Veteran Oversight Now

Fred Baker:
Welcome back to another podcast episode of Veteran Oversight Now, an official podcast of the VA Office of Inspector General. I'm your host, Fred Baker.
Each month on this podcast, we'll bring you highlights of the VA OIG’s recent oversight activities and interview key stakeholders in the office's critical work for veterans.
Joining us today is Leigh Ann Searight and Brent Arronte. Leigh Ann and Brent are both deputy assistant inspectors general for the Office of Audits and Evaluations. Welcome, Leigh Ann and Brent. How are you today?
Leigh Ann Searight:
Great, thank you, Fred.
Brent Arronte:
Doing well.
Fred Baker:
Well, your office just recently released two reports related to burn pits and toxic exposure. One was on VA's management of the registry and exam process, and the other was a review of veterans claims decisions associated with burn pit exposure.
This topic is very timely given the recent passage of the PACT Act, which will make available benefits to millions of veterans who were exposed to toxic substances during their military service. This is a very serious topic, but before we get to these two reports, I'd like to take this opportunity to introduce you to the listeners.
I'd like you to give us a little idea of who you are. Can you talk a little bit about yourself, your family, and your hobbies? And what brought you to the VA OIG? Leigh Ann, why don't you start?
Leigh Ann Searight:
Sure. I've been with the VA OIG for about four and a half years after 20 years with Army Audit Agency. I'm a mom of two rough and tumble boys, and I've decided that I'm going to soon be an aspiring senior circuit golfer once I retire. But good thing that I'm not retiring for at least another 15 years. I've got a long way to go.
Fred Baker:
What's your handicap?
Leigh Ann Searight:
I have no idea.
Fred Baker:
Okay, Brent.
Brent Arronte:
So, I joined the VA OIG in 2005, so I've been with the IG approximately 17 years. Prior to that, I am retired army, and then I worked for a VA regional office for about four or five years before joining the VA OIG.
Currently, I am located at our Bay Pines campus in Saint Petersburg, Florida, where my wife and son and two daughters also reside with me. I think one of my—two of my hobbies is I like refereeing young folk’s sports and baseball and football, and I also aspire to play golf. I'm not as good as Leigh Ann, and my handicap would be embarrassing.
Fred Baker:
Great. Great. Thanks. So, turning to the report—Brent, Leigh Ann, you both lead cohorts that have different oversight focuses, which is why we have two reports instead of just one.
Leigh Ann, explain to the listeners the focus of your cohort and how it applies to your report.
Leigh Ann Searight:
Sure.
Fred Baker:
And then, Brent, if you'll follow up with the same question.
Leigh Ann Searight:
So, my cohort is the Veterans Affairs—Veterans Health Affairs cohort, and our focus is really on any program and operations within the within the VHA portfolio, however, and that could stretch from supply chain management to suicide prevention. However, what we don't focus on is quality of care. We leave that work to the Office of Health Care Inspections.
Brent Arronte:
And my cohort, we are responsible for the oversight of the Veterans Benefits Administration, also known as VBA, and the National Cemetery Administration, also known as NCA.
Our coverage is over all disability and pension compensation claims, education services, vocational readiness or veteran readiness and employment, loan guarantee, and insurance programs.
Fred Baker:
Great. So, let's get into the content of the reports. Leigh Ann and Brent, can you both start by explaining to the listeners exactly what are burn pits and generally where they occurred. Help draw that picture for the listeners about what we're talking about. Because we're not really talking about just, you know, barrels of burning trash, right?
Brent Arronte:
Correct. Burn pits have been used by military forces as long as we've had military forces. As they relate to our reports, we focused on those burn pits located in Iraq, Afghanistan, and Djibouti. Burn pits are just that, pits dug into the ground that are used to dispose of solid waste. This waste can be anything from plastic, paper, and human waste. Typically, these military forces use some type of fuel, generally jet fuel, to ignite and burn the waste. Burn pits can be as small as a little hole in the ground, up to 10 to 20 acres wide. These toxins are—the toxins that come from these burn pits are a result of the waste being destroyed. But one of the issues is all the waste, 100% of the waste, is never destroyed. And the waste that gets into the air is transmitted to where our veterans are serving, our service members are serving. And we believe that as how exposure to these toxins occur.
Fred Baker:
Great. Leigh Ann, let's talk about your report first: Airborne Hazards and Open Burn Pit Registry Exam Process Needs Improvement. In 2013, Congress mandated the VA establish this airborne hazards and open burn registry to research potential health impacts of such exposures during military service.
