claim
decision is delayed and the AI/AN veteran feels further discouraged
from accessing the benefits he or she earned through his or her
service.
iv. issues with cultural competence
VA's one size fits all process for C&P exams does not account for
AI/AN cultural considerations, which can affect how claims are
processed and whether they are approved. For example, the VA's generic
Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire
does not address cultural issues. This lack of consideration leads to
many AI/AN veterans being denied benefits for PTSD and other mental
health issues or awarded benefits far below what their conditions
warrant. Additionally, aging veterans and those with certain types of
traumatic brain injuries affecting language that have reverted to their
traditional languages face a lack of translation services.
v. the need for solutions
AI/AN veterans deserve to receive the healthcare they earned
through their service. Therefore, NCAI suggests the following
solutions:
1. address the issue with tribal veteran service officer accreditation
by amending 38 c.f.r. 14.628(b) to recognize tribal nations as
accredited organizations.
In 2017, the VA amended regulations regarding the recognition of
tribal nations to establish Tribal Veteran Service Officers (TVSOs).
TVSOs are culturally competent advocates that provide meaningful
representation in prosecuting benefits claims and other services for
AI/AN veterans.
Unfortunately, the current regulation requires that for a tribal
nation to have representatives trained and accredited through the VA,
they must establish and fund an organization that has the sole purpose
of assisting veterans and survivors with their claims. Requiring a
tribal nation to establish and fund a separate organization fails to
recognize tribal sovereign decisionmaking and creates unnecessary
regulatory burdens. This burdensome regulatory structure is the reason
only three tribe-affiliated groups have applied for accreditation--and
only one has received accreditation. The regulations should be amended
to permit tribal nations to include TVSOs as employees of an agency or
department of the tribal government rather than having to establish an
entirely separate entity.
2. pass legislation to establish a veterans affairs tribal advisory
committee (vatac)
A VATAC would assist in increasing access to programs and make it
more likely that AI/AN veterans' voices and concerns are heard within
the VA. Specifically, the VATAC would advise the Secretary on how to
improve programs and services for AI/AN veterans, identify timely
issues related to VA programs, propose solutions to identified issues,
provide a forum for discussion, and help facilitate getting useful
feedback from across Indian Country. Building a strong relationship
between the VA and tribal nations will increase awareness and
understanding across the VA of the unique issues affecting AI/AN
veterans in tribal communities. This awareness paired with more direct
interaction with tribal leaders who regularly hear from AI/AN veteran
constituents will ultimately produce faster solutions and better
services for AI/AN veterans.
Legislation has been introduced in the House (H.R. 2791) and the
Senate (S. 524) to create a VATAC and provide vital opportunities for
collaboration, communication, and coordination between the VA and
tribal nations to help AI/AN veterans access the services they earned
through their service to this country.
3. invest in tribal infrastructure, road systems, and tribal transit
systems
Although outside this Committee's jurisdiction, supporting a strong
surface transportation reauthorization bill for Indian Country also
would help address some of the issues AI/AN veterans face when trying
to access VA services. NCAI urges Congress to provide significant
increases for the Tribal Transportation Program, the Tribal Transit
Program, and other programs that will improve road conditions and
promote road safety in Indian Country. Increased investment in these
programs will enhance the ability of AI/AN veterans to travel to VA
services.
vi. conclusion
Thank you for the opportunity to provide a written Statement for
the Record on this important topic. We greatly appreciate the work of
this Committee to address the many challenges and barriers faced by AI/
AN veterans. We look forward to working with this Committee to advance
Federal policies that support those who have served our country. Should
you have any questions, please contact Vice President of Government
Relations Jacob Schellinger ([email protected]) or Policy Analyst
Nicholas Courtney ([email protected]) or call 202-466-7767.
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Additional Submissions for the Record
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Submissions for the Record
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Prepared Statement of the American Federation of Goverment Employees,
AFL-CIO
Chairwoman Luria, Ranking Member Bost, and Members of the
Subcommittee:
The American Federation of Government Employees, AFL-CIO and its
National Veterans Affairs Council (AFGE) appreciate the opportunity to
provide our views on today's hearing titled, ``Update on VA Contracted
Exams, Quality Review Process, and Service to Rural Veterans.''
AFGE represents more than 700,000 Federal and District of Columbia
government employees, 260,000 of whom are dedicated VA employees. Our
membership includes the Veterans Benefits Administration (VBA) claims
processors who order the compensation and pension (C&P) exams that are
the subject of this hearing, as well as the VA clinicians who perform
these exams internally for the Veterans Health Administration (VHA).
