Veterans' Benefits: Quality Assurance for Disability Claims and  
Appeals Processing Can Be Further Improved (16-AUG-02,		 
GAO-02-806).							 
                                                                 
For fiscal year 2002, the Department of Veterans Affairs (VA)	 
will pay $25 billion in cash disability benefits to 3.3 million  
disabled veterans and their families. Veterans who are		 
dissatisfied with VA's 57 regional offices' decisions may file	 
appeals with VA's Board of Veteran's Appeals. In about half of	 
such appeals, the Board has either granted the benefits denied or
returned the cases to regional offices for rework. Additionally, 
VA reported an accuracy rate of less than 70 percent for regional
office disability decisions when it tested a new quality	 
assurance program in fiscal year 1998. When the Board itself	 
denies benefits, veterans may appeal to the U.S. Court of Appeals
for Veterans Claims. In over half of the appeals, the Court has  
either granted the benefits denied by the Board or returned the  
decisions to the Board for rework. In fiscal year 1998, the Board
of Veteran's Appeals established a quantitative evaluation	 
program to score its decision-making accuracy and collect data to
improve decision-making. The accuracy measure used by the Board  
understates its true accuracy rate because the calculations	 
include certain deficiencies, such as errors in a written	 
decision's format, which would not result in either a reversal or
a remand by the Court. VA does not assess the consistency of	 
decision-making across the regional office and Board disability  
adjudicators, even though VA acknowledges that in many cases	 
adjudicators of equal competence could review the same evidence  
but render different decisions. Even though available evidence	 
indicates that variations in decision-making occur across all	 
levels of VA adjudication, VA does not conduct systematic	 
assessments to determine the degree of variations that occurs for
specific impairments and to provide a basis for determining ways 
to reduce such variations.					 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-02-806 					        
    ACCNO:   A04128						        
  TITLE:     Veterans' Benefits: Quality Assurance for Disability     
Claims and Appeals Processing Can Be Further Improved		 
     DATE:   08/16/2002 
  SUBJECT:   Disability benefits				 
	     Veterans benefits					 
	     Claims processing					 
	     Decision making					 
	     Claims adjudicators				 
	     Performance measures				 
	     Veterans disability compensation			 

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GAO-02-806

   Report to the Ranking Democratic Member, Committee on Veterans* Affairs,
   House of Representatives

   United States General Accounting Office

   GAO

   August 2002 VETERANS* BENEFITS

   Quality Assurance for Disability Claims and Appeals Processing Can Be
   Further Improved

   GAO- 02- 806

   Page i GAO- 02- 806 Veterans* Disability Benefits Letter 1

   Results in Brief 2 Background 3 The Board Understates Its Accuracy and
   Does Not Capture Certain

   Data for Improving Quality 6 VA Does Not Systematically Assess Consistency
   of Decision

   Making 11 Conclusions 13 Recommendations for Executive Action 14 Agency
   Comments and Our Evaluation 15

   Appendix I Steps in the Disability Claims and Appeals Process 17

   Appendix II Board of Veterans* Appeals Illustrations of Difficult
   Judgments Resulting in Decision- Making Variations 19

   Appendix III Comments from the Department of Veterans Affairs 20

   Tables

   Table 1: Board*s Accuracy Rate Goals and Performance 8 Table 2: Board*s
   Quality Review Criteria 9

   Abbreviations

   SSA Social Security Administration VA Department of Veterans Affairs VBA
   Veterans Benefits Administration Contents

   Page 1 GAO- 02- 806 Veterans* Disability Benefits

   August 16, 2002 The Honorable Lane Evans Ranking Democratic Member
   Committee on Veterans* Affairs House of Representatives

   Dear Mr. Evans: For fiscal year 2002, the Department of Veterans Affairs
   (VA) estimates that it will pay about $25 billion in cash disability
   benefits to about 3.3 million disabled veterans and their families. When
   veterans submit disability claims, VA*s 57 regional offices make decisions
   to either grant or deny the requested benefits. Veterans who are
   dissatisfied with regional office decisions may file appeals with VA*s
   Board of Veterans* Appeals, and in about half of such appeals, the Board
   has either granted the benefits denied by the regional offices or remanded
   (returned) the cases to the regional offices for rework. Additionally, VA
   reported an accuracy rate of less than 70 percent for regional office
   disability decisions when it tested a new quality assurance program in
   fiscal year 1998. As a result, we issued two prior reports at your request
   on VA*s system for measuring and improving the accuracy of regional office
   decisions. 1

   Recently, questions have arisen about the quality of Board decisions. When
   the Board itself denies benefits requested by veterans, they may appeal to
   the U. S. Court of Appeals for Veterans Claims. In over half of such
   appeals, the court has either granted the benefits denied by the Board or
   remanded the decisions to the Board for rework. As a result, you now have
   asked that we examine VA*s efforts to ensure the quality of decisions made
   by the Board. Specifically, you asked that we assess the effectiveness of
   VA*s system for (1) measuring and improving the accuracy of the Board*s
   decisions and (2) determining the consistency (extent of variation) in
   decision making across the spectrum of regional office and Board
   disability adjudicators.

   1 U. S. General Accounting Office, Veterans* Benefits Claims: Further
   Improvements Needed in Claims- Processing Accuracy, GAO/ HEHS- 99- 35
   (Washington, D. C.: Mar. 1, 1999), and Veterans* Benefits: Quality
   Assurance for Disability Claims Processing,

   GAO- 01- 930R (Washington, D. C.: Aug. 23, 2001).

   United States General Accounting Office Washington, DC 20548

   Page 2 GAO- 02- 806 Veterans* Disability Benefits

   To address your request, we reviewed (1) data and documents of the Board
   of Veterans* Appeals; (2) data and documents of the Veterans Benefits
   Administration (VBA), the VA component responsible for the operations of
   the 57 regional offices; (3) reports on studies of VA disability claims
   processing conducted by the Veterans* Claims Adjudication Commission, the
   National Academy of Public Administration, and VA*s Claims Processing Task
   Force; and (4) data reported by the U. S. Court of Appeals for Veterans
   Claims on its disposition of veterans* appeals. We also interviewed
   officials of the Board and VBA about claims and appeals processing
   accuracy and consistency issues. We conducted our review from October 2001
   through June 2002 in accordance with generally accepted government
   auditing standards.