What can you tell us about the registry and what did veterans have to do to get on the registry?
Leigh Ann Searight:
Right. So, the registry, as you mentioned, was mandated in 2013 for VA to create, and VHA was assigned to that responsibility as they're the research and health care arm of VA.
However, the mandate didn't actually require exams, but VHA made the decision to add exams to that process so that they could use it as a platform to collect information to inform their research. So, the registry itself was established in 2014 and it's an online questionnaire with approximately 140 questions. And it usually takes the veteran about 30 minutes to an hour to complete. And the questionnaire gives veterans an opportunity to request an exam as part of that process. They're not required to do an exam, but they have the option to request that exam. And that's at no charge to the veteran to do the exam.
And the focus of the questionnaire really is on the length and proximity of exposure to the specific hazard. So that's really the information they're trying to gather out of that registry.
So, to even register to do the registry exam, you have to be eligible. And that eligibility is determined based on where you were deployed. So, if you were deployed to Southwest Asia after August 2, 1990, or if you were deployed to Afghanistan, Syria, Djibouti, Uzbekistan on September 19, 2001 or later, then you are eligible to apply and to complete the questionnaire.
Some of the benefits of the exam are to, you know, from the veteran's perspective, it identifies the medical conditions earlier. It complements the questionnaire, the answers to the questionnaire. So, it allows for better information to the providers as they do these exams. And it also supports potential claims for compensation related to service connection. And as I said before, and all of this information further informs research, which further informs care for all veterans.
Fred Baker:
So back to the exam is not automatic by filling out the questionnaire. I understand from reading the report there was some confusion on the veterans’ part with the questionnaire and them not realizing that completing it did not automatically amount to a request for an exam. So, what was the percentage of those who completed the questionnaire but didn't schedule an exam? And how should veterans request a registry exam?
Leigh Ann Searight:
Right. So, you know, almost three million, three and a half million veterans are actually eligible to apply for, to complete the questionnaire. And of those, about 384,000 started the questionnaire, and this is as of November 30, 2021. But only 58 percent of those 384,000 veterans actually completed the questionnaire. And then if you break that down further, we found that only 125,000 of those veterans, so almost half, indicated an interest in the exam. And sadly, only 15 percent of those veterans actually received an exam.
Fred Baker:
So, why have so few received the exam? And what is VHA doing to improve the registry exam process?
Leigh Ann Searight:
There's really a number of reasons on the exam process. So, one is to receive an exam, it's on the onus of the veteran, which is really kind of counter to VHA and being veteran-centric. But it's upon the veteran to reach out to the facility to schedule the exam.
And as you complete the exam, you express interest early on in the process. And then 30 minutes to an hour passes as you're filling this out. And it gives you a little bit of an impression that you're going to be contacted because you're giving all this information. But really, it's supposed to just give you information to then contact the facility. So, at the end, it provides you a link to say, you know, here's a participation letter, here's more information to where to contact, what facility you should contact, and then they'll walk you through the process or scheduled the exam.
But, you know, COVID, as with a lot of programs over the last few years, played a big part in slowing down that exam process. A lot of the resources that VHA had dedicated to the exams were reallocated to support COVID and the care needed as part of that.
But we really believe that the predominant reason that the exam rate is so low is because veterans didn't really understand that it was up to them. We also found that the contact information that was provided to these veterans wasn't up to date as well. So, the local coordinators contact information, their phone number was wrong, the person was wrong. So, the veterans really didn't know who to contact to be able to schedule that exam. And then no facilities, or really a majority of facilities, did any outreach to reach out to these veterans. There was no requirement for them to do that; however, they were provided information that would allow them to reach out to veterans. When we found facilities that did start outreach, you know, it was two or three years for some of these veterans since they had filled out the exam and they were like, “Well, we've been waiting, you know, for you to call me. What took you so long?” And so lastly, I think really just a lack of oversight. There is a very broad lack of awareness and oversight over the process. It was very localized in how it was handled.
