All Reports

Date Issued
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Report Number
24-00510-167
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Topics:  Financial Management

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No. 1
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to Veterans Benefits Administration (VBA)

Reduce improper and unknown payments to below 10 percent for the Pension Program. This is a repeat recommendation from the OIG’s FY 2022 report.

No. 2
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to Veterans Health Administration (VHA)

Reduce improper and unknown payments to below 10 percent for the Purchased Long-Term Services and Supports Program. This is a repeat recommendation from the OIG’s FY 2022 report.

Date Issued
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Report Number
23-01059-72
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Topics:  Claims and Medical Exams

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No. 1
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to Veterans Benefits Administration (VBA)

Formalize the executive director’s intent by requiring the submission to the OIG of a related plan and documentation of progress on implementing VA’s maintenance of an independent and updated list of contract facilities.

No. 2
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to Veterans Benefits Administration (VBA)

Comply with the requirements of the customer satisfaction survey contract to route exam comment cards directly between the survey vendor and veteran.

No. 3
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to Veterans Benefits Administration (VBA)

Develop and implement formal standard operating procedures for the contract exam facility site visits detailing roles, responsibilities, objectives, and monitoring.

No. 4
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to Veterans Benefits Administration (VBA)

Update the Medical Disability Examination Office site visit checklist to include a focus on specific ADA and OSHA criteria required by contracts with exam vendors.

No. 5
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to Veterans Benefits Administration (VBA)

Complete a standardized training plan for staff who conduct site visits at contract exam facilities to include ADA and OSHA compliance.

No. 6
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to Veterans Benefits Administration (VBA)

Ensure the Medical Disability Examination Office is conducting complaint-based contract facility inspections.

No. 7
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to Veterans Benefits Administration (VBA)

Enforce contractual requirements for vendors to conduct inspections and recertify all facilities to ensure ADA and OSHA compliance.

No. 8
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to Veterans Benefits Administration (VBA)

Review and analyze all veteran complaints related to exam facilities received through all entities and perform complaint-based site visits or create action plans, as necessary.

No. 9
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to Veterans Benefits Administration (VBA)

Make certain that the Medical Disability Examination Office develops a plan with the vendors to determine if each veteran seeking an exam requires accessibility arrangements prior to scheduling.

Date Issued
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Report Number
22-03463-60
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Topics:  Claims and Appeals

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No. 1
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to Veterans Benefits Administration (VBA)

Implement a plan to strengthen the National Work Queue division’s monitoring of claims awaiting decision at its own location to ensure its rules are operating as intended and make adjustments as needed.

No. 2
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to Veterans Benefits Administration (VBA)

Ensure the Office of Field Operations includes the National Work Queue division’s functioning in its annual internal controls assessment and statement of assurance.

Date Issued
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Report Number
23-02020-85
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Topics:  Appointment Scheduling and Wait Times ● Community Care

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No. 1
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to Veterans Health Administration (VHA)

Ensure that personal information of veterans who have passed away while waiting for community care consults to be scheduled is only shared with staff who need to know for specific work assignments.

No. 2
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to Veterans Health Administration (VHA)

Conduct a strategic business evaluation of the community care department’s workflow processes to determine if there are alternatives that could improve consult processing and scheduling efficiency and timeliness.

No. 3
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to Veterans Health Administration (VHA)

Continue to increase specialty provider availability in VA and the community for veterans assigned to the Martinsburg VA medical facility.

No. 4
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to Veterans Health Administration (VHA)

Ensure that the performance plan of the chief of community care has standards related to the metrics for community care.

Date Issued
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Report Number
23-00967-64
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Topics:  Education and Loan Guaranty

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No. 1
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to Veterans Benefits Administration (VBA)

Develop and implement policies and system controls to ensure all programs approved for use by vocational rehabilitation counselors for Veteran Readiness and Employment participants meet the requirements of applicable laws and regulations

No. 2
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to Veterans Benefits Administration (VBA)

Train all appropriate Veteran Readiness and Employment regional office staff on manual requirement to verify the programs are approved for use before selecting participants and to verify facility codes match from authorization through enrollment.

Total Monetary Impact of All Recommendations
Open: $ 387,000.00
Closed: $ 0.00
Date Issued
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Report Number
23-00153-41
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Topics:  Claims and Fiduciary

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No. 1
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to Veterans Benefits Administration (VBA)

Conduct a review of the convalescence claims for hip and knee replacements and resurfacing completed from February 7, 2021, through August 31, 2022, and take appropriate actions to correct convalescence periods and ensure monetary benefits are accurate.

