Veteran Oversight Now

Fred Baker
Welcome back to another 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 OIG's recent oversight activities and interview key stakeholders in the office's critical work for veterans.
This is a special hotline edition of Veteran Oversight Now and joining us today is Trina Rollins. Trina is the director for Hotline Coordination within the VA OIG's Office of Health Care Inspections. Trina is a board-certified physician assistant who worked at the VA North Texas Health Care system for eight years prior to joining the VA OIG in 2011.
Welcome. Trina.
Trina Rollins
Hi, Fred. Thanks for having me back.
Fred Baker
Happy that you're here. Today we're here to discuss the report Discontinued Consults Led to Patient Care Delays at Oklahoma City VA Medical Center. Before we start, as we typically do, give us some context on the size and the capabilities of this facility.
Trina Rollins
Sure. The Oklahoma City VA Medical Center is located in Oklahoma City, Oklahoma. It's a level 1B, which is a high complexity facility and is part of VISN 19, the Rocky Mountain Network. The facility operates 16 outpatient clinics and provides primary and specialty care, including surgery and behavioral health or mental health.

Fred Baker
Great. Thanks. And how did this hotline come to us and what were the allegations?

Trina Rollins
Sure. So, we received the allegation that the associate chief of staff of Behavioral Health Service, which we're calling the program manager in this report, was not following the consult management process, and was discontinuing these behavioral health consults, which then resulted in the patients not getting needed and recommended behavioral health services. The complainant actually provided us a list of 32 patients that they felt were impacted by the discontinuation. We reviewed it, and we were able to substantiate some of those. And so, we felt we needed to open the hotline to investigate further.

Fred Baker
So briefly, just explain what these consults are.

Trina Rollins
So, a consult is an electronic request for specific services for a patient. In this case, these were behavioral health consults. So, they were seen by a behavioral health provider. And it was a service that the provider felt the patient needed. And number one, the facility may or may not have had the capabilities of providing that service, or number two, that service wasn't provided at the facility, so they needed to go into the community to get the service.

Fred Baker
So, these were VA providers recommending care or trying to schedule care outside in the community.
Trina Rollins
Correct.
Fred Baker
And the other thing that struck me on this was the relatively low number of patients this impacted. VHA deals with thousands of patients daily. These allegations only included 32, the allegations included 32. Why was that a significant enough number for us to take on this project?
Trina Rollins
So, I'll answer that in that the allegation involved the program manager, behavioral health leadership. The associate chief of the Behavioral Health Service was denying behavioral health services for these veterans. That was the original allegation. When we looked at the 32 patients, 29 of those patients had their behavioral health consult discontinued. So, number one, that delays their care. Seven of those patients had a significant delay in their care. These numbers led us to believe that the problem could be much worse. You know, when you give a sample of 32 and we found an issue with 29 of them, that's pretty significant. So, we needed to ensure that the facility was able to review this concern thoroughly.
Fred Baker

And those seven who had that significant delay, what did that look like timewise?

Trina Rollins
Timewise it was upwards, over six months some of them were delayed.
Fred Baker
So, they could have been in a—for lack of a medical term—they could have been in a very bad spot and not receive care for six months.
Trina Rollins
They were in a very bad spot. Yeah. But, I mean, I will give kudos to the actual mental health providers at the facility because they continued to keep track of these patients. When the program manager was discontinuing consults, those providers were turning around and resubmitting that consult almost immediately to, again, to ensure that, you know, the program manager would get an understanding that these patients needed the care, that care was not available at the facility or not available timely at the facility. So, they continued to monitor those patients. And we can say confidently because of those delays, those seven patients did not experience any significant harm.

Fred Baker
Sure. So, as opposed to some of our reports that focus around very tragic events, this is more focused on the greater implications.

Trina Rollins
Yeah, that's a really great way of putting it. Yeah. Because this could have been very tragic.

Fred Baker
So described for context what the consult management process is.

Trina Rollins
Okay. So, VA has several consult designations. The consult can be in a pending status, and that means that it's been submitted to a service, but the service hasn't had a chance to review it yet. Active. Active means the service has reviewed it and are taking steps to move to the next step of scheduling or determining if they have the availability or if it needs to go out into the community.
Scheduled is obvious. They've scheduled an appointment. Complete means the appointment has happened and they've got the medical records and they close out the consult saying that care was provided. Discontinued and canceled are the last two designations. And they're kind of self-explanatory. But what these designations do is they help to indicate to the provider who placed the consult what's the progress of it. Has there been timely scheduling? And once the consult is closed, it signifies that, you know, this service has been provided and there's medical records available for that provider to review.
In 2021, VHA issued some updates to these designations, and they require the “discontinued” action to no longer be used. And the reason behind that is, when you discontinue a consult, there's no way to reopen that consult or do any further care on that consult. So, if they get additional information, you can't submit it into that consult and reactivate it and schedule the patient. You have to put in a brand-new consult, which again, is taking time. You know, more work, more steps. But if you use the canceled designation, you can reopen the consult after you have some additional information. And you don't need to resubmit that, submit more paperwork or, you know, electronic paperwork. But it won’t delay.