Fred Baker:
So, what did we recommend to address the issues with this report?
Leigh Ann Searight:
So, we made seven recommendations. First, you know, the primary recommendation that we made was to improve the questionnaire. The questionnaire is very intensive, and for good reasons. It's collecting a lot of information. But it really is wearing on the veterans to fill out. And so I think a lot of veterans lose interest in completing the questionnaire. So that's, you know, the first point of entry or removal from the process.
And then also to improve awareness and scheduling: how to schedule, increasing that outreach to allow for that scheduling, ensuring that the contact information is updated for the environmental health coordinators follow-up, requiring follow-up at the facilities to reach out to these veterans and get these scheduled, and then tracking the timeliness. They set these metrics, but then they had really no defined way to track that timeliness. So, we've asked them to assess that process as well.
And then just the, you know, the improvement of the data reliability. We found almost 14,000 veterans that were sort of lost in the data because their zip code information wasn't aligned appropriately to facilities. And then transferring, being able to transfer veterans from one facility to the next to ensure that they receive care where they need to receive care. And lastly, just the oversight and monitoring of the process, having VISN- and facility-level oversight at a greater level.
Fred Baker:
Great. Thanks, Leigh Ann.
So, is there anything else I missed about this report that you'd like to highlight?
Leigh Ann Searight:
The only other thing I would like to highlight is VHA has established or is in the process of establishing the Vet Homes Program, which is the Veterans Environmental Team Health Outcomes Military Exposure Call Center. And this is supposed to go live in October 2022. So hasn't happened yet, but they are working towards it and that is supposed to help improve the coordination of scheduling. It is still very much on the veteran to schedule those exams, but this is a better entry point into that process to allow for that. And then they'll also do telehealth exams to start the process with. And it's a call center to, you know, help veterans work through the questionnaire and answer questions.
Fred Baker:
Definitely sounds much more helpful.
Leigh Ann Searight:
Yes.
Fred Baker:
Thanks, Leigh Ann. So, we'll turn to Brent. Brent, talk about your burn pit report published in July. It was called Veterans Prematurely Denied Compensation for Conditions that Could be Associated with Burn Pit Exposure, and it focused, as we said earlier, on the process of claims related to burn pit exposure.
Can you tell us why you were conducting this review?
Brent Arronte:
Sure. It was straightforward, Fred. We were, we wanted to look at VBA's processes and procedures to make sure that they were following those accurately to ensure veterans received the compensation benefits that they deserved.
Fred Baker:
And your report says that you found that though VA staff nearly always made a correct decision in granting the compensation for conditions identified as burn pit related, you found that most denials were premature. Can you explain that?
Brent Arronte:
Sure. That's a great question. We looked at a statistical sample of claims that were granted by the VBA claims processors and the claims that were denied. The claims that were processed accurately and that were granted and processed accurately—we looked at 60, and 56 of the 60 were accurate. And the reason they were accurate is for two reasons. One, when the veterans submitted their claim, they clearly laid out that the claim was for a respiratory condition associated with burn pit exposure. That was a clear guidance, really, for the for the claims process there to say, “Oh, yes. This is a burn pit claim. I need to go follow those specific rules.” And they did. And they did it well.
We looked at a statistical sample of claims that they denied, and we found a high rate of premature denials. And that was twofold. One, in those cases, the veterans did not clearly say that this was a burn pit-related claim. And the second issue was, because of that, the claims processors did not, it just did, a light did not go off in their head saying, “Oh, this is a burn pit claim. I need to follow special rules for that.” They just saw this was a claim for a respiratory condition, and they did not associate those claimed respiratory conditions with the locations where veterans are being identified as exposed to burn pits such as Iraq, Afghanistan, and Djibouti.
Fred Baker:
So, is that what caused the premature denials, or were there other factors?
Brent Arronte:
