GAO Needto Be Timely ‘” . . . ,, : /: .: -‘.. .,: ,‘- n- United States GAO General Accounting Office Washington, D.C. 20648 Human Resources Division B-236840 May 30,199O The Honorable G.V. (Sonny) Montgomery Chairman, Committee on Veterans’ Affairs House of Representatives The Honorable Bob Stump Ranking Minority Member Committee on Veterans’ Affairs House of Representatives As you noted in your February 1, 1989, letter, medical evidence is the most critical element in adjudicating veterans’ claims for disability compensation. This report responds to your request that we determine . whether regional offices of the Department of Veterans Affairs (VA) are requesting medical examinations for the appropriate impairment for veterans applying for disability benefits; and . whether the medical reports received from VA medical centers are ade- quate, complete, and timely for eligibility determinations. Our review of a nationwide sample of veterans’ initial claims for disabil- Results in Brief ity compensation showed that (1) VA regional offices requested medical examinations for the appropriate medical impairment and (2) the medi- cal reports addressed all claims for compensation made by veterans. The medical reports contained diagnoses that were adequately supported by clinical tests and procedures and physical examinations performed by VA physicians. With few exceptions, these reports provided sufficient medi- cal evidence to VA medical and nonmedical rating board specialists to make a judgment about the extent of a veteran’s disability and assign disability ratings for compensation. On the other hand, medical reports frequently do not meet VA timeliness standards. -~ Veterans having diseases or injuries resulting from their military service Background are eligible to apply for disability compensation. Claims for compensa- tion are handled by VA regional offices and submitted to a rating board consisting of a physician and two nonphysician rating specialists. When evaluating a claim, the board determines whether the medical evidence in the veteran’s file is sufficient for it to make a rating determination. If not sufficient, the board forwards a request for a medical examination Page 1 GAO/‘HRJS9@11K Vetemn.4 Disability Compensation (Form 2507) to a VA medical center. Medical center physicians then per- form the necessary examinations and tests and submit medical reports to the rating board. The board then considers the medical report and other available evidence in the veteran’s file, including employment his- tory and educational background. VA’S Schedule for Rating Disabilities is the official guide for converting clinical findings into standard diagnostic codes, covering diseases or injuries and degrees of severity of impairment.’ Rating specialists con- vert diagnoses in medical reports to diagnostic codes in the rating sched- ule and select the appropriate degree of severity from the schedule. Severity is measured in percentages ranging from 0 to 100 (in incre- ments of 10 percent)-100 percent being totally disabled. To review VA medical reports, we randomly selected a nationwide sam- Scope and ple of cases from VA’S April 1989 disability compensation payment file. Methodology We reviewed 160 cases that we estimate are part of a universe of about 29,600 cases that had initial awards on or after January 1, 1988. The 160 cases included 34 in which disability determinations were made based on information received from non-VA physicians or medical cen- ters. In these cases, rating specialists determined that there was suffi- cient medical evidence in the veteran’s file to make a determination without a report from a VA medical center. The remaining 126 determi- nations were made by rating specialists after receiving a report from a VA center. We reviewed the 160 cases to determine whether the medical reports were adequate, complete, and timely as measured by VA criteria. Our chief medical advisor reviewed the medical reports and their supporting documentation to determine whether there was sufficient information for the rating specialists to make the disability rating in accordance with VA’S rating schedule. Our review did not include an evaluation of the actual ratings given to each veteran. Also, our findings apply only to VA’S initial claims approved during our sample period and not to claims that were reopened or denied and required a medical report during the period. Our review was made in accordance with generally accepted govern- ment auditing standards. We sought the views of responsible VA officials ‘We recommended needed improvements to the r&ii schedule in Veterans’ Benefits: Need to Update Medical Criteria Used in VAkDisability Rating Schedule (GAO/HRD89-28, Dec. 29,19SS). Page 2 GAO/HRD90-116 Veterans’ Disability Cknnpensation B-233349 during our work and incorporated their