VAOIG Report No. 7R1-A02-114, Date: August 6, 1997

Report No. 7R1-A02-114, Date: August 6, 1997
review was to follow-up on the status of implementation of recommendations contained in Report of
Audit, Timeliness of C&P Medical Examination Services, dated July 11, 1994

Requiring VHA facilities, when a veteran fails to keep an initial scheduled C&P
appointment, to call the veteran to reschedule a second appointment. The 35 day
"time clock" would be suspended for the period between the initial missed
appointment and the date of the rescheduled appointment. Exam requests are to be
returned to the VARO as incomplete if the veteran fails to keep the rescheduled
appointment.

MEMORANDUM FROM THE UNDER SECRETARY FOR HEALTH
DATED JULY 23, 1997
Department of
Veterans Affairs Memorandum
Date: July 24, 1997
From: Under Secretary for Health (10/105E)
Recommendation 2.: The Under Secretary for Health require VHA facilities to comply
with requirements to reschedule examinations when veterans miss an initial appointment.
Concur
VA policy M-1, Part I, Chapter 20 clearly states the actions to be taken to reschedule exams
when veterans miss initial appointments. These requirements were restated during a Health
Administration Service National Conference Call.
Completed July 16, 1997


REVIEW OF
COMPENSATION AND PENSION MEDICAL
EXAMINATION SERVICES
Report No. 7R1-A02-114
Date: August 6, 1997
Office of Inspector General
Washington DC 20420
By establishing performance
measures and working together the
VBA and the VHA can improve the
completion rate of C&P medical
examinations.
Memorandum to:
Under Secretary for Health (10)
Acting Under Secretary for Benefits (20)
Review of: Compensation and Pension Medical Examination Services
1. The Office of Inspector General (OIG) conducted a review of medical examination
services provided by the Department of Veterans Affairs (VA) to veterans with pending
compensation and pension (C&P) disability claims. The purpose of the review was to
follow-up on the status of implementation of recommendations contained in Report of
Audit, Timeliness of C&P Medical Examination Services, dated July 11, 1994, and to
identify whether additional opportunities exist to further enhance the quality and
timeliness of medical examination services.
2. VA’s C&P benefit programs are administered by the Veterans Benefits
Administration (VBA). Veterans Health Administration (VHA) medical facilities assist
the VBA by conducting medical examinations of veterans with pending C&P claims.
Proper accomplishment of medical examination services is important because VBA field
facilities, VA Regional Offices (VAROs), cannot properly complete actions on veterans’
claims until the requested examination results are furnished. When an examination is not
performed (examination request returned to VARO as incomplete), the veteran must have
another examination scheduled which prolongs the processing of his/her claim and
requires reprocessing by both the VBA and the VHA.
3. On July 11, 1994, OIG issued a report which found that the VBA and the VHA had an
opportunity to increase the rate of examinations completed and thereby improve C&P
examination services. VBA and VHA management agreed to recommended actions to
jointly improve coordination and communication among VBA and VHA facilities, and
veterans, and to implement better examination processing procedures. In
December 1994, the Under Secretary for Benefits and the Under Secretary for Health
executed a Memorandum of Understanding (MOU) on processing C&P examination
requests, subsequently published as VHA Directive 10-95-023. The MOU included:
ii
ï‚·ï€ Reaffirmation of the standard 35 calendar day average for VHA facilities to complete
medical exams with monitoring requirements to ensure compliance.
ï‚·ï€ Requiring VHA facilities, when a veteran fails to keep an initial scheduled C&P
appointment, to call the veteran to reschedule a second appointment. The 35 day
"time clock" would be suspended for the period between the initial missed
appointment and the date of the rescheduled appointment. Exam requests are to be
returned to the VARO as incomplete if the veteran fails to keep the rescheduled
appointment.
ï‚·ï€ A quality standard that no more than 3 percent of the exam reports completed each
month at each VHA facility are determined by VAROs to be insufficient for rating
purposes. This 3 percent requirement was also added to the VHA directors'
performance standards.
4. Notwithstanding management’s efforts to improve examination services, we found
that the percentage of incomplete examinations had not changed significantly between the
period of our prior review in Fiscal Year (FY) 1993, and FY 1996:
FY 1993 FY 1996
405,000 exam requests processed 361,000 exam requests processed
310,000 (76.5 percent) completed 282,000 (78.1 percent) completed
95,000 (23.5 percent) incomplete 79,000 (21.9 percent) incomplete
5. Our review focused on 6,238 examination requests that were returned to VAROs as
incomplete during March 1996. We selected a statistical sample of 147 cases for review
of veterans’ C&P claims folders and pertinent VHA records. Based on the results of our
review, we identified opportunities to reduce the percentage of incomplete examinations
in 89 (60 percent) of the cases. We estimate that 3,777 of the 6,238 examination requests
returned as incomplete during March 1996, could have been prevented by improving
coordination and communication among VBA and VHA facilities and veterans, and
rescheduling examinations after an initial appointment is missed.
