Veteranclaims’s Blog

June 27, 2009

VAOIG Finds C&P Scheduling and Denials Errors

VA’s use of failure to attend C&P examinations as the reason for denying or delaying veterans claims is wide spread, accounting for about 20% of denials. “VHA guidance states that C&P exams can be rescheduled on a one-time basis when a veteran requests that the exams be postponed for a valid reason” or reasonable request for a different appointment time, contrast this with “good cause” rulings by CAVC.

The VAOIG looked at how well the VA followed their scheduling guidelines in regard to: (1)rescheduling when a valid reason for not attending was presented; (2) compliance with VHA scheduling guidance which requires that the veteran be notified prior to scheduling the exam and involved in the process of scheduling their C&P exam appointments.

The VAOIG found that:

1. “[V]arious VA HCFs did not call veterans to schedule their appointments and only notified veterans of their C&P exam appointments by letter. This practice is not in compliance with VHA scheduling guidance and does not include veterans in the process of scheduling their C&P exam appointments.”

2. “[V]arious VA HCFs canceled subsequent exam appointments and the C&P exam request after veterans did not attend their initial appointments without first contacting the veteran.” This practice is not in compliance with VHA scheduling guidance and does not include veterans in the process of scheduling their C&P exam appointments.

3. “C&P exams were inappropriately canceled because VA HCF personnel did not reschedule the exam appointments based on the veteran’s reasonable request for a different appointment time.” This practice is not in compliance with VHA scheduling guidance.

<a href= “http://www.va.gov/OIG/publications/reports-list.asp”>VAOIG Report Page</a>
VA’s current ploicy on scheduling C&P examinations, as reviewed by the VAOIG, Report No. 08-01392-144 June 25, 2009.

“VSRs at VAROs determine the type of C&P exam(s) a veteran needs based on the available medical records and use one or more of 58 exam worksheets to describe the specific requirements for the medical examiner.”
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Processing of C&P Exam Requests
“VSRs at VAROs determine the type of C&P exam(s) a veteran needs based on the available medical records and use the Compensation and Pension Record Interchange (CAPRI) system to order C&P exams from the VA HCF of jurisdiction. VA HCF personnel determine where and how to conduct the C&P exam and contact the veteran to schedule the exam.”
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VHA guidance states that exams are to be scheduled within three days of receipt of the exam request.
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“VHA guidance states that VA HCF personnel are to contact veterans to schedule their C&P exam appointments and mail an appointment notification letter to the veteran. However, personnel at various VA HCFs did not call veterans to schedule their appointments and only notified veterans of their C&P exam appointments by letter. This practice is not in compliance with VHA scheduling guidance and does not include veterans in the process of scheduling their C&P exam appointments.”
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“In total, we determined that 97 of 424 incomplete C&P exam requests could have been prevented by VA. We projected nationwide that about 12,000 incomplete C&P exam requests canceled during the first half of FY 2008 could have been prevented by VA. Based on this projection, we estimated 24,000 incomplete C&P exam requests could have been prevented during FY 2008.”
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“VHA personnel did not consistently reschedule C&P exam appointments when veterans requested that the appointments be postponed for a valid reason. Further, VHA guidance does not state how to handle a situation when a veteran fails to report for an initial C&P exam and has subsequent appointments scheduled on the same exam request.”

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In total, we determined that 97 of 424 incomplete C&P exam requests could have been prevented by VA. We projected nationwide that about 12,000 incomplete C&P exam requests canceled during the first half of FY 2008 could have been prevented by VA. Based on this projection, we estimated 24,000 incomplete C&P exam requests could have been prevented during FY 2008.
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VHA personnel did not consistently reschedule C&P exam appointments when veterans requested that the appointments be postponed for a valid reason. Further, VHA guidance does not state how to handle a situation when a veteran fails to report for an initial C&P exam and has subsequent appointments scheduled on the same exam request.
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VHA had inconsistent practices related to the extent VA healthcare facilities (VA HCFs) contacted veterans by telephone to schedule their C&P exam appointments. The number of incomplete C&P exam requests could be reduced if VHA improved C&P exam scheduling procedures. For example, VHA guidance states that VA HCF personnel are to contact veterans to schedule their C&P exam appointments and mail an appointment notification letter to the veteran. However, personnel at various VA HCFs did not call veterans to schedule their appointments and only notified veterans of their C&P exam appointments by letter. This practice is not in compliance with VHA scheduling guidance and does not include veterans in the process of scheduling their C&P exam appointments. Personnel from 6 (29 percent) of the 21 VA HCFs included in our sample stated they did not always make telephone calls to schedule C&P exam appointments,