comments where appropriate. (A more detailed discussion of our scope and methodology is contained in app. I.) regional offices are requesting examinations that address medical Regional Offices VA impairments claimed by veterans in their initial applications for disabil- Request Examinations ity compensation. In the 126 cases that contained requests for examina- for Appropriate tions generated by rating boards, we compared the veterans’ claimed impairments as listed in their applications for compensation with (1) the Impairment VA Form 2507 (Request for Physical Examination) and (2) the impair- ments listed at the time of examination. In each instance, the informa- tion in the veterans’ claims matched the information contained in the rating board’s request and in the “complaints” section of the medical report (VA Form 2546). In addition, our chief medical advisor determined that the medical reports addressed each of the claimed impairments con- tained in these documents. Murray Grant, M.D., D.P.H., our chief medical advisor, reviewed the Medical Reports Are medical reports contained in the 160 cases and determined that in all but Complete and 3 cases, the reports contained diagnoses that were adequately supported Adequate for by clinical tests, procedures, and physical examinations and contained sufficient information about the condition’s severity. These reports pro- Disability vided sufficient medical evidence to VA medical and nonmedical rating Determinations specialists to make a judgment about the extent of a veteran’s disability and assign a disability rating for compensation purposes. On a nation- wide basis, we estimate that about 2 percent, or about 550, of the 29,600 cases did not meet VA criteria for adequate and complete medical reporting.2 VA has established general guidance for rating board specialists concern- ing what information should be contained in medical reports for them to be considered complete and adequate for rating purposes. The criteria are: 1. The report must include both a medical and an occupational history. 2. The report must contain appropriately documented results of a gen- eral medical or specialist examination, including all tests and procedures 2We are 96.percent confident that cases not meeting VA criteria for adequate and complete medical reports do not exceed 4.4 p+went or about 1,300 cases. Page 3 performed in diagnosing a given condition and any significant limitation of function resulting from the condition. 3. Any disagreements or conflicts concerning the diagnosis of a given condition or interpretation of test results must be resolved. 4. All medical reports must, be signed by the examining physician and reviewed by an appropriate screening physician, signed, and dated. The screening physician certifies that the report is adequate for rating pur- poses from the medical viewpoint. In reviewing our 160~casesample, our chief medical advisor found defi- ciencies in 3 cases based on the criteria outlined above. In 2 cases, the medical evidence in the report did not adequately support the final diag- nosis, nor did it adequately address the severity of the condition for rat- ing purposes. In the third case, he determined that although the diagnosis of the condition was adequately supported, insufficient infor- mation existed about the severity of the condition to make a rating determination. Reviews of medical reports by screening physicians are an important internal control mechanism required by VA to ensure that reports are complete and adequate for rating purposes. Of the 126 cases where examinations were conducted by VA medical centers, 24 percent lacked screening physician approval of the medical reportsz Despite this lack of review, however, our medical advisor judged the medical reports in these instances to be adequate for rating purposes. -. - Many cases in our sample did not meet VA’S timeliness standards. VA’s Timeliness of Medical criteria for timeliness are outlined in the form of performance standards Reports Does Not Meet set for the medical centers. For the period of our review, timeliness was VA Standards measured by the percentage of medical examinations that are completed in a given period. Table 1 compares the timeliness of medical reports in our sample with VA timeliness standards. 