6. During the review, we found VBA and VHA management had addressed
recommendations contained in the prior OIG audit and continue to address C&P issues
through joint task forces. Management had established and was monitoring the
achievement of specific performance measures to improve the timeliness and quality of
completed exams. As a result, during FY 1996 average timeliness for completed
iii
examinations was reduced to 30.4 days and the percentage of insufficient examinations
was 3.1 percent, nearing the 3 percent goal. However, VBA and VHA management’s
corrective actions in response to our previous audit were only marginally successful in
reducing the percentage of incomplete examinations. While emphasis was placed on
maintaining timeliness and improving quality of completed examinations, specific
performance measures to prevent and reduce the percent of incomplete medical exams
returned to VAROs for reprocessing had not been established.
7. Despite having no benchmarks or performance measures to improve the rate of
incomplete exams, we noted that several VAROs and VHA facilities have implemented
innovative procedures to enhance timeliness and quality of completed examinations and
reduce the percentage of incomplete examinations. For example, by working together
VBA and VHA facility directors in Oklahoma have achieved success in reducing the
number of incomplete examinations to 10 percent by increasing communication and
cooperation among management, staff, veterans service organizations, and veterans. By
establishing and monitoring performance measures designed to achieve improvement in
the rate of incomplete examinations, requiring local facility directors to work together to
reduce the percentage of incomplete examinations, and requiring VHA facilities to
reschedule examinations as required, the quality and timeliness of examination services
provided to veterans can be further improved.
8. We recommended that:
a. The Under Secretary for Benefits and the Under Secretary for Health improve the
quality and timeliness of C&P examination services by:
(1) Establishing performance measures for their field facilities, with the objective of
improving the rate of incomplete examinations.
(2) Requiring VBA Area Directors and VISN Directors to monitor progress in
reducing the percentage of incomplete examinations.
(3) Requiring VBA and VHA facility directors to work together to reduce the
percentage of incomplete examinations.
b. The Under Secretary for Health require VHA facilities to comply with requirements to
reschedule examinations when veterans miss an initial appointment.
iv
9. The Under Secretary for Health and the Acting Under Secretary for Benefits
concurred in principle with the recommendations and provided acceptable
implementation plans. We consider all issues resolved. However, we will follow up on
the implementation of planned corrective actions.
For the Assistant Inspector General for Auditing,
(Original signed by:)
THOMAS L. CARGILL, JR.
Director, Bedford Audit Operations Division
TABLE OF CONTENTS
Page
Memorandum to the Under Secretary for Health (10)
Memorandum to the Acting Under Secretary for Benefits (20) ................. i
RESULTS AND RECOMMENDATIONS
VBA and VHA Can Reduce the Percentage of Incomplete Examinations........ 1
Conclusion...................................................................................................... 5
Recommendations ......................................................................................... 6
APPENDICES
I BACKGROUND........................................................................................... 8
II OBJECTIVES, SCOPE AND METHODOLOGY ......................................... 10
III DETAILS OF REVIEW ................................................................................ 11
IV UNDER SECRETARY FOR HEALTH COMMENTS.................................. 12
V ACTING UNDER SECRETARY FOR BENEFITS COMMENTS................ 15
VI FINAL REPORT DISTRIBUTION ............................................................... 18
1
RESULTS AND RECOMMENDATIONS
VBA and VHA Can Reduce the Percentage of Incomplete Examinations
Our review of the Department of Veterans Affairs (VA) Veterans Benefits
Administration’s (VBA) and Veterans Health Administration’s (VHA) Compensation and
Pension (C&P) examination services showed that the percentage of incomplete
examinations could be reduced and the timeliness and quality of examination services
further improved. Notwithstanding management’s efforts to improve examination
services, the 23.5 percent rate of incomplete examinations that occurred during the period
of our prior review in Fiscal Year (FY) 1993, had declined only 1.6 percent during FY
1996. Based on the results of a statistical sample, we estimate that 3,777 (60 percent) of
the 6,238 examination requests returned incomplete during March 1996 could have been
completed by improving coordination and communication among VBA and VHA
facilities and veterans, and giving veterans a second chance by rescheduling exams when
an initial appointment is missed. By establishing and monitoring performance measures
designed to achieve improvement in the rate of incomplete examinations, requiring local
VBA and VHA facility directors to work together to reduce the percentage of incomplete
examinations, and requiring VHA facilities to reschedule examinations as required, the
quality and timeliness of examination services provided to veterans can be further
improved.
Background
VA’s C&P benefit programs are administered by the VBA. VHA medical facilities assist
the VBA by conducting medical examinations of veterans with pending C&P claims.