   In fiscal year 1998, the Board of Veterans* Appeals established its first
   quantitative program to evaluate and score its decision- making accuracy
   and to collect data to identify areas where the quality of decision making
   needs improvement. The accuracy measure used by the Board understates its
   true accuracy rate because the Board*s accuracy rate calculations include
   certain deficiencies, such as errors in a written decision*s format, which
   would not result in either a reversal or a remand by the Court. In fiscal
   year 2001, if the Board had excluded format deficiencies from its accuracy
   rate calculations, its accuracy rate would have been 92 percent versus the
   reported rate of 87 percent. Even so, the Board*s quality assurance
   program does not capture certain data that potentially could further help
   improve the quality of the Board*s decisions. For example, the Board does
   not record in its quality assurance database any information identifying
   the specific medical issues involved in cases where a Board decision was
   judged as being in error. Having such data could enhance the Board*s
   ability to target training needed for its decision makers.

   VA does not assess the consistency of decision making across the spectrum
   of regional office and Board disability adjudicators, even though VA
   acknowledges that in many cases two adjudicators of equal competence could
   review the same evidence but render different decisions due to the
   difficult judgments often required in decision making. The result is that
   variations may occur in the benefits provided to veterans who have similar
   impairments and circumstances. Even though available evidence provides
   indications that variations in decision- making may occur across all
   levels of VA adjudication, VA does not conduct systematic assessments to
   determine the degree of variation that occurs for specific impairments and
   to provide a basis for determining ways, if considered necessary, to
   reduce such variation. Results in Brief

   Page 3 GAO- 02- 806 Veterans* Disability Benefits

   This report contains recommendations to the Secretary of VA concerning
   actions to improve VA*s ability to better ensure the accuracy and
   consistency of disability decisions made across the spectrum of decision
   making in VA. In responding to a draft of this report, VA concurred fully
   or in principle with our recommendations. However, although VA agreed that
   consistency is an important goal, it did not fully respond to our
   recommendation regarding consistency because it did not describe how it
   will measure consistency and evaluate progress in reducing any
   inconsistencies it may find. Instead, VA said that consistency is best
   achieved through comprehensive training and communication among VA
   components involved in the adjudication process and discussed efforts
   underway to do so.

   VA has two basic cash disability benefits programs. The compensation
   program pays monthly benefits to eligible veterans who have
   serviceconnected disabilities (injuries or diseases incurred or aggravated
   while on active military duty). The payment amount is based on the
   veteran*s degree of disability, regardless of employment status or level
   of earnings. By contrast, the pension program assists permanently and
   totally disabled wartime veterans under age 65 who have low incomes and
   whose disabilities are not service- connected. 2 The payment amount is
   determined on the basis of financial need.

   VBA and the Board process and decide veterans* disability claims and
   appeals on behalf of the Secretary. The claims process starts when
   veterans submit claims to one of VBA*s 57 regional offices. (See app. I
   for the overall flow of claims and appeals processing.) By law, regional
   offices must assist veterans in supporting their claims. For example, for
   a compensation claim, the regional office obtains records such as the
   veteran*s existing service medical records, records of relevant medical
   treatment or examinations provided at VA health- care facilities, and
   other relevant records held by a federal department or agency. If
   necessary, the regional office arranges a medical examination for the
   claimant or obtains a medical opinion about the claim. The regional office
   adjudicator then must

    analyze the evidence for each claimed impairment (veterans claim an
   average of about five impairments per claim);

   2 Veterans age 65 or older do not have to be permanently and totally
   disabled to become eligible for pension benefits, if they meet the income
   and military service requirements. Background

   Page 4 GAO- 02- 806 Veterans* Disability Benefits

    determine whether each claimed impairment is service- connected (VA
   grants service- connection for an average of about three impairments per
   claim);

    apply VA*s Rating Schedule which provides medical criteria for rating
   the degree to which each service- connected impairment is disabling
   (disability ratings can range from zero to 100 percent, in 10- percent
   increments);

    determine the overall disability rating that results from the
   combination of service- connected impairments suffered by the veteran; and

    notify the veteran of the decision. If a veteran disagrees with the
   regional office*s decision, he or she begins the appeals process by
   submitting a written Notice of Disagreement to the regional office. During
   fiscal years 1999- 2000, the regional offices annually made an average of
   about 616,000 decisions involving disability ratings, and veterans
   submitted Notices of Disagreement in about 9 percent of these decisions.
   Veterans can disagree with decisions for reasons other than the outright
   denial of benefits that occurs, for example, in a compensation case when a
   regional office decides an impairment claimed by a veteran is not service-
   connected. The veteran also may believe the severity rating assigned to a
   service- connected impairment is too low and ask for an increase in the
   rating.

   In response to a Notice of Disagreement, the regional office provides a
   further written explanation of the decision, and if the veteran still
   disagrees, the veteran may appeal to the Board. During fiscal years 1999-
   2000, about 48 percent of the veterans who filed Notices of Disagreement
   in decisions involving disability ratings went on to file appeals with the
   Board. In fiscal year 2001, VBA began nationwide implementation of the
   Decision Review Officer position in its regional offices. Now, before
   appealing to the Board, a veteran may ask for a review by a Decision
   Review Officer, who is authorized to grant the contested benefits based on
   the same case record that the regional office relied on to make the
   initial decision. VBA believes this process will result in fewer appeals
   being filed with the Board.

   Located in Washington, D. C., the Board is an administrative body whose
   members are attorneys experienced in veterans* law and in reviewing
   benefits claims. The Board*s members are divided into four decision teams,
   with each team having up to 15 Board members and 61 staff attorneys. Each
   team has primary responsibility for reviewing the appeals that originate
   in an assigned group of regional offices. Board members*

   Page 5 GAO- 02- 806 Veterans* Disability Benefits

   decisions must be based on the law, regulations, precedent decisions of
   the courts, and precedent opinions of VA*s General Counsel. 3 During the
   Board*s appeals process, the veteran or the veteran*s representative may
   submit new evidence and request a hearing.

