Traumatic Brain Injury:

Better DOD and VA Oversight Can Help Ensure More Accurate, Consistent, and Timely Decisions for the Traumatic Injury Insurance Program

GAO-09-108: Published: Jan 29, 2009. Publicly Released: Jan 29, 2009.

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In 2005, Congress created a traumatic injury insurance benefit program, known as TSGLI, to help servicemembers with traumatic brain injury and other serious injuries with the financial burdens that they and their families face. The Department of Veterans Affairs (VA) administers the program, in collaboration with the Department of Defense (DOD), while the branches of service are responsible for deciding servicemembers' claims. GAO examined (1) the TSGLI approval rate for traumatic brain injury claimants, and whether DOD and VA have assurance that claims are processed accurately, consistently, and in a timely manner and (2) any challenges servicemembers with traumatic brain injury may have faced in accessing TSGLI benefits, and the extent to which DOD and VA have taken steps to address such challenges. GAO analyzed program data and interviewed DOD and VA officials, servicemembers, and medical professionals.

Although VA data show that 63 percent of servicemembers with traumatic brain injury were approved for TSGLI, the actual approval rate may be lower, and DOD and VA lack assurance that claim decisions are accurate, consistent, and timely within and across the branches of service. VA's data show that 520 of the 821 servicemembers who filed TSGLI claims for traumatic brain injury received benefits. However, the actual approval rate may be lower because VA does not include all denials for traumatic brain injury in its data. In addition, DOD and VA officials told us there is no systematic quality assurance review process to ensure that claim decisions are accurate and consistent within and across the services. Finally, DOD and VA lack reliable data on how long it takes the services to make decisions on traumatic brain injury claims. We identified three major challenges servicemembers with traumatic brain injury have faced and found that DOD and VA have taken a number of steps to address these challenges and expand access to the program. First, while TSGLI is intended as a quick benefit, servicemembers have had difficulties in starting claims soon after their injuries, in part because of a lack of awareness about the program. In response, DOD placed TSGLI staff in 10 of its largest medical treatment facilities to educate servicemembers and help them file claims. Second, the eligibility criteria for traumatic brain injury in place at the time of our review were subjective and unclear, which created some challenges for servicemembers. The criteria stated that a servicemember with traumatic brain injury must be completely dependent on another person to perform two of six activities of daily living, such as eating or getting dressed. However, medical providers may have differing opinions on whether someone who requires verbal instructions or reminders to perform these activities is considered completely dependent. VA has since clarified that a servicemember who requires verbal assistance is eligible, but acknowledged that subjectivity still exists in assessing functional ability. Third, servicemembers with traumatic brain injury have faced challenges in obtaining medical records to prove that they meet eligibility criteria. VA made a change to the program to allow servicemembers who can document a 15-day hospital stay to be eligible for a minimum benefit. DOD and VA are reviewing all claims that were denied or approved for less than the maximum amount to determine whether servicemembers are now eligible under these changes.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: The Department of Veterans Affairs (VA) has taken a two-pronged approach to implementing this recommendation. First, VA's contractor, the Office of Servicemembers' Group Life Insurance, created a claims analyst position. This analyst works with VA and the branches of service to review all incoming claims to validate decisions and develop reports to assess consistency of claims decisions across the branches of service. These reports identify opportunities for training needs and changes to the claims process. As of March 2010, the analysis of claims has resulted in two training sessions for the branches of service on a range of topics, including the consistency and quality of claims decisions. Second, VA implemented a quality review process whereby VA staff review a random sample of 50 claims on a quarterly basis. Results from this review also are used to identify areas for improvement and additional training.

    Recommendation: To improve management of the Servicemembers' Group Life Insurance Traumatic Injury Protection Program (known as TSGLI) and ensure that all injured servicemembers receive accurate, consistent, and timely treatment, the Secretary of Veterans Affairs should work with the Secretary of Defense and the branches of service to implement a systematic quality assurance review process to help ensure that TSGLI benefit decisions are accurate and consistent within and across the services. For example, VA could expand its planned review of a sample of TSGLI claim decisions into a systematic, ongoing quality assurance review process.

    Agency Affected: Department of Veterans Affairs

  2. Status: Closed - Implemented

    Comments: With regard to data required to assess approval rates for traumatic brain injury claims, the Department of Veterans Affairs (VA) reported that it implemented changes to its data systems to capture all injury types, including all traumatic brain injury claims. VA also reported it has implemented a systematic reconciliation process to improve the reliability of its timeliness data. Reports with missing or inaccurate dates are returned to the branches of service for correction or further explanation. VA held a conference call, sent written guidance, and produced a web-based training module for the branches of service to clarify definitions for key timeliness data. Finally, the agency has modified its data systems to allow it to calculate timeliness by type of injury, including traumatic brain injury.

    Recommendation: To improve management of the Servicemembers' Group Life Insurance Traumatic Injury Protection Program (known as TSGLI) and ensure that all injured servicemembers receive accurate, consistent, and timely treatment, the Secretary of Veterans Affairs should work with the Secretary of Defense and the branches of service to take steps to ensure that the data required to assess approval rates for traumatic brain injury and the timeliness of key steps in the TSGLI claims process are reliable and comprehensive.

    Agency Affected: Department of Veterans Affairs

 

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