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VA struggles with accuracy as disability claims get more complex
Friday - 12/6/2013, 9:32am EST
The Department of Veterans Affairs has made numerous changes under its claims transformation initiative designed to improve the speed and accuracy of its disability claims process. While VA figures show the changes have helped reduce the claims backlog, outside audits say VA is still struggling to get its most complex cases handled correctly.
VA says the number of complex claims it receives from veterans — those that involve multiple medical issues — is growing every year. The number of issues in an average claim went up 31 percent in just the last two years.
The department attributes the rise, in part, to major positive medical advances during the Iraq and Afghanistan wars. Injuries that would have been fatal in past eras are now survivable.
To handle those claims, the Veterans Benefits Administration decided to create three specialized "lanes" so that relatively simple cases could be processed quickly, and complicated ones would be tackled by VBA's most experienced field staff.
But according to audits by the department's inspector general, VA has a persistently high error rate with those complex claims. In one category the IG examined, Traumatic Brain Injury claims, VA personnel made errors in 31 percent of cases in 2011.
In response, VA made some changes to its quality assurance process. But during a follow up inspection during the last year, the error rate was still 29 percent.
Sondra McCauley, the deputy assistant IG for audits and evaluations, said her office is concerned that many of the department's regional offices are out of compliance with VA policy.
"In response to our May 2011 report, VBA began requiring second signature reviews of all TBI claims until raters demonstrate 90 percent accuracy in TBI claims processing," she told the House Veterans Affairs Committee on Wednesday. "However, in 2013, we saw only slight improvement since our first cycle of inspections. Twelve [regional offices] remained non-compliant in processing TBI claims for two consecutive inspections. Half of the errors were due to their own staff using inadequate medical exams to rate TBI claims."
VA disputes the error rates. By the department's reckoning, it completed 92 percent of all TBI claims accurately during fiscal 2013.
Tom Murphy, the director of VBA's compensation service says the disagreement has to do in part with different measurements for accuracy. He said the IG is more concerned about staff's strict compliance with VA policy, while the department's own numbers measure only whether the decision on a claim was ultimately correct.
"If you've varied from the process but you got the benefit entitlement decision right, I will not call that one an error, however, the IG will," he said. "But there's something more important that you need to hear, and it's a quote from the IG report. 'We sample claims we consider at higher risk of processing errors. Thus these results do not represent the overall accuracy of disability claims.' My point is this: The IG, by design, targets a specific subset of known high errors. If you take that number and extrapolate it, it's not an accurate representation of the sum of work for that regional office."
But McCauley says process is important. She said even if a claims adjudicator came up with the right answer while not adhering to policy in the case of one particular decision, missteps like not gathering proper medical evidence or properly developing a case file could have long-lasting repercussions for a veteran.
"Sometimes the benefits entitlement might be correct for the moment, but sometimes there are errors that are made that could have potential impact on benefits down the road, future benefits for the veteran. So we look at the totality of the claims processing exercise," she said.
Murphy also said the results of the IG audit are more of a reflection of past errors, and not of the progress VA has made within just the past 90 days.
He said the department has ratcheted up its emphasis on giving specialized training to staff to work on especially complicated disability cases like TBI, military sexual trauma and post-traumatic stress. That training, he said, clearly makes a difference.
"We did what we call a consistency study the first week of August, and we broke it down with six questions that were sent out to all people. This one happened to be for diabetes. And what we did is we broke it down by lanes. We broke it down for the quality review teams, for the star staff. And I laid all of the segment and populations of work lanes. And by a long shot, meaning in the mid-90 percent range, the special operations lane got those questions right at a much higher percentage. At the 93 percent, 94 percent rate, where the average for the total population was in the mid-80s," he said. "The point being that the higher experience level, the better education, the more training that we're doing with those individuals is yielding better results, more consistent results of higher quality. At the same time, we are concentrating those more trained, more experienced people on the most complex conditions that we are dealing with."