VA Disability Exams: Actions Needed to Clarify Program Requirements Regarding Examiners
Fast Facts
The Department of Veterans Affairs may require medical exams to determine veterans' eligibility for disability compensation. The COVID-19 pandemic contributed to an exam backlog.
To manage the backlog, certain examiners—e.g., psychologists—were temporarily authorized to give exams in states where they weren't licensed. But inaccurate guidelines and inadequate monitoring led to some providers who weren't covered under the authorization giving exams in other states.
VA said there is little-to-no risk to veterans' claims, but hasn't formally assessed the situation.
Our recommendations are to address these and other issues we found.
Highlights
What GAO Found
The Veterans Benefits Administration (VBA) and Veterans Health Administration (VHA) within the Department of Veterans Affairs (VA) reported expanding their use of telehealth for disability medical exams since the start of the COVID-19 pandemic. Both VA officials and the vendors that VBA contracts with to provide examiners reported a range of benefits associated with telehealth use, including more easily reaching veterans in underserved areas. VBA's vendors and VHA primarily used telehealth to conduct mental health exams, according to GAO analysis and interviews. However, the full extent of telehealth use is unknown because VHA medical facilities did not accurately record this information. In September 2021, VHA provided guidance to facilities to improve data collection.
VBA officials and vendors said that the temporary expansion of license portability–which allows contracted examiners in certain specialties to conduct exams in states other than where they are licensed–also expanded access in underserved areas. However, the guidelines VBA provided to its contracted exam vendors included inaccuracies, and VBA conducted inadequate monitoring of the vendors. This contributed to vendors allowing ineligible examiners to conduct exams using license portability. Examples of issues GAO found include:
- Inaccurate guidelines: VBA incorrectly listed dentists as eligible for license portability in the guidelines it provided to vendors. This contributed to two of VBA's three vendors using dentists to conduct exams in states other than where they were licensed.
- Inadequate monitoring: VBA did not review vendor-reported data to identify the types of examiners using license portability. GAO's review of these data found that one vendor used optometrists to conduct exams in states other than where they were licensed, which VBA officials said was not permitted.
During the course of GAO's review, VBA took steps to address these deficiencies. VBA issued new guidance memos to its vendors specifying that dentists and optometrists are not eligible for license portability. VBA also updated its monitoring process to review data on the types of examiners used for such exams. However, VBA has not yet developed formal procedures or documentation to guide this monitoring process. Without doing so, VBA cannot be confident that vendors are using license portability as intended.
VHA did not provide medical facilities with clear information to inform the recruitment and retention of VHA examiners. For example, VHA provided facilities with guidance to halt programmatic changes and comply with a requirement to pause efforts to eliminate examiner positions. However, the guidance did not clearly define what constituted a programmatic change or an examiner position. As a result, officials at the five facilities GAO selected for review had different interpretations of how and whether the guidance applied to them. Without clarifying the guidance, facilities may not implement it as intended, and they risk not being positioned to help address veterans' exam needs.
Why GAO Did This Study
In fiscal year 2021, VA paid nearly $99 billion in disability compensation to over 5 million veterans with service-connected disabilities. VA may ask a veteran to undergo a disability medical exam to help determine eligibility for disability compensation. VHA employees and examiners contracted by VBA conduct these exams.
The Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020 includes a provision for GAO to review certain aspects of VA's disability exam program. This report examines (1) VA's use of telehealth for disability medical exams, (2) how VA and its vendors used a temporary expansion of license portability, and (3) VHA's efforts to recruit and retain examiners and provide information to its medical facilities to inform such efforts.
GAO analyzed data on VA's use of telehealth from April 2020 through September 2022 and reviewed relevant VA guidance. GAO compared VA's guidance and practices to relevant federal standards for internal control. In addition, GAO interviewed officials from VA, exam vendors, and a non-generalizable sample of five VHA medical facilities, selected in part for variation in the number of exams completed and geographic location.
Recommendations
GAO is making three recommendations, including that VBA develop and document formal procedures to monitor license portability use and that VHA clarify guidance to facilities to define key terminology. VA generally agreed with the recommendations.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Veterans Affairs | The Under Secretary for Benefits should develop and document formal procedures to guide VBA's process for monitoring contracted exam vendors' use of license portability to help prevent ineligible examiners from conducting exams in states where they are not licensed. (Recommendation 1) |
VBA agreed with this recommendation. In June 2023, following issuance of our report, VBA completed a standard operating procedure for relevant Medical Disability Examination Office staff to complete monthly monitoring of exam vendors' use of temporary license portability. These procedures outline the steps staff should take to ensure only eligible providers have completed exams and how to work with vendors to correct any identified issues. Such monitoring can help ensure that VBA vendors' use license portability as intended.
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| Department of Veterans Affairs | The Under Secretary for Benefits should work with vendors to identify exams that were erroneously completed under license portability, assess any potential risks to veterans' claims, and develop and implement a corrective action plan to address any identified issues. (Recommendation 2) |
VBA agreed in principle with this recommendation. As of November 2023, VBA completed a final risk assessment and identified the number of exams erroneously completed under license portability and the number of veterans affected. VBA also consulted with VA's Office of General Counsel to measure the risk of a negative impact on veterans' disability claims. VBA determined that the exams were completed by licensed providers and, as such, any risk to veterans' claims from the erroneous use of license portability was very unlikely. As a result, VBA found that no corrective actions were needed.
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| Department of Veterans Affairs | The Under Secretary for Health should clarify guidance issued to VHA medical facilities regarding the statutory requirement to temporarily halt efforts to eliminate disability examiner positions. Specifically, the clarified guidance should define what constitutes (1) a programmatic change to disability exam services and (2) a medical examiner position. (Recommendation 3) |
VHA agreed with this recommendation. In September 2023, VHA provided updated guidance to its medical facilities regarding the requirement to temporarily halt efforts to eliminate disability examiner positions. This guidance provided definitions and examples of what constitutes a programmatic change to disability exam services and a disability medical examiner position. Additionally, the guidance identified incentives available to help facilities recruit and retain medical examiners. This guidance should help ensure a consistent understanding and implementation of potential changes to VHA's disability medical exam staffing across its medical facilities.
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