   During fiscal years 1999 and 2000, for all VA programs, the Board annually
   decided an average of about 35,700 appeals, of which about 32,900 (92
   percent) were disability compensation cases. The average appealed
   compensation case contains three contested issues. As a result, in some
   cases, the Board member may grant the requested benefits for some issues
   but deny the requested benefits for others. During fiscal years 1999 and
   2000, the Board in its initial decisions on appealed compensation cases
   granted at least one of the requested benefits in about 24 percent of the
   cases. In some instances, the Board member finds a case is not ready for a
   final decision and returns (or remands) the case to the regional office to
   obtain additional evidence and reconsider the veteran*s claim. During
   fiscal years 1999 and 2000, respectively, the Board in its initial
   decisions on appealed compensation cases remanded 38 percent and 34
   percent of the cases. 4 After obtaining additional evidence for remanded
   cases, if the regional office still denies the requested benefits, it
   resubmits the case to the Board for a final decision.

   If the Board denies benefits or grants less than the maximum benefit
   available under the law, veterans may appeal to the U. S. Court of Appeals

   3 According to VA, precedent opinions of the General Counsel are legal
   opinions that interpret court decisions, laws, or regulations. These
   opinions may apply such an interpretation to a certain set of facts, or
   they may be used to implement an interpretation of law consistently across
   VA. To the extent precedent opinions may contain any statements of VA
   policy, such policy statements are not binding on the Board merely because
   they appear in a precedent opinion. General Counsel precedent opinions
   also are binding on regional office adjudicators.

   4 Effective February 22, 2002, a new VA regulation allows the Board to
   obtain evidence, clarify evidence, cure a procedural defect, or perform
   most any other action essential for a proper appellate decision without
   having to remand the appeal to the regional office. It also allows the
   Board to consider additional evidence without having to refer the evidence
   to the regional office for initial consideration and without having to
   obtain the appellant*s waiver. Under this new regulation, the Board
   expects that the proportion of appeals remanded to regional offices will
   decline to about 12 percent. For those cases that previously would have
   been remanded to regional offices, the Board provides information to VBA
   on the reasons for actions taken by the Board itself under this new
   regulation, such as obtaining new evidence or clarifying evidence.

   Page 6 GAO- 02- 806 Veterans* Disability Benefits

   for Veterans Claims. 5 The court is not part of VA and not connected to
   the Board. During fiscal years 1999 and 2000, veterans filed appeals with
   the court in an estimated 10 percent of the Board*s decisions. Unlike the
   Board, the court does not receive new evidence, but considers the Board*s
   decision, briefs submitted by the veteran and VA, oral arguments, if any,
   and the case record that VA considered and that the Board had available.
   The court may dismiss an appeal on procedural grounds such as lack of
   jurisdiction, but in the cases decided on merit, the court may affirm the
   Board*s decision (deny benefits), reverse the decision (grant benefits),
   or remand the decision back to the Board for rework. During fiscal years
   1999 and 2000, the court annually decided on merit an average of about
   1,800 appealed Board decisions, and in about 67 percent of these cases,
   the court remanded or reversed the Board*s decisions in part or in whole.
   6 Under certain circumstances, a veteran who disagrees with a decision of
   the court may appeal to the U. S. Court of Appeals for the Federal Circuit
   and then to the Supreme Court of the United States.

   In fiscal year 1998, the Board established the first quantitative quality
   assurance program to evaluate and score the accuracy of its decisions and
   to collect data to identify areas where the quality of decision- making
   needs improvement. The accuracy measure used by the Board understates its
   true accuracy rate because the Board*s accuracy rate calculations include
   certain deficiencies that would not result in either a reversal or a
   remand by the court. Even so, the Board*s quality assurance program does
   not capture certain data that potentially could help improve the quality
   of the Board*s decisions. Such data include information identifying the
   specific medical issues involved in cases where a disability decision was
   judged as being in error. Having such data could enhance the Board*s
   ability to target training for its decision makers.

   5 Before appealing to the court, a veteran may ask the Board itself to
   review any previous Board decision on the basis of *clear and unmistakable
   error.* During fiscal years 1999 and 2000, the Board revised a total of
   only 23 of its decisions due to clear and unmistakable error. VA
   regulations state that clear and unmistakable error is a specific and rare
   kind of error, of fact or law, that when called to the attention of later
   reviewers compels the conclusion, with which reasonable minds could not
   differ, that the result would have been manifestly different if not for
   the error. Generally, either the correct facts, as they were known at the
   time, were not before the Board, or the statutory and regulatory
   provisions in effect at the time were not correctly applied.

   6 The court*s Annual Reports did not disaggregate data on remands and
   reversals, but according to the Board, the court reversed Board decisions
   in whole or in part in only about 1.6 percent of the cases. The Board

   Understates Its Accuracy and Does Not Capture Certain Data for Improving
   Quality

   Page 7 GAO- 02- 806 Veterans* Disability Benefits

   On the basis of the results of the quality assurance program it
   established in fiscal year 1998, the Board estimated that 89 percent of
   its decisions were accurate (or *deficiency- free*). Using these results
   as a baseline, VA established performance accuracy goals for the Board.
   One of the Board*s strategic performance goals is to make deficiency- free
   decisions 95 percent of the time. To calculate its estimated overall
   accuracy rate, the Board does quality reviews of selected Board decisions.
   7 We reviewed the Board*s methods for selecting random samples and
   calculating accuracy rates and concluded that the number of decisions
   reviewed by the Board was sufficient to meet the Board*s goal for
   statistical precision in estimating its accuracy rate. 8 However, we
   brought to the Board*s attention some issues that caused the Board to fall
   short of proper random sampling and accuracy rate calculation methods,
   such as not ensuring that decisions made near the end of the fiscal year
   are sampled or that the results from quality reviews are properly weighted
   in the accuracy rate calculation formula. We do not believe the overall
   accuracy rate reported by the Board for fiscal year 2001 would have been
   materially different if these methodological issues had been corrected
   earlier; however, if not corrected, these issues potentially could lead to
   misleading accuracy rate calculations in the future. The Board agreed in
   principle to correct these issues. As of June 2002, the Board had not yet
   instituted corrective actions.