Proper accomplishment of medical examination services is important because VBA field
facilities, VA Regional Offices (VAROs), cannot properly complete actions on veterans’
claims until the requested examination results are furnished. When an examination is not
performed (examination request returned to VARO as incomplete), the veteran must have
another examination scheduled which prolongs the processing of his/her claim and
requires reprocessing by both the VBA and the VHA.
On July 11, 1994, OIG issued Report of Audit, Timeliness of C&P Medical Examination
Services, which found that the VBA and the VHA had an opportunity to significantly
increase the rate of examinations completed and thereby improve the overall timeliness of
C&P examinations, reduce unnecessary delays and inconvenience to veterans, and avoid
unnecessary reprocessing of pending claims. We recommended that the VBA and the
VHA take joint action to increase the rate of medical examinations completed by (a)
improving coordination/communication between the VBA and the VHA, (b) improving
procedures for notifying veterans of their examination appointments, (c) requiring
medical facilities to attempt to reschedule examinations at least once before returning
2
unperformed examinations to the VARO when veterans fail to report for their originally
scheduled examinations, and (d) collecting and sharing better examination processing
procedures developed by local VBA and VHA facilities testing innovative case
management techniques. The VBA and the VHA responded that they would work
together to improve timeliness and prevent "incomplete" exams (see Appendix I, page 8
for details).
Notwithstanding management’s efforts to improve examination services, little progress
had been made to reduce the percentage of incomplete examinations between the period
of our prior review in FY 1993, and FY 1996:
FY 1993 FY 1996
405,000 exam requests processed 361,000 exam requests processed
310,000 (76.5 percent) completed 282,000 (78.1 percent) completed
95,000 (23.5 percent) incomplete 79,000 (21.9 percent) incomplete
During the review, we found VBA and VHA management had addressed
recommendations contained in the prior OIG audit and continue to address C&P issues
through joint task forces. Management had established and was monitoring the
achievement of specific performance measures to improve the timeliness and quality of
completed exams. As a result, during FY 1996 average timeliness for completed
examinations was reduced to 30.4 days and the percentage of insufficient examinations
was 3.1 percent, nearing the 3 percent goal. However, VBA and VHA management’s
corrective actions in response to our previous audit were only marginally successful in
reducing the percentage of incomplete examinations. While emphasis was placed on
maintaining timeliness and improving quality of completed examinations, specific
performance measures to prevent and reduce the percent of incomplete medical exams
returned to VAROs for reprocessing had not been established.
Audit Results Show 60 Percent of Examinations Not Performed Could Have Been
Completed
Our review focused on 6,238 examination requests that were returned to VAROs as
incomplete during March 1996. We selected a statistical sample of 147 cases for review
of veterans’ C&P claims folders and pertinent VHA records. Based on the results of our
review, we identified opportunities to reduce the percentage of incomplete examinations
in 89 (60 percent) of the cases. We estimate that 3,777 of the 6,238 examination requests
returned incomplete during March 1996 could have been prevented by improving
coordination and communication among VBA and VHA facilities and veterans, and
enhancing compliance with the requirement to reschedule examinations after an initial
appointment is missed (see Appendix III, page 11 for details).
3
We found in 48 of the cases sampled examinations could have been completed by
improving communication, coordination and procedures for scheduling and notifying
veterans of examinations. In 41 cases, examinations could have been completed by
allowing veterans’ missed appointments to be rescheduled at least once. The remaining
58 cases were generally beyond the control of VA.
Increased Communication and Coordination Among VBA, VHA and Veterans Can
Result in Completed Examinations
We identified 48 cases (32.6 percent) where improved communication, coordination and
procedures could have resulted in the completion of the original exam request:
ï‚·ï€ 29 cases where an incorrect address was used to notify the veteran of an appointment
when the correct address was available,
ï‚·ï€ 9 cases where exam requests were sent to the wrong clinic of jurisdiction, and
ï‚·ï€ 10 cases involving a variety of situations where better communication and
coordination between the VA parties and the veteran could have resulted in completed
examinations and a more satisfied veteran.
For example: A VARO request for an eye examination was received at the VAMC on
February 23, 1996. The VARO request did not provide the veteran’s current address,
although the VARO had the correct address. The VAMC scheduled the exam for March
8, 1996 and mailed notification to their address of record (an incorrect address). The
VAMC correctly scheduled the exam and rescheduled a second chance examination for
March 28, 1996. Again, the appointment notice was sent to an incorrect address. The
exam was returned incomplete for Failure to Report to the VARO on March 28 and the
veteran’s claim for benefits was denied. On June 7, 1996, the veteran resubmitted his
claim to the VARO, saying he had not received his examination appointment notices.
The examination was rescheduled and properly conducted on July 18, 1996. Based on
the examination, the VARO awarded the veteran monthly compensation totaling $391 on
November 18, 1996. If the VARO had furnished the VAMC the veteran’s correct
address, a 4 month delay in awarding benefits and the additional claims processing
between the VARO and the VAMC could have been avoided.