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Report No. 08-01392-144 June 25, 2009 VA Office of Inspector General Washington, DC 20420 Department of Veterans Affairs
Office of Inspector General
Audit of
VA Incomplete
Compensation and Pension
Medical Examinations
To Report Suspected Wrongdoing in VA Programs and Operations
Telephone: 1-800-488-8244 between 8:30 AM and 4 PM Eastern Time,
Monday through Friday, excluding Federal Holidays
E-Mail: vaoighotline@va.gov Audit of VA Incomplete Compensation and Pension Medical Examinations
Contents
Page
Executive Summary……………………………………………………………………………………….i-vi
Introduction
Purpose……………………………………………………………………………………………………………1
Background………………………………………………………………………………………………………1
Results and Conclusions
Request and Scheduling Processes Need Improvement…………………………………………..3
Appendixes
A. Scope and Methodology……………………………………………………………………………….12
B. Sampling Methodology and Estimates……………………………………………………………14
C. Acting Under Secretary for Health Comments…………………………………………………17
D. Under Secretary for Benefits Comments…………………………………………………………23
E. OIG Contact and Staff Acknowledgments……………………………………………………….25
F. Report Distribution……………………………………………………………………………………….26
VA Office of Inspector General Audit of VA Incomplete Compensation and Pension Medical Examinations
Executive Summary
Results in Brief
The Office of Inspector General (OIG) conducted an audit to identify opportunities for the Veterans Health Administration (VHA) and the Veterans Benefits Administration (VBA) to increase the number of completed compensation and pension (C&P) medical examinations (C&P exams). The audit also focused on identifying some of the causes of canceled C&P exams through a review of randomly sampled incomplete exam requests. When VHA or VBA personnel cancel a C&P exam request or a veteran does not attend their scheduled C&P exam appointment(s), it becomes an incomplete exam request.
The percentage of incomplete C&P exam requests has remained steady over the past few years at around 17 percent. However, reducing the number of incomplete C&P exam requests will help ensure that claims decisions are handled more efficiently and veterans’ disability benefits payments are timelier. Incomplete C&P exam requests often result in additional and unnecessary work for VA personnel and can be indicative of poor customer service to veterans. To improve service provided to veterans filing disability claims, it is important for VA to take steps to reduce the number of incomplete exam requests.
VHA had inconsistent practices related to the extent VA healthcare facilities (VA HCFs) contacted veterans by telephone to schedule their C&P exam appointments. The number of incomplete C&P exam requests could be reduced if VHA improved C&P exam scheduling procedures. For example, VHA guidance states that VA HCF personnel are to contact veterans to schedule their C&P exam appointments and mail an appointment notification letter to the veteran. However, personnel at various VA HCFs did not call veterans to schedule their appointments and only notified veterans of their C&P exam appointments by letter. This practice is not in compliance with VHA scheduling guidance and does not include veterans in the process of scheduling their C&P exam appointments. Personnel from 6 (29 percent) of the 21 VA HCFs included in our sample stated they did not always make telephone calls to schedule C&P exam appointments, and personnel from 4 (19 percent) of the VA HCFs stated they only sent notification letters and did not make telephone calls. Personnel from 11 (52 percent) of the VA HCFs stated they scheduled C&P exam appointments by telephone contact with the veteran. We could not verify these statements because the method used to schedule appointments was not documented. Without direct communications with veterans, VHA cannot ensure they are working effectively with veterans who need C&P exams before complete decisions can be made on their disability claims.
VHA’s practices related to rescheduling veterans’ C&P exam appointments also differed across VA HCFs. VHA guidance states that C&P exams can be rescheduled on a one-time basis when a veteran requests that the exams be postponed for a valid reason. However, several C&P exams were inappropriately canceled because VA HCF personnel
