Veteran Oversight Now

Louis Calderon:

This is Veteran Oversight Now, the Veterans Affairs Office of Inspector General official podcast. I’m your host, Louis Calderon.
Dr. Julie Kroviak, acting assistant inspector general for the Office of Healthcare Inspections, testified before the House Veterans’ Affairs’ Subcommittee on Oversight and Investigations on April 30. Her testimony focused on the OIG’s independent oversight of VA’s mental health services, programs, and policies. Dr. Kroviak discussed VHA personnel’s suicide risk assessments and the care management of veterans—from the first opportunity to screen veterans for risk factors through interventions and follow-up or ongoing care. In response to questions, she discussed actions VHA must take to implement the OIG’s recommendations regarding consistent execution of VHA policies to provide high-quality mental health services to veterans.

Dr. Julie Kroviak:

“Our mental health inspection teams consistently review the environment and care practices of VHA’s acute inpatient mental health units, repeatedly finding lapses in preparing patients for discharge. Because the highest risk for suicide occurs within the first 30 days after hospitalization, VHA staff should unfailingly carry out activities such as pre-discharge screenings, determinations of access to lethal means, and a suicide prevention safety plan to confirm that a hospital discharge is appropriate and safe for each patient. . . While the tragedy of a veteran suicide can overwhelm survivors and healthcare teams, lessons learned can and must support efforts to reduce future suicides. Our work has identified numerous delays and deficiencies in important internal VA reviews after a veteran completes suicide, including root cause analyses, peer reviews, institutional disclosures, and family interviews. Such delays not only impede improvements but also deprive loved ones of important grief management resources.”

Louis Calderon:

Several OIG investigations had updates in April.

A multiagency investigation resolved allegations that a national chain pharmacy filled unlawful prescriptions for excessive quantities of opioids and then sought payment from federal healthcare programs, including CHAMPVA. The pharmacy agreed to a $300 million civil settlement with the Department of Justice to resolve allegations that its pharmacies and various subsidiaries filled millions of fraudulent prescriptions for opioids and other controlled substances in violation of the Controlled Substances Act and False Claims Act for more than 10 years. The pharmacy also agreed to pay an additional $50 million if the company is sold, merged, or transferred prior to fiscal year 2032. VA’s portion of the settlement is approximately $632,000.
A VA OIG investigation revealed that a defendant owned and operated a for-profit, non-college degree school that purported to offer comprehensive massage training to veterans. Though the school was prohibited from offering distance learning, the investigation revealed that most veterans lived far away, received very few if any hours of instruction, and did not obtain their state-issued massage licenses. From 2012 to 2022, the defendant falsely represented veteran enrollments, which resulted in VA education benefits payments totaling $9.8 million. The defendant pleaded guilty in the District of Hawaii to conspiracy to commit wire fraud.
An investigation by the VA OIG, VA Police Service, and FBI resulted in charges alleging that a physician at the Bedford VA Medical Center in Massachusetts uploaded and stored suspected child pornography on several devices, including a cell phone that he kept in his VA office. The defendant was arrested and charged in the District of Massachusetts with the receipt and possession of child pornography.
Meanwhile, the OIG published 12 reports in April.
One of these reports is an independent audit on a transportation company’s billing practices under a VA healthcare system contract. VA asked the OIG to conduct an audit of a contractor that provided eligible veterans with wheelchair van and other nonemergency transportation services to and from medical appointments. The OIG found the company may not have complied with contract terms, resulting in an estimated $1.81 million in potential overbillings between January 1, 2019, and December 31, 2021. Of this amount, $1.34 million was related to unclear contract terms and the company’s methodology for billing remote trips with multiple stops as though each drop-off was a separate trip. The OIG also found that the company used mileage estimates instead of miles traveled and may have misclassified trips, resulting in potentially overbilling VA by more than $470,000. The OIG recommended—and VA agreed—that VA should confer with its Office of General Counsel on whether any funds could or should be recouped.
Another report resulted from the OIG receiving a hotline allegation from a VA medical center employee about improper sharing of sensitive information on VA’s internal network. The complainant reported that an employee could search for fellow employees on the internal network and find documents and emails that contained sensitive personal information, including human resources paperwork and personally identifiable information for veterans getting surgery. The OIG confirmed sensitive personal information was accessible by users who had no business need to access it and that the information exceeded the security authorizations of the systems it resided on. The OIG recommendations included removing unauthorized sensitive personal information from collaborative application sites such as SharePoint, as well as directing facilities and programs to: standardize SharePoint administration, inventory and consolidate their SharePoint sites, and enforce recommended architecture to allow greater control of permissions and content.
A report by the OIG’s Office of Healthcare Inspections discussed an OIG inspection of the VA Eastern Kansas Healthcare System. The inspection team substantiated that a patient experienced a delay in the diagnosis of and treatment for lung cancer. The OIG identified concerns with:
• the system providers’ failure to order a bronchoscopy and follow up on test results,
• community care staff’s failure to retrieve patient records, and
• the absence of an established process for community care providers to communicate abnormal test results to ordering providers.
The OIG also found a failure of community care staff to make three attempts to retrieve patient records within 90 days of completed community care appointments. Also, system leaders failed to develop the lung cancer screening program’s infrastructure prior to implementation, and the program lacked oversight and multidisciplinary engagement. The OIG made one recommendation to the under secretary for health related to the communication of patients’ abnormal test results and one recommendation to the VISN director regarding the system’s lung cancer screening program. Four recommendations related to test results, institutional disclosures, and community care records were made to the system director.
Other OIG reports published in April include three healthcare facility inspections reports on facilities in Tennessee, New York, and Colorado.
And we conclude April’s highlights with a featured hotline case.
The OIG Hotline received allegations that the Palo Alto VA Medical Center’s Home Oxygen Program lacked clinical oversight, posing a risk to the continued prescription eligibility of the 197 patients enrolled in home oxygen services. The matter was referred to VISN 21 officials for review, who substantiated the allegations and found that the program did not comply with VHA directives.
The review found that two of three program clinical leadership positions were vacant, and these vacancies resulted in poor program management and oversight. Also, providers failed to review and manage prescriptions—approximately 20 percent of the enrolled patients’ prescriptions had lapsed in FY 2024.
In addition, vendor audits in the second, third, and fourth quarters of FY 2024 were not conducted. The VISN implemented 10 corrective actions to bring the program into compliance, including assigning program clinical leaders, tasking the medical center’s chief of prosthetics to review and monitor all FY 2025 audits, and initiating provider training. The VISN also coordinated with facility clinical and prosthetics staff to create a proactive prescription monitoring process.
Read more about the VA OIG’s oversight work in April 2025 on our website at vaoig.gov. Stay up to date! Sign up to receive email messaging from the VA OIG. 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. Tune in monthly to hear how the VA OIG serves veterans, their families, and caregivers through meaningful independent oversight. 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 at vaoig.gov 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 988, press 1, and speak with a qualified responder now.