   According to VA*s performance reports, the Board has come close but has
   not achieved its annual interim goals for accuracy (see table 1). 9
   However, in calculating its reported accuracy rates, the Board includes
   deficiencies that are not *substantive** that is, they would not be
   expected to result in

   7 During our review, we brought to the Board*s attention certain issues
   regarding the compliance of its quality assurance program with the
   governmental internal control standard calling for separation of key
   duties and the governmental performance audit standard calling for
   organizational independence for agency employees who review and evaluate
   program performance. These issues arose because certain Board members who
   were directly involved in deciding veterans* appeals were also involved in
   reviewing the accuracy of such decisions. Effective May 2002, the Board
   took corrective actions to resolve these issues; now, all quality reviews
   from which accuracy rates are determined are done by persons not directly
   involved in deciding veterans* appeals.

   8 The Board*s goal is that VA can have 95 percent confidence that the
   Board*s true accuracy rate is no more than 5 percentage points higher or
   lower than the estimated accuracy rate. 9 The Government Performance and
   Results Act of 1993 requires VA, as well as other federal agencies, to
   clearly define its mission, set goals, measure performance, and submit to
   the Congress annual performance plans and annual reports on its success in
   achieving program performance goals. The Board Established Its

   First Quantitative Quality Assurance Program in 1998

   The Board*s Actual Level of Accuracy Is Higher Than Reported

   Page 8 GAO- 02- 806 Veterans* Disability Benefits

   either a remand by the court or a reversal by the court. 10 Consequently,
   the reported accuracy rates understate the Board*s level of accuracy that
   would result if only substantive deficiencies were counted in the
   calculation.

   Table 1: Board*s Accuracy Rate Goals and Performance

   In percentages

   Accuracy rate) Accuracy Measure FY1999 FY 2000 FY 2001 FY 2002 FY 2003
   Strategic goal

   Accuracy rate goal 90.5 91.5 90 91 92 95 Reported performance (estimated)
   84 86 87 a a a

   a No data available. Source: VA budget submissions and performance plans,
   fiscal years 2000- 2003.

   Under its quality assurance program, the Board*s quality reviewers assess
   the accuracy of selected decisions on the basis of six critical areas (see
   table 2). One error (or deficiency) in any of these six areas means that a
   decision fails the quality test. However, according to the Board, all six
   areas would include certain deficiencies that are not substantive. In
   particular, according to the Board, most deficiencies in the *format*

   category are not substantive. In fiscal year 2001, the format category
   accounted for about 38 percent of all recorded deficiencies. At our
   request, the Board recalculated its accuracy rate for fiscal year 2001,
   excluding format deficiencies, and the resulting accuracy rate was 92
   percent, as compared with the reported accuracy rate of 87 percent.
   Excluding all other nonsubstantive deficiencies presumably would have
   resulted in an even higher accuracy rate. In contrast with the Board,
   beginning in fiscal year 2002, VBA no longer includes nonsubstantive
   deficiencies in its accuracy rate calculations; however, it continues to
   monitor them. VBA took this action based on a recommendation by the 2001
   VA Claims Processing Task Force, which said that mixing serious errors
   with less significant deficiencies can obscure what is of real concern.

   10 The court may set aside the Board's findings of fact that are "clearly
   erroneous." A finding is clearly erroneous when, although there is
   evidence to support it, the reviewing court on the entire evidence is left
   with the definite and firm conviction that a mistake has been committed.
   If there is a plausible basis in the record for the Board's factual
   determinations, the court cannot overturn them, even if it might not have
   reached the same determinations.

   Page 9 GAO- 02- 806 Veterans* Disability Benefits

   Table 2: Board*s Quality Review Criteria Six critical areas Criteria

   Issues Did the decision maker identify and address all issues that were
   explicitly expressed in, or could be inferred from, the evidence? Evidence
   Did the decision maker account for all evidence, including the evidence in
   favor of and the evidence

   against the veteran*s claim? Laws and regulations Did the decision maker
   cite and set forth all applicable laws and regulations? Reasons and bases
   Did the decision maker fully and accurately coordinate the facts
   (evidence) and laws and regulations with

   each other and clearly explain how he or she reached the decision? Due
   process Did the decision maker address all technical aspects of due
   process such as accounting for jurisdictional

   problems, hearing requests, and possible remand reasons? Format Did the
   decision maker write the decision so that it meets the basic requirements
   of format such as correct

   grammar, spelling, decision structure, and requirements of statute?
   Source: Board of Veterans* Appeals, 2002.

   The Board*s quality review program subdivides the six critical areas shown
   in table 2 into 31 subcategories. For example, if a quality reviewer
   classifies an error as stemming from *reasons and bases,* the reviewer
   must then indicate whether the error was due to misapplying legal
   authority, failing to apply appropriate legal authority, using an
   incorrect standard of proof, or providing an inadequate explanation for
   the decision. This information is recorded in the Board*s quality review
   database, providing the Board with data that can be analyzed to identify
   training needed to improve quality.

   However, the Board does not record in its quality review database any
   information on the specific issue that prompted the appeal (such as
   whether a disability is service- connected) or the specific medical
   impairment to which an error is related. For example, a quality reviewer
   might find an error in a Board decision for an appeal that involved four
   separate medical impairments* two for which the veteran had requested
   service connection and two others for which he had requested a disability
   rating increase. On the basis of information that the quality review
   database currently captures, however, the Board could not determine which
   of the four impairments the error was related to, nor could the Board
   determine whether the error was related to a request for serviceconnection
   or an increased disability rating.

   This is not the case, however, for Board decisions remanded by the Court
   of Appeals for Veterans Claims. For these cases, the Board maintains a
   separate database with information on the reasons that the court remands
   decisions back to the Board for rework. For each issue that the court
   remands in a compensation case, the Board records in the database such The
   Board*s Quality Review

   Program Does Not Capture Certain Data That Could Help Improve Quality

   Page 10 GAO- 02- 806 Veterans* Disability Benefits

   information as: (1) whether the issue involved a request for
   serviceconnection or an increased rating, (2) the diagnostic code of the
   impairment involved in each issue, and (3) the reason for the remand.
   According to Board officials, being able to analyze the court*s reasons
   for remands by type of decisional issue and type of impairment enhances
   the Board*s ability to reduce remands from the court through appropriate
   training.