Fred Baker
Right. More steps inevitably lead to greater delay.

Trina Rollins
Correct.

Fred Baker
Do we have criteria on what VHA expects with respect to scheduling community care consults?

Trina Rollins
Yes, VHA does. So, when a consult a submitted to a service, they have two business days to change the status of that consult from pending to active, meaning they have about two business days to review it. The pending or active status is then changed to either scheduled, forwarded, completed, or canceled, and that should occur within three business days. So again, if they're in the midst of scheduling, that doesn't mean that the patient has already completed the appointment, but rather that the appointment has been scheduled. The appointment could be three weeks down the road. But you know it's scheduled for April 28, 2024.

Fred Baker
Right. Right.
Trina Rollins
So, they have three days to do that. For community care consults, there's an additional step in there. So remember, if these services weren't available at the facility, they should have been recommended for community care. If that occurs, then a clinical review needs to happen. So, again, within that two-business-day timeframe, that clinical review should be taking place. In this case, the program manager was doing that actual clinical care review, that clinical service level review for these consults which were recommended for community care. So, the scheduler had already looked at the availability within the facility, saw that there was no availability, contacted the patient and asked them whether or not they would be amenable to going into the community. And these patients had opted in, meaning they said yes, they would want to go to the community to get the care. And then the program manager came behind and pretty much wiped out all of that work by discontinuing the consults.
Fred Baker
So that was going to be my point. Both in the allegation and what we found was basically that the program manager lacked a working knowledge of this consult management and scheduling processes.
Trina Rollins
Exactly.

Fred Baker
What did they not understand and why? Explain a little bit more about what they were doing that actually delayed the action, the care.

Trina Rollins
Yeah, there were several issues. So, the program manager was using an appointment availability tool to check for available appointments in the facility. The problem is that tool was still under development, meaning it wasn't operational. So, the information in the tool was not reliable or accurate. So, as they looked for appointments, there were appointments there.

Fred Baker
When you say they looked for appointments and there were appointments there, they appeared there, but they were not actually there.

Trina Rollins
They weren't. They were using a tool that was not up to date. It wasn't fully operational. So, there was availability within the tool, but none of that information was accurate. The program manager was using the appointment availability tool to schedule patients for appointments at the facility when a behavioral health scheduler had already confirmed there was no appointments available and had taken the time to contact the patient and ensure their approval to go into community care. So, you know, the behavioral health schedulers know the clinic availability. This is what they do day in and day out. They schedule appointments for patients, and they know if there's nothing available within a 30-day timeframe, that automatically makes the patient eligible for community care. So, then they'll take the extra step to contact the patient and say, “There's no availability here at the facility within 30 days. Would you be amenable to going out into the community?” And the patient will either say yes or no. If they say “no,” then the scheduler will schedule them as soon as available within the facility. If they say “yes,” then it moves to the next step of community care.
The other thing that the program manager was doing was when she saw an open slot in this appointment availability tool, she would then instruct the scheduler by putting a comment in the consult to book that specific appointment for that specific day and time for the patient without consultation with the patient. This is another prohibited practice. It's called blind scheduling. Patients, VHA mandates that patients should be consulted with appointment available dates and times and be allowed to choose when they want to schedule their appointment because they could have something else scheduled or, you know, their kids could have appointments at times that could conflict. So, they should have some choice in that matter.
When we reviewed the 32 consults, we saw that 29 of them were discontinued. And to us, that meant that the behavioral health staff couldn't take any further actions to ensure the patient received the care they needed. And this prevented scheduling of those appointments. So, you can see it just kind of built one on top of another.

Fred Baker
Sure. And when we question this program manager on their use of the scheduling, with respect to the knowledge about the process, we received conflicting information from them. Correct?

Trina Rollins
Yes, exactly. The program manager initially reported receiving no training, but we were able to look back at their training records and see that the required trainings on how to execute consults was completed. But then later on, the program manager reported that they didn't understand how to complete the consults. They didn't understand the difference between the cancel action and the discontinue action. But, you know, upon further questioning, the program manager also didn't seek any clarification to try and figure out what the difference was.

Fred Baker
Isn't there, wasn't there an internal review process that should have caught these mistakes?

