[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]


                   VA DISABILITY EXAMS: ARE VETERANS
                      RECEIVING QUALITY SERVICES?

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

                                HEARING

                               BEFORE THE

                      SUBCOMMITTEE ON DISABILITY 
                      ASSISTANCE AND MEMORIAL AFFAIRS

                                 OF THE

                     COMMITTEE ON VETERANS' AFFAIRS

                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                         THURSDAY JULY 27, 2023

                               __________

                           Serial No. 118-28

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]       


                    Available via http://govinfo.gov
                    
                              __________

                   U.S. GOVERNMENT PUBLISHING OFFICE                    
53-306                     WASHINGTON : 2024                    
          
-----------------------------------------------------------------------------------                     
                    
                     COMMITTEE ON VETERANS' AFFAIRS

                     MIKE BOST, Illinois, Chairman

AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking 
    American Samoa, Vice-Chairwoman      Member
JACK BERGMAN, Michigan               JULIA BROWNLEY, California
NANCY MACE, South Carolina           MIKE LEVIN, California
MATTHEW M. ROSENDALE, SR., Montana   CHRIS PAPPAS, New Hampshire
MARIANNETTE MILLER-MEEKS, Iowa       FRANK J. MRVAN, Indiana
GREGORY F. MURPHY, North Carolina    SHEILA CHERFILUS-MCCORMICK, 
C. SCOTT FRANKLIN, Florida               Florida
DERRICK VAN ORDEN, Wisconsin         CHRISTOPHER R. DELUZIO, 
MORGAN LUTTRELL, Texas                   Pennsylvania
JUAN CISCOMANI, Arizona              MORGAN MCGARVEY, Kentucky
ELIJAH CRANE, Arizona                DELIA C. RAMIREZ, Illinois
KEITH SELF, Texas                    GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia        NIKKI BUDZINSKI, Illinois

                       Jon Clark, Staff Director
                  Matt Reel, Democratic Staff Director

       SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

                    MORGAN LUTTRELL, Texas, Chairman

C. SCOTT FRANKLIN, Florida           CHRIS PAPPAS, New Hampshire, 
JUAN CISCOMANI, Arizona                  Ranking Member
ELIJAH CRANE, Arizona                CHRISTOPHER R. DELUZIO, 
KEITH SELF, Texas                        Pennsylvania
                                     MORGAN MCGARVEY, Kentucky
                                     DELIA C. RAMIREZ, Illinois

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

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                         THURSDAY JULY 27, 2023

                                                                   Page

                           OPENING STATEMENTS

The Honorable Morgan Luttrell, Chairman..........................     1
The Honorable Chris Pappas, Ranking Member.......................     2

                               WITNESSES
                                Panel 1

Mr. Jeff London, Executive Director, Medical Disability Exams 
  Office, Veterans Benefits Administration, U.S. Department of 
  Veterans Affairs...............................................     4

        Accompanied by:

    Ms. Jacqueline Imboden, Assistant Director, Procedures & 
        Interagency/Milpay, Compensation Service, Veterans 
        Benefits Administration, U.S. Department of Veterans 
        Affairs

    Mr. Christopher Parker, Associate Executive Director, Office 
        of Acquisitions, Logistics and Construction, U.S. 
        Department of Veterans Affairs

    Dr. Henry Bridges, Senior Medical Officer for the Office of 
        Disability and Medical Assessment (VHA/11CS-DMA), U.S. 
        Department of Veterans Affairs

Ms. Elizabeth Curda, Director, Education, Workforce, and Income 
  Security, U.S. Government Accountability Office................     6

Mr. Stephen Bracci, Director, Claims and Medical Exams Inspection 
  Division, Office of Audits and Evaluations, U.S. Office of 
  Inspector General, U.S. Department of Veterans Affairs.........     7

                                APPENDIX
                    Prepared Statements Of Witnesses

Mr. Jeff London Prepared Statement...............................    25
Ms. Elizabeth Curda Prepared Statement...........................    32
Mr. Stephen Bracci Prepared Statement............................    45

                       Statements For The Record

Disabled American Veterans (DAV).................................    51
National Organization of Veterans' Advocates (NOVA)..............    56
Optum Serve Health Services......................................    59
Paralyzed Veterans of America (PAV)..............................    63
Quality. Timeliness. Customer Service. (QTC).....................    66
Veterans Evaluation Services (VES)...............................    77
American Federation of Government Employees, AFL-CIO.............    80

 
     VA DISABILITY EXAMS: ARE VETERANS RECEIVING QUALITY SERVICES?

                              ----------                              


                         THURSDAY JULY 27, 2023

             U.S. House of Representatives,
  Subcommittee on Disability Assistance & Memorial 
                                           Affairs,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10 a.m., in 
room 360, Cannon House Office Building, Hon. Morgan Luttrell 
(chairman of the subcommittee) presiding.
    Present: Representatives Luttrell, Ciscomani, Self, Pappas, 
Deluzio, and McGarvey.

         OPENING STATEMENT OF MORGAN LUTTRELL, CHAIRMAN

    Mr. Luttrell. The subcommittee will come to order. Good 
morning, everyone. Thank you for coming. Thank you, thank you, 
thank you. We are here today to discuss VA's management of 
disability exams. We will also have the opportunity to hear 
from our Office of Inspector General and Government 
Accountability Office (GAO) about their work and 
recommendations on this matter. VA disability exams are crucial 
to ensuring that veterans receive accurate decisions on their 
disability claims. They are an important piece of the veterans' 
disability claim file and a step toward ensuring that veterans 
can receive their earned benefits.
    Congress first granted the VA the authority to contract 
disability exams out in 1996 and the program has grown 
exponentially since. This freed up many of our Veterans Health 
Administration (VHA) providers who were previously conducting 
disability exams to focus on patient care.
    The contractors are now responsible for roughly 90 percent 
of the disability exams veterans receive. Because of this, it 
is important that the Veterans Benefits Administration (VBA) is 
conducting proper oversight of the contract medical exam 
program. Veterans deserve timely and high-quality decisions. 
From the first step of writing the contracts to ensuring--
issuing, excuse me--guidance to the contractors, to providing 
training, to holding the companies accountable for errors, this 
responsibility starts at the top.
    In a 2018 report, GAO found that only one contractor was 
meeting the VA target accuracy rating. As of today, VA reported 
that overall quality has been trending up for the past six 
quarters and the overall quality score is 90 percent. Job well 
done and thank you. As a veteran, thank you.
    Additionally, almost all of the vendors across all four 
regions have showed sustained and improved in some instances 
quality percentages from the first to second quarter of this 
fiscal year. VA has made strides in the past 5 years with this 
program to ensure that vendors are meeting their accuracy 
requirements and are holding them accountable if they do not. 
Veteran satisfaction and vendor quality both remain 
satisfactory. However, the production percentages for all 
vendors are seemingly not meeting contractual requirements.
    I am interested to see how VA is going to address this 
issue and what steps are being taken to rectify the issue. VA 
has made strides to implement the recommendations from the GAO 
and the Office of Inspector General (OIG), but there is always 
room for improvement especially with programs of this 
magnitude. That being said, more veterans have been applying 
for benefits since the passage of the Sergeant First Class 
Heath Robinson Honoring our Promise to Address Comprehensive 
Toxics (PACT) Act. Exam scheduling requests are up 30 percent 
so far and of these, 39 percent are connected to the PACT Act 
itself.
    VA must exercise effective oversight as the number of exams 
rise. I am looking forward to hearing from the GAO and the OIG 
on their relevant work as well as updates from VA on how they 
are implementing their recommendations. I want to thank 
everyone again for being here today and I am looking forward to 
a fruitful conversation. With that, I yield to the Ranking 
Member Pappas for opening statement.

       OPENING STATEMENT OF CHRIS PAPPAS, RANKING MEMBER

    Mr. Pappas. Thank you very much, Chairman Luttrell. Good 
morning, everyone. It is great to have you joining us for 
today's hearing on Compensation and Pension (C&P) exams at the 
Department of Veterans Affairs.
    Since this subcommittee's last hearing on C&P exams, VA 
appears to have made some progress, but I am concerned that 
there may be lingering effects of the COVID-19 pandemic. The 
passage of the PACT Act last year is certainly already showing 
up in the backlog of exams.
    The C&P exam is a critical step in the disability claims 
process. C&P exam findings are frequently used to decide 
whether VA will grant a veteran disability benefits. Ensuring 
these exams are conducted accurately and in a timely manner is 
critical to ensuring that veterans have a streamlined and 
reliable process so they can receive their deserved benefits as 
soon as possible.
    At our last hearing on C&P exams, VA indicated that its 
goal was to get the inventory of pending exam requests down 
from the 350,000 they were seeing at the time to a working 
level of about 140,000. Now, the latest data we have received 
indicates that the number of pending exams is still over 
300,000. At the same time, we are aware that contract exam 
providers are still conducting over 90 percent of the exams. 
This underscores the need for congressional oversight to ensure 
that veterans are satisfied and that taxpayer dollars are not 
being wasted.
    Now, I hear from veterans all the time. I hear countless 
stories actually of veterans who have had abysmal experiences 
trying to schedule an examination with VA contractors. One 
veteran in my district said that a contractor simply told him 
that he needs to show up for an appointment on August 30, 
provided no additional information or location for the 
appointment, and it took a conference call between myself--
between our office and the contractor, to get to the bottom of 
this and get the veteran the information that they needed. This 
kind of experience is just unsatisfactory.
    We also need to hear today from VA's witnesses about a 
solid plan for how they intend to get the number of pending 
exams down, utilizing all resources at VA's disposal, including 
contract providers and VHA providers. The timeliness of these 
exams is also a major contributor to VA's claims backlog, 
claims that have been pending for more than 125 days. Data the 
committee has received from VA shows that the claims backlog 
has risen from 77,000 at the beginning of the pandemic to over 
250,000 as of last week, which is almost a third of the 871,000 
claims currently being processed by VA.
    The committee has heard from VA that VHA and the contract 
exam providers have capitalized on the lessons learned from the 
pandemic and are maximizing the use of telehealth technology 
where appropriate. This is mostly used in mental health exams, 
but I imagine that it is far more convenient for the veterans 
than having to drive dozens or even hundreds of miles for an 
appointment. I hope that VA continues to research ways to 
maximize the use of teletechnology to facilitate exams for 
veterans where possible.
    While the growing number of pending exams is a major 
concern, we must also talk about the quality of these exams. 
Recent reports from the Government Accountability Office and 
the VA Office of Inspector General have raised some concerns 
about how VA assesses the quality of exams and what is done 
once exams are deemed inaccurate. I am also incredibly 
concerned that decisions are being made about veterans' 
benefits before those exams quality are checked by VA. What 
happens if the exam leads a rating official to grant benefits 
inappropriately? Many veterans cannot afford to have benefits 
clawed back after the fact.
    We need to have confidence that when a rating decision is 
made it is made using complete and accurate medical 
information. I hope to hear how VA is guaranteeing that the 
exams used to decide benefits are complete and accurate. This 
subcommittee has a long history of oversight of the C&P exam 
process. This is not the first conversation that we have had 
about the quality of exams. We have heard that VA has taken 
appropriate steps to improve oversight but I hope to hear from 
GAO and OIG whether they agree with VA's assessment of its 
oversight.
    A part of this conversation that I really do not want to 
get lost in this is that the process is meant to help veterans. 
As I have already made clear, I have heard stories from 
veterans about how the C&P exam process can be inconvenient, 
cumbersome, and inaccessible for some veterans. One veteran in 
my district in New Hampshire talked about getting an 
appointment scheduled for him more than five states away in 
Illinois. There are cascading effects from contractors not 
communicating well with veterans in a transparent and timely 
manner. Another constituent of mine submitted a claim but did 
not receive a response for 2-1/2 months. Upon submitting an 
inquiry on his behalf, VA responded that while they received 
his claim, the contractor stated they could not schedule the 
examination and therefore the request was canceled.
    All this can be incredibly frustrating to our veterans. 
What the contractor failed to add in that particular case is 
that there was a scheduling conflict with the date proposed. 
The contractor's customer service representative did not even 
offer him the option to reschedule that appointment.
    Expecting a veteran to navigate this confusing process or 
even travel halfway across the country is just ridiculous. I 
expect better of VA and contractors in providing these exams. I 
look forward to hearing from our witnesses today and I yield, 
Mr. Chairman.
    Mr. Luttrell. Thank you, sir. I would like to welcome all 
of our witnesses before the committee. Our first witness is Mr. 
Jeff London, who is the Executive Director of the Medical 
Disability Exams Office at the Veterans Benefits 
Administration. He is accompanied by Ms. Jacqueline Imboden, 
the Assistant Director of Procedures and Interagency for 
Compensation Service at the Veterans Benefits Administration. 
We have Mr. Christopher Parker, the Associate Executive 
Director for the Office of Acquisitions of Logistics and 
Construction, and Dr. Henry Bridges, the Senior Medical Officer 
for the Office of Disability and Medical Assessment. We also 
have Ms. Elizabeth Curda, Director of Education, Workforce, and 
Income Security at the Government Accountability Office, and 
finally, Mr. Stephen Bracci, Director of the Claims and Medical 
Exams Inspection Division for the Office of Audits and 
Evaluations at the Office of Inspector General. Man, that is a 
mouthful.
    Would you all please rise to be sworn in? Please raise your 
right hand.
    [Witnesses sworn.]
    Thank you, be seated. Thank you for being here today. Mr. 
London, you are now recognized for 5 minutes to deliver your 
opening statement.

                    STATEMENT OF JEFF LONDON

    Mr. London. Good morning, Mr. Chairman Luttrell, Ranking 
Member Pappas, and distinguished members of the subcommittee. 
We appreciate the opportunity to appear before you today to 
discuss the disability examinations administered by the 
Department of Veterans Affairs. I am joined by Jacqueline 
Imboden from Compensation Service, Dr. Henry E. Bridges, Jr. 
from the VHA Office of Disability and Medical Assessment, and 
Christopher Parker from the VA Office of Acquisitions Logistics 
and Construction.
    Mr. Chairman, I want to highlight the collaboration with 
VHA, OIG, and GAO in the overall improvements of the exam 
oversight process. We have made great strides this Fiscal Year 
with exam vendors completing over 1.9 million appointments 
consisting of over 200,000 acceptable clinical evidence, or ACE 
exams, and over 160,000 tele-C&P appointments, a 5 percent 
increase over Fiscal Year 2022. VHA also continues to support 
virtual care modalities, or nearly 26 percent of exams 
completed by VHA this year using ACE and the tele-C&P or 
telehealth processes, a 3 percent increase from Fiscal Year 
2022.
    VA welcomes the oversight of VA OIG, GAO, to improve 
services for veterans and has worked closely with both entities 
to resolve outstanding issues related to VA medical exams. For 
example, as a result of a GAO report on license portability, VA 
updated guidance and contractual language, removing ambiguity 
and established procedures and additional audits to address 
those concerns.
    GAO also issued a report identifying potential risks 
regarding exam quality and compacity. VBA is working 
collaboratively with VHA to execute a comprehensive workload 
allocation plan for C&P exams, including an assessment of the 
PACT Act on exam capacity. VA OIG found that VA needed to 
implement a process to monitor and assess vendors' compliance 
with contractual mileage and reimbursement requirements. In 
March 2023, we expanded oversight activities by modifying our 
third-party financial audit contract. OIG further examined VA's 
governance and accountability for exams, as well as VBA's 
disability exam inventory during the COVID-19 pandemic. Based 
on the collaboration between OIG and VBA, all actions have been 
completed and both reports were closed as fully implemented.
    Along with OIG and GAO, VBA consistently monitors quality, 
customer satisfaction, timeliness, and production. VA conducts 
regular site visits and desk reviews with contractors to ensure 
provider locations are in compliance with VA standards and the 
contract. So far in Fiscal Year 2023, VBA has conducted over 
200 in-person site visits at exam locations. All contract and 
VHA examiners must be certified and undergo the same existing 
training prior to conducting any disability exam. We also have 
third-party contracts that include invoice validation and 
verification of examiners' credentials, licensing, and 
training.
    Internally, VBA performs monthly quality reviews of 
Disability Benefits Questionnaires (DBQs) completed by exam 
vendors reviewing for accuracy and completeness. We also 
conduct special reviews and share feedback on specific exam 
types, providers, or based on error trends. The overall quality 
score for the contract program in Fiscal Year to date is 96.8 
percent. I am happy to report that the last quarter that we 
assessed is 97 percent.
    VA vendors continue to expand their provider networks and 
their internal workforce to increase exam production. Vendors 
are eligible for both positive and negative monetary incentives 
for scores in customer satisfaction, quality, timeliness, and 
production. These incentives and increased vendor provider 
networks have resulted in a nearly 25 percent completion 
increase this fiscal year. We are also working to meet all 
veterans including rural veterans where they are, rather than 
where we are located. A few examples include alternative 
modalities such as ACE and tele-C&P, which limit travel for in-
person exams. We are using traveling examiners, mobile units, 
claims clinics, and per diem or rented locations to assist all 
veteran populations.
    VA remains committed to the continuous improvement of 
medical disability exams and appreciates the oversight and 
authority provided by Congress in support of veterans, their 
families, caregivers, and survivors. This concludes my 
testimony. I would be happy to answer any questions you or the 
subcommittee members have. Thank you.

    [The Prepared Statement Of Jeff London Appears In The 
Appendix]

    Mr. Luttrell. Thank you, Mr. London. The written statement 
from Mr. London will be entered into the hearing record. Ms. 
Curda, you are now recognized for 5 minutes to deliver your 
opening statement.

                  STATEMENT OF ELIZABETH CURDA

    Ms. Curda. Good morning, Chairman Luttrell, Ranking Member 
Pappas, and members of the subcommittee. Thank you for inviting 
me to discuss our work on VA's disability medical exam program, 
including VA's capacity to meet the growing need for disability 
exams.
    VA performs over 1 million disability exams per year and 
its workload is projected to grow significantly. At the same 
time, VA's exam request backlog has almost doubled from about 
158,000 at the start of the COVID-19 pandemic to just over 
300,000 last month. Today, I will discuss VA's efforts to 
implement our prior recommendation on planning for exam 
workloads across VBA and VHA examiners. I will also discuss 
findings from our June 2023 report on VHA's recruitment and 
retention efforts, as well as VA's use of license portability 
and telehealth flexibilities.
    In 2021, we found that while VA was shifting most of its 
workload from VHA to VBA contract examiners, it had not 
developed a documented strategy and goals for the optimal 
allocation of exams between the two. We recommended that VA use 
sound planning practices such as developing goals, a timeline, 
and assessing risks related to planned workload allocations. VA 
drafted a plan but it lacked key information such as the 
desired distribution of exams between VBA and VHA and an 
assessment of any associated risks. According to VA, they are 
working on an updated plan that will include this information.
    Our recent work highlights why sound planning and 
communication are important. Indeed, in our most recent review, 
we found that VHA medical facilities did not have a clear 
understanding of what was expected of them to meet exam demand 
in two areas. First, medical facilities were uncertain whether 
VHA would continue to provide exams in the future. We found 
that while VHA did have plans to continue providing exams, 
officials at the facilities responsible for recruiting and 
retaining examiners were unsure of those plans. They were 
uncertain whether they would need to maintain examiner capacity 
or if all exams would shift to VBA contractors. VHA has since 
communicated to facilities that they will continue to conduct 
exams and should develop plans to meet workload demands.
    Second, VHA has yet to provide clear guidance to its 
medical facilities on a legislative requirement to halt the 
elimination of examiner positions until the exam backlog is 
back to pre-pandemic levels. While VHA issued guidance to its 
facilities to halt changes to exam services and pause the 
elimination of examiner positions, the guidance lacked key 
details and definitions.
    As a result, facilities had different interpretations of 
the changes they could make. For example, one facility said 
they were not supposed to eliminate examiner positions in their 
organization chart, but they could leave these positions vacant 
as examiners retired or left. Another facility said that the 
guidance left them leeway to continue moving away from 
conducting disability exams and prioritizing clinical care. We 
recommended that VHA clarify the guidance it provided to 
medical facilities to help position them to meet veterans' exam 
needs.
    Now, I would like to turn to VA's use of two flexibilities 
that have helped the Agency to meet exam demand, license 
portability and telehealth. First, VBA has been using license 
portability to allow more types of providers to perform exams 
in states other than where they are licensed.
    While this flexibility has helped VBA to meet exam needs, 
we found the Agency provided incorrect information to its 
vendors on who was eligible. For example, VBA mistakenly told 
contractors that dentists were eligible for license 
portability. VBA has since rectified these issues. VBA also did 
not adequately monitor the contractors' use of license 
portability and were unaware that non-eligible providers were 
being used.
    We recommended that VBA develop a way to regularly monitor 
vendors' use of portability. Since our report, the Agency 
developed guidance for monitoring portability use. We also 
recommended that VA assess any potential risks caused by 
ineligible providers conducting exams. The Agency has not yet 
fully implemented this recommendation.
    Finally, both VBA contractors and VHA increased their use 
of telehealth during the pandemic, especially for mental health 
exams. Both continue to use this flexibility citing several 
benefits such as more convenience for veterans who can not 
travel long distances and the ability to provide exams in 
difficult to reach areas.
    In summary, with the influx of exam requests and growing 
backlog, implementing our recommendations to plan for workload 
allocations, clearly communicate VHA exam capacity expectations 
to medical facilities, and conduct adequate oversight can help 
the Agency to improve their capacity to serve our Nation's 
veterans. This concludes my prepared statement and I will be 
happy to address your questions.