   VBA and the Board recognize that in some cases, different adjudicators
   reviewing the same evidence can make differing judgments on the meaning of
   the evidence, without either decision necessarily being wrong. In such
   cases, VBA and the Board instruct quality reviewers not to record an
   error. A hypothetical case provided by the Board furnishes an example. In
   this case, a veteran files a claim in 1999 asserting he suffered a back
   injury during military service but did not seek medical treatment at that
   time. One of the veteran*s statements says he injured his back during
   service in 1951, but another says he injured his back in 1953. An
   adjudicator may find that this discrepancy in dates adversely affects the
   claimant*s credibility about whether an injury actually occurred in
   service, but the quality reviewer may consider the discrepancy to be
   insignificant. Where such judgments are involved, the Board*s and VBA*s
   quality review programs recognize that variations in judgment are to be
   expected and are acceptable as long the degree of variation is within
   reason. (App. II provides other examples of difficult judgments that could
   result in decision- making variations and explains VA*s *benefit- of- the-
   doubt* rule.)

   The Board and VBA, however, differ in their approaches to collecting
   information about cases where this type of variation occurs. In such
   instances, the Board*s quality reviewers note why they believe an
   alternative decision could have been made and send the explanation to the
   deciding Board member. However, they do not enter any of this information
   in the quality review database. In contrast, VBA recently instructed its
   quality reviewers to enter such information in the VBA quality review
   database, even though no error is recorded in the database. VBA believes
   that by identifying and analyzing cases in which quality reviewers
   believed the adjudicator*s judgment was pushing against the boundary of
   reasonableness, it potentially can identify opportunities to improve the
   quality of decision making by improving training.

   Page 11 GAO- 02- 806 Veterans* Disability Benefits

   Even though evidence suggests decision making across regional office and
   Board adjudicators may not be consistent, VA does not systematically
   assess decision making consistency to determine the degree of variation
   that occurs for specific impairments and to provide a basis for
   identifying steps that could be taken, if considered necessary, to reduce
   such variation. In its 2003 performance plan, VA acknowledged that
   veterans are concerned about the consistency of disability claims
   decisions across the 57 regional offices. In a nationwide comparison, VBA
   projected in its fiscal year 2001 Annual Benefits Report that the average
   compensation payments per disabled veteran in fiscal year 2002 would range
   from a low of $5,783 in one state to a high of $9,444 in another state.
   According to a VBA official, this disparity in average payments per
   veteran might be due in part to demographic factors such as differences in
   the average age of veterans in each state. However, this disparity in
   average payments per veteran also raises the possibility that when
   veterans in the same age group submit claims for similar medical
   conditions, the regional office in one state may tend to give lower
   disability ratings than the regional office in another state.

   Indeed, in 1997, the National Academy of Public Administration reviewed
   disability claims processing and said VA needed to identify the degree of
   decision- making variation expected for specific medical issues, set
   consistency standards, and measure the level of consistency as part of the
   quality review process or through testing of control cases in multiple
   regional offices. Furthermore, in 2001, VA*s Claims Processing Task Force
   said there was an apparent lack of uniformity among regional offices in
   interpreting and complying with directives from VA headquarters and that
   VA*s regulations and the procedures manual for regional offices were in
   dire need of updating. The task force concluded that there was no
   reasonable assurance that claims decisions would be made as uniformly and
   fairly as possible to the benefit of the veteran. Even though such
   concerns and issues exist, VA does not systematically assess the
   decisionmaking consistency of regional office adjudicators.

   Similarly, VA does not assess consistency between decisions made by
   regional offices and the Board even though evidence suggests this issue
   may warrant VA*s attention. Because veterans may submit new evidence
   during the appeals process, one might assume that the Board generally
   grants benefits denied by regional offices due to the impact of such new
   evidence. However, an analysis in 1997 of about 50 decisions in which the
   Board had granted benefits previously denied by regional offices yielded a
   different viewpoint. Staff from both VBA and the Board reviewed these
   cases and concluded that most of these Board decisions to grant benefits
   VA Does Not

   Systematically Assess Consistency of Decision Making

   Page 12 GAO- 02- 806 Veterans* Disability Benefits

   had been based on the same evidence that the regional offices had
   considered in reaching their decisions to deny benefits. The reviewers
   characterized the reason for the Board members* decisions to grant
   benefits as a difference of opinion between the Board members and regional
   office adjudicators in the weighing of evidence. Furthermore, even in
   remanded compensation cases for which regional offices have obtained new
   evidence in accordance with the Board*s remand instructions and then again
   denied the benefits, the Board generally has granted benefits in about 26
   percent of these cases after they have been resubmitted for a final
   decision. This seems to indicate that, in these particular cases, Board
   members in some way differed with regional office adjudicators on the
   impact of the new evidence obtained by the regional offices before
   resubmitting the remanded cases to the Board.

   Available evidence also provides indications that the issue of variations
   in decision making among the Board members themselves may warrant VA*s
   attention in studies of consistency. Historically, there have been
   variances in the rates at which the Board*s four decision teams have
   remanded decisions to regional offices for rework. No systematic study has
   been done to explain the variances in remand rates. Board officials said
   that it is their perception that the remand rates vary among the Board*s
   decision teams because the quality of claims processing varies among the
   regional offices for which each team is responsible.

   Similar concerns about consistency of claims adjudication in the Social
   Security Administration (SSA) have prompted SSA to begin taking steps to
   assess consistency issues in its disability program. As we reported in
   1997, SSA*s primary effort to improve consistency has focused on
   decisionmaking variations between its initial and appellate levels. 11 To
   gather data on variations between these two levels, SSA instituted a
   system in 1993 under which it selects random samples of final decisions
   made by administrative law judges and reviews the entire decisional
   history of each case at both the initial and appellate levels. The
   reviewers examine adjudicative and procedural issues to address broad
   program issues such as whether a claim could have been allowed earlier in
   the process. Data captured through this system have provided a basis for
   taking steps to clarify decision- making instructions and provide training
   designed to

   11 U. S. General Accounting Office, Social Security Disability: SSA Must
   Hold Itself Accountable for Continued Improvement in Decision- Making,
   GAO/ HEHS- 97- 102 (Washington, D. C.: Aug. 12, 1997).