Not Adhering to the Rescheduling Requirement Delays the Benefit Decision
We identified 41 cases (27.8 percent) in which the medical facilities failed to reschedule
a second exam when the initial exam was missed. Failure to reschedule the exam results
4
in the veteran having to resubmit his/her claim, and the VARO having to resubmit an
exam request. Giving the veteran a second chance notification may have prevented return
of an examination request and delays in acting on benefit claims.
For example: The VARO submitted a C&P exam request to the VAMC on
March 7, 1996. The VAMC appropriately scheduled the examination and notified the
veteran of the appointment for March 26, 1996. The examination was returned to the
VARO as Failed to Report on March 26. The VAMC did not contact the veteran or
reschedule an appointment to make up for the missed exam. When the veteran called
April 8, 1996 requesting to reschedule an appointment, the VAMC referred him back to
the VARO to resubmit an exam request. The exam was completed June 15, 1996
resulting in an 80 day delay, and causing the VARO and VAMC to process the exam
request twice before completing action on the veteran’s monthly award of $314.
VBA and VHA Facility Directors Have Reduced Incomplete Exams by Working
Together
Our review of information submitted by the VAMCs on C&P exams, for the month of
March 1996, showed that the Muskogee and Oklahoma City VAMCs percentages of
incomplete C&P exams were among the lowest in the nation. Only 1 percent of exams in
Muskogee and 10 percent in Oklahoma City were incomplete.
Facility directors from VARO Muskogee and VAMCs Muskogee and Oklahoma City
have achieved success in reducing the number of incomplete examinations by increasing
communication and cooperation among management, staff, veterans service
organizations, and veterans. A task force consisting of staff from the three Oklahoma
facilities was formed in late 1992. The task force, comprising VARO Rating Specialists,
C&P Program Clerks, VAMC Medical Administration Service (MAS) personnel and
physicians, opened effective lines of communication and established a spirit of
cooperation that has resulted in the low number of incomplete exams. The task force
members meet "face to face" once a month, and also hold a teleconference monthly. Staff
members involved in the C&P exam process call each other when problems arise. The
task force developed a pamphlet which explains the C&P exam process to the patient.
They also developed a handbook to assist physicians performing C&P exams.
New York Facilities Established a Walk-in Clinic
In March 1997, a C&P Examination Unit was opened which is physically located at the
VARO New York. The exam unit was designed to accommodate “homeless” as well as
“walk-in” pension or compensation applicants and is staffed by VAMC and VARO
5
personnel. The veteran claimant can be scheduled for a same day appointment in the
Exam Unit or for a future date at either the Exam Unit or the VAMC. The veteran is
given the opportunity to speak with a VARO Case Manager and VA Health Staff before
and after the examination. The veteran is also given an “expectation sheet” which
explains the C&P claims procedure.
Conclusion
The review found that an estimated 3,777 (60 percent) of the 6,238 examinations not
performed during March 1996 could have been completed. In our opinion, the
examinations returned incomplete could have been prevented by improving coordination
and communication among VBA and VHA facilities and veterans, and enhancing
compliance with the requirement to reschedule examinations after an initial appointment
is missed. Communication and coordination between the VAROs and VAMCs to resolve
problems will allow more examinations to be completed. Communication with the
veteran to explain the medical examination process will assure and hasten the completion
of the C&P process. The intended perception for the veteran of “one VA” will be a
reality, and VA will have benefited in the completion and timely delivery of necessary
services at the lowest cost.
By establishing and monitoring performance measures designed to achieve improvement
in the rate of incomplete examinations, requiring local facility directors to work together
to reduce the percentage of incomplete examinations, and requiring VHA facilities to
reschedule examinations as required, the quality and timeliness of examination services
provided to veterans can be further improved.
6
Recommendations
We recommend that:
1. The Under Secretary for Benefits and the Under Secretary for Health improve the
quality and timeliness of C&P examination services by:
a. Establishing performance measures for their field facilities, with the objective of
improving the rate of incomplete examinations.
b. Requiring VBA Area Directors and VISN Directors to monitor progress in
reducing the percentage of incomplete examinations.
c. Requiring VBA and VHA facility directors to work together to reduce the
percentage of incomplete examinations.
2. The Under Secretary for Health require VHA facilities to comply with requirements to
reschedule examinations when veterans miss an initial appointment.
Under Secretary for Health Comments
The Under Secretary concurred with the findings and in principle with the
recommendations. The Under Secretary also stated that, to achieve real improvement, the
C&P examination process must be reengineered. The Under Secretary has requested the
Under Secretary for Benefits and the Assistant Secretary for Policy and Planning to assist
the VHA in reengineering the C&P examination process.