    [The Prepared Statement Of Elizabeth Curda Appears In The 
Appendix]

    Mr. Luttrell. Thank you, ma'am. The written statement of 
Ms. Curda will be entered into the hearing record. Mr. Bracci, 
you are not recognized for 5 minutes to deliver your opening 
statement.

                  STATEMENT OF STEPHEN BRACCI

    Mr. Bracci. Thank you and good morning. Chairman Luttrell, 
Ranking Member Pappas, and members of the subcommittee, thank 
you for the opportunity to discuss the OIG's oversight of VBA's 
contract medical exam program, which is administered by its 
Medical Disability Examination Office, or MDEO.
    The OIG has maintained oversight of this program due to its 
effect on veterans' disability compensation benefits, as well 
as the billions of dollars VBA pays contractors to conduct 
these exams. I will highlight three OIG reviews showing gaps in 
MDEO's oversight of the program and describe how these 
weaknesses can affect veterans' experiences with the disability 
claims process.
    First, our 2022 comprehensive review of the contract 
medical exam program found significant deficiencies that 
stemmed in part from limitations with VBA's oversight at the 
time of the review. We found specific issues with governance, 
accountability, communication, and contract language. During 
our review, vendor exams did not consistently meet accuracy 
criteria and contract wording restricted MDEO's ability to 
apply monetary disincentives to hold vendors accountable.
    Further, MDEO did not communicate errors they identified to 
VBA's Office of Field Operations or to its regional offices, 
which resulted in claims decisions based on erroneous or 
incomplete information. MDEO also did not analyze all readily 
available quality assurance (QA) data to help identify and 
correct systemic issues. We made four recommendations including 
assessing and modifying contract language, communicating exam 
errors to all appropriate VBA offices, and analyzing available 
error data to help improve the program. All four 
recommendations are closed as implemented.
    Our most recent review responded to veterans' concerns that 
they had to travel excessive distances for exams. We examined 
MDEO's monitoring of contractual mileage requirements because 
this travel can place a physical burden on veterans and 
increase VA's costs since veterans receive mileage 
reimbursements for driving to their exams. Although the 
contractors are required to get veterans' express consent to 
travel beyond 50 miles for non-specialist exams and 100 miles 
for specialist exams, our team found that MDEO was not 
fulfilling its responsibility to monitor this requirement.
    MDEO's leaders did not consider it a priority given what 
they described as the small percentage of veterans affected. 
They did not realize the impact until our team informed them 
that over 65,000 veterans, or 11 percent, were required to 
travel beyond the mileage restrictions at the time of our 
review.
    The OIG made three recommendations that focused on VBA 
overseeing vendors' compliance with mileage and travel 
reimbursement requirements, as well as collaborating with 
vendors to ensure their portals include proper documentation of 
expressed consent and mileage reimbursement information. All 
recommendations will remain open until we see evidence of 
sustained progress.
    The third review examined VBA's efforts to schedule and 
conduct disability exams during the pandemic. We found that VBA 
took significant actions to limit veterans' exposure to COVID-
19 by canceling in-person exams and provided guidance to the 
field regarding when it was appropriate to reschedule exams to 
ensure cancellations did not result in claim denials. However, 
we found first that early in the pandemic, guidance was unclear 
and led to inappropriately denied claims due to canceled in-
person exams. Second, that VBA's strategies for addressing the 
exam inventory required more attention and testing to ensure 
personnel are fully prepared for future emergencies.
    We made two recommendations to VBA. Improve its strategy to 
reduce the exam inventory through in-person, telehealth, and 
acceptable clinical evidence exams, and implement a plan to 
increase the use of telehealth exams. We closed the first 
recommendation as implemented. The second recommendation was 
closed as not implemented because VBA did not carry out its 
original action plan due to changes in circumstances.
    In conclusion, one of the critical foundations of 
accountability of any program is effective quality assurance 
and monitoring to detect and resolve issues. MDEO needs to 
improve its oversight of contract exam vendors and better 
communicate with other VBA offices to ensure veterans receive 
the benefits they are entitled to through VA's disability 
programs. The OIG remains focused on conducting oversight work 
in this area to help improve veterans' experiences during the 
claims process. Mr. Chairman, this concludes my statement, and 
I would be happy to answer any questions you or members of the 
subcommittee may have.

    [The Prepared Statement Of Stephen Bracci Appears In The 
Appendix]

