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VA Disability Benefits: VA Should Continue to Improve Access to Quality Disability Medical Exams for Veterans Living Abroad

GAO-20-620 Published: Sep 21, 2020. Publicly Released: Sep 21, 2020.
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Fast Facts

In 2019, out of about 1 million disability claims the Veterans Benefits Administration processed, about 18,000 were for veterans living abroad. The VBA often uses medical exams to determine if disability benefits are warranted.

Claims from veterans living abroad increased 14% from FY2014 to FY2019. In this period, claims processing times improved.

Veterans' access to disability exams abroad also improved as VBA increased the number of countries using VBA-contracted medical examiners instead of embassy-referred examiners. However, travel costs and other factors sometimes hinder access to quality exams. We made 5 recommendations for improvements.

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Number of Disability Claims Processed for Veterans Living Abroad, FYs 2014-2019


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What GAO Found

The number of disability claims for veterans living abroad—in foreign countries or U.S. territories—increased 14 percent from fiscal years 2014 to 2019. During this time period, claims processing time frames improved. In fiscal year 2019, the Veterans Benefits Administration (VBA) of the Department of Veterans Affairs (VA) approved comparable percentages of disability claims for veterans living abroad and domestically—63 percent and 64 percent respectively. However, for a subset of these claims—those where veterans likely received a disability medical exam scheduled by Department of State (State) embassy staff—approval rates were often lower.

Veterans' access to disability medical exams abroad improved as VBA has increasingly relied on contracted examiners, rather than embassy-referred examiners, to conduct these exams. According to VBA, this shift expanded the pool of trained examiners abroad and increased the frequency and depth of VBA's quality reviews for contract exams. These quality reviews help VBA and its contractor identify and address common errors, according to VBA and contractor officials. However, several factors continue to limit some veterans' ability to access quality disability medical exams (see figure).

Factors That Impair the Access of Veterans Living Abroad to Quality Disability Medical Exams

Factors That Impair the Access of Veterans Living Abroad to Quality Disability Medical Exams

Unknown quality of certain exams: A subset of veterans living abroad receive disability medical exams from an embassy-referred provider. VBA does not systematically assess the quality of these exams. Without doing so, VBA cannot determine if such exams affect the approval rates of veterans who receive them or contribute to longer processing times and are unable to make informed decisions about their use.

Travel reimbursement: Under current VA regulations, VA is not authorized to reimburse veterans for travel expenses for certain services incurred in foreign countries as it is for those incurred within the United States, including U.S. territories. Consequently, some veterans living in foreign countries may be unable to afford to travel to exams.

Examiner reimbursement: The Veterans Health Administration's (VHA) Foreign Medical Program reimburses examiners referred by embassy staff via paper checks in U.S. currency. These checks may be slow to arrive and not accepted by foreign banks, according to State and other officials and staff we interviewed. Such payment issues can deter examiners from being willing to conduct disability medical exams and thus limit veterans' access to these exams in foreign countries.

Why GAO Did This Study

Of the roughly 1 million disability claims VBA processed in fiscal year 2019, 18,287 were for veterans living abroad. Veterans living abroad are entitled to the same disability benefits as those living domestically, but GAO previously reported that veterans living abroad may not be able to access disability medical exams as readily as their domestic counterparts. VBA uses medical exam reports to help determine if a veteran should receive disability benefits. GAO was asked to review the disability claims and exam processes for veterans living abroad.

Among other things, this report examines disability claims trends for veterans living abroad and these veterans' ability to access quality disability medical exams. GAO analyzed VBA claims data for fiscal years 2014 to 2019; assessed data reliability; reviewed relevant federal laws, regulations, policies, and contract documents; and interviewed employees of VBA, State, and other stakeholders.