Implementation Plan
The Under Secretary provided an implementation plan which addressed each
recommendation. (See Appendix IV on page 12 for the full text of the Under Secretary’s
comments).
Office of Inspector General Comments
The implementation plan is acceptable and we consider all issues resolved. However, we
will follow up on planned corrective actions.
Acting Under Secretary for Benefits Comments
7
The Acting Under Secretary concurred in principle with the recommendations and stated
the entire C&P examination process is of great concern to the VBA. The Acting Under
Secretary also stated the VBA was working with the VHA and the Office of Policy and
Planning to address C&P examination processing issues.
Implementation Plan
The Acting Under Secretary for Benefits provided acceptable implementation plans for
Recommendations 1a, 1b, and 1c which applied to the VBA. (See Appendix V on page
15 for the full text of the Acting Under Secretary’s comments).
Office of Inspector General Comments
The implementation plan is acceptable and we consider all issues resolved. However, we
will follow up on planned corrective actions.
8
APPENDIX I
Page 1 of 2
BACKGROUND
Disability benefit payments are based, in part, on interpretations of medical evidence by
the Veterans Benefits Administration (VBA) disability rating specialists. That evidence
is developed by physicians employed or supervised by the Veterans Health
Administration (VHA), in the form of compensation and pension (C&P) examinations.
Examination timeliness and adequacy are significant quality of service indicators since
the VBA cannot complete payment action on veterans' disability claims until examination
results are received. When an examination is not performed (exam request returned to
the VBA as incomplete) or is insufficient for rating purposes, the veteran must have
another examination scheduled which can result in significant claim processing delays,
inconvenience to veterans, and additional costs to VA.
On July 11, 1994, OIG issued Report of Audit, Timeliness of C&P Medical Examination
Services, which found that the VBA and the VHA had an opportunity to significantly
increase the rate of examinations completed and thereby improve the overall timeliness of
C&P examinations, reduce unnecessary delays and inconvenience to veterans, and avoid
unnecessary reprocessing of pending claims. We recommended that the VBA and the
VHA take joint action to increase the rate of medical examinations completed by
(a) improving coordination/communication between the VBA and the VHA,
(b) improving procedures for notifying veterans of their examination appointments,
(c) requiring medical facilities to attempt to reschedule examinations at least once before
returning unperformed examinations to the VARO when veterans fail to report for their
originally scheduled examinations, and (d) collecting and sharing better examination
processing procedures developed by local VBA and VHA facilities testing innovative
case management techniques.
The VBA and the VHA responded that they would work together to improve timeliness
and prevent "incomplete" exams. Implementation plans included:
ï‚·ï€ ï€ Various options for notification of veterans of appointments and follow-up of missed
appointments.
ï€
ï‚·ï€ ï€ Efforts to improve communication between the VBA, the VHA, and the veteran on
the various portions of the C&P exam process.
ï€
ï‚·ï€ ï€ Enhancement of the Automated Medical Information Exchange (AMIE) exam
process.
APPENDIX I
9
Page 2 of 2
ï‚·ï€ ï€ Establishment of physician coordinators at VACO, medical centers and regional
offices.
ï€
ï‚·ï€ ï€ Establishment of a joint VBA/VHA education and training effort on C&P
examinations.
In December 1994, the Under Secretary for Benefits and the Under Secretary for Health
executed a Memorandum of Understanding (MOU) on processing C&P examination
requests, subsequently published as VHA Directive 10-95-023, dated March 3, 1995.
The MOU indicated that when a veteran submits a claim for C&P benefits, the VBA and
the VHA have a shared set of responsibilities to ensure: (a) The veteran receives service
of the highest quality; (b) The veteran is moved through the claims process as rapidly as
possible and with little, if any, inconvenience; and (c) The veteran's perception shall be
that he/she is dealing with one VA. The MOU's provisions included:
ï‚·ï€ Reaffirmation of the standard 35 calendar day average for VHA facilities to complete
medical exams.
ï‚·ï€ Monthly reports to VBA and VHA managers listing processing times for all facilities
with requirements for VAMC and VARO Directors to coordinate corrective action
when a medical facility fails to meet the 35 calendar day standard for two consecutive
months.
ï‚·ï€ Requiring VHA facilities, when a veteran fails to keep an initial scheduled C&P
appointment, to call the veteran to reschedule a second appointment. The 35 day
"time clock" would be suspended for the period between the initial missed
appointment and the date of the rescheduled appointment. Exam requests are to be
returned to the VARO as incomplete if the veteran fails to keep the rescheduled
appointment.
ï‚·ï€ No more than 3 percent of the exam reports completed each month at each VAMC are
determined by VAROs to be insufficient for rating purposes. This 3 percent
requirement was also added to the VHA directors' performance standards.
The VBA and the VHA had not established benchmarks or performance measures to
reduce the percentage of incomplete examinations.