    Mr. Luttrell. Thank you, Mr. Bracci. The written statement 
of Mr. Bracci will be entered into the hearing record. We will 
now move to questioning. I recognize myself for 5 minutes. Mr. 
Bracci, how long have you been working at the Office of OIG?
    Mr. Bracci. Nearly 22 years.
    Mr. Luttrell. Mr. London, how long have you been in your 
position?
    Mr. London. Since December 2021.
    Mr. Luttrell. Have recommendations from your office, Mr. 
Bracci, are they similar to previous recommendations that you 
have offered up to the Department of Veterans Affairs? Do you 
see any consistency in the recommendations?
    Mr. Bracci. Yes, sir. Based on work we have done within 
VBA, we commonly see issues of governance, accountability, and 
communication.
    Mr. Luttrell. That seems systemic. Mr. London, I am curious 
as a veteran myself, why this proverbial can continues to get 
kicked down the road. Can you give me some insight on why if 
the Office of Accountability is providing this information to 
the VA, why this continues to happen?
    Mr. London. Thank you very much for the question. First, 
let me tell you that oversight and compliance is near and dear 
to my heart. Most of my time with the Department of Veterans 
Affairs I spent my career making sure that we were in 
compliance with statute, regulations, and policies and 
procedures. Immediately after my appointment up to this 
position, I made a focus of making sure that one, we have 
internal processes to review any deficiencies, and we take 
seriously the feedback that we get from GAO, from OIG, and 
veterans, Veterans Services Organizations (VSOs), and their 
advocates.
    As a result of my leadership and my team's actions, we have 
improved the oversight capabilities that we have. The systemic 
issues that have been identified will not continue under my 
leadership. You have my commitment.
    Mr. Luttrell. I will take that as the next time that this 
panel is sitting in front of us with the OIG, the OIG report 
will not say governance, accountability, communications in the 
continuance of language.
    Mr. London. That is my commitment.
    Mr. Luttrell. Is that a fair assessment?
    Mr. London. Yes, sir.
    Mr. Luttrell. Thank you. Mr. London, on a staff call with 
the VA, the performance data of the vendors for the second 
quarter of the Fiscal Year 2023 was provided. The accuracy of 
veteran satisfactions of vendors seems to be above the 
requirements. However, the production standards do not seem to 
be meeting the requirements. Can you elaborate, please?
    Mr. London. Yes, thank you for the question. I believe you 
are referring to Quarter 2 of this Fiscal Year where their 
production rate was not meeting the standard. It is very 
important to note that Quarter 2 actually represents exactly 
when VA started processing PACT Act claims. In January, 
starting January 1, we started to receive an influx of 
additional exam requests, which we expected and anticipated. We 
have been working through that inventory.
    What we have subsequently done to make sure that we are 
meeting the demand of our veterans, we have changed the 
production requirement to match the receipts that we are 
getting and the projections that we have for exams. The exam 
vendors are completing more exams than ever. As I noted in my 
testimony, we have completed over 25 percent more than we 
completed last year, which was a record year. On a weekly 
basis, we complete over 50,000 exams. Generally, we get about 
50,000 exams requested each week. We are keeping pace with the 
demand and it is a reflection of the new standards that we 
have, which have started in Quarter 3, which we will be happy 
to report to you and your staff in the coming weeks.
    Mr. Luttrell. I think one of the major concerns of this 
committee is the implementation of the PACT Act and I give 
absolute credit to you, to the Department of Veterans Affairs, 
okay? I do. You guys are working hard. However, when--I should 
not say however. My concern is because we are already behind 
the eight-ball and the cases are going to continue to come in, 
do you honestly think in the next Fiscal Year the VA will be 
able to sustain an upward momentum of completing these cases?
    Mr. London. Thank you for the question. Our exam vendors 
continue to modernize their processes, to provide additional 
training, and to expand their network to make sure that they 
have the examiners available to meet the demand. If you look at 
how we are performing today, on average we complete exam 
requests within 30 days. As I mentioned, we are completing over 
50,000 exams each week. If you look at our current inventory 
that we have, which is roughly 285,000 pending exams, that 
represents the fact that we are processing these at 30 days at 
a time and they are in various stages of the exam process. That 
can be scheduling the appointments with the veteran, actually 
completing appointments, or actually filling out the DBQ or 
going through a QA process. I feel confident that where we are 
today and with our planned expansion that we will be able to 
maintain a healthy inventory and to continue to provide exams 
so that veterans can get access to their benefits and 
healthcare.
    Mr. Luttrell. Thank you, Mr. London. My time has expired. I 
now recognize the Ranking Member Pappas for his line of 
questioning.
    Mr. Pappas. Thank you very much, Mr. Chairman. Thanks to 
our panel for your comments. Obviously, the chairman mentioned 
the increase in claims due to PACT Act and how VA is working to 
meet that moment, especially as the workload continues to 
escalate. I am just wondering if, you talked a little bit, Mr. 
London, about the vendors, the other piece of the equation 
here, the VHA examiners. Can you talk about whether VHA 
facilities will hire additional examiners to increase staff 
capacity to help meet this moment and ensure that we do not 
fall further behind?
    Mr. London. Thank you very much for the question. As I 
mentioned in my testimony, the partnership with the VHA is 
absolutely critical to make sure that we can complete the exams 
for our veterans. We meet with VHA on a weekly basis to discuss 
the State of the workload and we are working as stated in the 
testimony to actually have a formal work allocation plan so 
that we have not only the confidence, but we have a common 
understanding of what the workload distribution is going to be. 
I am going to defer to my colleague, Dr. Bridges, to talk 
specifically about what VHA is doing.
    Mr. Pappas. Okay. While you answer that, if you could get 
to the point that I believe Ms. Curda made earlier, which was 
just about a lack of clarity within VA about what direction we 
are going in and whether or not we do want to fill positions 
and make sure VA is beefing up its staff of examiners.
    Mr. Bridges. Thank you for the question, Congressman. VHA 
is continuing work associated with communications from GAO 
needed to complete the recommendation and expect to meet the 
target date of November 2023. As Mr. London just stated, we are 
also working on a work allocation Memorandum of Understanding 
(MOU) and we anticipate that to be completed by September 2023 
and to be implemented by Fiscal Year 2024. The decision for 
increasing capacity of VHA providers is left up to the local 
facilities and the Veterans Integrated Services Network (VISNs) 
to make that decision based upon the workload for treatment 
exams as well as for C&P examiners. Thank you.
    Mr. Pappas. Okay. In terms of seeing that formal workload 
plan, so we are all clear on where we are going, when do we 
expect to see that? Mr. London, maybe if you want to take it.
    Mr. London. Sure, I can take that. Thank you for the 
question. As Dr. Bridges mentioned, we are actually working on 
the plan as we speak and we plan to have it drafted by the end 
of the fiscal year. It will then go through VBA and VHA 
leadership concurrence and obviously, there will be a 
discussion there, and we plan to implement that in Fiscal Year 
2024. I do not have a definitive timeline for the exact date 
that we will implement, but we will certainly have a draft 
ready for leadership by the end of the fiscal year.
    Mr. Pappas. Okay. Can you comment on what is happening in 
the interim? You know, to address this issue of lack of clarity 
and, you know, how VA is responding to this increase that we 
are seeing in folks that need these exams.
    Mr. London. Thank you for the question. First let me 
explain that every exam that is requested we first look to see 
if that local VHA facility closest to the veteran's home 
actually has the capacity to complete that examination. Every 
examination request goes through that process. If the capacity 
is not at their local facility, that is when the exam request 
is then forwarded to one of the exam vendors.
    As Dr. Bridges said, the first primary focus is to make 
sure that at the local level, they are providing the healthcare 
and treatment that our veterans have earned and that they 
deserve. If the capacity is not there, it then goes.
    Today, there are C&P examinations being completed by VHA 
and as the chairman mentioned, VHA is completing about 10 
percent of all exam requests.
    Mr. Pappas. Can I ask you just about maybe a philosophical 
question about timeliness and about quality whether those 
things are in conflict and you need to work to balance them. Or 
whether veterans can expect to see both through this process.
    Mr. London. My view--thank you for the question. My view is 
that they are equally as important. We expect to complete exams 
as quickly as we can with the highest quality possible. That is 
why we set a target of 96 percent for all quality and we will 
incentivize the vendors if they exceed that amount and equally 
if they go below 92 percent, we will actually charge a negative 
incentive to ensure that we are not only meeting the timeliness 
but the quality that our veterans deserve.
    Mr. Pappas. Well, since such a growing share of this work 
is being contracted out, I think the accountability for the 
vendors is such an important piece of this. Measuring that 
progress is important. Even if you hit a score of, you know, 
90, 95 percent in terms of timeliness or satisfaction, you are 
still talking about thousands of veterans that might not have a 
satisfactory experience. These are people that are owed nothing 
but the best. Perfection is critically important in both of 
those areas. I thank you for your work and I yield back.
    Mr. Luttrell. Thank you, ranking member. Mr. Ciscomani, you 
are recognized for 5 minutes, sir.
    Mr. Ciscomani. Thank you, chairman. Thank you for your time 
and thank you to the witnesses also for being here today and as 
the subcommittee conducts this hearing oversight over the 
medical exam process for disability claims.
    I am proud to represent over 70,000 veterans in my district 
in Southeastern Arizona. It is CD-6 in the southeastern corner 
of the state. We have a substantial veteran population and one, 
my community specifically in Sierra Vista, which is in Cochise 
County, has that substantial veteran population and it is also 
right on the U.S.-Mexico border. Cochise County also borders 
the State of New Mexico to the east with the nearest VA 
facility in Tucson, which is an hour and a half away or so from 
the Sierra Vista area.
    Veterans in Sierra Vista face limited options if they can 
not schedule a medical exam. Additionally, most of the 
surrounding areas are rural communities with limited providers. 
In the Isakson-Roe Veterans Healthcare and Benefits Act of 
2020, it granted temporary license portability for VBA 
contracted nurse practitioners, physician assistants, and other 
healthcare providers that conduct disability exams to provide 
exams across state lines. This is crucial for communities like 
mine in Sierra Vista with New Mexico being so close, as I 
mentioned. Mr. London, question for you, how have the 
flexibilities provided by license portability and telehealth 
exams helped the increased demand for disability exams?
    Mr. London. Thank you for the question. Without that 
flexibility, I believe that we would not be able to keep pace 
and report the numbers that I stated earlier about the 
increased production and how I feel confident that we are 
managing the exam requests appropriately. The vendors have 
utilized that authority to actually have traveling providers to 
go to places like your state to ensure that veterans can get 
the exams that they need.
    We also have a fleet, the vendors do, have a fleet of 
mobile exam units. There are approximately 28 and they are, as 
we speak, they are adding more to the fleet, where we are 
actually not only sending traveling providers, but we are 
actually going into the communities where veterans are. We have 
actually started doing in-person events across the country 
where instead of having veterans to travel, we are going to 
them especially in rural communities like the one that you 
serve. I feel as though that that particular authority has 
enabled us to be able to meet that demand and meet veterans 
where they are.
    Mr. Ciscomani. Well, you kind of answered my next question, 
if there was anything you want to expand on that. My follow up 
was going to be how do these flexibilities address the needs of 
rural veterans in ensuring they are able to receive quality and 
timely exams as well? As I mentioned, with quite frankly the 
state borderlines with New Mexico being almost the same 
distance as the closest nearest facility. The mobile, you know, 
facility of you going to them that is an example. Anything else 
you can think of that is making this, you know, access better 
and wider for the veterans there?
    Mr. London. Yes, thank you. It is a multi-pronged approach. 
First it is the traveling providers. Also, as I mentioned in my 
testimony, what the vendors are going is especially when they 
are large numbers of veterans that they need to see, they are 
actually leasing space in that area so they can have a routine 
presence there. They are also going in and as demand comes up, 
they are actually working with local entities to actually 
utilize their space to again, make sure that we can meet the 
demand.
    Again, that authority allows us the flexibility even if we 
do not have providers in a particular area to actually take 
advantage of utilizing our mobile units using that rented----
    Mr. Ciscomani. Yes.
    Mr. London [continuing]. space or that per diem space. We 
also want to make sure that we are using telehealth 
capabilities and also the acceptable clinical evidence so that 
veterans do not have to travel at all.
    Mr. Ciscomani. I am not sure how good your glasses are, but 
it seems like you are reading my notes because that was exactly 
my next question. Actually, that is going to go to Ms. Curda, 
if I can. Regarding telehealth, can you elaborate a little bit 
on how the flexibilities of license portability and telehealth 
reportedly help the VA to meet demand on disabilities exams?
    Ms. Curda. Sure. I mean, I have very similar things to say 
as VA. You know, we have heard from the contractors we spoke to 
and certainly veteran service organizations, as well as VA 
officials, are pretty much in agreement that these 
flexibilities have helped meet exam demand in a number of ways. 
They have helped provide exams in rural areas as we discussed.
    In addition, they have also broadened the pool of available 
providers, which we heard helped increase access to 
specialists, for example, audiologists and psychologists. 
Contract vendors were also able to send in experienced 
examiners from out of state to provide exams rather than 
needing to take the time to hire and train new providers.
    Finally, in addition to helping provide exams for rural 
veterans, we also heard that telehealth helped provide safer 
exams during the pandemic, saved some veterans time from 
traveling long distances, and eased physical space constraints 
experienced by VHA and vendor facilities so they could complete 
more exams.
    Mr. Ciscomani. Thank you. I am out of time. I just want to 
say that we, you know, realize that we need to clarify some 
technical issues here and guidelines regarding license 
portability. I also believe that many communities like mine can 
benefit from this. While I realize the temporary license 
portability is scheduled to expire here in January 2024, I hope 
we can work together to ensure that veterans can continue to 
benefit from easier access to these exams, especially when it 
is so crucial to their disability claims and disability ratings 
as well. Thank you and Mr. Chair, I yield back.
    Mr. Luttrell. Thank you, sir. Mr. Deluzio, you are 
recognized for 5 minutes, sir.
    Mr. Deluzio. Mr. Chairman, thank you and thank to you and 
the ranking member for your leadership here. We have got to get 
this right. We have got to make sure that we are protecting 
public money and of course making sure our fellow veterans are 
not missed when they are eligible to be receiving compensation 
and care in the VA. It is critical.
    Mr. Bracci, I will start with you. I want to interrogate a 
bit the assumptions around outsourcing and privatizing the C&P 
exams and make sure that those make sense. As I understand it, 
principally or first, the hope here, the goal is to save money 
without sacrificing quality and to free up VHA staff and 
personnel for care. Let us start with the first one. Are we 
saving money without sacrificing quality in outsourcing these 
exams?
    Mr. Bracci. As far as who conducts the exams, the OIG does 
not really take a position on who conducts them. We have just 
conducted our oversight of contract exams because that is where 
the bulk of the exams are done and that is where the bulk of 
the money is spent. We have not done any specific review to the 
topic that you are talking about.
    Mr. Deluzio. Sure. In other words, reviewing or comparing 
outcomes in VHA relative to the contractors who are doing these 
exams outside VHA.
    Mr. Bracci. Yes, sir, we have not done any reviews that 
focus on that aspect.
    Mr. Deluzio. Okay. Is there anything stopping you from 
doing that kind of analysis in terms of legislative authority 
or otherwise?
    Mr. Bracci. No, nothing legislatively that is preventing us 
from doing it.
    Mr. Deluzio. Okay. Then I guess I would, I will ask you as 
well, Mr. Bracci, does OIG have a view of whether using 
contract examiners has freed up VHA to use people and their 
time for care more effectively?
    Mr. Bracci. I do not think we have done the work to make 
that type of assessment. We have focused on MDEO's oversight of 
the contract exam program.
    Mr. Deluzio. Okay.
    Mr. Bracci. That is where we get into the issues of 
governance, accountability, and communication.
    Mr. Deluzio. Okay. Mr. London, I will ask you a version of 
those same questions. Do you have a view of whether this has 
been more effective financially without sacrificing quality to 
have so many of the exams be done by contractors?
    Mr. London. I do not have a view of it because I am not 
aware of any analysis that has been conducted to actually have 
a conclusion to answer your question. I thank you for the 
question.
    Mr. Deluzio. Does anyone on the panel have a thought about 
that? Okay. Something we need to be digging in on. That is the 
basis assumption I think of why we are doing these and why we 
are having contractors do these rather than folks within VHA.
    Dr. Bridges, do you have a view of whether the reliance on 
contractors has freed up VHA staff to do more and provide more 
care relative to what they were doing previously?
    Mr. Bridges. Thank you for the question, Congressman. 
Unfortunately, I do not have an answer for that question that 
you are posing but I can take it back to leadership.
    Mr. Deluzio. Please do. Does anyone else have a thought on 
that or have any view on that at all? Okay. I will take that as 
a no.
    Mr. Bracci, back to you. Your testimony highlighted issues 
with the distance veterans are being asked to travel for their 
exams. You have mentioned in your testimony here today your 
team found on average veterans were asked to travel 93 miles 
more than the contract limitations, which are, and you will 
have to correct me if I am wrong, 50 miles for non-specialists, 
100 miles for specialists, each way. What percent, and I think 
you mentioned it earlier, what percent do you estimate of all 
veterans are being forced to travel beyond the contractual 
limitations on these exams?
    Mr. Bracci. Yes. At the time of our review, it was about 11 
percent who were having to travel beyond the mileage 
restrictions, and that amounted to about 65,000 veterans.
    Mr. Deluzio. Your findings were that MDEO was not 
exercising really any oversight of the contract examiners in 
terms of how far they were asking veterans to travel?
    Mr. Bracci. Yes, the oversight was lacking as far as that 
particular topic. Once, to their credit, once we came in and we 
did our review, and we identified issues and made 
recommendations, they were responsive and started to take 
action.
    Mr. Deluzio. Okay. Does OIG have a sense of whether we are 
now seeing veterans traveling within the limitations in the 
contracts in those geographic ranges or we are still seeing 
folks have to travel too far?
    Mr. Bracci. We are just now getting into our follow-up 
process, which starts about 90 days after report publication. 
We will be tracking that as we go through that follow-up 
process.
    Mr. Deluzio. Okay. Mr. London, last question as I almost 
run out of time. If a veteran has a sensitive issue like 
military sexual trauma where they would want to see an examiner 
within the VA, are they able to request and receive that type 
of exam?
    Mr. London. Yes. Thank you for the question. Veterans are 
afforded their preference of the gender of the examiner for 
military sexual trauma related claims.
    Mr. Deluzio. I was not asking about gender. I am asking 
about whether they can ask for someone within the VA to do that 
exam who might have more specialized experience with veterans 
in military sexual trauma rather than a contract examiner?
    Mr. London. Thank you for the clarification. As I mentioned 
earlier, every exam, regardless of exam type, we first look to 
see if the local VHA facility has the capacity to complete 
that. As it relates to a military sexual trauma related claim, 
if the availability is not there and the veteran reaches out to 
VA, we will do everything in our power to accommodate the 
veteran's request.
    Mr. Deluzio. Okay. Mr. Chairman, I am out of time. Thank 
you. I yield back.
    Mr. Luttrell. Thank you, sir. Mr. McGarvey, you are 
recognized for 5 minutes, sir.
    Mr. McGarvey. Thank you, Mr. Chairman. Thank you, Mr. 
Chairman for having this hearing as we focus on making sure 
that our vets are getting the care they need. A little 
concerned with what we just heard right now from Mr. Deluzio's 
questions. That there is no position taken on who is giving 
these exams and how they are doing. That there is no sort of 
monitoring of what is going on. When in the conclusion of the 
statement, Mr. Bracci, that you offered to the committee, it 
says the OIG has found that MDEO needs to improve its quality 
assurance processes and better monitor its contract exam 
vendors to help ensure veterans receive the benefits they are 
entitled to through the VA's disability programs.
    When we talk to our vets in our districts, what do we tell 
them? You guys know there is a problem and right now there are 
seemingly no answers on what we are going do about it. What 
should we tell our vets back home that you guys are planning to 
do to make it so that they can get the benefits they have 
earned and they are entitled to?
    Mr. London. Thank you for the question. May I respond?
    Mr. McGarvey. Please.
    Mr. London. I would not characterize it that we are not 
monitoring the quality of examinations that are being completed 
under the contract. We review approximately 1,500 quality exams 
every single month and almost 17,000 annually. As I reported 
earlier, quality is currently at 97 percent. OIG identified 
that we had an opportunity to improve our communication, which 
we have done.
    On a monthly basis, we send our quality errors to the 
Office of Field Operations that work with the claims processors 
at each regional office to ensure that any errors that we 
identify does not negatively impact the veterans' access to 
benefits. I would characterize that we have a strong program 
and we have adequate oversight and we are communicating 
information and we see improvement each and every month.
    Mr. McGarvey. I am glad of that. I mean, again, we want our 
vets to get the care they need. I think everybody on this panel 
wants our vets to get the care they need. We are appreciative 
of the work that is being done to help take care of our 
veterans but obviously we want that work to be the best.
    You know, so one of the things we are talking about we are 
talking about 97 percent, we are talking about these numbers. 
There is still an incredible backlog. I mean, I understand why 
we are needing contractors. We want to make sure those 
contractors are doing a good job and addressing the backlog 
that exists because, you know, right now the current number of 
C&P exams outstanding is 300,000. I know that there are some 
COVID concerns. It is still over a quarter of a million 
backlogged exams. COVID alone does not explain the backlog 
because prior to the pandemic, the backlog was about 160,000.
    These issues have been a longstanding area of concern. We 
have got to get the backlog. We want to make sure that in 
getting the backlog the veterans are having quality exams done 
by these contractors. What can we do to help? What can Congress 
do to help this backlog? What resources do you need? What 
legislative changes do you guys recommend, if any, that we can 
help with?
    Mr. London. Thank you very much for the question. I will go 
back to one example is license portability authority. First, 
renewing that authority or making it permanent as VA requested, 
and also, giving VA the authority to expand the types of 
providers that can utilize that authority. I believe that that 
will allow us to make extreme inroads on the already excellent 
progress that we are making in completing exams on average in 
30 days.
    Mr. McGarvey. I appreciate that. Just one last question 
because we are getting short on time. Would putting certain VA 
clinicians who are VHA employees on the VBA payroll change the 
VHA's hesitancy of assigning clinicians to perform the C&P 
exams?
    Mr. London. Thank you for the question. I will defer that 
question to my VHA colleague, Dr. Bridges.
    Mr. Bridges. Can you repeat the question for me?
    Mr. McGarvey. Sure. Would putting certain VA clinicians who 
are VHA employees on the VBA payroll change the VHA's hesitancy 
of assigning clinicians to perform the C&P exams, helping with 
the backlog?
    Mr. Bridges. I do not think I have a good answer for you on 
that question. I will have to take that one back to leadership 
for the answer.
    Mr. McGarvey. Thank you, please do. Thank you, Mr. 
Chairman. I yield back.
    Mr. Luttrell. Thank you, sir. Mr. Self, you are now 
recognized for 5 minutes, sir.
    Mr. Self. Thank you, Mr. Chairman. Mr. London, how many GAO 
recommendations have not been implemented across let us just 
stick with VBA?
    Mr. London. Across VBA?
    Mr. Self. Mm-hmm.
    Mr. London. Not just my office?
    Mr. Self. Yes.
    Mr. London. Thank you for the question. I just wanted to 
clarify. We will have to take that back and get back to you. I 
do not have that number offhand.
    Mr. Self. Yes, from the macro perspective, across VA as a 
whole, it is in the hundreds. That is from the macro. Mr. 
Bracci, is that, am I getting that right?
    Mr. Bracci. Yes, sir.
    Mr. Self. I have heard the incentives that the providers, 
that the contractors have, do you have any monetary penalties 
should they not meet the standards?
    Mr. Bracci. I know within the new contracts that were 
written there they have the option of providing monetary 
incentives and monetary disincentives in order to hold vendors 
accountable. I think that question can be better answered by 
Mr. London and his team.
    Mr. Self. Mr. London.
    Mr. London. Yes, thank you for the question. For each of 
the five performance elements that we have, quality, customer 
service, timeliness, average days that an exam request is 
pending, and average days to complete an exam request, all of 
those particular performance measures are eligible for both 
incentives and negative incentives.
    Mr. Self. How often do you exercise the penalties?
    Mr. London. Thank you for the----
    Mr. Self. Disincentives as you call them.
    Mr. London. Yes, thank you for the follow-up question. As 
Mr. Bracci mentioned, we just recently changed the contract to 
be able to specifically address quality and customer service. 
Before, we did not have elements to do those. However, before, 
we focused on production and timeliness. We have assessed 
negative incentives exceeding $26 million.
    Mr. Self. Okay. That is good to hear because my experience 
as short as it is in Congress, the administration responds 
primarily to money.
    I wanted to talk about the density of your contract 
examiners. As we talk about time it takes, Mr. Bracci, I think 
I am back to you. The time it takes for veterans to get to an 
exam, do we have the density of contract examiners that we 
need? Or are they located primarily in urban areas? Talk to me 
about the rural areas.
    Mr. Bracci. Yes, sir. As far as questions of resources and 
process, I think Mr. London would better answer that.
    Mr. London. Thank you for the question. If you look at 
where VA facilities are located and you look at where the 
contractors either have their branded locations or they have 
partnerships with third-party examiners, we are exactly where 
VHA facilities are. We also have density into some rural areas 
as well. As I mentioned before, we utilize the license 
portability authority to have traveling providers to go to 
those communities. We also have mobile units that go there. 
From a density standpoint, we are located where large 
populations of veterans reside. For those areas where veterans 
are in rural communities, we are doing everything that we can 
to go to where they are so they do not have to travel long 
distances.
    Mr. Self. I know that broadband is an issue in some rural 
areas, including part of my district. Does the lack of 
broadband hinder your telemedicine attempt?
    Mr. London. Thank you for the question. In some limited 
situations, I have heard of circumstances where the veteran 
either does not have the equipment or the access to broadband. 
As far as the equipment, the vendors do have the capability to 
actually send equipment to the veteran so they could 
participate in a telehealth exam. As far as the broadband 
availability, there are unfortunately situations where I know 
veterans do not have access to that capability.
    Mr. Self. How often to you send equipment to them to use? 
That is interesting.
    Mr. London. Thank you for the question. That is at the 
veteran's request. I will have to take that back to give you 
definitive numbers. I do know that that capability is being 
used across our vendor network.
    Mr. Self. I would like to get that answer. That is very 
good. Okay. My time is up, Mr. Chairman. I yield back, thank 
you.
    Mr. Luttrell. Thank you, Mr. Self. To the panel, we have, 
the ranking member and I have a few more questions for you. I 
recognize the ranking member, sir.
    Mr. Pappas. I am all set.
    Mr. Luttrell. You are good?
    Mr. Pappas. Sure.
    Mr. Luttrell. Okay. Well, I have a question. Mr. London, a 
prehearing brief with the staff mentioned that the total cost 
for the contract programs including exams, salaries, and 
reimbursement for Office of Information and Technology (OIT), 
among other things was roughly 2.3 billion last Fiscal Year but 
not all was used. How much was left over?
    Mr. London. Thank you very much for the question. I do not 
have the direct number that is leftover. I will be sure to come 
back to you because we actually have that number still 
available because we have not de-obligated those funds because 
there are still invoices that are being processed from last 
fiscal year.
    Mr. Luttrell. The remaining funds will be utilized where 
they--where we sent them initially?
    Mr. London. That is correct. Any unused funds will be de-
obligated and sent back to Treasury.
    Mr. Luttrell. Okay. Mr. Bracci, when you finish your 
report, who is the first person you send that to inside the 
Department, a name? I want a name.
    Mr. Bracci. There is a group within VBA who we route----
    Mr. Luttrell. No, somebody is in charge, one person. Who is 
it?
    Mr. Bracci. Our report and recommendations go directly to 
the Under Secretary for Benefits. It goes through an office 
but----
    Mr. Luttrell. Remind me who that is, please.
    Mr. Bracci. Mr. Jacobs.
    Mr. Luttrell. Mr. Jacobs. Well, I know who that is.
    Mr. Bracci. Yes.
    Mr. Luttrell. All right, thank you. Ms. Curda, on your 
report when it is completed and you send it out, who does that 
go to directly?
    Ms. Curda. Our recommendations are directed to whoever is 
most directly responsible for implementing them. In the case of 
our most recent report, it was the Secretary of the VA 
McDonough.
    Mr. Luttrell. It was Mr. McDonough?
    Ms. Curda. Yes.
    Mr. Luttrell. Okay, thank you. Ms. Imboden, how are you 
today?
    Ms. Imboden. Good, thank you.
    Mr. Luttrell. I just wanted you on the record so everybody 
knew that you were here.
    Ms. Imboden. Thank you.
    Mr. Luttrell. All right. Okay. I want to thank you all for 
appearing today to discuss this important issue. Disability 
exams are an important part of our disability claims process 
and ensuring veterans receive their earned benefits.
    Oh, I am sorry. I did not see you come in.
    Mr. Ciscomani. I just got back.
    Mr. Luttrell. You are recognized for 5 minutes.
    Mr. Ciscomani. Good.
    Mr. Luttrell. Go ahead.
    Mr. Ciscomani. Thank you, Mr. Chairman. It will be quick. I 
do not want to be that guy that holds everybody else up. Let me 
just, I did have one more--a couple more questions here and I 
will start with you, Mr. London, again. On the issue of license 
portability, what other providers can we expand the license 
portability to?
    Mr. London. Thank you very much for the question. First I 
will give you two examples, two examples cited in GAO's report. 
Dentists, for example, and ophthalmologists. Those are two 
examples of providers that currently do not have the authority 
that further expansion will allow us to serve more veterans.
    Mr. Ciscomani. Good. That is really what I had for you, 
sir. Then again, Ms. Curda, real quick the GAO reported that 
the VBA contracted examiners who were ineligible for license 
portability, conducted exams in the states other than they were 
licensed to do that. Has the VA reviewed how many exams were 
incorrectly conducted under license portability? If so, what 
did the VA find on that just in terms of the accountability, 
also that Mr. McGarvey was talking about?
    Ms. Curda. I am not aware that they have completed that 
assessment. That was one of our outstanding recommendations, 
that they do a thorough assessment of the ineligible examiners 
and also from a risk perspective to determine if anything needs 
to be done regarding the claims that were decided. I would just 
defer back to Mr. London to address their progress on that.
    Mr. London. Thank you for the question. We have conducted a 
more formal risk assessment. We did do an initial assessment 
and provided that information to GAO when they issued their 
report. We have since done a deeper dive and we have consulted 
with the Office of General Counsel.
    Specific to your question in the spirit of transparency, we 
did identify that approximately 300 veterans were impacted by 
the use of dentists and optometrists. Again, that analysis has 
been completed. We have made recommendations to leadership and 
so that recommendation is being finalized and we will share 
that information in the next coming weeks with GAO.
    Mr. Ciscomani. I am interested in getting a copy of that as 
well, please. What is being rectified and what are the next 
steps to prevent that from happening again.
    Mr. London. Absolutely. Thank you, sir.
    Mr. Ciscomani. Thank you. Mr. Chair, I yield back.
    Mr. Luttrell. Thank you, sir. I yield to the ranking member 
for his closing remarks.
    Mr. Pappas. Well, thank you, Mr. Chairman. Thank you to our 
panel for your comments here today and I want to thank you for 
joining this conversation on VA's C&P exam processes. It is 
clear that there is more work to do to ensure that veterans 
receive the exams in a timely fashion and in a convenient 
manner. That the reports of those exams are complete and 
accurate.
    It is critical to these veterans that they receive the 
benefits that they deserve for medical issues related to their 
military service and we certainly own them nothing less. The 
exam process is a key cog in the machinery that results in them 
receiving that benefit. I look forward to partnering with you 
all and you, Mr. Chairman, and the contractors and VSOs to 
ensure that our veterans receive the care and benefits that 
they deserve and that this process is working for them.
    I certainly continue to challenge our witnesses and the 
contractors that are tasked by VA to do these exams to keep 
rededicating yourself to improving this experience for veterans 
because again, we hear feedback from time to time that is not 
positive. We work to help veterans who have frustrations with 
these experiences and, you know, we can celebrate statistics. 
We have to recognize that there are individual veterans behind 
these statistics and it is not always working in an optimal 
fashion for them.
    Timeliness and quality matter. We can get both of those 
right and continue to improve. Does the treatment of veterans 
in the scheduling process as well, which can be a pain point 
for them in terms of getting that time and location right and 
just the customer service that they receive from these 
contractors and from VA. Mr. Chairman, I yield back. I thank 
you for holding this hearing.
    Mr. Luttrell. Thank you, sir. Thank you, ranking member. To 
mimic what the ranking member just said, in all your successes, 
it is our job if one of our veteran constituents has an issue, 
we are going to bring it to you until it is perfect.
    With that I ask unanimous consent that all members have 5 
legislative days to revise and extend their remarks and include 
extraneous material. Without objection, so ordered. This 
hearing is adjourned.
    [Whereupon, at 11:02 a.m., the subcommittee was adjourned.]
    
=======================================================================


                         A  P  P  E  N  D  I  X

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


                    Prepared Statement of Witnesses

                              ----------                              


                   Prepared Statement of Jeff London

    Chairman Luttrell, Ranking Member Pappas and distinguished members 
of the Subcommittee, thank you for the opportunity to appear before you 
today to discuss the disability examinations administered by the 
Department of Veterans Affairs (VA).
    Accompanying me today are Jacqueline Imboden, Assistant Director, 
from Compensation Service, Veterans Benefits Administration (VBA), 
Henry E. Bridges Jr., M.D., Senior Medical Officer from the Office of 
Disability and Medical Assessment, Veterans Health Administration (VHA) 
and Christopher Parker, Associate Executive Director from the Office of 
Acquisition Logistics and Construction (OALC).
    Today, I will provide an update on the oversight of Compensation 
and Pension (C&P) examinations, discuss VA's progression on 
implementing the recommendations from the U.S. Government 
Accountability Office (GAO) and the VA Office of the Inspector General 
(OIG) and highlight the strong partnership and collaboration VBA has 
with the Medical Disability Examination (MDE) vendors and VHA. 
Together, we have expanded capacity and alternative modalities to 
provide quality and timely disability examinations to Veterans and 
Service members worldwide to ensure access to vital benefits and 
services.
    Congress first authorized VA to contract for C&P examinations in 
1996 in 10 heavily Veteran populated locations through P.L. 104-275. 
Congress further expanded the authority in 2003 under P.L. 108-183 and 
again in 2016 under P.L. 113-235. The 2015 law provided VA the ability 
to contract for C&P exams in all 50 states and worldwide. To ensure all 
Veterans receive a quality disability examination, all contract 
examiners must hold an active and unrestricted state license to 
practice medicine, with no previous or pending disciplinary proceedings 
involving professional conduct. Exam results conducted by contract 
examiners are given the same weight and consideration in the VBA 
disability compensation claim process as those conducted by VHA 
examiners, to include VBA decision reviews and appeals to the Board of 
Veterans' Appeals (BVA) and the Federal courts.

Disability Examinations

    VBA requires disability examinations and/or medical opinions if 
there is medical and/or lay evidence of a current disability and 
evidence indicates that the disability or symptoms may be associated 
with the claimant's active military, naval, air or space service, but 
the file does not contain sufficient medical evidence for a decision on 
the claim.
    Beginning in 2010 and finishing in 2011, VA began mandating all 
contract and VHA disability examination results be recorded using 
Disability Benefits Questionnaires (DBQ). These forms are developed and 
maintained through a partnership between elements of VBA, VHA and BVA.
    Since the expansion of the C&P examination program in 2016 through 
the end of fiscal year (FY) 2022, VA has seen the number of Examination 
Scheduling Requests (ESRs) completed increase 69 percent from 1.2 
million in FY 2016 to over 2 million in FY 2022. Through the end of 
June 2023, VA has completed over 1.9 million ESRs, a 21.8 percent 
increase from the same period in FY 2022. At the current rate of 
production, VA should complete over 2.4 million exams this fiscal year.
    As of June 30, 2023, the C&P pending inventory for MDE vendors was 
approximately 287,000 with nearly 113,000 (39.2 percent) of those being 
PACT Act-related ESRs. When excluding PACT Act ESRs, MDE pending 
inventory was approximately 174,000, an increase of 7.3 percent from 
the same period in FY 2022.