   Page 13 GAO- 02- 806 Veterans* Disability Benefits

   improve consistency between the initial and appellate levels. However, no
   systematic evaluations have been done to determine the effectiveness of
   these actions. In its January 2001 disability management plan, SSA said
   that it needed to take further steps to promote uniform and consistent
   disability decisions across all geographic and adjudicative levels. 12

   Opportunities exist to improve the quality of the Board*s reporting of
   accuracy and decision making. The Board includes nonsubstantive
   deficiencies in its accuracy rate calculation. By doing so, the Board may
   be obscuring what is of real concern. In addition, the Board*s quality
   assurance database does not capture data on specific medical disability
   issues related to the reasons for errors found in Board decisions. Also,
   in contrast with VBA, the Board*s quality assurance program does not
   collect information on cases in which quality reviewers do not charge
   errors but have differences of opinion with judgments made by Board
   members. We believe that analysis of such data could lead to improvements
   in quality through improved training or by clarifying regulations,
   procedures, and policies.

   Furthermore, because variations in decision making are to be expected due
   to the difficult judgments that adjudicators often must make, one must ask
   the questions: For a given medical condition, how much variation in
   decision making exists and does the degree of variation suggest that VA
   should take steps to reduce the level of variation? VA, however, does not
   assess variation in decision making. None of the quality review efforts of
   either VBA or the Board are designed to systematically assess the degree
   to which veterans with similar medical conditions and circumstances may be
   receiving different decisional outcomes or to help identify steps that
   could reduce such variation if necessary. Without ongoing systematic
   assessments of consistency across the continuum of decision making, VA
   cannot adequately assure veterans that they can reasonably expect to

   12 Since 1994, SSA has recognized the need to focus more attention on the
   agency*s overall quality assurance program; however, SSA had made little
   progress in this effort as of early 2002. Since then, the Commissioner of
   SSA has appointed a senior manager for quality who reports directly to the
   Commissioner and who is responsible for developing a proposal to establish
   a quality- oriented approach to all SSA business processes. See U. S.
   General Accounting Office, Social Security Disability: Disappointing
   Results from SSA*s Efforts to Improve the Disability Claims Process
   Warrant Immediate Attention, GAO- 02- 322 (Washington, D. C.: Feb. 27,
   2002) and Social Security Disability: Efforts to Improve Claims Process
   Have Fallen Short and Further Action is Needed, GAO- 02- 826T (Washington,
   D. C.: June 11, 2002). Conclusions

   Page 14 GAO- 02- 806 Veterans* Disability Benefits

   receive consistent treatment of their claims across all decision- making
   levels in VA.

   We recognize that our recommendations will have to be implemented within
   the context of VA*s current major efforts to reduce a large and persistent
   backlog of disability claims and appeals and to reduce the average
   processing time. Nevertheless, we believe it is critical that VA take the
   necessary steps to support improvements in training and in regulations,
   procedures, or policies that could enhance the quality of disability
   decision making across the continuum of adjudication and to help provide
   adequate assurance to veterans that they will receive consistent and fair
   decisions as early as possible in the process. Indeed, maintaining and
   improving quality should be of paramount concern while implementing a
   major effort to reduce backlogs and processing time.

   Accordingly, we recommend that the Secretary of VA direct the Chairman of
   the Board of Veterans* Appeals to:

    Revise the quality assurance program so that, similar to VBA, the
   calculation of accuracy rates will take into account only those
   deficiencies that would be expected to result in a reversal of a Board
   decision by the U. S. Court of Appeals for Veterans Claims or result in a
   remand by the court.

    Revise the Board*s quality assurance program to record information in
   the quality review database that would enable the Board to systematically
   analyze case- specific medical disability issues related to specific
   errors found in Board decisions in the same way that the Board is able to
   analyze the reasons that the court remands Board decisions.

    Monitor the experience of VBA*s quality assurance program in collecting
   and analyzing data on cases in which VBA*s quality reviewers do not record
   errors but have differences of opinion with regional office adjudicators
   in the judgments made to reach a decision. If VBA finds that the analysis
   of such data helps identify training that can improve the quality of
   decision making, the Board should test such a process in its quality
   assurance program to assess whether it would enable the Board to identify
   training that could improve the quality of Board decisions.

   We also recommend that the Secretary direct the Under Secretary for
   Benefits and the Chairman of the Board of Veterans* Appeals to jointly
   Recommendations for

   Executive Action

   Page 15 GAO- 02- 806 Veterans* Disability Benefits

   establish a system to regularly assess and measure the degree of
   consistency across all levels of VA adjudication for specific medical
   conditions that require adjudicators to make difficult judgments. For
   example, VA could develop sets of hypothetical claims for specific medical
   issues, distribute such hypothetical claims to multiple adjudicators at
   all decision- making levels, and analyze variations in outcomes for each
   medical issue. Such a system should provide data to determine the degree
   of variation in decision making and provide a basis to identify ways, if
   considered necessary, to reduce such variation through training or
   clarifying and strengthening regulations, procedures, and policies. Such a
   system should also assess the effectiveness of actions taken to reduce
   variation. If departmental consistency reviews reveal any systematic
   differences among VA decision makers in the application of disability law,
   regulations, or court decisions, the Secretary should, to the extent that
   policy clarifications by VBA cannot resolve such differences, direct VA*s
   General Counsel to resolve these differences through precedent legal
   opinions if possible.

   We received written comments on a draft of this report from VA (see app.
   III). In its comments, VA concurred fully or in principle with our
   recommendations. With regard to our first recommendation, VA said that the
   Board intends to revise its quality review system to count only
   substantive errors for computational and benchmarking purposes but will
   continue to track all errors. On the basis of VA*s comments, we also
   modified the report to accurately reflect the standard of review employed
   by the U. S. Court of Appeals for Veterans Claims in reviewing Board
   decisions. With regard to our second recommendation, VA said that it would
   use its Veterans Appeals Control Locator System to gather information on
   case- specific medical disability issues related to specific errors found
   in Board decisions. VA questioned our basis for concluding that tracking
   such information will yield useful data for improving the adjudication
   system. As stated in the draft report, we based our recommendation on the
   fact that the Board has already concluded that such information is
   beneficial for analyzing the reasons for remands from the Court of Appeals
   for Veterans Claims. With regard to our third recommendation, VA said
   representatives of the Board and VBA will meet so that a system may be
   established for the Board to access and review VBA*s methodology for
   assessing, reporting, and evaluating instances of

   *difference of opinion* between the quality reviewer and the decision
   maker. Agency Comments

   and Our Evaluation

   Page 16 GAO- 02- 806 Veterans* Disability Benefits

   In its comments, VA concurred in principle with our fourth recommendation.
   VA agreed that consistency is an important goal and acknowledged that it
   has work to do to achieve it. However, VA was silent on how it would
   measure consistency for specific medical conditions that require
   adjudicators to make difficult judgments. Instead, VA described the kinds
   of actions underway that it believes will generally reduce inconsistency.
   While we support these efforts, we maintain that without a way to evaluate
   and measure consistency, VA will be unable to determine the extent to
   which such efforts actually improve consistency of decisionmaking across
   all levels of VA adjudication now and over time. Neither will VA have
   information needed to identify ways to reduce decisionmaking variations
   for specific medical conditions, if considered necessary.

