[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




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                    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

                              ----------                              

                      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

                              ----------                              


                      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.]

      
      
      
      
      
      
      
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                         A  P  P  E  N  D  I  X

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                    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]
               
                                ------                                


    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.
---------------------------------------------------------------------------
    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

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


                       Submissions for the Record

                              ----------                              


 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.
---------------------------------------------------------------------------
    \1\ VA OIG 18-04266-115 June 10, 2019
    \2\ VA OIG 18-04266-115 Page 10 June 10, 2019
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \3\ VA OIG 18-04266-115 Page ii June 10, 2019
---------------------------------------------------------------------------
                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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
                          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.
                                 ______
                                 

        Letter to Representative Steube from Bay Pines VA Office

               [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


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