Examination Experience

    It is imperative that the Veteran experience be at the center of 
the C&P examination process. We recently conducted a human-centered 
design study with our Veterans Experience Office (VEO) partners, and 
learned that scheduling, traveling and attending examinations can be 
extremely difficult for Veterans both physically and emotionally. VBA 
and VHA continue to leverage telehealth to provide C&P exams reducing 
the need for Veterans to travel for appointments. We continue working 
to improve the Veteran's experience to ensure our customers feel 
informed, safe and heard throughout the entire C&P examination process.
    In June 2020, VHA partnered with VEO to implement the national VHA 
C&P satisfaction surveys. The surveys are comprised of two survey 
instruments that gain feedback from the Veterans' interaction with VHA 
C&P on two touch points--Scheduling an Appointment for their C&P 
examination and the Veteran's interaction with the Examining C&P 
Clinician. Both surveys noted increases in satisfaction scores in FY 
2023 compared to FY 2022 and the majority of scores are in the 80th 
percentile.
    VA continues working to improve the Veteran experience in numerous 
other ways such as collaborating with vendor partners to improve their 
direct interactions with Veterans and changing internal processes to 
deliver better service to Veterans. VA continues to use alternate 
examination modalities such as Telehealth in cases where that is 
appropriate and has provided guidance to MDE vendors on notifying 
Veterans of their right to designate the gender of the examiner for 
certain examination types.
    All examination vendors send a customer satisfaction survey card 
and the choice of completing an online survey within the appointment 
notification packets, to Veterans scheduled for examinations. The 
completed surveys are analyzed, results are scored and reported monthly 
to VA and MDE vendors. MDE vendors must submit service recovery plans 
addressing any actions they are taking to address negative customer 
service trends. In FY 2023, through March 2023, the aggregate customer 
satisfaction for all vendors is 95.94 percent.
    VA is also examining how trust can be measured within the customer 
satisfaction survey instrument and in cooperation with all instruments 
being utilized, regardless of modality. These changes will help to 
determine how adjustments to the program are received by Veterans and 
allow the program to make adjustments to improve the opinion of our 
Veterans based on their direct feedback. Trust is seen as a primary 
motivator in the process and the more VA can understand this element, 
the better we can steer the program toward innovative concepts and 
improvements.
    To help ensure that exam facilitates meet the needs of Veterans, VA 
conducts in-person site visits and separately, virtual desk reviews to 
ensure that provider locations where Veterans are seen for exams are in 
compliance with the contract terms. Post-site visit reports consist of 
best practices and items requiring vendor actions. All action items are 
tracked until completion.
    Additionally, VBA is actively working with VEO to adapt a current 
MDE customer experience survey to the enterprise-wide Veterans Signals 
survey platform already being used for customer input on VHA-
administered C&P exams. This would allow for detailed analysis of 
customer input regarding their MDE exam experience by asking Veterans 
for their perspectives on elements such as receiving appointments at 
preferred dates and times, being treated with courtesy and respect 
during the exam process, being treated with care and compassion by the 
examiner and fostering an exam experience that allows for Veterans to 
ask questions or raise concerns during the exam. This input will be 
directly leveraged to identify and act upon identified pain points 
requiring corrective action or quality improvement in the C&P vendor 
exam process.

Contractual Oversight

    VBA oversees 18 exam contracts and 9 ancillary contracts. These 
contracts provide additional oversight by applying metrics for 
timeliness, production, quality and customer satisfaction. Ancillary 
contracts verify examiners' credentials and provide financial and data 
audits to include invoice validation and beneficiary travel. VBA 
contracts with a third-party vendor to audit and ensure providers have 
current and appropriate licenses to practice within their healthcare 
specialty. Additionally, ancillary contracts are in place to deliver, 
and track required contract vendor training.

Training

    All contract examiners are required to complete extensive training 
prior to conducting any disability medical examination. In addition to 
general certification courses, courses on Veteran culture and 
experience, suicide awareness and prevention, lethal means safety and 
various specialty courses are included in the required training.
    All examiners, both contract and VHA, undergo the same specific C&P 
exam training and certification, regardless of whether they complete 
exams part-time or full-time. The required training consists of online 
courses initially developed by VHA's Office of Disability and Medical 
Assessment (DMA). In addition to general certification training, all 
examiners who provide specialized exams (e.g., traumatic brain injury, 
mental health, etc.) are required to take supplementary courses 
specific to those specialty exam types. VBA contracts also require MDE 
vendors to provide examiners with a basic overview of VA programs. 
Contract examiners are required to complete recertification training 
every five years. Further, any contract examiners who have not 
completed an exam in the previous 12 months must recertify before 
conducting an exam.
    VBA exam contracts include a requirement for all vendors to provide 
detailed training plans for all examiners, support staff and 
subcontractors who have routine contact with Veterans to reinforce VA 
requirements, regulations, and quality assurance. VBA reviews each plan 
to ensure training plans address all contract training requirements; 
training assessments and evaluation feedback; how the vendor 
disseminates training material and documents to completion; and how new 
training courses are incorporated into training plans. VBA provides 
feedback to vendors as appropriate and ensures updates are made prior 
to approval of any training plan.
    Training validation is a critical VBA oversight function. VBA uses 
monthly rosters of invoiced DBQs completed to perform compliance 
reviews of randomly selected active examiners. These samples allow VA 
to validate that examiners who are actively conducting examinations are 
properly certified. VHA validates training through the quality 
assurance program by ensuring examiners signing DBQs are trained and 
certified to complete C&P exams.

Quality

    VA is committed to the quality of all disability examinations 
completed. To assess the quality of vendor exams, VBA reviews a sample 
for each contract using standardized audit criteria, resulting in 
approximately 1,400 quality reviews conducted each month. Each quality 
review is completed using a quality criteria checklist and confirms the 
examiner complied with all government instructions, addressed all 
questions completely and that the exam report aligns with information 
of record and includes explanations when it does not. The resulting 
accuracy findings are used to assess vendor performance and presented 
in a quarterly report.
    VBA provides quality feedback to its vendors in various ways, to 
include monthly error citation reports for each contract, vendor-
specific monthly quality calls, vendor--specific monthly clinician 
calls and ad-hoc answers to questions. Additionally, VBA conducts 
special reviews on specific exam types, providers, or based on error 
trends to provide additional oversight and feedback. The quality 
requirement outlined in the contract is 96 percent. In FY 2023, through 
March 2023, the aggregate quality score for all vendors is 96.8 
percent. Overall quality has been trending upward for the past six 
quarters, culminating with an FY 2023 Q2 quality of 97 percent.
    To assess the quality of VHA disability exams, the VHA C&P Quality 
Assurance Program employs an audit review process and a performance 
measurement component. VHA uses a web-based Quality Audit Review tool 
that utilizes quality indicators developed by VBA and VHA subject 
matter experts. Of note, these indicators are not indicative of 
clinical quality but rather evaluate the completeness of DBQs. The 
quality requirement is 90 percent which VHA national C&P exam quality 
scores have exceeded for the past six years at 97 percent or greater. 
This fiscal year through May 2023 the aggregate quality score for VHA 
C&P examiners is 98 percent. Results from the audits are shared 
nationally with C&P staff during national calls. In addition, monthly 
reports are nationally accessible through the VHA Support Service 
Center (VSSC).
    VHA conducts approximately 5,000 oversight audits of completed C&P 
examinations annually. VHA's sampling methodology was developed using a 
statistical analysis and is based on the total number of completed 
examinations. VHA's DMA develops and monitors Veterans Integrated 
Service Networks and overall VHA quarterly quality and timeliness 
performance measures for the VHA C&P examination process.

Contract Improvements

    VBA MDE vendors continue to expand provider networks and their 
internal workforce to increase examination production. Vendors are 
adding both privately owned facilities as well as per-diem locations as 
needed. VA also added a fourth vendor to the Pacific Region, which 
began processing exam requests on December 16, 2022. VA added two new 
vendors to the Predischarge contracts and one new vendor to the 
international contract in April 2022.
    Monetary incentives, both positive and negative, are part of every 
MDE vendor contract. Vendors are eligible for an up to 3 percent 
positive or negative incentive for five performance areas: production, 
average days pending, average days to complete, quality of DBQs and 
customer satisfaction. The intent of the incentive is to encourage 
continuous operational and quality improvement over the life of the 
contract, and to drive desired outcomes to meet performance requirement 
targets set by VBA. Eligibility to receive the monetary incentive is 
based on the contractor's performance in accordance with the 
contractual performance requirements. These incentives and increased 
vendor provider networks allowed VA to increase ESR completions by 10.9 
percent in FY 2022 as compared to FY 2021. VA is on track to further 
increase disability exam completions by 24.7 percent during FY 2023.

Examination Access

    VA and its MDE vendors are working to ensure all Veterans, 
including rural Veterans, have access to the benefits and care they 
have earned more easily by using modalities that limit travel for in-
person examinations. Furthermore, through the contract exam process, VA 
has the ability to conduct examinations for Veterans worldwide through 
several different exam modalities In FY 2023, the number of 
international examinations is expected to increase from 26,063 in FY 
2020 to over 45,000.

Virtual Exam Modalities

    In 2012, VA began using Acceptable Clinical Evidence (ACE) and in 
2020, Tele-C&P examinations were utilized to increase flexibility in 
examination scheduling. Under ACE, VA examiners complete a DBQ by 
reviewing existing medical evidence and can supplement it with 
information obtained during a telephone interview with the Veteran, 
alleviating the need for the Veteran to report to an in-person 
examination. Similarly, Tele-C&P examinations provide the equivalent of 
in-person C&P evaluations through the use of telehealth video 
technologies - they are safe, effective, and often more convenient for 
the veteran. So far, this fiscal year, through June 2023, MDE vendors 
have completed over 1.9 million total appointments consisting of over 
200,000 (11.9 percent) ACE and over 160,000 (8.2 percent) Tele-C&P 
appointments. This is a 5.3 percent and 5.1 percent increase 
respectively from the same period in FY 2022.
    VHA also continues to support the use of virtual care modalities to 
complete medical disability exams for Veterans as appropriate. To date 
this fiscal year, nearly 26 percent of DBQs completed by VHA have been 
completed virtually via ACE and Tele-C&P, a 3 percent increase from the 
previous fiscal year.

Rural Veterans

    In addition to increased examination modalities, MDE vendors are 
using traveling providers, claims clinics and per-diem or rented 
locations to assist rural Veteran populations. Vendors have mobile 
units which are deployed throughout the country to augment existing 
provider networks and provide a full range of exam services to meet 
Veterans where they are, rather than where we are. Mobile units are 
equipped to complete general medical and most specialty examinations, 
as well as diagnostic testing. The units are handicap accessible, with 
wheelchair lifts and ramps, and are fully self-contained with power 
supply and internet connectivity, allowing for secure evidence 
transmission to VA systems. Vendors continue to expand their mobile 
unit fleets and collectively have 28 operational individual units.
    Another innovation used by MDE vendors is boothless technology for 
audio exams. Boothless technology is an equivalent alternative to 
traditional hearing evaluations which occur in sound booths. By virtue 
of technology that measures and reduces background noise, a complete 
hearing evaluation may occur in non-traditional settings such as an 
individual's home, prison facility, nursing home, military theatre, 
schools, and clinic waiting areas. By extension, for the home-bound or 
for those experiencing transportation barriers, this technology allows 
greater access and reduces wait times without degrading the quality of 
the hearing exam.

PACT Act

    The passage of the Sergeant First Class (SFC) Heath Robinson 
Honoring our Promise to Address Comprehensive Toxics (PACT) Act of 2022 
on August 10, 2022, empowered VA to deliver additional care and 
benefits to millions of Veterans and their survivors. In addition to 
expanding presumptive criteria for disability compensation claims, the 
PACT Act created a new examination requirement for claims related to 
Toxic Exposure Risk Activities (TERA).
    To prepare for the expected increase in exam and opinion requests 
related to toxic exposures, additional training for C&P medical 
examiners was developed. VBA worked with the War-Related Illness and 
Injury Study Center (WRIISC) and Health Outcomes Military Exposures 
(HOME) VHA staff to ensure all VHA and VBA contract examiners received 
training to assess deployment-related environmental exposures. VBA also 
developed comprehensive PACT Act training products for VHA and contract 
medical examiners. These included courses on Key Terms and Medical 
Opinions, Airborne Hazards and Burn Pits Exposures, and job aids for 
review of TERA and Individual Longitudinal Exposure Records (ILER). 
Additionally, VBA developed a reference guide for conducting these 
types of exams. Since the implementation of the PACT Act, VA has 
completed over 459,000 PACT Act-related ESRs and as noted earlier, 
approximately 39 percent of the total currently pending MDE vendor ESR 
inventory is related to PACT Act claims.

Separation Health Assessment (SHA)

    As reported in the FY 2022 VA/Department of Defense (DOD) Joint 
Executive Committee Annual Report,\1\ VA and DOD completed a multi-year 
effort to establish content of a single common Separation Health 
Assessment (SHA) for discharging Service members. SHAs are comprised of 
both subjective patient histories and objective clinical evaluations. 
This combined effort streamlines the disability claim process, reduces 
redundant examinations and ensures medical assessments for those 
separating from the service are accurate and complete. These changes 
are intended to substantially improve both the physical and mental 
health assessments of separating Service members, including real-time 
assistance and necessary referral services.
---------------------------------------------------------------------------
    \1\ Department of Veterans Affairs-Department of Defense Joint 
Executive Committee annual Joint Report Fiscal Year 2022
---------------------------------------------------------------------------
    To streamline SHAs, clinical subject matter experts and specialty 
groups covering audiology, mental health, women's health, environmental 
and occupational exposure, traumatic brain injury, vision and dental 
health identified baseline elements for inclusion in the common form. 
Further collaborative efforts produced high-value improvements that 
address suicide and violence risk screenings, reporting of exposures to 
occupational and environmental hazards and the communication of 
resources for survivors of sexual trauma in the military.
    VA and DOD have been working tirelessly to implement this new 
assessment through a joint agency asynchronous launch plan. VA is 
pleased to report that we began completing SHAs in the new format on 
May 1, 2023, for all Service members filing claims with VA through the 
Benefits Delivery at Discharge claim program or the Integrated 
Disability Evaluation System. DOD is expected to begin completing all 
discharge examinations in the new SHA format, for those not filing 
claims with the VA, in FY 2024 across the Service Departments. By the 
close of FY 2024, all separating Service members will receive their 
discharge examination in the new format.

Claims Automation Support

    VBA is undergoing business modernization efforts designed to 
leverage technology by automating administrative tasks and workflows, 
known as Automated Decision Support (ADS) technology. The VBA Medical 
Disability Examination Office (MDEO) is currently collaborating on 
Modern Claims Processing (MCP) and efforts with its Office of Business 
Automation (OBA). This collaboration is yielding positive results in 
the fields of data ingestion and automation.
    ADS is currently being leveraged to order ESRs, when certain 
business rules are met. Approximately 12,557 ESRs (0.7 percent) have 
been requested by ADS from December 2, 2022 through July 19, 2023. 
Additionally, the DBQ content validation initiative enables the 
validation of all DBQs in real-time, promoting interoperability within 
VA and other agencies through the National Information Exchange Model 
(NIEM) and ensuring DBQs are ready for review when making claims 
decisions.
    DBQ results are also being modernized to transmit as computable 
data. Currently, 69 of 82 DBQs are received as computable data from the 
MDE vendors. This allows VA to leverage automated data ingestion which 
develops logical mapping between DBQ fields and corresponding Veterans 
Benefits Management System (VBMS) rating calculators. Software 
automatically populates rating calculators to produce consistent and 
standardized disability ratings while simultaneously reducing manual 
data transcription activities for employees.

Internal VBA Collaborations

    In FY 2022, VBA established the Over-Development Reduction Task 
Force for the purpose of reducing over-development within the C&P 
claims process. Over-development is an unneeded action taken by an 
employee when processing a claim, resulting in unnecessary delays in 
providing decisions. The task force, which consisted of members across 
VBA, analyzed the C&P claims development process to determine ways to 
streamline and provide more timely claims decisions for Veterans and 
their beneficiaries.
    In order to reduce the overall development timeline and get 
Veterans their examinations more quickly, the task force focused on 
improving procedural guidance, updating training, completing special 
focused reviews and providing targeted feedback to claims processors 
and implementing system enhancements. The task force's next phase will 
focus on eliminating inefficiencies and redundancies in the examination 
process while providing recommendations for updates to policies, 
procedures, legislation and/or system enhancements.

GAO/OIG Reports

    In June 2023, GAO issued a report \2\ on the increased use of 
telehealth examinations and the expansion of license portability. The 
report identified an opportunity for VA to improve its guidance to 
contract examiners in these areas. As a result, VBA provided 
clarification in April 2023 regarding the type of examiners eligible 
for the License Portability Act via Vendor Guidance Memo (VGM) 23-36. 
Specifically, this VGM clarified that ``the only providers currently 
eligible for license portability are those providers listed in P. L. 
116-315, Sec.  2002, which are Physicians, Nurse Practitioners, 
Physician Assistants, Audiologists and Psychologists.'' VBA has also 
established procedures to ensure that only providers authorized in 
statute to use license portability authority are completing 
examinations across State lines.
---------------------------------------------------------------------------
    \2\ GAO Report 105787, Actions Needed to Clarify Program 
Requirements Regarding Examiners.
---------------------------------------------------------------------------
    Additionally, GAO examined VA's planning and oversight of 
contracted disability exams.\3\ GAO identified potential risks 
regarding capacity and exam quality. In order to mitigate these, VBA 
continues to work with VHA to execute a memorandum of understanding 
(MOU) on a comprehensive workload allocation plan for C&P examinations. 
VBA and VHA continue to assess the impact of the PACT Act on the 
capacity of VBA's vendors and on VHA's capacity to perform primary care 
and C&P exams. VBA and VHA will also address potential risks in the 
exam distribution process in the MOU. VA expects the MOU to be drafted 
by the end of FY 2023. Through VBA's efforts, the number of ESRs 
performed by VBA contract examiners increased from roughly 180,000 in 
FY 2012 to 1.1 million in FY 2020. This total represented more than 
three-quarters of the 1.4 million ESRs performed in FY 2020.
---------------------------------------------------------------------------
    \3\ GAO Report 21-543, VA: Disability Exams: Better Planning Needed 
as Use of Contracted Examiners Continues to Grow.
---------------------------------------------------------------------------
    In addition to the oversight provided by the GAO, VA's OIG 
conducted several reviews of the contract examination process. The OIG 
found that VA needed to implement a process to monitor and assess 
vendors' compliance with contractual mileage and travel reimbursement 
requirements, collaborate with vendors to ensure portals include 
documentation of express consent of Veterans to travel longer distances 
and finally to ensure mileage reimbursement information is available in 
the vendor portals-\4\. VA expanded its oversight activities in these 
areas by modifying its third-party financial audit contract in March 
2023. These audits assist in ensuring proper reimbursements are made to 
Veterans traveling to appointments, supporting documentation is 
available in vendor portals and added visibility to the VA's oversight. 
VBA continues to work with OIG on improving this area of oversight.
---------------------------------------------------------------------------
    \4\ OIG Report 22-02067-82, The Medical Disability Examination 
Office Needs to Better Monitor Mileage Requirements for Contract Exams.
---------------------------------------------------------------------------
    OIG further examined VA's governance of and accountability for 
contract medical disability exams.\5\ Through these findings, VBA has 
modified its contracts in order to hold contractors accountable for 
unsatisfactory performance through monetary disincentives. VBA also 
revised the contracts to require vendors to take all corrective actions 
when a deficit is identified by VBA. In addition, MDEO worked with 
Compensation Service and the Office of Field Operations to implement 
procedures for error correction and analysis of all error data in order 
to provide issues and trends to vendors. Each month, MDEO reviews 
random samples of vendors' exams for compliance with contract quality 
standards. These quality reviews identify instances when the vendor has 
not complied with contract quality requirements. The results are then 
compiled into monthly and quarterly performance reports to assess the 
vendors' performance and determine whether they are meeting the 
contractual 92 percent accuracy requirement. As a result of VBA's 
efforts, in May 2023, OIG agreed to close this report as fully 
implemented.
---------------------------------------------------------------------------
    \5\ OIG Report 21-01237-127, VBA Contract Medical Exam Program 
Limitations Put Veterans At Risk for Inaccurate Claims Decisions.
---------------------------------------------------------------------------
    In addition to the areas discussed above, OIG examined VBA's 
disability exam inventory.\6\ VBA has worked with VHA to expand the use 
of alternative exam modalities in a safe and logically feasible manner. 
VA used these efforts to reduce the exam inventory caused by the 
temporary suspension of in-person examinations due to the COVID-19 
pandemic. VA reached a peak inventory of 361,854 on March 11, 2021, 
which was reduced by 24 percent by the end of FY 2021. In October 2021, 
OIG agreed to close the report as fully implemented.
---------------------------------------------------------------------------
    \6\ OIG report 20-02926-07, Reduce Disability Exam Inventory Due to 
Pandemic and Errors Related to Canceled Exams.