There were other factors that caused the premature denials. Our team found that the claims processors failed to request a required medical examination. When a veteran files a claim for one of these respiratory conditions, a medical exam is needed, and a medical opinion is required that the examiner will link the veteran's current diagnosis of a respiratory condition to a burn pit exposure. That was probably the major reason why all of these were prematurely denied because they did not obtain all the required evidence before they made the decision.
Fred Baker:
And the report mentions that VBA has since updated some of its guidance. What's been updated, and how does that affect the report's findings and recommendations?
Brent Arronte:
Another good question. Yes, VBA did update their guidance. The new guidance expands the criteria to be considered when a veteran files a burn pit related claim. This new criteria now recognizes back to August of 1994, the first Gulf War, which they never considered that time period. And they also added several countries in Southwest Asia to include Syria, Egypt, Jordan, Yemen, and Lebanon. That was the major crux of their change in guidance.
And this is going to expand now for veterans that were in those areas to now file claims for burn pit because they are now in countries that are recognized as areas where these burn pits were being used extensively.
Fred Baker:
So, what were your final recommendations to VBA regarding the process in the burn pit claims.
Brent Arronte:
So, like Leigh Ann’s report, we made seven recommendations to the department. These recommendations centered around taking a relook at those claims that were prematurely denied. Go back and gather the appropriate evidence and then remake a decision. And the decision could still be a denial, but at least they now have all the evidence to make a sound decision. We asked them to update their procedures for how to process a burn pit claim, update their training materials and what's critical is to modify the medical exam request to help the examiner also understand that the claim is a burn pit claim, and they also have to now consider special criteria to determine if these respiratory conditions have the likelihood of being a result of exposure to burn pits.
Fred Baker:
So, if they know the individual served there and they're filing for a respiratory claim, that light bulb can go off and they can, “Say this is burn pit-related.”
Brent Arronte:
Right, not just for the claims processor, but for the examiner as well because if the examiner is not made aware, they're going to treat this like a regular claim for direct service connection. And if the veteran is claiming asthma, and they look in the service medical records and there's no indication of treatment for asthma, and without the consideration that they were exposed to burn pits, they would probably be denied.
Fred Baker:
Got it. Got it. Perfect. So as both of you know, the president signed the PACT Act, which was a long awaited bill expanding health care, VA health care benefits for those impacted by toxic military burn pits. Of course, after your reports were published and out of the scope of those reports, what, if any, does the passage of this legislation Have on your findings and recommendations?
Leigh Ann Searight:
For our audit, the impact, in my mind, on the PACT Act to our audit is that training is going to be reinforced, and access and awareness. Veterans now have a greater access to the exams as they enter VHA, just as a new entrant into the VHA health care realm. They'll get the burn pit toxic exposure exam from the start.
Whether they fill out the registry or not, they'll already have that exam done, which then helps ensure that their health outcomes are being monitored and if there's any association. I think that this really is going to improve that awareness and information.
Fred Baker:
Great, great. Brent?
Brent Arronte:
I agree with Leigh Ann. There's going to be increased awareness. Staff are going to have to be trained on how to evaluate and rate these types of disabilities. The PACT Act expands the areas and specific types of diseases of veterans can claim service connection for. That's not really an impact to our project, but it's going to significantly increase awareness of what types of exposures and where folks were stationed, to help them get benefits. However, I think the PACT Act is going to have a significant impact on VBA’s ability to tackle their backlogs. They are going to see an increase in claims like they have probably never seen. And this is going to test their resources.
Fred Baker:
Great. Great. Leigh Ann, Brent, is there anything else you'd like to add before we sign off today?
Leigh Ann Searight:
Nothing on my end.
Brent Arronte:
Nothing here. I appreciate you having us, Fred.
Fred Baker:
Well, thank you. Thank you for taking the time to discuss these very timely reports.
To read the full reports, go to the VA OIG website at va.gov/oig and click on reports under the Publications tab.
Now I'll turn it over to cohost Adam Roy, who will present the most recent monthly highlights of the VA OIG's oversight work. Take it Adam.
Adam Roy:

Thanks, Fred. Now, I’ll highlight some of the work the VA OIG completed in July 2022.

Emphasis on the VA’s Electronic Health Record Modernization program continued as the VA OIG testified before congress and published two more related reports.

On July 20, Deputy Inspector General David Case testified before the Senate Veterans’ Affairs Committee. The hearing focused on VA’s challenges with deploying the new electronic health record, a recently released life cycle cost estimate for the program, and the OIG’s recent reports discussing an “unknown queue” of unfulfilled medical orders and other risks to patient safety at medical facility and clinic initial operating sites. Mr. Case answered questions about the system’s unknown queue of thousands of medical orders that the system did not deliver to their intended location and other concerns the OIG has about VA’s implementation and transparency.

A week later, on July 27, Mr. Case, now joined by Principal Deputy Assistant Inspector General for Healthcare Inspections Dr. Julie Kroviak, testified before the House Veterans’ Affairs’ Subcommittee on Technology Modernization. Here, the hearing focused on VA’s deployment timeline for the new electronic health record, the program’s costs, and the OIG’s recent reports detailing problems that include the unknown queue and other risks to patient safety, as well as the barriers users face to providing prompt access to high-quality care. They answered questions about patient harm resulting from the unknown queue and voiced concerns about identified problems and their mitigation. Of note, they discussed the lack of transparency when the then Change Management leaders from VA’s Office of Electronic Health Record Modernization submitted inaccurate information to the OIG during a review of the user training for the new system and its evaluation of trainees’ proficiency.

You can find Mr. Case’s written testimony for both of these hearings on our website under the media tab. And we’ve included a link to the committees’ website in July’s monthly highlights, available under the publications tab, if you’d like to watch recordings of these hearings as well.

Both of these hearings stem from two reports on the VA’s Electronic Health Record Modernization program published in July.

The first report highlights an administrative investigation by the Office of Special Reviews. The investigation found that two leaders in VA’s then Office of Electronic Health Record Modernization Change Management group did not intentionally seek to mislead OIG healthcare inspectors during a prior review of VA’s training for medical facility staff on a new record system. However, the leaders’ carelessness resulted in delayed and inaccurate information being submitted to the OIG that impeded oversight efforts. Errors in removing all failing scores and not disclosing that data were removed and were possibly unreliable led to misreporting more favorable pass rates than those initially calculated internally. OIG recommended giving guidance to program staff on providing timely, accurate, and complete responses to OIG requests, encouraging direct staff-level communication to resolve questions, and considering whether administrative action should be taken concerning the conduct of the two leaders.

In a separate report, the OIG assessed a safety concern with the new electronic health record that resulted in patient harm. The OIG reviewed the safety risk and found that the new EHR sent thousands of orders for medical care to an undetectable location, or unknown queue, instead of the requested location. VA end-users were unaware of the unknown queue. VHA staff completed clinical reviews to assess patient harm and found the unknown queue caused 149 patient harm events. In late 2021, VHA staff provided the deputy secretary and the executive director for VA’s EHR modernization effort with information on the unknown queue safety concern and patient harm. Despite actions to minimize orders being routed to the unknown queue, the OIG has concerns with the effectiveness of Oracle Cerner’s plan to mitigate the safety risk of the unknown queue.

Now for some updates to investigations by our special agents.

An investigation by VA OIG, FBI, and the Orange County Sheriff’s Office revealed an accounting technician at the Orlando VA Medical Center solicited and received sexual content from a 13-year-old victim. The defendant used his VA-issued computer in furtherance of the sexual exploitation of this victim. This defendant pleaded guilty in the Middle District of Florida to sexual exploitation of a child and possession of child pornography.

In another investigation conducted by VA OIG and the Social Security Administration OIG resulted in charges alleging that a veteran received VA individual unemployability benefits and social security disability benefits while self-employed as a construction worker and business operator. The defendant allegedly obtained additional social security benefits for his daughter based upon his false claims as well. The defendant was found guilty by a federal jury in the Eastern District of Arkansas on charges of conspiracy to defraud the United States, theft of government funds, and bankruptcy fraud. The total loss to the government is approximately $396,000. Of this amount, the total loss to VA is approximately $132,000.

Read more about these and other cases the VA OIG investigated in the July monthly highlights.

Including the two reports I mentioned above, the VA OIG published 16 reports in July. I’ll briefly highlight a few of them.