Veterans are better served by receiving their care, including C&P
exams, internally within the VA, and the problems identified in the
Office of the Inspector General (OIG) Report titled ``Inadequate
Oversight of Contracted Disability Exam Cancellations'' underscores the
need to reverse the outflow of these exams into the private sector and
bring them back within the VA.
problems identified by the ig
The OIG Report titled ``Inadequate Oversight of Contracted
Disability Exam Cancellations,'' \1\ states that the IG, first alerted
by a VA hotline tip, discovered that 8,770 C&P exams were cancelled
because of the inability of a contractor, Medical Support Los Angeles,
to meet the requirements of its contract, which resulted in significant
delays for veterans who were waiting to have their claims completed and
receive benefits. While this performance was unacceptable,
unfortunately, this trend of cancelling appointments was not limited to
a single contract. As the VA OIG continued its investigation, it noted
that ``VBA provided documentation showing that claims processors
requested 1,342,123 DBQ [Disability Benefits Questionnaires] exams from
November 1, 2017, through April 20, 2018--an approximate 19 percent
increase over the previous 6-month period (May 1, 2017, through October
31, 2017). The OIG team determined that during these same timeframes,
cancellations increased by 74 percent. Given the recent increases in
contracted disability exam cancellations and the number of veterans
involved, effective oversight is critical.'' \2\ The gross inability of
the contractors to live up to their obligations demonstrates the need
for the VA to perform increased oversight, stop eliminating the jobs of
VA C&P examiners, as the VA recently did at the Denver VA Medical
Center, rebuild the VA's internal C&P capacity, and eliminate the
practice of contracting out C&P exams.
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\1\ VA OIG 18-04266-115 June 10, 2019
\2\ VA OIG 18-04266-115 Page 10 June 10, 2019
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The Medical Disability Examination (MDE) program was established by
the VA to monitor and track C&P exams performed by contractors. Upon
examination ``[h]owever, the OIG team found that MDE staff were
hampered in their ability to provide oversight because of limitations
with VBA's electronic exam management systems, the lack of reliable
data, and inadequate staffing of the program.'' \3\ AFGE urges the VA
to immediately fill the nearly 50,000 current vacancies, including
contract oversight positions. This will allow the VA to fulfill its
oversight obligation over C&P contractors.
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\3\ VA OIG 18-04266-115 Page ii June 10, 2019
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problems identified after the ig report
Subsequent to the release of the OIG report, an email from VBA to
staff prohibited employees from sending C&P exams that need to be
``Reworked'' to a particular contractor. Such a disruption in service
likely caused additional delays and costs for veterans seeking
treatment and compensation. AFGE urges the Subcommittee to conduct
immediate oversight on the accuracy and reliability of exams produced
by contractors, as followup to the GAO report titled ``VA DISABILITY
EXAMS: Improved Performance Analysis and Training Oversight Needed for
Contracted Exams (October 12, 2018).
problems identified by the gao
During a hearing on November 15, 2018, titled ``Exploring VA's
Oversight of Contract Disability Examinations,'' AFGE raised concerns
about the problems with contract C&P exams highlighted in the U.S.
Government Accountability Office report titled ``VA DISABILITY EXAMS:
Improved Performance Analysis and Training Oversight Needed for
Contracted Exams (GAO-19-13, October 12, 2018).'' \4\ That hearing
highlighted many inadequacies with contract C&P exams including that
``VBA reported that almost all contractors missed VBA's quality target
of 92 percent in the first half of calendar year 2017.'' \5\ Moreover,
the GAO also reported ``VBA relies on contractors to verify that their
examiners complete required training, [...] VBA does not review
contractors' self-reported training reports for accuracy or request
supporting documentation, such as training certificates, from
contractors.'' \6\ These findings further lengthen the record of
problems plaguing contract C&P exams, and demonstrate why increased
oversight is necessary and C&P exams should be conducted internally.
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\4\ U.S. Gov't Accountability Office, GAO-19-13, ``VA DISABILITY
EXAMS: Improved Performance Analysis and Training Oversight Needed for
Contracted Exams (October 12, 2018).
\5\ Id. at 11.
\6\ Id. at 24.
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afge recommendations
VA's own highly trained, highly credentialed, highly experienced,
and highly accountable employees should perform C&P exams, with very
few exceptions. The continued failures of C&P contractors make the
elimination of in-house C&P capacity around the country all the more
troubling. AFGE welcomes the opportunity to work with the Subcommittee
on new legislation to restore VA's internal C&P exam capacity and
narrow the VA Secretary's unrestricted authority to contract out these
exams. In the near term, AFGE urges immediate action to stop the
elimination of C&P examiner positions around the Nation, and urges the
VA to only provide internal C&P exams for mental health and specialty
claims to better assist veterans when immediate or emergency treatment
is needed.
AFGE appreciates the House Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs holding this
important hearing, and we look forward to working with the Committee to
find ways to improve C&P exams for all veterans.
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Letter to Representative Steube from Bay Pines VA Office
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