---------------------------------------------------------------------------
Conclusion

    I want to express my appreciation for your continued support of 
Veterans, their families, caregivers, and survivors. VA 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 further streamline 
the examination process.
    This concludes my testimony. I would be happy to address any 
questions you or other members of the subcommittee may have.
                                 ______
                                 

                 Prepared Statement of Elizabeth Curda
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                  Prepared Statement of Stephen Bracci

    Chairman Luttrell, Ranking Member Pappas, and members of the 
Subcommittee, thank you for the opportunity to testify on the Office of 
the Inspector General's (OIG) oversight of the Veterans Benefits 
Administration (VBA) contract medical exam program. The OIG is 
committed to conducting independent audits, reviews, and inspections 
that result in clear findings and practical recommendations to help VA 
promptly provide veterans with the quality care, services, and benefits 
they are due. To that end, the OIG works diligently to ensure every 
report it releases--even if focused on a single medical facility or 
benefits office--serves as a road map for VA leaders nationwide and 
contributes to overall program improvements.
    When veterans file claims for disability benefits, VBA claims 
processors may request medical exams for the veterans before making 
decisions on their claims. The exams provide critical evidence used to 
help establish a connection between the claimed disability and the 
veteran's military service (referred to as ``service connection'').\1\ 
Exams also help determine the degree of the disability's severity, 
which translates into a disability rating, and this in turn defines the 
monthly monetary benefit the veteran receives. While Veterans Health 
Administration (VHA) personnel can perform these exams, they are most 
often performed by providers working for vendors under contract with 
VBA. The OIG has maintained oversight of VBA's contract medical exam 
program due to persistent allegations of deficiencies related to the 
exams that raise concerns regarding not only veterans' service-
connected disability compensation but also the billions of dollars VBA 
has spent on these contracts.
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    \1\ Service-connected disabilities are those proven to be caused by 
diseases or injuries incurred or aggravated during active military 
service.
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    This statement highlights three OIG reviews of VBA's contract 
medical exam program. The reports illustrate gaps in VBA's oversight of 
the program and describe how identified weaknesses can affect veterans' 
experience with the disability benefits claims process and the impacts 
of premature or improper decisions. The first report (released in June 
2022) is a comprehensive review of VBA's oversight of contract medical 
exam quality standards and program improvement.\2\ The two other 
reports describe more specific concerns: the distance veterans need to 
travel for exams and the changes made to the program during the 
pandemic.\3\ While the findings and recommendations discussed in this 
statement relate to the oversight of contractor-provided exams 
specifically, they can also apply to exams provided by VHA clinicians, 
which are equally critical to the accuracy of benefit claims decisions.
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    \2\ VA OIG, Contract Medical Exam Program Limitations Put Veterans 
at Risk for Inaccurate Claims Decisions, June 8, 2022.
    \3\ VA OIG, The Medical Disability Examination Office Needs to 
Better Monitor Mileage Requirements for Contract Exams, April 20, 2023; 
VA OIG, Enhanced Strategy Needed to Reduce Disability Exam Inventory 
Due to the Pandemic and Errors Related to Canceled Exams, November 19, 
2020.

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CONTRACT MEDICAL EXAM PROGRAM ADMINISTRATION AND OVERSIGHT

    To better understand who is responsible for implementing the OIG 
recommendations related to the contract medical exam program, some 
context is first provided on responsible offices and individuals.

Medical Disability Examination Office (MDEO)

    VBA's Medical Disability Examination Office (MDEO) administers 
VBA's contract medical exam program.\4\ VBA currently has 18 contracts 
with four vendors: OptumServe Health Services, Quality Timeliness and 
Customer Service Medical Services, Veterans Evaluations Services Inc., 
and Loyal Source Government Services, LLC.\5\ Two MDEO suboffices--
Acquisition and Budget, and Medical Disability Examination Quality--are 
responsible for overseeing vendor performance and contract medical 
disability exam quality, respectively. Acquisitions and Budget enforces 
the technical terms of the contract, such as coordinating contract 
modifications and monitoring spending.
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    \4\ On October 1, 2020, MDEO, which was formerly part of VBA's 
Compensation Service, became its own business line due in part to the 
increased volume contract medical exam workload.
    \5\ Under the Office of Procurement, Acquisitions and Logistics, 
VA's Strategic Acquisition Center developed and awarded VBA's medical 
disability exam contracts. The contracts are divided among four US 
geographic regions and two districts outside the continental United 
States. The contracts anticipate executing approximately 7.7 million 
exam scheduling requests over the 10-year life of the contracts. From 
fiscal years 2019 through 2022, VBA reported completing over 5.6 
million contract exam scheduling requests.
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    MDEO's quality component conducts reviews to determine each 
vendor's level of accuracy. Quality analysts assess a random sample of 
the vendor's disability exam reports for compliance with contractual 
requirements, including all the necessary medical history for the 
condition(s) at issue.\6\ If the quality analyst finds that a specific 
requirement was not met, the exam report is considered ``completed in 
error,'' and the vendor is responsible for taking applicable corrective 
action. MDEO quality staff interact with vendors monthly to share 
quality review findings, discuss trends, and address concerns and 
training issues.\7\
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    \6\ The healthcare provider completes the exam using VA-provided 
disability benefits questionnaires, which are referred to as ``exam 
reports'' and added to the veteran's claim file.
    \7\ Vendors are responsible for locating and subcontracting with 
qualified examiners to conduct exams in response to exam requests 
received from VA. Vendors ``shall also train all examiners, staff 
support, and subcontractors who have routine contact with veterans.'' 
MDEO Contract Region 4, November 20, 2019.

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Office of Field Operations and Compensation Service

    Two other VBA entities, the Office of Field Operations (OFO) and 
the Compensation Service, also support the exam process. OFO monitors 
and tracks the delivery of benefits and services to veterans by VBA's 
56 regional benefits offices. This includes overseeing the regional 
office claims processors who request the exams, determine exam 
sufficiency once completed, and prepare the decision on benefits 
claims. The Compensation Service is responsible for developing and 
implementing policies and procedures related to the administration of 
VBA's disability compensation program.

CONTRACT MEDICAL EXAM PROGRAM LIMITATIONS PUT VETERANS AT RISK FOR 
INACCURATE DECISIONS

    VA spent nearly $6.8 billion on contract medical exams from the 
contracts' award in October 2016 through December 2021.\8\ Given the 
importance of medical exams to claims accuracy and the significant 
investment of taxpayer dollars in VA's contracts for exam providers, 
the OIG conducted a review to determine whether VBA
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    \8\ VA OIG, Contract Medical Exam Program Limitations Put Veterans 
at Risk for Inaccurate Claims Decisions, June 8, 2022.

      oversaw contract medical exams to ensure they met quality 
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standards and contractual requirements in support of claims decisions,

      established procedures for correcting errors found during 
quality reviews, and

      gave feedback to vendors to improve exam quality.

    The OIG found in its June 2022 report that VBA governance of and 
accountability for the contract medical exam program needed to improve. 
The deficiencies the OIG team identified stemmed in part from 
limitations with VBA's management and oversight of the program at the 
time of the review.

Vendor Exams Did Not Consistently Meet Accuracy Criteria

    Although MDEO's quality component proficiently reviewed the 
contract medical exams, MDEO did not use the results of the quality 
reviews and hold vendors accountable when exams did not consistently 
meet all accuracy criteria. The contracts state that the government 
``will measure the quality of vendor's performance in completing 
examination requests.'' Every quarter, MDEO reviews a sample of 
vendors' exam reports for accuracy, with accuracy less than 92 percent 
considered ``unsatisfactory performance.'' \9\ MDEO reported that the 
three vendors, who were under contract with VBA at the time of the OIG 
review, were consistently below the 92 percent requirement and have 
been since at least 2017.\10\ Additionally, the OIG team determined 
that even though MDEO identified errors in its quality reviews, these 
errors were not corrected before or after claims processors made their 
decisions.
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    \9\ MDEO worked with a third-party contractor that did an analysis 
of the quality program and recommended a different method to measure 
vendor performance. The recommended method would put the MDEO vendor 
quality process more in line with industry standards and with the 
methodology used by the Compensation Service for claims quality.
    \10\ At the time of the OIG review there were three vendors: 
OptumServe Health Services (then known as Logistics Health, Inc.), 
Quality Timeliness and Customer Service Medical Services, and Veterans 
Evaluations Services Inc.
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    Even though vendors did not meet the 92 percent contract 
requirement, MDEO did not use the monetary incentive/disincentive tools 
in the contracts. The assistant director of Medical Disability 
Examination Quality stated that vendors were providing the quality of 
service they were being paid for. She further stated that there were 
some errors with contract compliance that were only discrepancies that 
would not affect a claims processor's decision, but the vendors still 
``have room for improvement.''

Contractual Wording Restricted VA's Ability to Apply Disincentives

    According to the contract wording in effect during the OIG's review 
in 2020, vendors could receive monetary incentives or disincentives 
based on their quarterly performance in three categories: quality, 
timeliness, and veteran satisfaction.\11\ If a vendor exceeded the 
expected performance standard for all three criteria, the VA 
contracting officer could apply a monetary incentive for that quarter. 
If the vendor failed to meet the criteria, the VA contract officer 
could apply a monetary disincentive. While the wording was specific on 
how to apply the monetary incentives to encourage continuous 
improvement by vendors, the contract wording was not specific regarding 
the application of monetary disincentives. According to the VA 
contracting officer, vendors had to fail in all three categories to be 
penalized, but the contract language was too subjective to validate 
that interpretation. Notably, in February 2020, the VA contracting 
officer suspended the incentives and disincentives and stated vendors 
never were awarded an incentive or disincentive or penalized for poor 
performance.
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    \11\ Exam accuracy is based on a pass-fail model using MDEO's 
contract medical disability exam checklist. A contractor's quarterly 
compliance score is the percent of compliant exams. For example, if 250 
exams are reviewed for Contractor A and 200 exams are found to have no 
errors (i.e., to be fully compliant), Contract A's compliance score is 
80 percent (200 Compliant/250 Total Reviewed = 0.80). MDEO calculates 
timeliness by measuring the number of days from when the exam is 
requested from the vendor to the date VA receives the completed exam. 
Veteran satisfaction is measured by feedback provided by veterans in 
response to their exam experience.
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    The OIG found that due to the subjective contract wording and the 
suspension of incentives and disincentives, MDEO and the VA contracting 
officer did not have a clear method to enforce monetary incentives and 
disincentives. The OIG recommended that VBA assess and modify contracts 
to ensure that vendors can be held accountable for unsatisfactory 
performance by applying monetary disincentives. On October 1, 2021, VBA 
executed new contracts with such provisions, referred to as negative 
incentives.\12\ As a result, the OIG closed this recommendation as 
implemented.
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    \12\ A negative incentive is assessed on a quarterly basis if the 
contracts' combined required levels for timeliness and production 
performance have not been met.

Vendors Were Not Contractually Required to Correct MDEO-Identified 
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Errors

    Additionally, the contracts did not require the vendor to correct 
the errors that MDEO identified during quality reviews. MDEO managers 
stated that vendors do not need to make corrections because MDEO 
usually reviews exams after VBA has decided the claims. However, the 
OIG found vendors can correct errors at any time, even if a decision 
had been made, and claims processors can change a decision in light of 
revisions or new evidence. For example, during the OIG review, the team 
identified an error that was detected as part of an MDEO quality review 
was not corrected until the OIG presented the information to the office 
that can take corrective action. In this instance, an MDEO quality 
reviewer had correctly determined that a contract exam provider 
submitted an insufficient exam report solely based on available medical 
records--without physically examining the veteran. A VBA claims 
processor made an incorrect decision on the veteran's claim given the 
insufficient exam. The OIG team confirmed the error and notified OFO, 
which led to a new exam and ultimately an increased disability rating 
for the veteran.
    Because vendors were not required to fix errors that MDEO 
identified, claims processors were basing decisions on potentially 
inaccurate exam information. Accordingly, veterans may have received 
inaccurate decisions and not received the benefits and services to 
which they were entitled. The OIG recommended that VBA assess and 
modify contracts and any renewals to ensure procedures are established 
for vendors to correct errors identified by MDEO. VBA executed 
contracts that included procedures for vendors to correct these errors, 
enabling the OIG to close this recommendation.

MDEO Did Not Communicate Exam Errors to OFO and VBA Regional Offices 
for Resolution

    Although the contracts in place during the review did not require 
vendors to correct MDEO-identified errors, they did require vendors to 
correct exams that regional offices returned for clarification. The OIG 
determined it is crucial that MDEO inform OFO and VBA's regional 
offices when exams are returned to provide a needed layer of 
accountability.
    The OIG team found 26 errors in its sample of 99 quality reviews 
were not communicated to OFO and regional offices. While MDEO correctly 
identified errors, the veteran's electronic claims folders showed the 
errors were not communicated to the regional office and claims 
processors decided these claims without seeking clarification. Regional 
offices determined that for four of the 26 exam errors, no additional 
action was required. Of the remaining 22 exam errors, 11 decisions led 
to veterans not receiving the benefit sought. After receiving the new 
exams, the regional office rendered new decisions.
    At the time of the OIG's review, current and former MDEO employees 
told the team that MDEO managers discouraged them from directly 
relaying exam issues to claims processors. The deputy under secretary 
for OFO stated that MDEO should share errors it identifies with 
regional offices, since claims processors need to know what exam errors 
they are missing. Further, this information could be used to provide 
additional training. The OIG recommended VBA implement procedures 
requiring MDEO to communicate exam errors to OFO and the regional 
offices and demonstrate progress in correcting the identified errors. 
The OIG also closed this recommendation after reviewing VBA's new error 
referral standard operating procedure and obtaining documentation 
showing improved communication of errors between MDEO and OFO.

MDEO Did Not Analyze All Readily Available Data to Identify Systemic 
Exam Issues

    The OIG team found that MDEO did not analyze the findings from its 
quality reviews or other available data sources--such as deficiencies 
identified by VBA's internal quality programs and claims processors--to 
identify systemic issues, error trends, and areas for improvement. 
Leaders from OFO, the Compensation Service, and MDEO all agreed that 
MDEO's designated data and analysis team could track these data; 
however, MDEO leaders also stated they lacked adequate staff to do so. 
Despite the staffing and other challenges identified, VBA took 
corrective action in response to the OIG's recommendation that VBA 
implement procedures requiring MDEO to analyze all available error data 
and provide systemic exam issues and error trends to vendors. The OIG 
closed this recommendation after reviewing VBA's new standard operating 
procedure for resolving exam issues as well as obtaining documentation 
showing process improvements.

MDEO NEEDS TO BETTER MONITOR MILEAGE REQUIREMENTS FOR CONTRACTS

    The most recent OIG review involving the contract exam process 
examined MDEO's monitoring of mileage requirements because veterans 
reported on satisfaction surveys that they had to travel excessive 
distances to attend exams.\13\ The April 2023 report explained that the 
vendors' contracts require that exams be scheduled
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    \13\ VA OIG, The Medical Disability Examination Office Needs to 
Better Monitor Mileage Requirements for Contract Exams, April 20, 2023.

        as close to the veteran's home of record as feasible, but no 
        farther than 50 miles for non-specialist exams and 100 miles 
        for specialist exams. Traveling long distances, while necessary 
        for some medical exams, can be an unnecessary burden on 
        veterans, especially the elderly and those with disabilities. 
        Authorization may be granted for additional mileage when 
        [veterans] expressly indicate their willingness to exceed the 
        above limits.\14\
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    \14\ VA Manual 21-1, ``Examinations Requests Overview,'' sec. 
IV.i.2.A in Adjudication Procedures Manual, topic 1g, updated May 31, 
2022. A specialist exam is any exam conducted by a clinician who 
specializes in a particular field. Examples may include those for 
vision, hearing, dental, and psychiatric exams.

    That express consent must be documented and included in the record 
available to VBA employees.\15\
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    \15\ In September 2021, a modification was made to each contract to 
further clarify the definition of ``record'' to include the veteran 
portal, the vendor portal, and the Veterans Benefits Management System 
electronic claims folder.
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    The OIG found that MDEO was not monitoring whether vendors obtained 
and documented veterans' express consent to travel beyond contractual 
mileage limits for exams. MDEO was also not sufficiently monitoring 
vendor portals to ensure all required details of mileage reimbursement 
were available to veterans. MDEO was not monitoring compliance because 
its leaders did not consider it a priority given what they describe as 
the small percentage of veterans affected. However, MDEO is responsible 
for ensuring vendors comply with all contract requirements, including 
mileage requirements and reimbursements. Without monitoring, VBA cannot 
identify or implement improvements for veterans traveling to these 
exams.
    The OIG team assessed an initial statistical sample of 183 contract 
exams (of approximately 65,100) completed by all three vendors from 
July 1 through December 31, 2021, that MDEO reported as having exceeded 
contract mileage requirements. The team found 138 exams without 
documentation of express consent. Based on the statistical sample 
results, the team estimated that fewer than 12,000 of the 65,100 exams 
(18 percent) completed during the review period included viewable 
documentation of express consent.\16\ On average, the team found 
veterans were scheduled for exams about 93 miles (round trip) beyond 
the contractual limitations.\17\
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    \16\ Estimate percentages were weighted to represent the population 
from which they were drawn.
    \17\ The mileage restrictions were 50 miles one way (100 miles 
round trip) for non-specialty exams and 100 miles one way (200 miles 
round trip) for specialty exams.
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    Interviews revealed that all three vendors documented the express 
consent of some veterans within internal records systems. However, 
their internal records systems were not viewable by VBA employees 
charged with overseeing those requirements. All three vendors notified 
the OIG that updates were made to vendor portals during the review 
period. Therefore, the team reviewed an additional judgmental sample of 
90 cases from January 1 through June 30, 2022, to determine if the 
updates resulted in improvements. The team's review suggests that 
although progress had been made, about 21 percent of the exams still 
lacked documentation of the veteran's express consent in the record. If 
vendors do not obtain and document express consent from veterans to 
exceed contractual mileage limitations, veterans may not be made aware 
of their right to undergo exams within reasonable distances of their 
homes. It also may cost VA more money because veterans are reimbursed 
for certain travel costs.
    The OIG also found vendors were not always providing mileage 
reimbursement details on their portals, which can impede veterans from 
viewing the status of their payment details as required by contract. 
During the course of this review, vendor portals were updated to help 
fix identified problems.
    The OIG made three recommendations to the under secretary for 
benefits:

    1. Implement a process to monitor and demonstrate progress to 
assess vendors' compliance with contractual mileage and travel 
reimbursement requirements.

    2. Collaborate with vendors to ensure portals include proper 
documentation of express consent.

    3. Collaborate with vendors to ensure mileage reimbursement 
information is available in vendor portals.

    Although VBA requested closure of the recommendations at 
publication, all recommendations remain open until adequate 
documentation has been received sufficient to demonstrate 
implementation.\18\
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    \18\ The OIG considers all recommendations currently open pending 
the submission of sufficient documentation that would support that 
adequate progress has been made on implementation to close them. The 
OIG requests updates on the status of all open recommendations every 90 
days. This is reflected on the recommendations dashboard found on the 
OIG website. For this report, the OIG will request the first update in 
late July 2023.

ENHANCED STRATEGY NEEDED TO REDUCE DISABILITY EXAM INVENTORY DUE TO THE 
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PANDEMIC AND ERRORS RELATED TO CANCELED EXAMS

    A November 2020 report details an OIG review of VBA's efforts to 
schedule and conduct disability exams during the COVID-19 pandemic.\19\ 
The review team found that VBA took significant actions to limit 
veterans' exposure to COVID-19. On April 2, 2020, VHA notified VBA to 
transfer exams conducted by VHA examiners to VBA disability exam 
contractors to the greatest extent possible. This shift was necessary 
to allow VHA facilities to prioritize essential and critically needed 
healthcare services during the pandemic. VBA then modified procedures 
and redirected exam requests to the contractors used before the 
pandemic as part of its routine operations.\20\ It notified veterans of 
changes to the exam process through various means, including websites, 
social media, and veterans service organizations. These actions were 
necessary and appropriate but inevitably resulted in increases to the 
backlog of disability exams. VBA provided guidance to the field on 
multiple occasions regarding when it was appropriate to reschedule 
canceled exams and to ensure cancellations did not result in claim 
denials. These efforts, however, sometimes resulted in confusion and a 
lack of consistent practices. Once clear guidance was issued, VBA took 
action to review prematurely or improperly denied claims on the basis 
of a canceled exam. The OIG review found that early in the pandemic 
unclear guidance led to inappropriately denied disability claims due to 
canceled in-person exams, and that VBA's strategies for reducing 
inventory and backlog required more attention and testing to ensure 
personnel are fully prepared for future emergencies that may affect the 
disability claims process.
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    \19\ VA OIG, Enhanced Strategy Needed to Reduce Disability Exam 
Inventory Due to the Pandemic and Errors Related to Canceled Exams, 
November 19, 2020.
    \20\ MDE vendors were sent an email on April 3, 2020, directing all 
in-person exams be discontinued immediately.
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    On May 7, 2020, VA issued Charting the Course: Maintaining 
Continuous Services to Veterans and Resuming Normal, Pre-COVID-19 
Operations. This document outlined VA's plan to resume normal, pre-
COVID-19 operations in three phases, in accordance with the White House 
National Guidelines, Opening Up America Again, but provided limited 
information on exams. It stated VBA would work with its contractors to 
formulate a plan to resume in-person exams. Also in May 2020, VA 
established the Program Integration Office to oversee disability exams. 
It was formed to provide new leadership and oversight as VBA has taken 
on more responsibilities for conducting exams so that VHA can focus on 
its healthcare mission and additional demands related to COVID-19.
    The OIG first recommended that VBA further develop, implement, and 
test its strategy to reduce the exam inventory through in-person, 
telehealth, and acceptable clinical evidence (commonly known as 
``ACE'') exams, as safety circumstances permitted. To address this 
recommendation, the under secretary for benefits said VBA would use 
``in-person, tele-[compensation and pension exams] (using telehealth 
technology) and acceptable clinical evidence modalities in a safe and 
logistically feasible manner'' to reduce the exam inventory by the end 
of the fiscal year. The OIG has closed this recommendation.
    The OIG also recommended VBA develop and implement a plan to 
increase the use of telehealth exams. VBA was called on to ensure 
contractors followed VHA's Office of Disability and Medical 
Assessment's telehealth guidance on exams to determine whether 
telepresenter-specific medical equipment was required. While VBA 
initially concurred in principle with this recommendation, during the 
follow-up process, the OIG closed it in June 2021 as not implemented 
because the recommendation was unable to be satisfactorily addressed 
due to a lack of resources.

