VA Improperly Processed Over 30,000 Veterans Claims Involving the Spine

The mission of the Office of Inspector General (OIG) is to serve veterans and the public by conducting effective oversight of the programs and operations of the Department of Veterans Affairs through independent audits, inspections, reviews, and investigations.  In September 2019, OIG conducted a review of the Veterans Benefits Administration’s processing of veterans’ claims involving the spine.

Summary of the OIG Review for Claims of the Spine

According to Veterans Benefits Administration (VBA) data, approximately 1.5 million veterans have been granted service connection for disabilities involving the spine as of September 30, 2018.  Conditions related to the spine account for two of VA’s top ten most prevalent service-connected disabilities.  The OIG identified that disability claims related to conditions of the spine are at a higher risk for processing errors, which can result in veterans not receiving the disability compensation benefits for which they are eligible.  This OIG review sought to determine the following:

1. Whether VBA staff accurately processed veterans’ claims for conditions; and
2. Whether VBA personnel were accurate in processing claims for secondary service-connected conditions related to the spine.

What the Review Found

The OIG determined that VBA incorrectly processed more than half (56 percent) of the 62,500 veterans’ claims decided from January 1, 2018 to June 30, 2018.  Processing errors included improper evaluations, missed secondary conditions, and evaluations based on inadequate exams.  The OIG team identified processing errors in two different categories:

1. About 5,000 errors involved disability claims that VBA decided incorrectly and that affected veterans’ compensation benefits payments. These errors resulted in inaccurate payments (i.e. any payments that should not have been made or that were made in an incorrect amount, including both overpayments and underpayments) of at least $5.9 million.
2. About 29,800 errors involved disability claims that had the potential to affect veterans’ compensation benefits payments because rating specialists made decisions before completing all required VBA procedures as set out in the adjudication procedures manual (e.g. returning medical exams to obtain clarification when needed). In these cases, the OIG team could not determine the specific monetary impact of the errors.  Had rating specialists completed all required actions, it could have led to a different decision.

Overall, the OIG found that all 34,700 incorrectly decided veterans’ claims resulted from VBA’s inadequate process for ensuring accurate and complete evaluation.  The OIG team estimated that VA could pay an additional $58.9 million in improper payments over the next five years unless VBA implements procedures to improve the decision-making process for veterans’ claims for conditions of the spine.

Such improvements may involve the following: (1) an updated rating disabilities schedule and procedures manual to establish objective criteria for spine-related conditions; and (2) updated internal controls to help ensure the accuracy and consistency of claims decisions for conditions of the spine.

VBA acknowledged that the issues the OIG identified were problematic and has taken steps to update some of its tools and guidance.  Additionally, VBA has initiated mandatory training on medical opinion requirements for all rating specialists and quality reviewers.

OIG Recommendations for Claims of the Spine

The OIG recommended that the VA undersecretary for benefits, Dr. Paul Lawrence, conduct a focused analysis to assess the accuracy of claims processors seeking clarification on exams and develop a plan to update the following: the rating schedule, procedures manual, and disability questionnaire forms for conditions of the spine.  Dr. Paul Lawrence concurred with these recommendations and provided acceptable action plans.  Going forward, the OIG will monitor VBA’s progress and follow up on implementation of the recommendations until all proposed actions are completed.