3We are Sbpercent confident that cases lacldng screening physician approval ranged between 16 and 32 percent, or abut 4.7or1 to 9,400 cases. Page 4 GAO/HRDSO-116 Veterans’ Disability Compensation Table 1: Compartron of GAO Sample With VA Timeliness Standards Days to complete VA standard GAO sample result Sampling error medical exams (percent) (percent) (percentage points) 300rless 65 32 +9 60 or less 90 61 +7 160orless 100 99 T2 Based on our sample, the average elapsed time was 63 days for the med- ical centers to schedule and complete medical examination reports4 VA has instituted new timeliness criteria, effective in fiscal year 1990, which establish criteria for each step in the process. These new stan- dards set the number of days in which these activities must be com- pleted as follows: . Schedule exam after request received-5 days. l Complete exam after request received-45 days. l Document exam after completion-5 days. l Return exam to requester-7 days. In addition, VA is currently field-testing a new information exchange sys- tem, which, if successful, VA believes should eliminate virtually all the current delays involved in mailing documents between regional offices and medical facilities. The first element of this exchange process uses computerized links between the various installations allowing electronic transmission of requests for examinations and written medical reports. Supporting test results, for example, X rays, are then forwarded by mail. A second element in this new system is the development of standardized examination reports for various body systems. These reports are designed to capture data elements based directly on specifics contained in VA’S rating schedule that are necessary to determine the type and degree of severity of a given condition. Currently, 40 such examination reports have been developed, with 20 more in the planning stage. We are sending copies of this report to appropriate congressional com- mittees; the Secretary of VA; the Director, Office of Management and Budget; and other interested parties. 4We are 96.percent confident that the actual average number of days falls somewhere between 66 and 70. Page 6 GAO/HRB!WllK Veterans’ Disability Compensation B-236840 Please call me on (202) 275-6193 if you or your staffs have any ques- tions about this report. Other major contributors to the report are listed in appendix II. Joseph F. Delfico Director, Income Security Issues page 6 GAO/HBDsol16 Vettmws Disability Compensation Page 7 GAO/EIBDw)-116 Veterans’ Disability c.m~~ti.,,, Appendix I Scopeand Methodology VA provided us with a random sample of 5 percent of all disability com- pensation and pension cases (approximately 3.6 million) on VA’s pay- ment file, as of April 24, 1989. From this 5-percent sample, we identified 1,750 compensation cases in which, according to the automated file, the initial award was made on or after January 1,1988, and the veteran was alive as of the April 1989 payment date. We selected a random sample of 180 of these 1,750 cases for a detailed review. We included 160 of the 180 selected cases in our detailed review. VA could not provide the claims files for 4 of the 180 cases sampled when we needed them for review. In reviewing the remaining 176 case files, we found that in 16 cases the initial award had been made before Janu- ary 1, 1988. The estimates presented in this report are generalizable to all of the estimated 29,600 veterans who were initially awarded disabil- ity compensation between January 1,1988, and April 24,1989, and who were alive as of the April 1989 payment date. Because our estimates are based on a sample, each estimate is subject to a sampling error. The sampling errors for estimates cited in this report are computed at a 95 percent confidence level. They are noted where appropriate. In keeping with the objectives of this request, we looked only at the medical reports submitted to rating boards used as a basis for the diia- bility determination. We did not review the rating board’s determination of whether a specific diagnosed condition was service connected. We reviewed the adequacy of medical reports with respect to aI1 conditions determined to be service connected, even if the disability rating given was 0 percent. We did not, however, examine the accuracy or appropri- ateness of the disability rating percentage because this determination can be influenced by evidence contained not in the medical report but elsewhere in the veteran’s file. Page 8 GAO/HlW9@116 Veterans Dhbility Compe~tion Appendix II Major Contributors to This Report James F. Walsh, Assistant Director, (202) 233-5281 Human Resources John C. Boyd, Assignment Manager Division, Murray Grant, M.D., D.P.H., Chief Medical Advisor Washington, D.C. Clarita A. Mrena, Social Science Analyst Irma E. Arispe, Social Science Analyst Margaret A. McGregor, Evaluator-in-Charge Philadelphia Regiona1 John Kirstein Site Senior Office Frank Foley, iechnical Advisor (106703) Page 9 GAO,‘HRB9S116 Veterans’ Disability compensation usseeneml -0ifice PO& OffIce Bar 6016 Gaithers~Marylaud20877 Telephone 202-276-6241 ‘.‘. ‘, ..-: ‘> .,; ;” P I., ’ -.- >Y
Veterans' Compensation: Medical Reports Adequate for Initial Disability Ratings but Need to Be More Timely
Published by the Government Accountability Office on 1990-05-30.
Below is a raw (and likely hideous) rendition of the original report. (PDF)