No. 2
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to Veterans Benefits Administration (VBA)

Implement a plan to assist employees with determining the effective date, incorporating the initial month under 38 C.F.R. § 4.30, and calculating the duration of convalescence.

No. 3
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to Veterans Benefits Administration (VBA)

Develop implementation procedures to include monitoring the accuracy of claims processing when the related rating schedule has been revised.

No. 4
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to Veterans Benefits Administration (VBA)

Supplement training on the rating schedule updates to include how to apply the changes to help ensure comprehension.

Total Monetary Impact of All Recommendations
Open: $ 3,300,000.00
Closed: $ 0.00
Date Issued
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Report Number
23-01690-31
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Topics:  Claims and Appeals

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No. 1
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to Veterans Benefits Administration (VBA)

Direct the Office of Financial Management to continue to develop a system for digitally capturing, analyzing, and monitoring public questionnaires to identify inauthentic or potentially fraudulent questionnaires and work with the Compensation Service to develop policies for reviewing and remediating any such public questionnaires identified.

No. 2
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to Veterans Benefits Administration (VBA)

Have the Medical Disability Examination Office update the examiner certification and signature section found in public questionnaires to include that the form is being completed under the penalty of perjury and to ask examiners to list any organizations that requested they complete the examinations on the claimant’s behalf.

No. 3
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to Veterans Benefits Administration (VBA)

Instruct the Compensation Service to provide claims processors guidance in the procedures manual on how to identify a potentially fraudulent public questionnaire, and provide the steps they should take when they suspect that a public questionnaire may be inauthentic or potentially fraudulent.

No. 4
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to Veterans Benefits Administration (VBA)

Require the Compensation Service to inform claims processors as part of the public questionnaire review process that they have a duty to review and weigh all the evidence of record, including public questionnaires, and that they have the responsibility to assign low or no probative value if they have reason to suspect that the public questionnaire is inauthentic or potentially fraudulent.

No. 5
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to Veterans Benefits Administration (VBA)

Direct the Veterans Benefits Administration to develop and provide training on authentication and fraud, including training related to public questionnaires, to provide claims processors with the knowledge to identify inauthentic or potentially fraudulent public questionnaires, and include what steps claims processors should take when they make that determination.

Date Issued
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Report Number
21-02984-179
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Topics:  Care Coordination ● Community Care ● Contract Integrity ● Patient Care Services Operations

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No. 1
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to Veterans Health Administration (VHA)

Coordinate with the executive director of the Prosthetic and Sensory Aids Service and officials from the Veterans Health Administration’s Procurement and Logistics Office and the VA Office of Acquisition, Logistics, and Construction to develop and implement a sourcing strategy, such as national contracts or a pricing catalog across all contracts by vendor for eyeglasses prescribed by a VA provider.

No. 2
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to Veterans Health Administration (VHA)

Coordinate with the executive directors of the Prosthetic and Sensory Aids Service and the Veterans Health Administration’s Office of Procurement to implement a process to ensure contracting officers coordinate before awarding any Veterans Integrated Service Network–level contracts for eyeglasses to make sure these vendors offer the Veterans Health Administration the best pricing that is also consistent for the same or similar items to the extent possible.

Total Monetary Impact of All Recommendations
Open: $ 6,500,000.00
Closed: $ 0.00
Date Issued
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Report Number
22-02936-175

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No. 1
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to Veterans Benefits Administration (VBA)
Implement technology improvements and demonstrate progress to ensure the accuracy and completeness of information on the hypertension summary sheet.
No. 2
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to Veterans Benefits Administration (VBA)
Implement a process to communicate any change in policy, procedure, or the claims processing manual associated with all automated diagnostic codes between the Office of Automated Benefits Delivery, the Office of Policy and Oversight, the Office of Field Operations, and Compensation Service to ensure guidance is clear and consistent for all claims processors.
No. 3
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to Veterans Benefits Administration (VBA)
Implement an improved quality assurance process and monitor the results to ensure the accuracy of hypertension summary sheets and final decisions.
No. 4
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to Veterans Benefits Administration (VBA)
Create or amend metrics to compare the timeliness of claims processing using automation tools versus the traditional process.
Date Issued
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Report Number
22-01624-143