GAO is making five recommendations, including that VBA assess the quality of embassy-referred exams, VBA and VHA assess whether to reimburse beneficiaries for travel to disability medical exams in foreign countries, and that VBA and VHA pay examiners located by embassy staff electronically. The Department of Veterans Affairs concurred with GAO's recommendations.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Veterans Affairs The Under Secretary for Benefits should work with State and SSA to identify and implement ways to help ensure that embassy staff and RFBOs are made aware of relevant changes in VA policy and standard operating procedures in a timely and consistent manner and can more readily identify available resources so they can efficiently help veterans living abroad with VA's disability claims process. (Recommendation 1)
Closed – Implemented
VA agreed with this recommendation and identified actions VBA has taken to provide relevant policy changes to the State, Bureau of Consular Affairs program staff who provide support to the embassies and SSA, and steps to help embassy staff readily identify available VBA resources. For example, VBA continues to communicate with points of contacts at State and SSA to ensure shared lines of communication remain open and work continues with these agencies to identify and implement improvements to the process as needed. VBA has taken additional actions to improve the flow of policy change information to Regional Federal Benefits Officers and embassy staff and increase embassy staff's awareness of available resources. Specifically, VBA works with Department of State's Bureau of Consular Affairs to review and provide updates to the VA section of Department of State's Foreign Affairs Manual (FAM) and that information and guidance on VBA benefits and services, as well as information on the process to file claims, is available for embassy staff. These steps will help ensure State employees have needed information to assist veterans with their claims.
Department of Veterans Affairs The Under Secretary for Benefits should identify and implement an interim strategy to consistently document the complete contact information for veterans living abroad within VBMS, while OIT and VBA continue to explore a long-term solution. (Recommendation 2)
Closed – Implemented
VBA agreed with this recommendation and provided additional guidance to its staff on how to update and capture address information in the Veterans Benefits Management System (VBMS) and the SHARE system that captures addition claims data. VBA also updated its guidance for staff on where complete address information is located and notified staff of the update in October 2020. The updated information is maintained in user guides and on VBA's Compensation Service intranet page so it is accessible to all staff. These steps will help ensure VBA staff have and use accurate address information when they contact veterans living abroad while VBA continues to explore a long-term solution to update VBMS.
Department of Veterans Affairs The Under Secretary for Benefits should systematically assess the quality of embassy-referred exams and use the results of this review to identify whether there are common problems related to the use of these exams, and, if necessary, take steps to address those problems, such as by developing tailored technical assistance for embassy-referred examiners. (Recommendation 3)
Closed – Implemented
VBA initiated procedures to track embassy-referred exams to help collect information that could address this recommendation. VBA implemented a special issue flag to track embassy-referred exams. Since then, VA started to use contract providers to complete exams for veterans living in locations that would have previously been seen by embassy-referred providers. VBA will continue to track any outstanding embassy-referred exams manually. By tracking embassy-referred provider exams, VBA is positioned to assess the quality of these exams. Additionally, exams that are now being conducted by contract providers will undergo the standard quality assessment that VBA uses for contracted exams.
Department of Veterans Affairs The Under Secretary for Benefits and Under Secretary for Health—in concert with the General Counsel—should assess and decide whether to reimburse beneficiaries for travel to disability medical exams in foreign countries. (Recommendation 4)
Closed – Implemented
VA stated that the Office of General Counsel, VBA, and VHA have discussed this recommendation and the impact to its respective programs. Specifically, they noted that VBA, with support from VHA, is working to prepare the documentation necessary to request regulatory authority to pay beneficiary travel for veterans residing in foreign locations. These actions help ensure VA has thoroughly considered and assessed the merits of reimbursement for veterans' travel to foreign disability exam.
Department of Veterans Affairs The Under Secretary for Health, working with the Under Secretary of Benefits, should identify ways to reimburse examiners who conduct disability medical exams via direct deposit in the local currency, assess the cost-effectiveness of these options, and implement the method it selects. (Recommendation 5)
Closed – Implemented
VA agreed with this recommendation and has taken steps to address it. Specifically, VBA and VHA developed a working group to discuss options, in conjunction with the Office of General Counsel. VA determined that the agency would use a contract to provide disability medical exams to veterans who reside in foreign locations rather than continue to use U.S. embassies to identify providers. VA stated that this option replaces VA's need to obtain examinations through U.S. embassies. VA also stated that it will ensure veterans who have their private medical providers complete the necessary Disability Benefits Questionnaires for the exam request can submit a reimbursement form to VA. Subsequently, on April 1, 2022, VBA awarded two international contracts with options extending to September 30, 2028 to provide these exams. This long-term shift to using contract examiners means VA will not have to reimburse examiners identified by U.S. embassies using paper checks in U.S. currency -- a practice that deterred providers from offering exams. Contractors do not face reimbursement-related challenges with recruiting willing providers because they have other options to pay them, such as direct deposit in local currency. Thus, the steps VA has taken will help ensure that veterans living in foreign countries can access quality disability medical exams.

Full Report

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