Trina Rollins
Actually, that's exactly what happened. The internal process is what caught the error. Yes, it was reported to OIG, but on a facility level, it actually occurred about the same time. A staff person can submit concerns about patient safety issues through a system called the Joint Patient Safety Reporting System. Someone actually did report it, placed a JPSR and then that report goes to patient safety, the Department of Patient Safety within the facility, who then review those concerns. When this was submitted, the patient safety officer or Patient Safety Office then reported it directly to the facility director. That's when a review with the facility compliance officer was initiated. And then once they determined yes, there was a prohibited practice confirmed, the facility then opened up an administrative investigation board to review it even further.
Fred Baker
And this was roughly in the same timeframe that we initiated our hotline?
Trina Rollins
It was, and they had already started the review so that when we actually engaged with them and got on site, you know, a good majority of this had already taken place and they were able to tell us the results of that.
Fred Baker
And the patients? They were able to get them scheduled appropriately?
Trina Rollins
Yes, thankfully, yes. As I mean, as I said earlier, the providers at the facility were very diligent about caring for their patients and continuing to place consults and checking up on those patients until they got the care they needed.
Fred Baker
Great. So, what were our recommendations?
Trina Rollins
So, we had one recommendation to the facility director to review the community care consult management process and appointment scheduling processes to help identify any deficiencies and then take action as warranted.
Fred Baker
And their response?
Trina Rollins
So, it was very positive. The VISN and the facility director concurred with the recommendation and already reported that ongoing monitoring and auditing of the consults had been initiated even before the report was published. So again, that doesn't mean that our recommendation was closed. We'll continue to monitor their audits and ensure that everything looks good before we close out that recommendation.
Fred Baker
Definitely some positive movement in the right direction on behalf of the facility.
Trina Rollins
Yes.
Exactly. Yeah. They did what they were supposed to do. Facility staff reported it. The director took the information and investigated and were able to take action to correct it.
Fred Baker
Great.
Trina, as always, we appreciate you going through these somewhat complex reports with us. Do you have anything else you would add?

Trina Rollins
I just hope everyone will take time to read the report.

Fred Baker
Well, thanks, Trina. And we will get together soon on another hotline podcast. Thank you.

Fred Baker
As mentioned in this podcast, you can submit a complaint to the VA OIG by phone 1-800 488-8244 or you can go to our website site, www.vaoig.gov/hotline and fill out a hotline complaint there. However, if you are a veteran in crisis or someone who is concerned about one, please call the Veterans Crisis Line. Dial 988 and then press one.
Now, let's go to Lauren for the highlights of our oversight work for this past month.
Lauren O’Connor
Thanks, Fred.
Eleven OIG investigations had updates in May. This includes a multiagency investigation resulting in charges alleging that two laboratories engaged in a kickback scheme involving marketers and physicians that resulted in approximately $300 million in losses to the government. Of this amount, the loss to VA is approximately $165,000. The laboratories, through marketers, paid hundreds of thousands of dollars to doctors for advisory services that were never performed in return for laboratory test referrals. The owner of one laboratory was sentenced in the Northern District of Texas to 30 months in prison, two years of supervised release, approximately $180,000 in restitution, and a fine of $10,000. A doctor was sentenced to 18 months in prison, two years of supervised release, $143,000 in restitution, and a fine of $40,000.
A VA OIG investigation found that a veteran lied to VA about being unable to use both his feet, which resulted in his receipt of VA disability compensation benefits for almost two decades and vehicle adaption benefits to which he was not entitled. The veteran was sentenced in the District of New Hampshire to 18 months in prison, 36 months of supervised release, and $662,000 in restitution after pleading guilty to making false statements.
The VA OIG published 13 reports in May. Two reports concerned the awarding of monetary incentives to VA senior executives.
In September 2023, VA announced it had erroneously awarded millions of dollars in critical skill incentive payments to senior executives in the VA central office, also known as VACO. VA cancelled the payments, notified Congress, and requested that the OIG review the matter. Critical skill incentives were authorized by the PACT Act. The OIG found VA’s award of $10.8 million in incentives to 182 VACO senior executives lacked adequate justification and was inconsistent with the PACT Act and VA policy. This was due, in part, to breakdowns in VA leadership and controls, as well as missed opportunities to intervene at multiple levels.
VA concurred with the OIG’s two findings and eight recommendations and provided acceptable action plans. The OIG will monitor VA’s progress until sufficient documentation has been received to close the recommendations as implemented.
Then additional analysis of the improper critical skill incentive awards has raised concerns that the under secretary for health may have recommended incentives for at least 10 VACO senior executives who directly reported to him, and for whom he was, therefore, not authorized to act as the approving official. Because there were inconsistencies in available data on direct reports, the OIG released a supplemental memorandum to summarize information conveyed to the VA secretary to further assess whether additional actions are warranted. The OIG also asked that VA provide information on whether any other approving officials exceeded their authority in recommending or approving critical skill incentives to VACO senior executives and factor the results into its action plans for implementing the related OIG report recommendations.
Other OIG reports published in May include three Comprehensive Healthcare Inspection Program, or CHIP reports, as well as several reports about VA information technology and benefits.
To learn more about the reports the OIG published in May as well as updates on criminal investigations, see the monthly highlights under the reports tab on our website, www.vaoig.gov.