VA Office of Inspector General i Audit of VA Incomplete Compensation and Pension Medical Examinations
did not reschedule the exam appointments based on the veteran’s reasonable request for a different appointment time. Instead, the exam requests were canceled and returned incomplete to the requesting VA Regional Office (VARO).
VARO personnel request more than one C&P exam, if necessary, when a veteran’s application contains multiple claimed conditions. VHA’s practices related to handling C&P exam requests with multiple exam appointments were not consistent across VA HCFs. VHA guidance does not address how to handle a situation when a veteran fails to report for an initial C&P exam and has subsequent appointments scheduled under the same request. Personnel at various VA HCFs canceled subsequent exam appointments and the C&P exam request after veterans did not attend their initial appointments without first contacting the veteran.
The number of incomplete exam requests could also be further reduced if VARO personnel submitted complete and accurate C&P exam requests to VA HCFs. We identified cases where VARO personnel sent C&P exam requests to the incorrect VA HCF. In these instances, VARO personnel sent C&P exam requests to incorrect VA HCFs based on the veterans’ residence, sent the requests to VA HCFs based on incorrect veterans’ addresses, or sent the requests to VA HCFs where the veterans were employed, which is contrary to VA guidance. We also identified C&P exam requests where VARO personnel did not include sufficient information for the exams to be scheduled and conducted, or the exams requested did not correctly address the veterans’ claimed conditions. About 11 percent of the incomplete C&P exam requests we reviewed were canceled because the requests were incomplete or inaccurate.
In a joint effort, VHA and VBA established the Compensation and Pension Examination Program (CPEP) Office in 2001 to improve and monitor the C&P exam process. CPEP personnel conduct quality assurance reviews of completed C&P exam requests; however, CPEP personnel have not extended their reviews to determine why some exam requests are canceled. Expanding quality assurance reviews to include incomplete C&P exam requests would allow CPEP to identify issues and causes that contribute to incomplete C&P exam requests and provide opportunities for continuous improvement.
We estimated 24,000 incomplete C&P exam requests could have been prevented during FY 2008. Minimizing the number of canceled exams would enable VA to provide veterans C&P benefits more quickly, reduce unnecessary work for VA personnel, and provide veterans with better service.
Background
Veterans initiate claims for disability compensation or pension by filing an application online or at a VARO. Upon receipt of an application, VBA’s Veterans Service Representatives (VSRs) request a C&P exam to determine the current level of disability or to provide a medical opinion as to whether the current disability is related to the veteran’s military service.
VA Office of Inspector General ii Audit of VA Incomplete Compensation and Pension Medical Examinations
Processing of C&P Exam Requests
VSRs at VAROs determine the type of C&P exam(s) a veteran needs based on the available medical records and use the Compensation and Pension Record Interchange (CAPRI) system to order C&P exams from the VA HCF of jurisdiction. VA HCF personnel determine where and how to conduct the C&P exam and contact the veteran to schedule the exam. VHA guidance states that VA HCF personnel are to contact the veteran to schedule their C&P exam appointments and mail notification letters to the veteran.
Finding
Request and Scheduling Processes Need Improvement
To reduce the number of incomplete C&P exams, VHA needs to improve exam scheduling procedures, VBA needs to improve the quality of C&P exam requests, and CPEP needs to improve quality assurance review procedures. Our review of 424 incomplete C&P exam requests showed that at least 97 (23 percent) could have been prevented. C&P exams were not completed because VHA personnel did not always contact veterans by telephone to schedule their C&P exam appointments in accordance with VHA guidance. In addition, VHA personnel did not consistently reschedule C&P exam appointments when veterans requested that the appointments be postponed for a valid reason. Further, VHA guidance does not state how to handle a situation when a veteran fails to report for an initial C&P exam and has subsequent appointments scheduled on the same exam request.
