Veterans' Benefits: Quality Assurance for Disability Claims and Appeals Processing Can Be Further Improved
Highlights
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 these 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 decisionmaking accuracy and collect data to improve decisionmaking. 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 decisionmaking 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. Although available evidence indicates that variations in decisionmaking 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.
Recommendations
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Veterans Affairs | The Secretary of VA should direct the Chairman of the Board of Veteran's Appeals to revise the quality assurance program so that, similar to the Veterans Benefits Administration (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. |
Closed – Implemented
In 2004, Board officials confirmed that the Board had implemented GAO's recommendation. As part of its permanent procedures, the Board is now calculating accuracy rates to take into account only the deficiencies that would be expected to result in a reversal or a remand by the court.
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| Department of Veterans Affairs | The Secretary of VA should direct the Chairman of the Board of Veterans' Appeals to 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. |
Closed – Not Implemented
In June 2006, the Board said it did not intend to implement this recommendation because it believes the benefits would be too limited to justify the substantial reprogramming of the data system that would be required to collect issue-specific data. The Board also pointed out that the issue-specific data captured for court remands have not proven to be as useful as expected in identifying ways to provide training that could reduce court remands.
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| Department of Veterans Affairs | The Secretary of VA should direct the Chairman of the Board of Veterans' Appeals to monitor the experience of VBA 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 judgements 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. |
Closed – Not Implemented
In June 2006, the Board said it did not intend to implement this recommendation because VBA has not been able to provide any evidence that it has identified training needs by collecting and analyzing data on cases in which its quality reviewers do not record errors but have differences of opinion with regional office adjudicators in the judgments made to reach a decision.
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| Department of Veterans Affairs | The Secretary should direct the Under Secretary for Benefits and the Chairman of the Board of Veteran's Appeals to jointly 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 judgements. 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. |
Closed – Implemented
VA concurred in principle with GAO's recommendation but took no action. However, in November 2004, GAO again recommended that VA formulate a plan for studying decision-making consistency (GA0-05-99). This time, VA concurred with the recommendation and began a project to study variances in rating decisions on disability claims for hearing loss, knee conditions, and post-traumatic stress disorder (PTSD). In March 2005, VA tasked a group of regional office subject matter experts with devising tools for reviewing variances. VA validated these tools in April 2005 and assigned a group of 10 subject matter experts to review a total of 1,750 regional office decisions. Also, each subject matter expert was required to rate three cases for each of the three conditions under review. VBA completed its analysis of the study data in May 2005, and is developing a schedule for future studies of specific ratable conditions and recommending a schedule for periodic follow-up studies of previously studied conditions.
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