10
APPENDIX II
OBJECTIVES, SCOPE AND METHODOLOGY
Objectives
The purpose of this review was to conduct a follow-up on the status of implementation of
recommendations contained in Report of Audit, Timeliness of C&P Medical Examination
Services, dated July 11, 1994, and identify whether additional opportunities exist to
further enhance the quality and timeliness of medical exam services.
Scope and Methodology
We obtained a universe of 6,238 incomplete compensation and pension examinations
(C&P) examinations for March 1996 from VHA facilities. We also performed the
following:
ï‚·ï€ ï€ Reviewed the applicable VBA/VHA policy and procedures for C&P examinations.
ï€
ï‚·ï€ ï€ Discussed the scope, our review process and findings at various stages of the review
with VBA, VHA, Board of Veterans Appeals, and Assistant Secretary for
Management officials.
ï€
ï‚·ï€ ï€ Statistically sampled 147 of the 6,238 incomplete examinations for March 1996.
ï€
ï‚·ï€ ï€ Reviewed veterans’ claims folders and pertinent VHA records for the 147 cases
sampled.
ï€
ï‚·ï€ ï€ Visited three VBA Regional Offices and four VA Medical Centers to test policies and
procedures.
The review was conducted in accordance with government auditing standards for
qualifications, independence, and due professional care.
11
APPENDIX III
DETAILS OF REVIEW
Sampling Plan and Results
Review Universe
Our review universe was created from VHA facility responses to an issued OIG request
for a listing of incomplete compensation and pension medical examinations for the period
March 1996. Responses from 139 VHA facilities contained a universe of 6,238
incomplete exams for March 1996 (18 facilities had deleted their March 1996 incomplete
exam records).
Sample Design
The sample included 147 randomly selected cases and was based on a non-stratified
sampling design at a 95 percent confidence level. We validated the C&P incomplete
examination data by verifying the information in the VAROs’ claims folders and the
VAMCs’ patient data base.
Sample Results
We found in 89 (60 percent) of the 147 cases sampled, there were opportunities to reduce
the number of incomplete examinations. In 48 cases, improved communication and
coordination between the VAROs and VAMCs could have resulted in the completion of
the original examination request. In 41 cases, returning examination requests could have
been avoided by rescheduling the examination as required by VHA policy. We estimate
that 3,777 (60 percent) of the 6,238 examinations returned incomplete during March 1996
could have been completed.
12
APPENDIX IV
Page 1 of 3
MEMORANDUM FROM THE UNDER SECRETARY FOR HEALTH
DATED JULY 23, 1997
Department of
Veterans Affairs Memorandum
Date: July 24, 1997
From: Under Secretary for Health (10/105E)
Subj: OIG Draft Report, Review of Compensation and Pension (C&P) Medical
Examination Services
To: Assistant Inspector General for Auditing (52)
1. The draft report was reviewed by appropriate Veterans Health Administration (VHA)
program offices and we concur with your report findings and concur in principle with the
recommendations. We recognize that providing C&P exams is one of our most basic services,
one which not only directly affects veterans, but also is a direct reflection of our ability to
provide high quality service to potential new VA users. Facilities and Veterans Integrated
Service Networks (VISNs) have tried different approaches, with varying degrees of success, to
reduce the number of insufficient and incomplete exams. We appreciate your
acknowledgement of the success of our performance measures to improve the timeliness and
quality of completed exams, reducing the percentage of insufficient exams to 3.1 percent,
which nearly meets the stated goal of 3 percent. As your report shows, however, despite our
success in reducing the percentage of insufficient exams, the C&P examination process still
needs significant improvement. Based on our own efforts, several other studies and now your
report, it is clear that to achieve real improvement, we must reengineer the C&P examination
process.
2. We have already taken several actions to initiate this process which also respond to your
recommendations. I have established a new forensic medicine strategic healthcare group (SHG)
which will focus on ensuring that superior service is provided by VHA in the C&P examination
process. The forensic medicine SHG will also coordinate the reengineering effort for VHA.
Obviously this effort will involve a number of organizations, including the Veterans Benefits
Administration (VBA). On May 20, 1997, I formally requested that both the Under Secretary for
Benefits and the Assistant Secretary for Policy and Planning (008) assist VHA in reengineering
the C&P examination process. The reengineering group effort is now taking form, so we cannot
yet provide you with the details of the approach to be taken or when to expect implementation.
We will provide this information to you when it is available. We can assure you, however, that
the specifics of recommendation 1 will be addressed in the process.
3. In the meantime, we plan to explore issuing a joint VHA/VBA statement of expectations
for cooperative local efforts between VHA and VBA to improve exam
VA Form 2105
Mar 1989
13
APPENDIX IV
Page 2 of 3
2. Assistant Inspector General for Auditing (52)
completion rates. This statement would emphasize the importance of improving exam
completion rates and will endorse the view that cooperation between VHA and VBA at
the local level is the path to immediate improvement. In addition, we will reemphasize
the already existing requirements for rescheduling exams when veterans miss an initial
appointment as required in recommendation 2. This was accomplished during the July
16, 1997, Health Administration Service National Conference Call.