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No. 1
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to Acquisitions, Logistics, and Construction (OALC),Veterans Health Administration (VHA)
Issue guidance clarifying that allergens are exempt from the public law and include how the determination was reached.
No. 2
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to Acquisitions, Logistics, and Construction (OALC),Veterans Health Administration (VHA)
Formalize and communicate the process for manufacturers to request exemptions.
No. 3
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to Acquisitions, Logistics, and Construction (OALC),Veterans Health Administration (VHA)
Formalize the internal process for granting exemptions.
No. 4
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to Acquisitions, Logistics, and Construction (OALC),Veterans Health Administration (VHA)
Establish a procedure for monitoring covered drugs identified in this report as not commercially sold.
No. 5
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to Acquisitions, Logistics, and Construction (OALC),Veterans Health Administration (VHA)
Develop a procedure to monitor covered drugs identified in this report as newly launched to ensure they have an established ceiling price, and make certain they are made available on the Federal Supply Schedule at the end of the 75-day period.
No. 6
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to Acquisitions, Logistics, and Construction (OALC),Veterans Health Administration (VHA)
Request that noncompliant manufacturers identified by the Office of Inspector General conduct a self-audit and submit their findings for remediation.
No. 7
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to Acquisitions, Logistics, and Construction (OALC),Veterans Health Administration (VHA)
Engage with the Food and Drug Administration to ensure that when manufacturers request new national drug codes, they are made aware of the public law requirements.
No. 8
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to Acquisitions, Logistics, and Construction (OALC)
Require contracting staff at the National Acquisition Center to conduct a covered drug check for all of a manufacturer’s drugs when any pharmaceutical Federal Supply Schedule proposal or product addition modification is submitted.
Total Monetary Impact of All Recommendations
Open: $ 28,100,000.00
Closed: $ 0.00
Date Issued
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Report Number
23-01011-148

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No. 1
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to Veterans Health Administration (VHA)

The under secretary for health to make sure all scheduling guidance and other materials correctly refer to the date that should be used to determine wait-time eligibility for community care.

No. 2
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to Veterans Health Administration (VHA)

The under secretary for health to make sure the Office of Integrated Veteran Care provides ongoing oversight to ensure all facilities are using nationally approved scheduling tools.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The under secretary for health to develop an oversight process to verify that schedulers are using the correct dates to calculate wait-time eligibility for community care.

No. 4
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to Veterans Health Administration (VHA)

The under secretary for health to develop a mechanism to notify schedulers when it is appropriate to consider wait-time eligibility for community care regardless of which scheduling system schedulers are using.

Date Issued
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Report Number
22-02064-155

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No. 1
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to Veterans Health Administration (VHA)
Require the Office of Regulations, Appeals, and Policy, in coordination with the Office of General Counsel, to determine whether the Office of Dentistry and the Consolidated Patient Account Center Program have appealable benefits decisions governed by the AMA, and if so, to update program policies, processes, and procedures accordingly, including ensuring that claimants receive written decision notices that meet all act requirements.
No. 2
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to Veterans Health Administration (VHA)
Require the Office of Regulations, Appeals, and Policy to evaluate the program offices’ barriers to including all required elements in decision notices and take corrective action, seeking congressional relief if needed.
No. 3
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to Veterans Health Administration (VHA)
Using the evaluation findings from recommendation 2, require Payment Operations to update its systems to generate AMA-compliant decision notices to the extent possible.
No. 4
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to Veterans Health Administration (VHA)
Using the same evaluation findings, require the Veteran and Family Member Programs to update its systems to generate AMA-compliant decision notices to the extent possible.
No. 5
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to Veterans Health Administration (VHA)
Require the Office of Regulations, Appeals, and Policy and the program office for Member Services’ Eligibility and Enrollment Division to ensure that priority group assignment decision notices are provided with enrollment handbooks given to veterans.
No. 6
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to Veterans Health Administration (VHA)
Identify resources and assign duties to conduct quality control reviews of decision letters with program offices to remediate deficiencies.
No. 7
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to Veterans Health Administration (VHA)
Work with the Office of Information and Technology to update Caseflow to address identified VHA system requirements within specified deadlines, including adding a program identifier and facilitating entries for individuals and entities that are not veterans.
No. 8
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to Veterans Health Administration (VHA)
Establish interim tracking procedures with the program offices until Caseflow can be considered a reliable system for VHA oversight.
No. 9
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to Veterans Health Administration (VHA)
In coordination with the Office of General Counsel, seek clarification on how the reporting metrics sections of the Appeals Modernization Act apply to VHA, and then develop those measures.
No. 10
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to Veterans Health Administration (VHA)
Issue policy and other clear guidance that includes standard tracking processes and procedures, and oversight of that tracking.
No. 11
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to Veterans Health Administration (VHA)
Work with VBA and others to allow access to all VHA program offices, and ensure that those offices in turn require that staff use the Centralized Mail Portal for all decision reviews or establish another mechanism that ensures all decision reviews are tracked from request receipt through routing and processing.
No. 12
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to Veterans Health Administration (VHA)
Work with the Office of Information and Technology to determine the best way to create a central repository and identify the necessary resources to implement and maintain it.
No. 13
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to Veterans Health Administration (VHA)
Develop decision review retention standards and communicate to the relevant programs what types of claims and appeals documentation should be stored, for how long, and where.
No. 14
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to Veterans Health Administration (VHA)
Implement training on processing and tracking appeals that is mandatory for VHA staff who process decision reviews.
Date Issued
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Report Number
22-02194-152