We identified cases where C&P exam requests were canceled after veterans did not attend their initial appointments. VA HCF personnel canceled subsequent appointments, scheduled on the same exam request, without contacting the veteran to determine why he or she missed their initial appointment or whether he or she planned to attend the subsequent appointments. C&P exams were also not completed because VBA personnel did not always provide complete and accurate information on the C&P exam requests they sent to VA HCFs. We identified cases where VARO personnel sent the requests to the incorrect VA HCFs, did not include sufficient information for the exams to be scheduled, and requested incorrect exams.
Of the other 327 (77 percent) cases that we reviewed, 162 (50 percent) C&P exam requests were incomplete because the veterans did not attend their scheduled appointments. The available records did not document why the veterans missed these appointments; therefore, we could not determine the causes of these incomplete C&P exam requests. We believe, however, that many of the 162 missed appointments could have been prevented had VHA personnel followed scheduling guidance and made direct communication with the veterans to schedule their C&P exam appointments.
Based on our site visits and case reviews, we concluded proactive VA HCFs that telephoned veterans to schedule their C&P exam appointments were more likely to have
VA Office of Inspector General iii Audit of VA Incomplete Compensation and Pension Medical Examinations
fewer incomplete exam requests. Three of the four VA HCFs we visited during our audit did not contact veterans directly to negotiate an appointment date and time before scheduling appointments.
These three facilities had average incomplete exam rates ranging from 18.5 to 23.7 percent during the period reviewed. The other facility did attempt to contact veterans directly to negotiate an appointment time, and the incomplete exam rate for this facility was 4.3 percent. This comparison is a strong indicator that following VHA guidance and involving veterans in scheduling their appointments may be a valuable way to reduce the number of veterans who do not attend their C&P exams. In the remaining 165 (50 percent) cases, we determined that incomplete exam requests were canceled for reasons beyond VA’s control, such as cases where veterans canceled their appointments or withdrew their disability claims.
VA’s quality assurance reviews of C&P exam requests are not adequate. While CPEP personnel conduct quality assurance reviews of completed C&P exam requests, they do not conduct reviews of incomplete exam requests. Therefore, CPEP is missing an opportunity to identify and address recurring or systemic causes for incomplete C&P exam requests.
Conclusion
C&P exams are necessary for VBA personnel to make decisions on veterans’ disability claims. VA’s ability to effectively complete C&P exams impacts whether or not veterans receive timely disability benefits and good customer service. In order to increase the number of completed C&P exams, VHA needs to improve their procedures for scheduling C&P exam appointments, and VBA needs to improve the quality of C&P exam requests submitted to VA HCFs. Additionally, CPEP needs to expand their quality assurance review coverage to include incomplete C&P exam requests in order to identify issues and causes that contribute to incomplete C&P exam requests. If VA does not accomplish this, veterans will likely continue to experience delays in receiving their entitled disability benefits, and VA will miss opportunities to improve the service provided to veterans.
Recommendations
1.
We recommended the Under Secretary for Health establish requirements for VA healthcare facility personnel to contact veterans by telephone to schedule their compensation and pension examination appointments and reschedule appointments when a veteran requests postponement for a valid reason.
2.
We recommended the Under Secretary for Health provide guidance to ensure that VA healthcare facility personnel do not cancel subsequent appointments on the same request when a veteran does not attend their initial compensation and pension