4. We are committed to improving our performance on C&P examinations, as it is an
important component for ensuring veterans’ satisfaction. Thank you for the
opportunity to review this report. If you have any questions, please contact
Paul C. Gibert, Jr., Director, Reports Review and Analysis Service (105E), Office of
Policy, Planning and Performance, at 273.8355.
(Original signed by:)
Kenneth W. Kizer, M.D., M.P.H.
Attachment
14
APPENDIX IV
Page 3 of 3
Action Plan in Response to OIG/GAO/MI Audits/Program Evaluations/Reviews
Name of Report: Review of Compensation and Pension (C&P) Medical Examination Services
Project No.: None
Date of Report: Undated draft
______________________________________________________________________________
Recommendations/ Status Completion
Actions Date
______________________________________________________________________________
Recommendation 1.: The Under Secretary for Benefits and the Under Secretary for Health
improve the quality and timeliness of C&P examination services by:
a) establishing performance measures for their field facilities, with the objective of improving
the rate of incomplete examinations;
b) requiring VBA Area Directors and VISN Directors to monitor progress in reducing the
percentage of incomplete examinations; and,
c) requiring VBA and VHA facility directors to work together to reduce the percentage of
incomplete examinations.
Concur in principle
On May 20, 1997, the Under Secretary for Health requested that the Under Secretary for Benefits
and the Assistant Secretary for Policy and Planning assist VHA in the reengineering of the C&P
examination process. Recommendation 1. a) through 1. c) will be addressed as part of the
reengineering process. As an interim measure, a joint VBA/VHA statement emphasizing the
importance of improving the process and working cooperatively in this effort will be issued to all
field directors by September 30, 1997.
In process To be determined
Recommendation 2.: The Under Secretary for Health require VHA facilities to comply
with requirements to reschedule examinations when veterans miss an initial appointment.
Concur
VA policy M-1, Part I, Chapter 20 clearly states the actions to be taken to reschedule exams
when veterans miss initial appointments. These requirements were restated during a Health
Administration Service National Conference Call.
Completed July 16, 1997
15
APPENDIX V
Page 1 of 3
MEMORANDUM FROM THE ACTING UNDER SECRETARY FOR
BENEFITS DATED JULY 25, 1997
Department of
Veterans Affairs Memorandum
Date: July 25, 1997
From: Acting Under Secretary for Benefits (20)
Subj: Draft Report -- Review of Compensation and Pension Medical Examination Services
To: Assistant Inspector General for Auditing (52)
1. We have received and reviewed your draft report entitled “Review of Compensation and
Pension Medical Examination Services.” We are pleased to respond to the recommendations
which were included in your report.
2. The entire examination process is of great concern to us in the Veterans Benefits
Administration. I believe this concern is reflected by the number of work groups and task teams
addressing elements of the process as well as the whole work process itself. These groups include:
the work of various Business Process Reengineering (BPR) teams; the C&P Examination Process
Reengineering Group with VHA, VBA, and Office of Policy and Planning involvement; the
Examination Process Work Group with membership from VBA, VHA, and BVA (which is
concerned with examination process matters including the revision of examination worksheets, the
revision of the Physician’s Guide for Disability Evaluation Examinations; examination reports that
are insufficient for rating purposes and those that are returned as incomplete; and the preparation
of training for physicians who perform C&P exams); the AMIE Expert Panel (which considers
and prioritizes suggestions for correction or enhancement of the AMIE system); the former AMIE
DHCP Linkage Work Group (which reviewed current business practices and made
recommendations with several options for the improvement of AMIE information exchange) and a
November 1995, VHA/BVA/VBA Exam Process Focus Group.
3. The return of incomplete examinations increases our workload and exacerbates claims
processing delays. For our veteran customers any preventable delays in claims processing are
unacceptable. We welcome recommendations from OIG that address this concern. We will
address each of your recommendations.
Recommendation 1a: Your draft report recommended that the Under Secretary for Benefits
and the Under Secretary for Health improve the quality and timeliness of C&P examination
services by establishing performance measures for their field facilities, with the objective of
improving the rate of incomplete examinations.
We concur in principle with this recommendation. The Veterans Benefits Administration and
the Office of Policy and Planning (008) have been requested to assist the Veterans Health
Administration in reengineering the C&P examination process. Since the reengineering effort
is now taking form, we cannot specify the details of the approach to be taken or when to expect
implementation. Your recommendation will be addressed in the process and we will provide
more information when it is available.
VA Form 2105
Mar 1989
16
APPENDIX V
Page 2 of 3
Page 2.