We issued two reports about VA Regional Procurement Office, or RPO, activities. Because of problems identified in a FY 2020 report on contract closeout compliance at RPO East, the OIG reviewed to determine whether RPO Central and RPO West contracting officers adequately performed and documented contract closeout requirements. The OIG reviewed a random sample of contracts and found contracting officers at the two RPOs did not perform required closeout duties. Reasons included unclear policies and systems, ineffective oversight of the process, and heavy workload. The OIG recommended the executive directors for RPO Central and RPO West establish consistent quality assurance reviews, balance contracting officer workload, and update guidance on simplified acquisition procedures. The OIG also recommended considering additional strategies to ensure contract closeout compliance and verifying that the contract files for the 81 sampled contracts have complete closeout documentation.

In another report, the OIG reviewed whether RPO West contracting officials administered contracts and accepted supplies and services in accordance with federal and VA regulations. The OIG found they did not always maintain documentation to demonstrate proper acceptance of supplies and services. Several factors contributed to noncompliance, including officials not understanding their responsibilities, heavy workload, ineffective oversight, and prioritization of awarding contracts. This noncompliance resulted in $12.8 million in questioned cost. The OIG made eight recommendations to RPO West’s executive director to strengthen contract administration, including establishing controls to ensure electronic files are created for all contracts requiring a representative, delegation memorandums are completed when required, and representatives upload required acceptance documentation. The executive director should also assess existing contracts for compliance and correct as needed.

VA OIG’s Office of Healthcare Inspections also published two Comprehensive Healthcare Inspection reports. These reports focused on the Martinsburg VA Medical Center in West Virginia and the VA Capitol Health Care Network in Maryland.

And lastly, I’ll share a recent VA OIG hotline case. This month’s featured hotline case involves an allegation that the Community Based Outpatient Clinic in Princeton, West Virginia, had over 900 appointments that had not been scheduled. The complainant also alleged that no correspondence was sent, and no documentation was uploaded to the Computer Patient Records System. The clinic’s parent facility—the Beckley VA Medical Center—conducted a review and identified all patients seen at the clinic between January 1, 2020, and December 31, 2021.

The review found that 386 patients experienced a wait time of greater than 60 days from the patient indicated date. The review determined that 382 patients did not experience any type of harm because of the delay, and the remaining four patients were determined as unknown. As a result of the findings, the clinic implemented several corrective actions. These include using resources from Beckley VA Medical Center to help the Princeton clinic work their backlog; a new daily checklist for medical support assistants to certify daily completion of their requirements; a new local standard operating procedure for medical support assistants to process orders and other documents; and the elimination of unnecessary processes.

That’s it for the July highlights. Read all monthly highlights on our website.

While you are there, check out a relatively new feature—the VA OIG’s Fraud Toolkit and Crime Alerts. The VA OIG investigates a wide range of potential crimes—from financial crimes to threats against VA personnel and property to actions associated with patient harm.

The toolkit provides a list of key possible indicators specific to various types of fraud. The list is far from exhaustive, but it identifies common signs that VA personnel, contractors, and the veteran community, and maybe some of you listening out there, should be aware of in order to report suspicious activity and alleged wrongdoing to the OIG hotline. Examples of potential indicators include compensation benefits fraud, healthcare fraud, public corruption and kickbacks, and fraud related to public health crises, like we have seen recently with the pandemic. You can find the toolkit right on our home page.

That’s it for this episode of Veteran Oversight Now.

I encourage you to check out other episodes wherever you listen to podcasts. Thanks for listening.

This has been an official podcast of the VA Office of Inspector General. Veteran Oversight Now is produced by the Office of Communications and Public Affairs and is available at va.gov/oig. Tune in monthly to hear how the VA OIG serves veterans, their families, and caregivers, through meaningful independent oversight. Check out the website for more on the VA OIG oversight mission, read current reports, and keep up to date on the latest criminal investigations. Report potential crimes related to VA; waste or mismanagement; potential violations of laws, rules, or regulations; or risks to patients, employees, or property to the OIG online or call the hotline at 1-800- 488-8244. If you are a veteran in crisis or concerned about one, call the Veterans Crisis Line at 1-800- 273-8255, press 1, and speak with a qualified responder now.