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No. 1
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to Veterans Benefits Administration (VBA)

The under secretary for benefits update the instructions provided to examiners for completing Gulf War general medical examinations to add the definitional requirements for medically unexplained illness as outlined in 38 C.F.R.§ 3.317 and clarify the instructions and related procedures to reflect that an examiner’s determination that a disability pattern is an undiagnosed illness or a medically unexplained illness requires a written explanation.

No. 2
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to Veterans Benefits Administration (VBA)

The under secretary for benefits implement a plan to update the Gulf War general medical examination disability benefits questionnaire to add the definitional requirements for medically unexplained illness as outlined in 38 C.F.R.§ 3.317.

No. 3
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to Veterans Benefits Administration (VBA)

The under secretary for benefits implement a plan to incorporate into the Gulf War general medical disability benefits questionnaires the clinical requirements listed in 38 C.F.R.§ 3.317 for an undiagnosed illness and a medically unexplained illness.

No. 4
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to Veterans Benefits Administration (VBA)

The under secretary for benefits implement a plan to incorporate into the appropriate medical disability benefits questionnaires the diagnostic criteria for functional gastrointestinal disorders from 38 C.F.R.§ 3.317 and require examiners to provide an explanation of whether the disorder is functional or structural. This should include a requirement that any necessary testing has been completed before examiners diagnose specific functional gastrointestinal disorders.

No. 5
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to Veterans Benefits Administration (VBA)

The under secretary for benefits update VA’s Adjudication Procedures Manual to clearly state that all the requirements of 38 C.F.R.§ 3.317 must be met to award benefits. Clarify and reiterate instructions to claims processors that benefits should only be awarded after taking into consideration the overall evidence of record.

Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 25,600,000.00
Date Issued
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Report Number
22-03806-162
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Topics:  Electronic Health Records Modernization (EHRM)

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No. 1
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to Veterans Benefits Administration (VBA)
Conduct national refresher training on the Electronic Health Record Modernization National Process Memorandum and assess training effectiveness
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)

Consider updating VA Manual 21-4 to reflect that quality assurance measures include addressing failures to consider all Veterans Health Administration records as directed in the Adjudication Procedures Manual that are subject to an enterprise-wide search in the Compensation and Pension Records Interchange system whether or not directed to those records by the claimant and ensure staff are advised of the changes.

Date Issued
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Report Number
22-03543-151
Related Media: Video

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)

The Pension and Fiduciary Service clarifies procedural requirements to fiduciary hub staff on how to verify whether VA-derived funds of deceased beneficiaries must be returned to VA, including whether the fiduciary identified any valid will or heir to whom the funds are otherwise due.

No. 2
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to Veterans Benefits Administration (VBA)
The Pension and Fiduciary Service considers reimplementing the procedural requirement to verify the disbursement of VA-derived funds to deceased beneficiaries’ estates when a valid will or heir exists.
No. 3
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to Veterans Benefits Administration (VBA)

The Pension and Fiduciary Service identifies existing or implements new electronic controls that allow VBA staff to track Fiduciary Program tasks, timeliness, and workload related to the return of deceased beneficiaries’ VA-derived funds to VA that would otherwise escheat to a state if not disbursed to heirs.

No. 4
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to Veterans Benefits Administration (VBA)

The Pension and Fiduciary Service and the Office of Field Operations establish a methodology and monitor workload to ensure the prompt return of deceased beneficiaries’ VA-derived funds.