VA Office of Inspector General iv Audit of VA Incomplete Compensation and Pension Medical Examinations

examination appointment without contacting the veteran to determine why he or she did not attend their initial appointment.
3.
We recommended the Under Secretary for Benefits establish a process at VA Regional Offices to ensure complete and accurate information is provided on compensation and pension examination requests.
4.
We recommended the Under Secretary for Health and the Under Secretary for Benefits jointly require the Compensation and Pension Examination Program Office’s quality assurance reviews include a routine review of incomplete compensation and pension examination requests, report identified deficiencies, and recommend improvement actions as needed.

Management Comments and OIG Response
The Acting Under Secretary for Health and the Under Secretary for Benefits agreed with the findings and recommendations in the report and provided acceptable implementation plans. (See Appendix C for the full text of the Acting Under Secretary for Health’s comments, and Appendix D for the full text of the Under Secretary for Benefits’ comments.)
VHA is addressing the issue of personal patient contact by facility personnel for all outpatient appointments, including those for C&P exams. A revised scheduling directive is in the final concurrence process and is expected to be published before the end of July 2009. The new directive provides guidance on the efforts that must be taken to establish contact with veterans throughout the scheduling process. In cases where telephone contact cannot be established, written correspondence must be sent requesting the veteran call within a specified time period to schedule an appointment. The directive will also require appropriate follow-up if a veteran fails to appear for a scheduled appointment. VHA has developed a training program for all personnel involved with scheduling, and the training will be initiated when the revised directive is released. One emphasis of the training will be to ensure schedulers do not cancel subsequent appointments without adequate justification when an initial appointment is missed. In addition, VHA is revising their C&P handbook and procedure guide to incorporate these changes.
CPEP has revised their quality assurance review process to include a routine review of incomplete C&P exam requests. CPEP will assess the extent to which unclear, incorrect jurisdiction, or otherwise flawed exam requests submitted by VBA contribute to the number of incomplete C&P exam requests. VBA will develop an action plan to improve training of personnel who are responsible for ordering C&P exams, and establish workgroups involving both VBA and VHA personnel to help improve communication.
VA Office of Inspector General v Audit of VA Incomplete Compensation and Pension Medical Examinations VA Office of Inspector General vi
We consider these planned actions acceptable, and we will follow up on their implementation. We will close the recommendations when all proposed actions have been completed by VHA, VBA, and CPEP.
(original signed by:)
BELINDA J. FINN
Assistant Inspector General
for Auditing Audit of VA Incomplete Compensation and Pension Medical Examinations
Introduction
Purpose
The Office of Inspector General (OIG) conducted an audit to identify opportunities for the Veterans Health Administration (VHA) and the Veterans Benefits Administration (VBA) to increase the number of completed compensation and pension (C&P) medical examinations (C&P exams). The audit also focused on identifying some of the causes of canceled C&P exams through a review of 424 randomly sampled incomplete exam requests.
Background
Veterans initiate claims for disability compensation or pension by filing an application online or at a VA Regional Office (VARO). Upon receipt of an application, VBA’s Veterans Service Representatives (VSRs) request a C&P exam to determine the current level of disability or to provide a medical opinion as to whether the current disability is related to the veteran’s military service. VSRs request more than one C&P exam, if necessary, when a veteran’s application contains multiple claimed conditions. When VA healthcare facility (VA HCF) or VARO personnel cancel a C&P exam request or a veteran does not attend their scheduled C&P exam appointment(s), it becomes an incomplete exam request.
Public Law 108-183 authorized VBA to contract for C&P exams. However, the majority of C&P exam requests are submitted to VA HCFs rather than contractors. During the period reviewed, approximately 85 percent of C&P exam requests were submitted to VA HCFs. This audit focused only on those incomplete C&P exam requests that had been submitted to VA HCFs.
Processing of C&P Exam Requests
VSRs at VAROs determine the type of C&P exam(s) a veteran needs based on the available medical records and use one or more of 58 exam worksheets to describe the specific requirements for the medical examiner. VSRs use the Compensation and Pension Record Interchange (CAPRI) system to order C&P exams from the VA HCF of jurisdiction.
VARO personnel need to submit complete and accurate exam requests to facilitate the scheduling and conducting of C&P exams by VA HCF personnel. Requests must include the following elements.

Veteran’s full name

Veteran’s verified social security number

Veteran’s last known address

VA Office of Inspector General 1 Audit of VA Incomplete Compensation and Pension Medical Examinations

Veteran’s last known telephone number

Specific exam(s) required and specific condition(s) for each exam

Name and telephone number of VARO requestor

VA HCF personnel determine where and how to conduct the C&P exam and contact the veteran to schedule it. C&P exam notification letters are generated through the Veterans Health Information Systems and Technology Architecture (VistA) and mailed to the veteran. VHA has established a timeliness standard of 35 calendar days to complete C&P exams. The 35-day standard is measured from the day an exam request is received by the VA HCF through the day when all exam components, including laboratory and ancillary test results, are provided to the VARO.
Statistical Data on Incomplete C&P Exam Requests
The VHA Chief Business Office’s (CBO) Performance and Operational Web-Enabled Reports include data on incomplete C&P exam requests. The data shows that the percentage of incomplete C&P exam requests has remained steady at about 17 percent since FY 2006 (see Table 1).
Table 1. Incomplete C&P Exam Request Data
Period     Total No. of C&P  Exam Requests  Made to VA HCFs     Total No. of Incomplete  C&P Exam Requests     Incomplete Percentage
FY 2006     513,771     89,587     17.4%
FY 2007     581,736     98,800     17.0%
FY 2008     640,778     110,700     17.3%

Compensation and Pension Examination Program Office
In a joint effort, VHA and VBA established the Compensation and Pension Examination Program (CPEP) Office in 2001. The CPEP Office, which is located in Nashville, TN, was established to improve and monitor the C&P exam process to ensure improvements in the quality of C&P exams and veterans’ satisfaction. The major goals of CPEP are as follows.

