The vast majority of claims processors at the Department of Veterans Affairs failed to follow procedures on disability claims that involved requesting medical opinions or disability exams, which could have led to delays and denials for veterans, an inspector general investigation found.
The VA's top watchdog said Wednesday that 68% of processors didn't properly handle the section of the claims process that requests the opinions and exams, according to a statistical sampling of claims handled in fiscal 2021. The VA processors also did not include important relevant information in 38% of requests and didn't include all the necessary details that examiners use to make recommendations in 19% of the requests.
As part of the claims process, VA examiners use information provided by processors to determine the extent of a veteran's disability and whether it's covered. Without a complete understanding of the medical conditions and claim, examiners may miss issues or make an incorrect assessment, Office of the Inspector General investigators found.
"These failings can lead to inaccurate medical opinions, incorrect decisions on veterans' claims, delayed decisions for veterans, and wasted resources (for example, if the medical opinion is returned for staff to rework," wrote the OIG's Office of Audits and Evaluations in the report released Wednesday.
According to the investigation, claims processors did not consistently identify relevant medical evidence needed for the review, did not always use "adequate language" or regularly request all necessary medical opinions, and "sometimes requested unnecessary medical opinions."
These exams or medical opinions are a key part of the disability claims process for veterans, who must show the extent of their disability and prove that the disabling condition is service related.
The VA processes roughly 1.5 million disability claims each year, providing $88 billion in benefits to roughly one-quarter of the nation's 19 million veterans, according to the U.S. Census Bureau and the Government Accountability Office.
Claims processors are trained to identify which applications require a medical opinion or exam, and they must include all relevant medical evidence for the examiner to review. They also write requests for medical opinions, and errors at any stage in the process can lead to delays or rejections.
As of Sept. 3, the Veterans Benefits Administration -- the arm of the VA that handles compensation and benefits -- was processing 635,026 claims, with 152,560 considered to be backlogged, or 125 days or older.
To address these claims and eliminate the backlog, the VA has set a goal to hire more than 2,000 claims processors and is automating its system to expedite claims for health conditions commonly diagnosed in veterans.
The department is also upgrading the VBA's electronic systems to process claims more efficiently, developing a course to improve training and medical opinion requests, and modifying its existing quality review checklist to ensure that medical opinion requests get the attention they need, according to the VA's response to the OIG request.
VA Secretary Denis McDonough said earlier this year that the department will reduce its claims backlog to below 100,000 by 2024. To get there, claims processors are working overtime, setting a record in February by processing more than 7,000 claims a day for nearly four straight weeks.
"That means tens of thousands of veterans are now getting the benefits they've earned and so rightly deserve," McDonough said.
-- Patricia Kime can be reached at Patricia.Kime@Military.com. Follow her on Twitter @patriciakime.