   As agreed with your office, unless you publicly announce its contents
   earlier, we plan no further distribution of this report until 30 days
   after its issue date. At that time, we will send copies of this report to
   the Secretary of the Department of Veterans Affairs, appropriate
   congressional committees, and other interested parties. We will also make
   copies available to others upon request. In addition, the report will be
   available at no charge on the GAO Web site at http:// www. gao. gov.

   If you have questions about this report, please call me on (202) 512- 7101
   or Irene Chu on (202) 512- 7102. Other key contributors were Ira Spears,
   Steve Morris, Patrick diBattista, and Mark Ramage.

   Sincerely yours, Cynthia A. Bascetta Director, Education, Workforce,

   and Income Security Issues

   Appendix I: Steps in the Disability Claims and Appeals Process

   Page 17 GAO- 02- 806 Veterans* Disability Benefits

   Note: We did not include claims and appeals data for fiscal year 2001 in
   the basis for estimating the disposition of the 100,000 cases because of
   anomalies related in whole or in part to the implementation of the
   Veterans Claims Assistance Act of 2000. These fiscal year 2001 anomalies
   included a substantial increase in the regional offices* inventory of
   claims to be completed and substantial increases in the proportion of
   appeals remanded by the Board and the Court. See U. S. General Accounting
   Office, Veterans* Benefits: Despite Recent Improvements, Meeting Claims
   Processing Goals Will Be Challenging, GAO- 02- 645T (Washington, D. C.:
   Apr. 26, 2002). a The estimated disposition by VA*s regional offices of
   the 100,000 claims (in boxes 1 and 2) is based

   on data for claims involving disability ratings for fiscal years 1997 to
   2000. During those years, veterans submitted Notices of Disagreement in
   about 9 percent of the regional office decisions and went on to file
   appeals with the Board in about 40 percent of the cases in which they had
   submitted such notices. b Decisions appealed by veterans to the Board
   reach one of the following dispositions before veterans can appeal to the
   U. S. Court of Appeals for Veterans Claims: the Board makes an initial
   decision to grant or deny requested benefits (boxes 4 and 5); the regional
   office grants requested benefits in cases remanded by the Board for
   further development and reconsideration (box 7); the Board grants or
   denies benefits in remanded cases that regional offices resubmit to the
   Board because the regional offices denied the requested benefits after
   developing further evidence (boxes 4 and 5); the veteran withdraws his or
   her appeal while the case is in remand status at the regional office (box
   8); or the regional office closes the case while in remand status because
   the veteran fails to respond to requests for information needed for the
   appeal to proceed (box 8). Therefore, the estimated disposition the 3, 657
   appealed cases is accounted for in boxes 4, 5, 7, and 8 (1,153 + 1,956 +
   339 + 209 = 3,657).

   Appendix I: Steps in the Disability Claims and Appeals Process

   Illustration of the estimated disposition of 100,000 hypothetical
   compensation claims.

   Veterans Benefits Administration 57 Regional Offices Decide Claims and
   Notify Veterans of Decisions (estimated disposition of 100,000
   compensation claims filed with regional offices)

   1. Veterans either agree with regional offices decisions or take no
   further action in 90,880 cases. a 2. Veterans submit Notices of
   Disagreement to regional

   offices in 9,120 cases. In 3,657 of these cases, veterans go on to file
   appeals with the Board. a

   3. Board remands 1,311 cases to regional offices to develop further
   evidence and reconsider their decisions (Board remands 211 of these cases
   twice). c

   4. Board grants at least one requested benefit in 1,153 cases (Board makes
   269 of these grants after regional offices resubmit remanded cases). d

   Board of Veterans' Appeals Board Members Review Regional Office Decisions
   Appealed by Veterans (estimated disposition of 3,657 compensation cases
   appealed to Board) b

   5. Board denies all benefits in 1,956 cases (Board makes 494 of these
   denials after regional offices resubmit remands). d

   6. Regional offices obtain more evidence but deny requested benefits in
   839 cases and resubmit these cases to the Board for a final decision (of
   the 211 remanded twice, regional offices deny benefits in 135 and resubmit
   them to Board). d

   7. Regional offices obtain more evidence and grant requested benefits in
   339 cases (47 of these 339 grants occur after the second remand). d

   8. Veterans withdraw or regional offices close 209 cases (28 of these 209
   withdrawals or closures occur after second remand). e

   9. Veterans appeal 307 cases to U. S. Court of Appeals for Veterans
   Claims. f

   U. S. Court of Appeals for Veterans Claims Court Reviews Board Decisions
   Appealed by Veterans (estimated disposition of 307 compensation cases
   appealed to the court) f

   10. Court dismisses 74 cases on procedural grounds.

   11. Court affirms Board decisions in whole in 77 cases (all requested
   benefits denied).

   12. In whole or in part, Court reverses Board decisions (grants requested
   benefits) or remands Board decisions in 156 cases. g