Improve the quality of exam requests,

Improve the quality of exam reports, and

Contribute to improvements in the quality and timeliness of claims processing.

VA Office of Inspector General 2 Audit of VA Incomplete Compensation and Pension Medical Examinations
Results and Conclusions
Request and Scheduling Processes Need Improvement
To reduce the number of incomplete C&P exams, VHA needs to improve exam scheduling procedures, VBA needs to improve the quality of C&P exam requests, and CPEP needs to improve quality assurance review procedures. Some C&P exams were not completed because VHA personnel did not contact veterans by telephone to schedule their C&P exam appointments. Making direct communication with veterans to schedule their C&P exam appointments involves veterans in the process and increases the likelihood they will attend their appointments. In addition, VHA personnel did not consistently reschedule C&P exam appointments when veterans requested that the appointments be postponed for a valid reason. By not ensuring that veterans’ requests to reschedule C&P exam appointments are accommodated, VA is missing an opportunity to provide veterans with better customer service. C&P exams were also not completed because VBA personnel did not always provide complete and accurate information on the C&P exam requests they sent to VA HCFs. Without this information, VA HCF personnel cannot schedule and conduct C&P exams.
Ultimately, reducing the number of incomplete C&P exam requests will help ensure that claims decisions are handled more efficiently and veterans’ disability benefits payments are timelier. Incomplete C&P exam requests cause additional and often unnecessary work for VA personnel and can be indicative of poor customer service to veterans. To improve service provided to veterans filing disability claims, it is important for VA to take steps to reduce the number of incomplete exam requests.
Our review of 424 incomplete C&P exam requests showed that at least 97 (23 percent) could have been prevented. We projected that about 12,000 (23 percent) C&P exam requests canceled during the first half of FY 2008 could have been prevented. Based on this projection, we estimated 24,000 incomplete C&P exam requests could have been prevented during FY 2008. Minimizing the number of canceled exams would enable VA to provide veterans C&P benefits more quickly, reduce unnecessary work for VA personnel, and provide veterans with better service.
Of the other 327 (77 percent) cases that we reviewed, 162 (50 percent) C&P exam requests were incomplete because the veterans did not attend their scheduled appointments. The available records did not document why the veterans missed these appointments; therefore, we could not determine the causes of these incomplete C&P exam requests. We believe, however, that many of the 162 missed appointments could have been prevented had VHA personnel followed scheduling guidance and made direct communication with the veterans to schedule their C&P exam appointments. Based on our site visits and case reviews, we concluded proactive VA HCFs that telephoned veterans to schedule their C&P exam appointments were more likely to have fewer incomplete exam requests. Three of the four VA HCFs we visited during our audit did
VA Office of Inspector General 3 Audit of VA Incomplete Compensation and Pension Medical Examinations
not contact veterans directly to negotiate an appointment date and time before scheduling appointments. These three facilities had average incomplete exam rates ranging from 18.5 to 23.7 percent during the period reviewed. The other facility did attempt to contact veterans directly to negotiate an appointment time, and the incomplete exam rate for this facility was 4.3 percent. This comparison is a strong indicator that following VHA guidance and involving veterans in scheduling their appointments may be a valuable way to reduce the number of veterans who do not attend their C&P exams. In the remaining 165 (50 percent) cases, we determined that incomplete exam requests were canceled for reasons beyond VA’s control, such as cases where veterans canceled their appointments or withdrew their disability claims.
VA’s quality assurance reviews of C&P exam requests are not adequate. While CPEP personnel conduct quality assurance reviews of completed C&P exam requests, they do not conduct reviews of incomplete exam requests. Therefore, CPEP is missing an opportunity to identify and address recurring or systemic causes for incomplete C&P exam requests.
Of the 97 preventable incomplete exam requests, 44 (45 percent) were within the control of VA HCFs and 53 (55 percent) were within the control of VBA’s regional offices.
VHA Needs to Improve Controls for Scheduling C&P Exam Appointments.
Scheduling Practices Inconsistent with VHA Guidance
VHA’s procedures for scheduling C&P exam appointments need to be improved in order to better accommodate veterans. VHA Procedure Guide 1601E.01 states that VA HCF personnel are to contact the veteran to schedule their C&P exam and that exam notification letters are to be generated in VistA and mailed to the veteran. The procedure guide states that C&P exams can be rescheduled on a one-time basis when a veteran requests that the exams be postponed for a valid reason. The new appointments must be rescheduled within 30 days from the original appointment dates, unless the veteran specifies differently. The additional processing days to reschedule an appointment must be manually tracked and can be backed out of the total exam day count. In other words, the delay caused by rescheduling a veteran’s appointment(s) does not negatively impact the 35-day timeliness measure for completing C&P exam requests because VA HCF personnel can “stop the clock” if the veteran requests a new appointment date.
VHA had inconsistent practices related to the extent VA HCFs contacted veterans by telephone to schedule their C&P exam appointments. For example, VA HCF personnel did not consistently contact veterans before scheduling their appointments. This practice is not in compliance with VHA scheduling guidance and does not include veterans in the process of scheduling their C&P exam appointments. Personnel from 6 (29 percent) of the 21 VA HCFs in our sample stated they did not always make telephone calls to schedule C&P exam appointments, and personnel from 4 (19 percent) of the VA HCFs stated they only sent notification letters. Personnel from 11 (52 percent) VA HCFs stated they scheduled C&P exam appointments by telephone contact with the veteran.
VA Office of Inspector General 4 Audit of VA Incomplete Compensation and Pension Medical Examinations
We could not verify these statements because the method used to schedule appointments was not documented. Without direct communication with veterans, VHA cannot ensure they are working effectively with veterans who need C&P exams before complete decisions can be made on their disability claims. More veterans attending their C&P exam appointments would ensure that claims are processed more efficiently and benefit entitlement decisions are made timelier.
Following are scheduling practice deficiencies we identified during our case reviews.