CONCLUSION

    One of the critical foundations of accountability of any program is 
effective quality assurance and monitoring to detect and resolve 
issues. The OIG has found that MDEO needs to improve its quality 
assurance processes and better monitor its contract exam vendors to 
help ensure veterans receive the benefits they are entitled to through 
VA's disability programs. While VBA has made progress in updating its 
contracts and procedures to provide oversight of its contracts, there 
is clearly more work to be done. The OIG remains focused on conducting 
oversight work and providing recommendations to help improve veterans' 
experiences during the disability claims process.
    Mr. Chairman, this concludes my statement. I would be happy to 
answer any questions you or members of the subcommittee may have.

                       Statements for the Record

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         Prepared Statement of Disabled American Veterans (DAV)

    Chairman Luttrell, Ranking Member Pappas and Members of the 
Subcommittee:
    Thank you for inviting DAV (Disabled American Veterans) to submit 
testimony for the record of your oversight hearing titled, ``VA 
Disability Exams: Are Veterans Receiving Quality Services?''
    DAV is a congressionally chartered and VA-accredited 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 benefits advocates called 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.
    Based on our experience with the VA claims process, we will address 
the question posed by this hearing as we discuss VA Disability 
examinations, the Veterans Benefits Administration's (VBA) Medical 
Disability Examination Office (MDEO), oversight and quality of exams, 
and the importance of license portability for examiners. We will wrap 
up this testimony with our recommendations and our concerns moving 
forward.

                       VA DISABILITY 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 VBA. Per 
VA's fiscal year (FY) 2022 annual report updated in February 2023, over 
360,000 new veterans and survivors started receiving VA disability 
compensation.
    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 & 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.
    In many cases, the VA exam is the linchpin to establish or deny a 
claimed benefit. However, if a veteran fails to appear for an exam or 
it is canceled 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 canceled 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 canceled 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 canceled 
exams can negatively impact a veteran's claim and disability rating. If 
a negative decision is rendered based on a missed or canceled 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.

VBA'S Medical Disability Examination Office

    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 10 VAROs 
could participate. These contract exams, originally managed by the 
Veterans Health Administration (VHA), were expanded from 10 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 MDEO 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 Pandemic's Effect

    The enormity of the impact of the COVID-19 pandemic will be felt 
for years to come with continued lessons learned. In November 2020, the 
VA Office of the Inspector General (OIG) report ``Enhanced Strategy 
Needed to Reduce Disability Exam Inventory Due to the Pandemic and 
Errors Related to Canceled Exams,'' made the following findings:

      VBA discontinued in-person exams to protect veterans

      Protective measures contributed to VBA's exam inventory 
growth

      VBA prepared for increased use of telemental health and 
ACE exams

      VBA's use of telehealth was limited by the need for a 
telepresenter for some exams

      VBA prematurely or improperly denied claims based on 
canceled exams

      VBA needs to further develop and test Its strategy to 
address the inventory of exams

    At the beginning of the pandemic, there were roughly 140,000 
pending VA exam requests with an average of 21 days to completion. 
Despite challenges posed by the pandemic, in 2022, the MDEO reduced the 
contract medical examination pending inventory from 258,000 to 189,195. 
Overall in 2022, contract vendors completed 1,844,399 exam requests.
    The contract vendors continue to increase their volume of completed 
exam requests each month, resulting in a decrease in the excess 
inventory of examinations. The MDEO forecasts contract medical 
examination vendors will complete medical disability exam requests for 
over 3 million veterans in 2023 and over 3.3 million in 2024.
    Given this surge of exams, DAV is greatly concerned with quality of 
the VA exam process, whether exams are conducted by contract examiners 
or the VHA.

                   OVERSIGHT AND QUALITY OF VA EXAMS

    VA examinations, with the exception of certain specialty exams, are 
conducted by vendors through the MDEO. As noted, this increased 
utilization began in 2017. VBA must be providing adequate oversight to 
ensure the vendors are providing quality exams. This has been 
problematic in the past.
    In the 2018 Government Accountability Office (GAO) report, 
``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 BA's monitoring of contractors;

      VBA's data limitations hinder its ability to oversee 
certain contract provisions;

      VBA did not conduct comprehensive performance analysis; 
and

      Although the auditor verified contracted examiner 
licenses, VBA did not verify training completion or collect information 
on training effectiveness.

    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.
    In June 2019, the VA 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.
    At the September 2019 House Veterans' Affairs Subcommittee on 
Disability Assistance and Memorial Affairs hearing, VBA noted that VA 
contract examination quality is evaluated quarterly and the results are 
used to identify training needs and provide feedback to contractors. It 
also addressed the need to improve delivery and tracking of training 
requirements for examiners. Further, it was noted that all vendors were 
achieving an overall customer satisfaction rating of 90 percent.
    The VA OIG report of June 2022, ``Contract Medical Exam Program 
Limitations Put Veterans at Risk for Inaccurate Claims Decisions,'' 
found that VBA governance of and accountability for the contract 
medical disability exam program needed to improve. The deficiencies 
noted stemmed from limitations with VBA's management and oversight of 
the program at the time of the review.
    The OIG further concluded that VBA's MDEO was deficient because it 
did not hold vendors accountable for correcting errors and improving 
exam accuracy. However, the OIG did determine that MDEO performed 
quality reviews correctly. The MDEO's results were substantiated by the 
report, estimating that MDEO reached the correct conclusion on at least 
95.1 percent of reviews completed in 2020. The June 2022 OIG report 
made the following recommendations:

        1. Assess and modify contracts and any renewals to ensure that 
        vendors can be held accountable for unsatisfactory performance 
        by applying monetary disincentives.

        2. Assess and modify contracts and any renewals to ensure 
        procedures are established for vendors to correct errors 
        identified by the MDEO.

        3. Implement procedures requiring the MDEO to communicate exam 
        errors to the Office of Field Operations and the regional 
        offices and demonstrate progress in correcting the identified 
        errors.

        4. Implement procedures requiring the MDEO to analyze all 
        available error data and provide systemic exam issues and error 
        trends to vendors.

    At the time of the report, the VA's Acting Under Secretary for 
Benefits concurred in principle with recommendations 1 and 2, provided 
information on actions taken--in particular, executing new contracts--
and requested closure of the recommendations. Additionally, VBA 
concurred with recommendations 3 and 4 and provided an action plan to 
address each recommendation. VBA's responses to the recommendations 
follow:

      Recommendation 1. On October 1, 2021, VBA executed new 
contracts that hold vendors accountable for unsatisfactory performance 
through application of monetary disincentives, referred to as negative 
incentives. A negative incentive is assessed on a quarterly basis if 
the contracts' combined timeliness and production performance 
requirement levels are not met. VBA considers this recommendation fully 
implemented and requests closure.

      Recommendation 2. VBA executed contracts that include 
established procedures for vendors to correct errors identified by 
MDEO. The contractor must take corrective action when examination 
deficiencies are identified and provide the corrective action to VBA 
upon receipt of the request. VBA considers this recommendation fully 
implemented and requests closure.

      Recommendation 3. VBA initiated development of procedures 
that refer disability benefits questionnaire errors from MDEO to the 
Office of Field Operations for review.

      Recommendation 4. MDEO will work with Compensation 
Service to identify a process to receive error trend data that is a 
result of incorrect exams. MDEO will also develop a procedure for 
obtaining and assessing rework data. MDEO will analyze both data sets 
to identify systemic exam issues and communicate those error trends to 
vendors.

    Recently, MDEO noted they are meeting twice a week with vendors for 
executive and operations concerns and monthly to specifically address 
quality of exams directly with vendors. Additionally, the office noted 
that veteran satisfaction with exams is nearly 96 percent. Comparing 
the reports from 2018 to recent information, the quality and veteran 
satisfaction with exams has vastly improved.
    DAV has met directly with the vendors on the issue of quality 
within the past 45 days. All of the vendors have provided us with their 
own internal quality review processes, which we believe has added to 
the improved quality of VA contract exams. We also believe that in the 
expansion of the license portability has improved the VA contract exam 
process and provided exams to rural and underserved veteran 
populations.

                     IMPACT OF LICENSE PORTABILITY

    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.
    This allows contract exam vendors to provide examining physicians 
to rural areas that may not have examining physicians available in 
their state or territory. The provision speaks only to physicians and 
psychiatrists; however, it did 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.
    In our testimony before this Subcommittee in September 2019, we 
recommended to 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.
    In January 2021, the Johnny Isakson and David P. Roe, M.D. Veterans 
Health Care and Benefits Improvement Act of 2020 granted certain types 
of VBA-contracted examiners temporary authority, until January 2024, to 
conduct exams in states other than those in which they hold a license.
    The GAO report of June 2023, ``Actions Needed to Clarify Program 
Requirements Regarding Examiners,'' looked specifically at this 
temporary portability used by contracted examiners. VBA officials and 
vendors said that the temporary expansion of license portability 
expanded access in underserved areas.
    The report noted that the guidelines VBA provided to its contracted 
exam vendors included inaccuracies and VBA conducted inadequate 
monitoring of the vendors. This contributed to vendors allowing 
ineligible examiners to conduct exams using license portability. For 
example, VBA incorrectly listed dentists as eligible for license 
portability in the guidelines it provided to vendors. This contributed 
to two of VBA's three vendors using dentists to conduct exams in states 
other than where they were licensed.
    Additionally, GAO's review found that one vendor used optometrists 
to conduct exams in states other than where they were licensed, which 
VBA officials said was not permitted. VBA acknowledged these errors and 
agreed with the GAO recommendations for correction.
    The report also showcases the impact of the expanded license 
portability. Vendors were able to send examiners to rural and high-need 
areas that did not have enough examiners to meet local demand. One 
vendor said license portability allowed them to continue serving 
veterans when natural disasters disrupted the availability of examiners 
in the affected states. For example, this vendor reported using license 
portability to send mobile clinics to Florida following Hurricane Ian 
in September 2022.
    Another vendor said license portability helped them serve more 
veterans living on tribal lands. All three vendors said expanded 
license portability helped them serve incarcerated veterans. Officials 
from one vendor said reaching these veterans historically has posed a 
challenge because not all examiners are willing to physically enter a 
prison, and license portability allowed them to use examiners willing 
to do so.
    Recent information from MDEO indicates that this license 
portability expansion in January 2021 has resulted in 1,462 providers 
completing over 150,000 medical appointments and nearly 425,000 
disability benefits questionnaires (DBQs). As part of this VA exam 
discussion, it is clear that license portability has increased service 
to rural and underserved veterans.

                    DAV RECOMMENDATIONS AND CONCERNS

    The totality of our testimony shows how vital the VA exam process 
is to ensure that veterans are obtaining the benefits and health care 
they have earned. Additionally, it displays the issues with the MDEO 
and vendor examinations in the past through the reports of the VA OIG 
and GAO. It also shows the improvements and progress that VBA has made. 
To this end, we have the following recommendations about the VA exam 
process moving forward, to include:

      Continue Oversight on Quality--As early as 2018, the VA 
OIG and GAO reports clearly outline deficiencies within MDEO and VA 
contract exams. Since that time, notable improvements have been made. 
However, we recommend that Congress and VA OIG continue to vigilantly 
provide oversight to ensure quality is being maintained and improved 
upon. Exams can be the determinative factor on whether a veteran 
receives benefits; therefore, quality exams, regardless of who provides 
them, will always be of concern.

      Extension of license portability--The provision of 
license portability has had a positive impact for veterans living in 
rural areas and tribal lands, and for incarcerated veterans, all while 
assisting in reducing the backlog of exams which has a direct impact on 
the backlog of claims. We are greatly concerned that this temporary 
portability ends in January 2024.

        DAV recommends the immediate introduction and passage of 
        legislation to extend this portability on a permanent basis. 
        Additionally, as it was noted, not all medical professionals 
        are covered within the existing portability; therefore, we 
        recommend that all medical professionals that are able to 
        conduct VA exams within VHA be included in the permanent 
        extension of license portability.

      Validate veterans' experience in the examination 
process--DAV has received feedback from our National Service Offices 
around the country in reference to VA exams. The number one complaint 
from veterans regarding contract exams was that they felt the exams 
were not thorough enough; next was that examiners were not 
knowledgeable 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.

        We acknowledge the recent reporting from MDEO of a 96 percent 
        veteran satisfaction rating for contract exams. However, based 
        on the perception of veterans we noted above, we recommend that 
        VBA continue to address the customer satisfaction with their 
        contractors, but also include VHA, and conduct surveys or town 
        hall-like events to communicate directly with veterans 
        concerning their satisfaction with VA examinations.
    There have been many discussions and ongoing debates on who 
provides a more quality exam, VHA professionals or contractors. Many 
believe that returning the VA disability exam process to VHA will 
eliminate veterans' negative perceptions on the quality of exams. We 
have concerns.

      Data for a comparison does not exist--Prior to 2017, VHA 
was the predominant provider for VA disability exams. VA was not 
capturing the data that is currently required of contract examiners. 
So, a look at VHA versus contract provided exams cannot be conducted to 
arrive at an impartial decision. Over the past several decades, DAV has 
reviewed all types of VA disability examinations and have not taken a 
side in this debate, as we believe, that regardless of who provides the 
VA disability exam, quality, accuracy and timeliness are the most 
important aspects for veterans claims.

      VHA does not currently have the capacity--Currently VHA 
has over 40,000 health care vacancies that need to be filled; thus, VHA 
does not have the current staffing or capacity to take over the VA 
disability examination process.

    We are aware of the June 23, 2023, memorandum from the VHA 
Undersecretary for Health. It encourages VA Medical Centers to return 
to providing VA disability exams at the levels prior to the pandemic, 
based on existing resources and staffing levels. Given these 
parameters, it does not indicate that VHA will be taking over the VA 
disability exam process from contract vendors.

      Increasing in the VA claims backlog--Currently, VBA has 
over 800,000 claims pending and more than 250,000 are backlogged, which 
means they have been pending over 125 days. The incoming PACT Act 
claims have exceedingly increased the number of claims, thus the 
current number of pending claims. If VHA were to take over the VA 
disability exam process, given its shortfalls in staffing, this would 
almost certainly increase the number of backlogged claims, requiring 
veterans to wait even longer for VA claims decisions. This would create 
a crisis that is completely avoidable.
    Mr. Chairman, we believe that DAV's recommendations would help to 
improve the quality of VA exams and importantly--the overall veteran 
experience.
    In conclusion, the VA exam process is integral to the VA claims 
process. By continuing oversight of the VA disability exam process, we 
will ensure that veterans are obtaining the benefits and health care 
they have earned. We urge this Subcommittee to take immediate action on 
extending and expanding license portability to provide VA exams in all 
areas, specifically for rural and underserved veteran populations.
    This concludes my testimony on behalf of DAV.
                                 ______
                                 

  Prepared Statement of National Organization of Veterans' Advocates 
                                 (NOVA)

    Chairman Luttrell, Ranking Member Pappas, and members of the 
Subcommittee, the National Organization of Veterans' Advocates (NOVA) 
thanks you for the opportunity to offer our views on VA disability 
examinations and the quality of those services received by veterans.
    NOVA is a not-for-profit 501(c)(6) educational membership 
organization incorporated in the District of Columbia in 1993. NOVA 
represents more than 800 accredited attorneys, agents, and qualified 
members assisting tens of thousands of our Nation's military veterans 
and families seeking to obtain their earned benefits from VA. NOVA 
works to develop and encourage high standards of service and 
representation for persons seeking VA benefits. In 2000, the U.S. Court 
of Appeals for Veterans Claims (CAVC) recognized NOVA's work on behalf 
of veterans with the Hart T. Mankin Distinguished Service Award.
    NOVA members represent veterans before the Department of Veterans 
Affairs and the Board of Veterans' Appeals (BVA). Accredited attorneys 
continue to represent more appeals before BVA than any other service 
organization or listed category; in FY 2022, attorneys represented 
appellants in 23.4 percent of decided appeals. With agent 
representation included, that level reached 25.7 percent. U.S. 
Department of Veterans Affairs, Board of Veterans' Appeals Annual 
Report Fiscal Year 2022 at 49-50 (https://www.bva.va.gov/docs/
Chairmans--Annual--Rpts/bva2022ar.pdf).
    NOVA members also appear before the CAVC, the U.S. Court of Appeals 
for the Federal Circuit, and the Supreme Court, representing individual 
appellants and advancing veterans law in the process. As an 
organization, NOVA also advances important cases and files amicus 
briefs in others. See, e.g., NOVA v. Secretary of Veterans Affairs, 710 
F.3d 1328 (Fed. Cir. 2013) (addressing VA's failure to honor its 
commitment to stop applying an invalid rule); Procopio v. Wilkie, 913 
F.3d 1371 (Fed. Cir. 2019) (amicus); NOVA v. Secretary of Veterans 
Affairs, 981 F.3d 1360 (Fed. Cir. 2020) (M21-1 rule was interpretive 
rule of general applicability and agency action subject to judicial 
review); National Organization of Veterans' Advocates, Inc., et al., v. 
Secretary of Veterans Affairs, 2020-1321 (Sept. 20, 2022) (Federal 
Circuit invalidated knee replacement rule); Arellano v. McDonough, 598 
U.S._(2023) (amicus); Terry v. McDonough, CAVC 20-7251 (amicus) (case 
pending).

                              Introduction

    NOVA has long detailed deficiencies in the disability examination 
process, which result in poor quality of exams, inferior service to 
veterans, and ongoing delays across the entire VA disability 
adjudication system. See, e.g., National Organization of Veterans' 
Advocates, Statement for the Record Before the House Committee on 
Veterans' Affairs Concerning Fulfilling Our Pact: Ensuring Effective 
Implementation of Toxic Exposure Legislation (Dec. 7, 2022); National 
Organization of Veterans' Advocates, Statement for the Record Before 
the House Committee on Veterans' Affairs, Subcommittee on Disability 
Assistance and Memorial Affairs Concerning Supporting Survivors: 
Assessing VA's Military Trauma Programs (Nov. 17, 2021); National 
Organization of Veterans' Advocates, Statement for the Record Before 
the House Committee on Veterans Affairs Concerning Discussion Draft: 
Veterans Appeals Improvement and Modernization Act of 2017 (May 2, 
2017). We address these issues in detail below.

