VHA Faces Challenges Implementing the Appeals Modernization Act

Report Information

Issue Date
Report Number
22-02064-155
VISN
1
State
District
Continental
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Audits and Evaluations
Report Type
Review
Recommendations
14
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The Appeals Modernization Act (AMA) of 2017 charged VA with establishing a new process for more quickly and transparently reviewing benefit claims decisions with which veterans disagree. VA implemented the AMA in 2019, and though it largely focuses on Veterans Benefits Administration benefits decisions, it also applies to those made by the Veterans Health Administration (VHA), such as clothing allowances related to prosthetics use and reimbursement of non-VA emergency care. The VA Office of Inspector General (OIG) previously reported on difficulties with the appeals modernization rollout. Additional concerns prompted this review to determine whether VHA processed and tracked appeals of benefits decisions in accordance with the AMA’s requirements and two VHA interim policy notices. Based on a nonstatistical sample of 180 decision reviews initiated between February 19, 2019, and June 27, 2022, the OIG found • VHA program offices did not give claimants the information needed to initiate higher-level reviews and supplemental claims regarding benefits decisions. Before VHA can process decision reviews, both the AMA and VHA’s interim policy notices require that claimants receive an explanation as to why a claim was denied, steps for seeking further review of a denied benefit, and other information. • VHA did not accurately track reviews because it did not implement effective systems, sufficient policies, or adequate training. VHA’s many programs were operating independently, and most did not have effective tracking systems. VHA’s two interim policy notices required tracking but lacked specificity and were in effect for only one year each. By not effectively tracking reviews, VHA risks not processing reviews or not granting veterans the benefits to which they are entitled. The OIG made 14 recommendations to the under secretary for health to improve information given to claimants, centralize intake, and better track and standardize retention of decision reviews.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
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
Open Recommendation Image, Square
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
Open Recommendation Image, Square
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
Open Recommendation Image, Square
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
Open Recommendation Image, Square
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
Open Recommendation Image, Square
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
Open Recommendation Image, Square
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
Open Recommendation Image, Square
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
Open Recommendation Image, Square
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
Open Recommendation Image, Square
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
Open Recommendation Image, Square
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
Open Recommendation Image, Square
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
Open Recommendation Image, Square
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
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Implement training on processing and tracking appeals that is mandatory for VHA staff who process decision reviews.