   13. Veterans appeal 25 Court decisions to the U. S. Court of Appeals for
   the Federal Circuit. 14. The Board or the regional offices grant or deny
   benefits in

   the cases remanded by the court. h

   Appendix I: Steps in the Disability Claims and Appeals Process

   Page 18 GAO- 02- 806 Veterans* Disability Benefits

   c The estimate of 1, 311 remanded cases (in box 3) is based on Board data
   for fiscal years 1999 and 2000. d On the basis of Board data for fiscal
   years 1999 and 2000, in its initial decisions on appealed

   compensation cases, the Board: (1) granted at least one of the requested
   benefits in about 24 percent of the cases, (2) denied all requested
   benefits in about 40 percent of the cases, and (3) remanded about 36
   percent of the cases to regional offices for rework. After obtaining the
   additional evidence required by the Board for remanded cases, the regional
   offices granted requested benefits in about 22 percent of the remanded
   cases and denied requested benefits in 64 percent of the cases. After
   regional offices resubmitted denied cases to the Board for a final
   decision, the Board granted at least one of the requested benefits in
   about 26 percent of the cases, denied all benefits in about 49 percent,
   and remanded about 25 percent once again to regional offices for further
   rework. For this illustration, we assumed that the Board did not remand a
   case more than two times. e On the basis of Board data for fiscal years
   1999 and 2000, appellants withdrew about 13 percent of remanded
   compensation cases while at the regional offices, and the regional offices
   closed less than 1 percent of the remanded cases because appellants did
   not respond to requests for information needed to proceed with the appeal.
   f The estimate of 307 cases appealed to the U. S. Court of Appeals for
   Veterans Claims (in box 9), the

   court*s estimated disposition of these 307 cases (in boxes 10, 11, 12),
   and the estimated number of decisions appealed to the U. S. Court of
   Appeals for the Federal Circuit (in box 13) are based on fiscal years 1999
   and 2000 data from the court*s annual reports. g The court*s annual
   reports did not disaggregate data on reversals and remands. According to
   the

   Board, the court reversed Board decisions in whole or in part in only
   about 1. 6 percent of the cases during fiscal years 1999 and 2000. h The
   Board did not have any data that would provide a basis for estimating the
   number of grants and denials made by the Board or regional offices in
   cases remanded by the court (in box 14). Source: Prepared by GAO using
   data from VBA, Board of Veterans* Appeals, and the U. S. Court of Appeals
   for Veterans Claims.

   Appendix II: Board of Veterans* Appeals Illustrations of Difficult
   Judgments Resulting in Decision- Making Variations

   Page 19 GAO- 02- 806 Veterans* Disability Benefits

   Adjudicator*s task Examples of difficult judgments

   Assessing credibility of sources of evidence To be granted benefits for
   post- traumatic stress disorder, a veteran*s claim must have

   credible evidence that a stressor occurred during military service. Assume
   the record shows a claimant served in Vietnam as a supply specialist, and
   he identified mortar attacks as a stressor. Reports prepared by his
   military unit in Vietnam indicate a single enemy mortar attack occurred
   where the claimant was stationed. The claimant*s testimony was vague about
   the number and the time of the attacks. One adjudicator may rely on the
   unit*s reports and conclude the claimant engaged in combat and is entitled
   to have his lay statements accepted without further corroboration as
   satisfactory evidence of the in- service stressor. Another adjudicator may
   conclude that the claimant is not credible as to exposure to enemy fire
   and require other credible supporting evidence that the in- service
   stressor actually occurred. Evaluating and assigning weight to evidence
   Assume an appeal for either service connection or a higher disability
   rating has two

   conflicting medical opinions, one provided by a medical specialist who
   reviewed the claim file but did not actually examine the veteran and a
   second opinion provided by a medical generalist who reviewed the file and
   examined the veteran. One adjudicator could assign more weight to the
   specialist*s opinion, while another could find the generalist*s opinion to
   be more persuasive. Thus, depending on which medical opinion is given more
   weight, one adjudicator could grant the claim and the other deny it. Yet,
   a third adjudicator could find both opinions to be equally probative and
   conclude that VA*s *benefit- of- the- doubt* rule requires that he decide
   in favor of the veteran*s request for either service- connection or a
   higher disability rating. Under the benefit- of- the- doubt rule, if an
   adjudicator concludes that there is an approximate balance between the
   evidence for and the evidence against a veteran*s claim, the adjudicator
   must decide in favor of the veteran. Applying subjective standards in VA*s
   Rating Schedule The Rating Schedule does not provide objective criteria
   for rating the degree to which

   certain spinal impairments limit a claimant*s motion. The adjudicator must
   assess the evidence and draw a conclusion as to whether the limitation of
   motion falls into one of three severity categories: *slight, moderate, or
   severe.* Similarly, in assessing the severity of incomplete paralysis, the
   adjudicator must draw a conclusion as to whether the veteran*s incomplete
   paralysis falls into one of three severity categories: *mild,

   moderate, or severe.* In each case, each severity category in itself
   encompasses a range of severity, and the judgment as to whether a
   claimant*s condition is severe enough to cross over from one severity
   range into the next could vary in the minds of different adjudicators.

   The Rating Schedule provides a formula for rating the severity of a
   veteran*s occupational and social impairment due to a variety of mental
   disorders. However, the formula actually is a nonquantitative,
   behaviorally oriented framework for guiding adjudicators in making
   judgments and drawing conclusions as to which of the following
   characterizations best describes the degree to which a claimant is
   occupationally and socially impaired: (1) totally impaired; (2) deficient
   in most areas such as work, school, family relations, judgment, thinking,
   or mood; (3) reduced reliability and productivity; (4) occasional decrease
   in work efficiency and intermittent periods of inability to perform
   occupational tasks; (5) mild or transient symptoms that decrease work
   efficiency and ability to perform occupational tasks only during periods
   of significant stress or symptoms can be controlled by continuous
   medication, and (6) not severe enough to interfere with occupational or
   social functioning or to require continuous medication.

   Source: Board of Veterans* Appeals.

   Appendix II: Board of Veterans* Appeals Illustrations of Difficult
   Judgments Resulting in Decision- Making Variations

   Appendix III: Comments from the Department of Veterans Affairs

   Page 20 GAO- 02- 806 Veterans* Disability Benefits

   Appendix III: Comments from the Department of Veterans Affairs

   Appendix III: Comments from the Department of Veterans Affairs

   Page 21 GAO- 02- 806 Veterans* Disability Benefits

   Appendix III: Comments from the Department of Veterans Affairs

   Page 22 GAO- 02- 806 Veterans* Disability Benefits

   Appendix III: Comments from the Department of Veterans Affairs

   Page 23 GAO- 02- 806 Veterans* Disability Benefits (130085)

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