VA OIG: Improvements Needed for VBA’s Claims Automation Project

What the Review Found

VBA needs to improve its oversight of the ABD project to achieve the goals of supporting accurate and consistent decisions for veterans and improving claims processing timeliness, while minimizing manual processes. Failure to do so may result in veterans not receiving the benefits to which they are entitled and VBA investing in a process and technology that do not deliver the intended outcomes. The OIG found four main deficiencies with the ABD project’s processing of claims for increased evaluation of hypertension, as described in the sections that follow.

Summary Sheet Shortcomings

The team reviewed an initial sample of 30 claims for increased evaluation of hypertension completed by ABD project personnel from December 2021 to May 2022 (of 97 claims completed during that period), and a subsequent sample of 30 claims (of 86 total) completed from June through September 2022. Review results indicated the summary sheets did not provide ABD project RVSRs accurate and reliable evidence needed to evaluate veterans’ claims for hypertension. Deficiencies found with the summary sheet included missing blood pressure readings, inaccurate blood pressure readings, missing medications prescribed for hypertension, and lack of sufficient context such as whether readings were taken during a time of distress like an emergency room visit. Overall, the summary sheets the team reviewed did not contain comprehensive blood pressure reading information that would assist RVSRs in accurately deciding claims for increased evaluation of hypertension and did not lessen the RVSRs’ burden of manually reviewing all relevant evidence…

Inaccurate Claims Decisions

The OIG team’s testing revealed that 27 percent of all claims reviewed (16 of 60 claims) contained inaccurate and inconsistent determinations regarding the predominant (most common or prevailing) blood pressure readings for hypertension or when evidence was sufficient to decide a claim without an exam.9This ultimately resulted in inaccurate decisions on veterans’ claims…

Oversight Gaps

The team found that VBA’s quality assurance for the summary sheet and oversight of decision accuracy was lacking due to insufficient monitoring. ABD’s quality assurance results initially conflicted with the OIG’s findings of deficiencies regarding the summary sheet, but similar deficiencies were later also found on all summary sheets reviewed by a VBA contractor…

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