Assistant Inspector General for Auditing (52)
In addition to developing VBA performance measures, we anticipate release of an all-station letter
by September 30, 1997, in which we will share with our regional offices the reasons for success in
reducing incomplete examinations at some regional offices and medical centers which were
identified in the IG draft report. We will direct that the regional offices ensure that examination
requests contain the most current address of record and that they are sent to the proper clinic of
jurisdiction. We will also direct that examination requests provide day and night time (home and
work) telephone numbers and the name of any power-of-attorney. Where necessary, we will ask
that our regional offices encourage their medical facility counterparts to use the telephone to
remind veterans of scheduled examinations and to reschedule examinations when there was a
failure to report.
We should and will direct VBA regional offices to work on reducing the number of incomplete
examinations in cooperation with VHA medical facilities. We will join with VHA in the issuance
of a joint statement of expectations for cooperative local efforts between VHA and VBA to
improve examination completion rates. We anticipate the joint statement will be provided to the
VHA and VBA fields by September 30, 1997.
Through the use of VBA and VHA Compensation and Pension Examination Coordinators, we will
direct that our regional offices continue to maintain close liaison with the medical centers to work
together to improve examination quality and timeliness, including the reduction of the number of
incomplete examinations. In all-station letter 97-05, we provided the regional offices with the
names and telephone numbers of all the current VBA and VHA examination coordinators and
urged use of the coordinators to improve liaison with the medical centers.
Recommendation 1b: Your draft report recommended that the Under Secretary for Benefits and
the Under Secretary for Health improve the quality and timeliness of C&P examination services by
requiring VBA Area Directors and VHA VISN Directors to monitor progress in reducing the
percentage of incomplete examinations.
We concur with this recommendation. Not only will it assist veterans, but it will also reduce
workload and improve the processing time for rating-related claims. We anticipate release of a
joint VBA/VHA letter to the Area and VISN Directors by September 30, 1997, in which they will
be informed of this requirement.
Recommendation 1c: Your draft report recommended that the Under Secretary for Benefits and
the Under Secretary for Health improve the quality and timeliness of C&P examination services by
requiring VBA and VHA facility directors to work together to reduce the percentage of incomplete
examinations.
We concur with this recommendation for the same reasons discussed above. We anticipate release
of a joint VBA/VHA letter to the Area and VISN Directors by September 30, 1997, in which they
will also be informed of this requirement.
17
APPENDIX V
Page 3 of 3
Page 3.
Assistant Inspector General for Auditing (52)
Recommendation 2: Your draft report recommended that the Under Secretary for Health require
VHA facilities to comply with requirements to reschedule examinations when veterans miss an
initial appointment.
This is an issue solely within the jurisdiction of the Under Secretary for Health. I defer to VHA’s
response to this recommendation.
(Original signed by:)
Stephen L. Lemons
18
APPENDIX VI
FINAL REPORT DISTRIBUTION
VA Distribution
Secretary (00)
Under Secretary for Health (105E)
Under Secretary for Benefits (20A11)
Assistant Secretary for Management (004)
Assistant Secretary for Policy and Planning (008)
General Counsel (02)
Deputy Assistant Secretary for Congressional Affairs (60)
Deputy Assistant Secretary for Public Affairs (80)
Director, Office of Management Controls (004B)
Chief Network Officer (10N)
Director, Compensation and Pension Service (21)
Chief Research and Development Officer (12)
Chief Financial Officer (17)
Chief Information Officer (19)
Chief Financial Officer (24)
VBA Area Directors
Directors, VISNs 1-22
Non-VA Distribution
Office of Management and Budget
U.S. General Accounting Office
Congressional Committees:
Chairperson, Senate Committee on Governmental Affairs
Senate Ranking Minority Member, Committee on Governmental Affairs
Chairperson, Senate Committee on Veterans Affairs
Senate Ranking Minority Member, Committee on Governmental Affairs
Chairperson, Senate Committee on Appropriations
Senate Ranking Minority Member, Committee on Appropriations
Chairperson, Subcommittee on VA, HUD, and Independent Agencies,
Senate Committee on Appropriations
Senate Ranking Member, Subcommittee on VA, HUD, and Independent
Agencies, Committee on Appropriations
Chairperson, House Committee on Veterans' Affairs
House Ranking Democratic Member, Committee on Veterans' Affairs
Chairperson, House Committee on Appropriations
Chairperson, Subcommittee on Benefits, Committee on Veterans Affairs
House Ranking Democratic Member, Subcommittee on Benefits,
Committee on Veterans Affairs
Chairperson, Subcommittee on Oversight and Investigations,
Committee on Veterans Affairs
House Ranking Democratic Member, Subcommittee on Oversight and Investigations,
Committee on Veterans Affairs
Chairperson, Subcommittee on Health, Committee on Veterans Affairs
House Ranking Democratic Member, Subcommittee on Health, Committee on Veterans Affairs