        I. VA and Its Contractors Struggle to Provide Veterans with 
        Adequate Examinations.

    The CAVC has repeatedly emphasized VA's role in obtaining 
examinations and ensuring those examinations are adequate. See, e.g., 
McLendon v. Nicholson, 20 Vet.App. 79, 81 (2006) (outlining when VA 
must obtain an examination); Barr v. Nicholson, 21 Vet.App. 120, 123 
(2007) (when VA seeks an opinion, the Secretary must ensure it is 
adequate); Acevedo v. Shinseki, 25 Vet.App. 286, 293 (2012) (adequate 
medical report must be based on correct facts and reasoned medical 
judgment).
    Despite this clear precedent, VA frequently failed to ensure 
veterans received timely, adequate VA disability examinations when the 
Veterans Health Administration conducted nearly all examinations. See, 
e.g., Department of Veterans Affairs (VA) Appeals Data Requested by 
House Committee on Veterans' Affairs Subcommittee on Disability 
Assistance and Memorial Affairs (January 2015) (reasons for remands 
between FY 2009 and 2014 centered on issues with medical examinations 
and opinions). This problem has not been solved with the shift to 
contract examinations.
    During stakeholder discussions leading up to the passage of the 
Veterans Appeals Improvement and Modernization Act of 2017 (AMA) and 
before this Subcommittee, NOVA testified to the importance of adequate 
examinations and the problems created when claims are sent back time 
and again for new examinations when the first examination or subsequent 
ones are deficient. Even with the 2019 implementation of the AMA, which 
was intended to reduce remands, NOVA members continue to report a 
significant number of cases remanded due to inadequate examinations. 
Current BVA statistics confirm these reports.
    Frequently, BVA orders a particular type of examination, but it is 
conducted by an inappropriate provider, e.g., an OB/GYN nurse 
practitioner handling a neck and back exam. Or BVA provides specific 
instructions that are ignored by the examiner. Example: The veteran's 
claims for bilateral knee conditions were remanded back to BVA from the 
CAVC in 2020. BVA remanded in May 2021 and February 2022 for new 
medical opinions. In February 2022, BVA specifically ordered the VA 
examiner to address the veteran's competent lay statements regarding 
the history and chronicity of his knee symptoms. Because the VA 
examiner failed to comply with these instructions, BVA yet again 
remanded these claims for the examiner to comply with the order, adding 
untold months of waiting before the veteran receives resolution.
    Unfortunately, a BVA remand under the AMA is far more costly than 
one in the legacy system. When BVA remands an appeal in the legacy 
system, a veteran, survivor, or family member who is dissatisfied with 
the results of the remand can return to BVA with the same docket date 
as before. By contrast, an AMA remand means the appellant loses their 
original docket date. If their appeal is remanded and denied again, 
they must start over again with a new docket date if they choose to 
return to BVA. Because backlogs at BVA continue unabated and the 
promise to reduce remands has not been kept, absent qualifying for 
advancement on the docket, the appellant will wait many years for BVA 
to issue a decision.
    In addition, NOVA members report that confusing examination 
requests contribute to inadequate exams and deficient reports. Many 
times, the request does not match the veteran's claims or incorporate 
the remand instructions articulated by BVA or the CAVC. Sometimes, the 
request is not clear as to whether the veteran must appear for an exam 
or the examiner can write the report based on a record review. Without 
clear guidance, examiners burdened with large workloads are bound to 
conduct inadequate exams and write incomplete reports.
    Just a year ago, in a report highlighted by this Subcommittee in 
its June 27, 2023, invitation, the VA Office of Inspector General 
acknowledged that ``[r]esults of medical exams are critical pieces of 
evidence in supporting veterans' claims for benefits, and the exams 
represent a significant investment by VBA.'' Department of Veterans 
Affairs, Office of Inspector General, Veterans Benefits Administration: 
Contract Medical Exam Program Limitations Put Veterans at Risk for 
Inaccurate Claims Decisions i, June 8, 2022 (https://www.va.gov/oig/
pubs/VAOIG-21-01237-127.pdf). The report also found, among other 
things, that ``[a]ll three vendors failed to consistently provide VBA 
with the accurate exams required by the contracts'' and ``vendor exam 
accuracy has not improved and exam errors have not been resolved.'' Id. 
at 8; 10. Contract examiners must comply with the terms of their 
contracts and be held accountable when they fail to do so. Furthermore, 
contractors must correct errors and provide adequate examinations to 
reduce repeated remands, which result in continuing delay and backlogs.
    NOVA urges this Subcommittee to conduct additional oversight to 
understand and quantify the root causes of inadequate examinations, the 
ongoing high remand rates due to inadequate examinations and potential 
overdevelopment, and the resulting delays endured by veterans with 
claims and appeals before the Veterans Benefits Administration and the 
Board of Veterans' Appeals due to these factors.

        II. VA Seeks Additional Development When Adequate Evidence of 
        Record Exists.

    NOVA members also report that VA frequently orders additional 
examinations even when adequate medical evidence of record exists and a 
favorable opinion has been rendered. VA may not undertake ``additional 
development if a purpose [is] to obtain evidence against an appellant's 
claim.'' Mariano v. Principi, 17 Vet.App. 305, 312 (2003). In some 
instances, NOVA members report the ordering of additional examinations 
that appear to be ``tie breakers,'' e.g., when there is one negative 
and one favorable opinion. Such exams are in contravention of VA law 
and policy requiring adjudicators to grant the claim when the evidence 
is in relative equipoise.
    Example 1: In February 2022, a VA contract examiner provided a 
favorable opinion on the veteran's claim for service connection for an 
arthritic condition. Despite this favorable opinion, VA obtained a 
second set of exams, which were unfavorable, and VA's denial made no 
mention of the first favorable exam. After a higher-level review, the 
claim was sent back for more development due to the ``difference of 
opinion.'' This time, the original examiner ultimately concluded the 
condition was ``more likely than not'' service connected. Nonetheless, 
VA denied the claim.
    Example 2: In July 2023, VA sent a claim out for an additional 
medical opinion where the VA examiner already provided a nexus opinion 
advising that the veteran's depression was secondary to his service-
connected hypothyroidism. The veteran, as a result of his Agent Orange 
exposure, is also service connected for Parkinson's disease.
    Furthermore, VA also routinely rejects favorable, well-
rationalized, private medical opinions for improper/unlawful reasons, 
such as the examiner's ``failure to review the veteran's claims file'' 
or because the examiner's opinion ``was based on the history reported 
by the veteran.'' The CAVC has repeatedly admonished BVA for rejecting 
favorable evidence for these reasons, yet these types of rejections 
continue to occur on a regular basis. See, e.g., Nieves-Rodriguez v. 
Peake, 22 Vet.App. 295, 304 (2008) (Board may not reject a private 
medical opinion in favor of a VA opinion solely because the VA examiner 
reviewed the claims file); Kowalski v. Nicholson,19 Vet.App. 171, 179-
80 (2005) (Board may not disregard a medical opinion solely because the 
opinion was based on a history provided by the veteran); see also 
Coburn v. Nicholson, 19 Vet.App. 427, 432 (2006) (``[R]eliance on a 
veteran's statement renders a medical report incredible only if the 
Board rejects the statements of the veteran.'').
    In July 2022, NOVA filed a statement in support of draft 
legislation, i.e., No Bonuses for Bad Exams Act, before the Senate 
Committee on Veterans' Affairs. National Organization of Veterans' 
Advocates, Statement for the Record Before the Senate Committee on 
Veterans' Affairs Concerning Pending Legislation to Include Discussion 
Draft, S._ , No Bonuses for Bad Exams Act of 2022 (July 13, 2022). That 
bill would have ensured inadequate examinations do not adversely impact 
veterans' claims, e.g., by prioritizing new exams and subsequent claims 
processing when a veteran has received an inadequate examination, by 
permitting reports of inadequate or unnecessary examinations to be 
removed from the veteran's record, and by ensuring inadequate or 
unnecessary examinations are not used for adjudication, review, or 
litigation purposes. The House and Senate Committees on Veterans' 
Affairs should take up such legislation in this Congress and conduct 
ongoing oversight of the VA disability examination process.

        III. Contractors Must Improve Communication to Veterans and 
        Their Accredited Representatives and Provide More Overall 
        Transparency.

        A. Accredited Representatives Should Receive Copies of All 
        Communication Between the Contractor and Veteran.

    NOVA members report confusion and a lack of clear communication 
about scheduling to veterans that causes them to miss examinations. 
When a veteran cannot make the scheduled examination, it needs to be 
properly and timely rescheduled or there is a strong likelihood VA will 
deny the claim. Accredited representatives can assist their clients 
with navigating this process but timely notice is necessary.
    At this Subcommittee's March 2023 hearing, NOVA provided a 
statement which supported, among other bills, H.R. 1530, Veterans 
Benefits Improvement Act. This bill would require that every 
communication from a contractor to a claimant regarding the scheduling 
of a covered medical disability examination be ``contemporaneously 
transmitted'' to the accredited representative. Contractors should 
agree to provide this notice without the need for legislation, but if 
not, Congress should move to pass this bill.
    In addition, any legislation should contain a new section that 
requires VA to automatically mail a copy of the veteran's examination 
report to the veteran and his or her accredited representative (if one 
has been appointed by the veteran). This amendment is necessary given 
the CAVC's recent unfavorable interpretation of the statute. See, e.g., 
Martinez v. Wilkie, 31 Vet.App. 170 (2019) (VA not required to provide 
copy of examination report under 38 U.S.C. Sec.  5103A).
    Finally, contractors should recognize and respect the veteran/
representative relationship. NOVA members report that contractors state 
they are only authorized to speak with the veteran. If contractors do 
not have access to the signed 21-22 or 21-22a, they should be provided 
with such and accept the assistance of the veteran's representative who 
is authorized to speak for the veteran.

        B. Contractors Need to Take Additional Steps to Improve 
        Scheduling and Related Issues.

    NOVA members report continuing issues, outlined below, that result 
in unnecessary denials and poor service to veterans. Contractors should 
take the necessary steps to eliminate these issues.

      Failure to confirm appointment with veteran. Timely 
notice is not always provided, the appointment is not confirmed, and 
when the veteran does not show, they are penalized because they have 
not shown good cause for missing the appointment. Contractors should 
ensure the appointment is properly confirmed.

      Providers unable to accept cancellations. When an issue 
or illness arises that prevents the veteran from attending an 
appointment shortly before, or the day of, the examination, the 
provider will refuse to accept the cancellation or inform a veteran 
they must contact the contractor. In many instances, the veteran does 
not have that information, and then gets marked as a ``no-show.'' 
Providers should be able to handle these cancellations.

      Failure to provide basic information upon request. 
Sometimes examiners refuse to answer basic questions raised by the 
veteran, such as their full name, specialty, diagnosis, or ROM 
measurements. Veterans have a right to know this basic information and 
it should be provided when requested.

                               Conclusion

    Many aspects of the VA disability examination process remain 
problematic. NOVA urges this Subcommittee to continue oversight, with 
an emphasis on examining the high remand rates due to inadequate 
examinations and overdevelopment that add to ongoing backlogs before 
the Veterans Benefits Administration and the Board of Veterans' 
Appeals.

    For more information:

    NOVA staff would be happy to assist you with any further inquiries 
you may have regarding our views on this important legislation. For 
questions regarding this testimony or if you would like to request 
additional information, please feel free to contact Diane Boyd Rauber 
by calling NOVA's office at (202) 587-5708 or by emailing Diane 
directly at [email protected].
                                 ______
                                 

           Prepared Statement of Optum Serve Health Services

    Chairman Bost, Ranking Member Takano, and members of the House 
Committee on Veterans' Affairs Subcommittee on Disability Assistance 
and Memorial Affairs: Chief Executive Officer of Optum Serve Health 
Services, I am pleased to submit this written statement for the record 
regarding our work on the U.S. Department of Veterans Affairs (VA)--
Veterans Benefits Administration (VBA) Medical Disability Exam (MDE) 
program in the four geographic and pre-discharge regions.
    On behalf of all the women and men at UnitedHealth Group (UHG), 
including Optum Serve Health Services, who work every day to help 
people live healthier lives and make the health system work better for 
everyone, I appreciate the opportunity to discuss our delivery of 
medical disability examinations, in support of the VBA, Veterans and 
their families, Service Members, Veteran and Military Service 
Organizations, community providers, and our program partners. Optum 
Serve Health Services brings parent company UnitedHealth Group's (UHG) 
broad commercial and government experience, and extensive resources 
with Optum's innovation, technology, scalability, and federal 
healthcare program experience to ensure our nation's Veterans and 
Service Members receive quality, objective, and timely compensation and 
pension examinations in accordance with VBA regulations and the terms 
of our contracts.
    Let me also acknowledge the Committee's important work to pass the 
Sergeant First Class Heath Robinson Honoring our Promise to Address 
Comprehensive Toxics Act, or PACT Act for short, this past year. This 
important legislation greatly expands health care and benefits for 
Veterans exposed to toxic substances and represents our Nation's 
commitment to taking care of those who have served. Optum Serve Health 
Services is similarly committed to serving Veterans and Service Members 
and supporting our government partners in the execution of their 
missions. Our VBA MDE program is a prime example of this commitment as 
demonstrated by our performance of this work for more than a decade, 
our responsiveness to the challenges faced during the unprecedented 
COVID-19 pandemic, our rapid expansion to support the increased and 
sustained volumes resulting from the passage of the PACT Act, and our 
continued collaborative partnership with the VBA.
    Optum Serve Health Services, formerly Logistics Health Incorporated 
(LHI), began performing medical disability exams on behalf of the VA in 
2011. Starting with one contract managed by the Veterans Health 
Administration (VHA), Optum Serve Health Services, custom designed a 
program and a system to process examination requests efficiently and 
accurately. In 2018, oversight of the MDE program shifted from the VHA 
to the VBA and the second generation of MDE contracts were awarded. 
Optum Serve Health Services initially held competitive awards for 
contracts in Regions one (1), two (2) and three (3), and in 2021, Optum 
Serve Health Services was awarded a single-year, sole-source contract 
for Region four (4). Then in 2022, Optum Serve Health Services received 
competitive awards for the Region four (4) (March 2022) and the Pre-
discharge contracts (April 2022), resulting in our current program 
which completes more than 20,000 appointments per week across five 
separate contracts and in all 50 states.
    At the heart of the Optum Serve Health Services VBA MDE program is 
a network of certified compensation and pension examiners and 
diagnostic service providers. We have more than 4,300 examiners and 
over 1,900 diagnostic service providers operating in our network of 
clinics, provider offices and mobile examination units. The Optum 
branded and vendor partner clinics serve as the backbone of our network 
where examiners conduct compensation and pension examinations on a 
full-time basis. These clinics are located in larger markets and/or 
close to military bases where consistent demand for exam services 
exists. The clinics contain a mix of examiners (general medical, 
behavioral health, audiology, optometry, dental), diagnostic radiology 
and other diagnostic testing services based on the needs of the market 
and the availability of contracted examiners and diagnostic service 
providers in each specific market. Contracted examiners and diagnostic 
service providers add depth and breadth to our network and allow us to 
look at additional options when sourcing exam locations closer to where 
Veterans and Service Members live. Single examiner offices embedded in 
existing medical practices and our mobile medical units give us 
flexibility to provide services in more rural or underserved areas as 
well as addressing surges in demand in larger markets. Individual 
examiners also travel to different locations as needed to help fill 
temporary capacity gaps, provide services to incarcerated or home bound 
Veterans, and to provide additional coverage in rural communities.
    Regardless of where an examination occurs, Optum Serve Health 
Services is committed to ensuring the highest levels of quality for the 
services we provide through the VBA MDE program. Each Optum Serve 
Health Services examiner is credentialed by Optum Serve Health 
Service's National Committee for Quality Assurance (NCQA) certified 
Provider Credentialing Department and must complete the VBA required 
training courses in the VHA TrainingFinder Real-time Affiliate-
Integrated Network (TRAIN) learning management system. They are also 
supported and tutored by our own dedicated provider training and 
support team, who provide additional training, tutor examiners that 
need assistance, and create references and resources that are available 
to our examiners in our provider portal. We also provide tutor 
examiners should our providers need any additional support. Once an 
exam occurs, all required documentation is reviewed through system 
validation and manual checks by our Clinical Quality Review Department, 
prior to electronic submission to the VBA.
    We are committed to providing a high-quality experience for the 
Veterans and Service Members we are honored to serve. In addition to 
the training and internal quality reviews performed by Optum Serve 
Health Services, we also work collaboratively with the VBA MDE Program 
Office and VA Regional Offices to identify and correct quality and 
patient experience issues. Optum Serve Health Services receives monthly 
reports and audit scores from the VBA MDE Program Office Quality 
Department as well as the VBA Veteran and Service Member experience 
survey results for each contract. Both of these reports are tied to 
performance metrics in our contracts and are part of the oversight the 
VBA exercises on our work. They communicate trends and identify areas 
for improvement as well as areas of outstanding performance during 
recurring quality, operations, and performance calls. Optum Serve 
Health Services uses this information to make adjustments to our 
processes and communicate necessary changes and adjustments to our 
entire network. The VBA Veteran and Service Member experience survey is 
administered by another VBA contractor and provides valuable feedback 
on Optum Serve Health Service's examiners and other aspects of the 
program. In partnership with VBA's MDE Program Office, the Veteran and 
Service Member feedback is leveraged as we continuously review the 
quality and experience provided by the program. We continuously monitor 
examiner training and credentialing and investigate all inquiries. Any 
examiner who does not maintain the proper credentialing and training, 
or who does not meet the quality and experience requirements of the 
contract is removed from our network. During the past year, our program 
quality audit and patient experience survey scores have consistently 
exceeded the requirements in the contract.
    These positive changes in quality and member experience occurred 
during a demanding time for the program as we exited the pandemic and 
then responded to the increased demand resulting from enactment of the 
PACT Act. During the pandemic, face-to-face exams were temporarily 
suspended by the VBA, COVID precautions were put in place to protect 
Veterans and Service Members, and changes were made to scheduling and 
exam processing guidelines to avoid negative impacts to claims. Once 
face-to-face exams resumed and operations normalized, our program 
leveraged flexibilities in the use of telehealth and license 
portability legislation to schedule and complete exams, extending the 
reach of our network and providing options to Veterans and Service 
Members to receive their examinations in the way that was most 
convenient for them, while still maintaining objectivity and quality. 
Optum Serve Health Services used telehealth primarily for behavioral 
health exams and leveraged our fleet of mobile medical units and 
traveling examiners to provide services to Veterans and Service Members 
in rural and underserved areas. Telehealth, mobile medical units and 
travel examiners were also utilized to respond to fluctuations in exam 
volume in larger markets or covering for examiners who were personally 
impacted by COVID or chose not to practice during the pandemic. Even 
when the VBA adjusted its processes and guidelines in response to the 
relaxing of pandemic restrictions at the start of 2022, telehealth and 
license portability remained important enablers for Optum Serve's MDE 
program. Many behavioral health providers have not returned to face-to-
face practice and continue to see patients remotely. The use of mobile 
medical units and traveling examiners has only increased as the volume 
of exam requests grew with the PACT Act and the health care industry 
continues to feel the reverberations of the pandemic. Optum Serve 
Health Services recommends making license portability provisions 
permanent and adding dentists, optometrists, and other types of 
licensed health care professionals to the legislation as this will 
provide additional flexibility and capacity to meet demand while 
providing options to support Veteran and Service Member preferences.
    Since the passage of the PACT Act, the volume of weekly exam 
requests Optum Serve Health Services receives from the VBA has 
increased by approximately 45 percent. Optum Serve Health Services 
responded by opening or expanding clinics in 78 different locations, 
adding six (6) mobile medical units, and increasing appointment volume 
by 51 percent, resulting in a 47.5 percent increase in completed exam 
service requests per week. Even with these increases, our expansion 
efforts are ongoing as the VBA projects demand for exams will continue 
to increase into 2024. We use a continuous assessment process to 
monitor demand, identify changes in demand patterns, and initiate 
examiner network adjustments. In addition, we continue to enhance our 
systems and exam processes to best utilize our examiner's time, 
streamline the exam experience, and increase throughput without 
sacrificing quality or member experience.
    Overall, the industry faces a historic maldistribution of medical 
professionals and increasing administrative demands on providers, such 
as the modality, quality, and length of the training required for MDE 
providers to become certified compensation and pension examiners. We 
routinely encounter medical providers who want to work with us in 
support of Veterans and Service Members, but then decline to become 
part of our network when we present them with the training 
requirements. We are currently collaborating with the VBA MDE Program 
Office, and they have been open to feedback about adjustments to the 
training courses in VHA TRAIN. We believe that through collaboration 
between the VBA and the MDE program vendors, we can identify ways to 
decrease the total time required to complete the training while 
retaining the key content necessary for continued high quality 
delivery, and we hope that Congress will be supportive of these 
efforts. This is especially important in the context of the challenging 
health care industry labor market. Many providers and other types of 
medical professionals left health care during the pandemic, and the 
industry continues to change as we move into the post-pandemic period. 
In addition to the historic shortages of providers, technicians, and 
support staff in rural and underserved areas, there now seems to be a 
true shortage of providers in the aggregate, making it extremely 
important for the program to use different types of medical providers 
to perform this critical work. The continued use of mid-level medical 
providers as well as physicians, both general medical practitioners and 
specialists, is critical to meeting the demand of examination requests 
from the VBA.
    Optum Serve Health Services supports the end-to-end examination 
process and through collaboration with the VBA and our own team's 
pursuit of innovation, we are evolving our processes to continue to 
find ways to better serve Veterans and Service Members. First, with 
communication and scheduling, our customer service, operations, and 
information technology teams are implementing multiple changes to 
engage Veterans and Service Members digitally and improve the 
appointment scheduling process. We updated our entire caller 
identification system so our outbound calls can easily be recognized, 
and Veterans and Services Members know they are coming from a valid 
source. Each member is contacted through multiple channels (text, 
email, phone) and then allowed to indicate their preferred method of 
communication going forward.
    A second area with significant enhancement underway is the receipt 
and preparation of the claims files and supporting documents that are 
shared with examiners. In coordination with the VBA MDE Program Office, 
the process for receiving the claims files from VBA is being updated so 
the annotations made by VA Regional Office staff as they develop the 
claim will be exported as part of the file the vendors receive. This 
will ensure the information in the claims file that is most relevant is 
easily seen by the examiners who complete the exams. This is in 
addition to other changes made in the past year to more clearly 
identify relevant evidence, including layperson statements in the 
examination scheduling requests and the claims file. These changes will 
improve our examiners' ability to provide comprehensive and high-
quality examinations, reduce rework requests, and likely result in 
fewer appeals. In addition to these changes made in collaboration with 
the VBA, Optum Serve Health Services also continues to refine our 
automated and manual processes for preparing the claims files for the 
examiners. Every claim file is reviewed, and key information is 
identified for examiners to ensure it is not missed during the 
examination process.
    A final area to highlight is our focus on reducing barriers for 
Veterans and Service Members to get to appointments, consistent with 
Optum Serve Health Service's overall focus on health equity. The VBA 
reimburses Veterans for their travel to and from appointments, however, 
Veterans often indicate they do not have reliable transportation or 
cannot pay the money up front to travel to appointments. The Optum 
Serve Health Services MDE Program Operations team constantly looks at 
these challenges, interfaces with the VBA MDE Program Office and the VA 
Regional Offices and seeks to remove barriers to appointment 
attendance. In some cases, this means submitting a medical travel 
request and receiving approval from the VBA for special travel support. 
In other cases, we may coordinate a home-bound exam or utilize an Optum 
Serve Health Services mobile unit to offer services at or near a 
member's home. All of this is done in conjunction with the VBA and 
within the bounds of our current contracts. In addition to these 
methods, Optum Serve Health Services often goes above and beyond 
contract requirements by arranging for mileage reimbursement payments 
prior to an appointment or we will arrange and pay for the 
transportation ourselves. Earlier this calendar year, we started a 
transportation pilot with one of the premier ride share providers to 
supply transportation for Veterans to their appointments. In delivering 
this pilot, we coordinate with the Veteran directly to schedule their 
appointment and then also schedule rides to and from the appointment, 
easing the upfront burden and reducing out-of-pocket costs. Optum Serve 
Health Services will continue close collaboration with the VBA MDE 
Program Office by sharing the data and results from this pilot to 
support further evaluation of including transportation services such as 
this in the MDE contracts.
    Optum Serve Health Services is committed to delivering a high-
quality program that meets or exceeds our MDE contractual obligations 
in support of the overall health of those who have served our great 
Nation. Our highly dedicated program team works very closely with the 
VBA MDE Program Office and has established a robust cadence of 
connections around operations, quality, systems integration, and 
overall program performance. The VBA MDE Program Office conducts 
frequent audits on mileage reimbursement, scheduling and appointment 
completion processes, examiner training and credentialing, exam 
quality, contract performance, monthly invoices, and many other aspects 
of the program. They are receptive to feedback about program guidelines 
and requirements, and consistently offer support and guidance on 
difficult cases.
    In closing, we appreciate the opportunity to submit this statement 
for the record to provide information regarding our work in support of 
the VBA. Thank you for your continued efforts to shape legislation that 
reduces barriers to access, allows medical professionals to deliver 
services across the Nation, increases coverage for members, and 
streamlines the claims and examination processes. Our highly dedicated 
team looks forward to our continued collaboration with the VBA, this 
Subcommittee, and all of our partners, as we collectively ensure our 
Nation's heroes continue to receive the health care they have earned 
and deserve.
                                 ______
                                 

       Prepared Statement of Paralyzed Veterans of America (PVA)

    Chairman Luttrell, Ranking Member Pappas, and members of the 
Committee, Paralyzed Veterans of America (PVA) would like to thank you 
for the opportunity to submit our views on the Department of Veteran's 
(VA) disability exams process. The Veterans Benefits Administration's 
(VBA) Compensation and Pension (C&P) examination process often acts as 
the first stop for servicemembers and veterans trying to access their 
earned VA benefits and health care. This is particularly true for 
veterans who have incurred a spinal cord injury or disorder (SCI/D) and 
their ability to access VA benefits without delay is critical for their 
care and recovery.
    Any conversation about the C&P process should begin by noting that 
many veterans find it difficult to file even a basic claim for 
disability because the VA Form Application for Disability Compensation 
and Related Compensation Benefits form (21-526EZ) is long and contains 
a multitude of instructions, which makes the process confusing. This is 
why PVA has service officers staged throughout the country at VA's 
Regional Offices and the Department's 25 SCI Centers to help veterans, 
their families, and even VA employees navigate the Department's complex 
disability process. At the same time, we cannot overlook the good, 
often extraordinary work and efforts of so many VA employees. It is 
these employees, these people who most often make such a profound 
difference in the lives of the veterans and families we serve.
    When a veteran with multiple sclerosis (MS) or amyotrophic lateral 
sclerosis (ALS) receives a Veterans Health Administration (VHA) 
conducted exam, they are normally evaluated by a neurologist, a doctor 
who specializes in treating diseases of the nervous system. From our 
experience, this greatly enhances the likelihood of getting an 
examination right, and significantly decreases the chance of errors.
    However, in the case of VA contracted exams, a veteran with MS may 
be examined by a family practitioner, pediatrician, obstetrician, or 
other provider who may have little to no expertise with the disease. 
These inadequate contractor exams can result in lengthy claim 
processing times, VA Rating Decisions that provide a lesser degree of 
benefits, and necessitate the need for lengthy appeals which hurts our 
most severely disabled veterans and creates more work for VA at greater 
costs. For example, PVA is currently working with a 40 percent service-
connected veteran who has been seeking service connection for his right 
knee and his back, secondary to his service-connected left knee since 
2011. The matter has been remanded by the Board of Veterans' Appeals 
(Board) multiple times, with instructions in 2016 to specifically 
obtain an opinion from an orthopedist. It has also been appealed to the 
Veterans Court. There, the VA Secretary and the veteran agreed that the 
prior medical opinions had not been adequate for rating purposes and 
requested a new opinion. The Board then remanded the claim and 
specifically requested that an opinion be provided by an orthopedist. 
Instead, a nurse practitioner provided an opinion. The Board conceded 
the nurse practitioner was not qualified and remanded the claim again, 
but did not specifically request an orthopedist. This time around, an 
obstetrician provided the new opinion which of course, triggered 
additional appeals and decisions by the Board. Twelve years later, a 
rather simple claim by this veteran is still not resolved, but it 
serves as an excellent example of how convoluted the process can be 
when an exam is not conducted by a specialty provider. A PVA member 
with MS who was examined by a contractor with a specialty in orthopedic 
surgery produced similar outcomes, and we have many other similar 
examples of this happening with other disabilities.
    At times, it seems these contract exam requests are being sent to 
any available medical provider, regardless of their practice area. This 
just results in challenges and delay; it's not a good use of VA's 
resources or anyone's time and it certainly isn't beneficial to the 
veteran. A contractor's inexperience with VA and lack of knowledge of 
veterans can adversely affect the claims process as well. Too often, we 
have seen contractors submit an exam to VBA, and then VBA is forced to 
go back to the contractor, two, three, four, or maybe even more times 
for clarifications on something. This also causes lengthy delays in 
decisions on a claim and again can result in poor decisions that must 
be appealed.
    We agree that C&P exams completed by contractors may be sufficient 
for some of the more common or less severe disabilities. However, in 
most cases, they are inadequate for veterans with SCI/D and other 
complex and more significant disabilities. PVA strongly believes only 
VHA examiners should provide C&P exams for veterans with complex 
claims. This would greatly reduce errors and ensure VBA obtains 
everything it needs during the initial examination.
    A June 2022, VA Office of the Inspector General (VA OIG) report 
faulted the Department for not ensuring that its contract exam vendors 
were held accountable for correcting errors and improving exam 
accuracy.\1\ The report indicated that all three of the Department's 
current contractors have an accuracy rate, in many cases well below the 
92 percent accuracy requirement, with little to no improvement from 
2017 through 2020. We understand the formula used by VA OIG may be 
slightly flawed because errors noted in an exam that had no relevance 
to deciding a claim, service connection, or the percentage of 
disability, counted toward a deficiency in the accuracy score. We also 
understand a more effective methodology is now being used and it 
indicates a 95-97 percent accuracy rate. That still means three to five 
percent of exams are inaccurate which translates into millions of 
veterans that may have been awarded a higher or lesser level of 
benefits that they deserved, or worse, had their claims denied based on 
inaccurate exams. VA has paid $6.8 billion for contract exams since 
2017 and as noted above, there was little to no improvement in accuracy 
from 2017 - 2020. Yet, and although they were reportedly suspended, we 
question why would VA provide monetary incentives to contractors, to 
improve upon the work they are already being paid to do.
---------------------------------------------------------------------------
    \1\ Contract Medical Exam Program Limitations Put Veterans at Risk 
for Inaccurate Claims Decisions (va.gov)
---------------------------------------------------------------------------
    VA also maintains that a Rating Veterans Service Representative 
(RVSR) can always send an inadequate exam back to the contractor. While 
this is true, it can delay a decision on a veteran's claim. 
Additionally, the language used in these requests is confusing and seem 
more like computer generated requests, than a person speaking in plain 
language, telling the contractor what is needed.
    The Department further attempts to minimize the issue of low 
accuracy by stating an RVSR is required to review and consider the 
entire evidence of record when deciding a claim, not just the 
contracted C&P exam. While it's true an RVSR is supposed to review the 
entire evidence of record, this is not reality. C&P exams are the 
documents RVSRs rely on the most in deciding claims. A veteran's 
digital file in the Veterans Benefits Management System can have 
hundreds, if not thousands, of documents. Although not all of the 
documents are relevant to a particular claim, many are, and it's 
unrealistic to believe an RVSR is going to spend days pouring through 
hundreds of documents on one claim, when they are required to meet 
certain quotas.
    If one of our service officers determines an exam is inadequate, we 
can appeal a decision. However, since implementation of the Veteran 
Appeals Improvement and Modernization Act of 2017 (P.L. 115-55), there 
are other avenues that must be taken, such as a Higher-Level Review and 
Supplemental Claims, before an appeal to the Board of Veterans' 
Appeals, if necessary. All of this takes time and resources, and can 
cause significant delays.
    In addition to concerns about contracted exams, we also believe VA 
simply orders too many unnecessary exams. Under 38 U.S.C. 5125, VA can 
accept private medical evidence alone to support a claim for benefits, 
and there are many cases in which it would be much more efficient both 
in cost to VA and time to the veteran if they just accepted a 
claimant's evidence. We see cases where, at least in retrospect, there 
was credible private evidence and the exam looks more like they are 
laying the groundwork for a VA denial. Recently, we had a veteran 
receive an award for his heart condition based on his PTSD. VA rated 
the veteran based on his medical records and awarded him Individual 
Unemployability because he met the criteria with the new ratings. This 
action provided benefits for the veteran without delaying the award for 
exams. This could and should be happening more frequently.
    Finally, there seems to be a disconnect between whoever is 
scheduling the exams and the experts and the veterans. It's as if the 
schedulers either don't know, don't care, or more likely, don't have 
the authority to deal with situations whenever a veteran tries to 
prevent being scheduled for an exam by a specialist without expertise 
in their claims. The question to ask is if it is unreasonable for 
veterans to be evaluated by someone with experience and knowledge of 
their condition as well as treatment options and emerging science 
regarding it. Again, we feel very strongly that disability claims 
examinations for veterans with SCI/Ds and other complex and more severe 
disabilities should only be conducted by VHA providers specializing in 
the field of medicine for the disability being claimed. In the 
instances where they are not, a veteran should have the right, and VA 
contractors should have the ability, to schedule them with a provider 
actually practicing in the field of medicine for the condition under 
consideration.
    PVA would once again like to thank the Subcommittee for the 
opportunity to submit our views on this issue, and we would be happy to 
answer any questions you may have.

  Information Required by Rule XI 2(g) of the House of Representatives

    Pursuant to Rule XI 2(g) of the House of Representatives, the 
following information is provided regarding federal grants and 
contracts.

                            Fiscal Year 2023

    Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events----Grant to support rehabilitation sports 
activities--$479,000.

                            Fiscal Year 2022

    Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events----Grant to support rehabilitation sports 
activities--$ 437,745.

                            Fiscal Year 2021

    Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events----Grant to support rehabilitation sports 
activities--$455,700.

                     Disclosure of Foreign Payments

    Paralyzed Veterans of America is largely supported by donations 
from the general public. However, in some very rare cases we receive 
direct donations from foreign nationals. In addition, we receive 
funding from corporations and foundations which in some cases are U.S. 
subsidiaries of non-U.S. companies.
                                 ______
                                 

   Prepared Statement of Quality. Timeliness. Customer Service. (QTC)
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

        Prepared Statement of Veterans Evaluation Services (VES)
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

Prepared Statement of American Federation of Government Employees, AFL-
                                  CIO

    Chairman Luttrell, Ranking Member Pappas, and Members of the 
Subcommittee:
    The American Federation of Government Employees, AFL-CIO (AFGE) and 
its National Veterans Affairs Council (NVAC) appreciate the opportunity 
to submit a statement for the record on today's hearing titled ``VA 
Disability Exams: Are Veterans Receiving Quality Services?'' AFGE 
represents more than 750,000 federal and District of Columbia 
government employees, 291,000 of whom are proud, dedicated Department 
of Veterans Affairs (VA) employees. These include front-line providers 
at the Veterans Health Administration (VHA) who VA disability exams, 
including Compensation and Pension (C&P), as well as the VBA claims 
processors who request claims to help determine a veteran's benefits. 
AFGE appreciates the opportunity to provide our views at today's 
hearing that will review the Department of Veterans Affairs (VA) 
oversight of disability exams conducted by Veterans Health 
Administration clinicians and contractors.

Background:

    There is no need to belabor the history of C&P exam outsourcing 
over the past three decades. Suffice it to say that disability exams, 
including C&P exams, used to be performed almost exclusively by VA 
clinicians. As should be well known by the Subcommittee, in 1996, 
Congress authorized a limited program allowing only 10 VBA Regional 
Offices (ROs) to assign C&P exams to outside contractors. The pilot 
program was later expanded, and gradually allowed all ROs to engage 
outside contractors starting in Fiscal Year 2017.
    The migration of C&P exams from the VA to private contractors has 
far exceeded what Congress intended when it authorized the VA to use 
private contractors in a limited and supplemental manner for the 
provision of C&P exams. Today, approximately 90 percent of all 
disability exams are performed by VA contractors. The cost of this 
privatization of has been staggering. In 2016, the VA expanded the 
contracting of C&P exams by awarding 12 contracts to private 
contractors valued at $6.8 billion over five years.
    AFGE has closely monitored the effect of the VA's reliance on 
contractors has had on the provision of C&P exams. Based on the growing 
evidence of deficiencies in contracted C&P exams and feedback from VA 
employees whom AFGE represents, it is AFGE's judgment that veterans 
requiring C&P exams - as well as taxpayers would - be far better served 
if these exams were conducted in-house by VA professionals than by 
private contractors.

Benefits of VHA In House Exams

    No one disagrees that the outcome of C&P exam has a far-reaching 
impact on a veteran's future. A veteran's economic security and well-
being, as well as that of his or her family's, can be decisively 
affected by the results of this exam. Because so much is riding on it, 
we all want the VA to get the C&P exam right, and on the first try. 
Above all, we all want the veteran receiving the exam to have the 
confidence that his or her exam has been conducted by a highly skilled 
and experienced clinician whose allegiance is to the VA's mission and 
values and who is directly accountable to the VA for the quality of the 
exams performed and the treatment and respect accorded to the veteran.
    To achieve this, AFGE believes there should be uniformity and 
consistency in the clinicians who are charged with this important task. 
In many ways, a C&P examiner is a judge, expected to render an 
objective and fair decision that considers the veteran's entire medical 
history and military service. At the same time, a C&P examiner is a 
caregiver, expected to treat the veteran before him or her with 
compassion and sensitivity.
    To the extent others share AFGE's conviction, it is hard to 
understand why we would tolerate an overwhelming volume of C&P exams 
migrating from VA clinicians to a panoply of private contractors.
    Simply put, the most important determinant in the outcome of 
veteran's exam is the clinician performing the exam. And it logically 
follows that who employs the clinician has a strong correlation on how 
the clinicians goes about this important work. Every place of 
employment, public or private, has its own unique culture and 
incentives that manifest themselves in how employees are paid, how much 
flexibility employers give their employees to manage their caseload, 
and how much opportunity employees are given to practice and perfect 
their professional trades.
    AFGE believes that compared to private contractors, VA has a vastly 
superior culture and incentive structure for C&P examiners that 
redounds to the benefit of veterans and their families, with a focus on 
quality instead quantity driven approach of private contractors.

Workplace Culture and Incentive Structure

    C&P examiners work for the VA and are paid fixed salaries for their 
work. Importantly, this means that their compensation does not vary 
based on the number of exams they perform each day or week. 
Consequently, examiners give each veteran before them the time and 
attention to conduct the exam thoroughly. They have no financial 
incentive to rush through a disability exam. To the extent examiners do 
have incentives, they are often harmful. An exam rife with errors or 
omissions will impair a VA clinician's performance evaluation and 
result in disciplinary action - one of the most important features of 
Title 5 and Title 38 governing VA employees that does not apply to 
private contractors.
    Additionally, with no incentive or pressure to rush through their 
work, VA clinicians can be thorough in their examination. This is 
particularly important in the administration of the Integrated 
Disability Evaluation System (IDES), one of the true innovations in the 
care of veterans in which disability claims examiners play a critical 
role - and which private contractors, because of the complex nature of 
the IDES program, do not. The IDES program was developed by VA and the 
Department of Defense to improve the experience of service members 
facing potential medical discharges. By integrating the VA claims 
process into the DoD disability evaluation process, IDES provides 
participants with a single set of medical exams and a single-source 
disability rating that serves as the basis for VA's disability 
determinations. IDES ensures consistency in disability determinations 
and the timely award of VA Disability Compensation Benefits to service 
members who are medically discharged and is an underutilized method of 
effectively and efficiently getting veterans their disability rating 
without filing claims at VBA.
    In contrast, private contractors' focus is time - specifically, how 
to fit as many C&P exams in the time they allocate for them. There is 
no getting around the basic fact that private contractors take on C&P 
exams to make money. Their secondary focus on veterans. The incentive 
and focus on quantity results in a loss in quality, with less attention 
being given to the veterans whose exams are at issue, and can lead to 
more mistakes, the need for additional exams, and a delays in receiving 
benefits that can last years.

Unique Expertise

    It is by now widely recognized that veterans medical care, like 
pediatrics and gerontology, is a specialty focused on a distinct 
population. Like VA medical professionals generally, VA C&P examiners 
exclusively practice veteran medicine. They are constantly acquiring 
experience and expertise diagnosing health care conditions either 
unique to or prevalent among veterans, such as Traumatic Brain Injury 
(TBI), Post Traumatic Stress Disorder (PTSD), Military Sexual Trauma 
(MST), Veterans who served as Prisoners of War (POWs), and toxic 
exposure illnesses covered under the PACT Act. A workforce of 
clinicians who regularly, if not exclusively, perform disability exams 
offers veterans a significant benefit for their exam.

Failure of Accountability

    At a time when the House Veterans Affairs Committee examined 
accountability at the VA, the committee must direct that focus on more 
accountability and oversight of private C&P contractors and their 
substandard performance.
    Numerous studies by GAO and the VA Office of Inspector General in 
the past few years show that the track record of private contractors 
performing C&P exams, the VA's oversight of contractors, and the 
savings promised to taxpayers have fallen far short of expectations. 
Outsourcing has resulted in problems of cost, quality, overbilling, 
lack of subject matter expertise, and training of those conducting the 
exams. Congress must admit and correct these serious problems, not 
double-down on a privatization model that has failed veterans.
    These studies show that the vast and rapid expansion of 
privatization has not been accompanied by a corresponding increase in 
VA oversight of private contractors. For example, the department has 
been slow to adopt clinical quality measurement for, and evaluation of, 
contractor exams. The VA has also consistently lacked sufficient 
information on contractors' performance regarding the quality and 
timeliness for exams. To the extent the VA has been able to rate 
performance, most contractors' quality scores have fallen below VBA's 
target score. Even a task as basic as verifying contractors' claims of 
veterans failing to show up for C&P exam appointments, for which the VA 
is obligated to pay penalties, has not been carried out by the VA in a 
consistent and vigorous manner, potentially resulting in millions of 
dollars in payments to contractors for false no-shows that could 
instead be used to insource these exams.

Recommendations:

    AFGE recommends that VA's own highly trained, credentialed, 
experienced, and accountable employees should perform C&P exams, with 
very few exceptions, and should be the VA's exclusive provider for 
specialty exams. 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 House 
Committee on Veterans' Affairs Subcommittee on Disability Assistance 
and Memorial Affairs to build on the progress made in the last Congress 
and craft 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.

                                 [all]