Reasonable Rescheduling Requests. Eleven C&P exam requests (from seven different VA HCFs) with scheduled appointments were inappropriately canceled because VA HCF personnel did not reschedule the exam appointments based on the veteran’s reasonable request for a different appointment time. Instead, the exam requests were canceled and returned incomplete to the requesting VARO.
For example, on December 13, 2007, VA HCF personnel scheduled a veteran for two C&P exam appointments on December 17 and 21, but did so without contacting the veteran. After the veteran received his appointment notification, he notified the VA HCF that he was not provided sufficient advance notice for the appointments, as he had to consider his needs relative to saving money for gas and allowing sufficient time to make the 3 hour drive. The veteran requested the appointments be rescheduled, but the VA HCF did not reschedule them. The VA HCF canceled the appointments and returned the incomplete C&P exam request to the VARO. VA HCF personnel stated they do not reschedule veterans’ C&P exam appointments if they cannot attend an appointment within 30 days. Instead, they cancel the request and return it to the requesting VARO.
Upon receipt of the canceled C&P exam request, the VARO rated the veteran’s claim and did not award disability compensation. The veteran appealed the rating decision and the disability compensation claim was reopened. A new C&P exam request was issued and the C&P exams were completed in March 2008. Upon receipt of the completed C&P exams, the VARO rated the veteran’s claim and the veteran was evaluated 70 percent service-connected. Although the veteran received retroactive compensation benefits, the veteran did not receive payment until June 2008. The veteran likely would have received disability compensation benefits earlier had the VA HCF rescheduled rather than canceled the veteran’s initial C&P exams in December 2007. In addition, VA could have avoided the additional workload of an appealed rating decision and reopened compensation claim.

Procedural Issues. Seven C&P exam requests, from three different VA HCFs, were canceled due to various procedural issues. In these cases, VA HCF personnel took actions when scheduling appointments that were inconsistent with VHA guidance and/or locally established VA HCF procedures.
For example, one VARO submitted a C&P exam request on January 28, 2008. Seventeen days later, on February 14, the VA HCF scheduled a C&P exam appointment for March 10. This action did not comply with VHA guidance that states

VA Office of Inspector General 5 Audit of VA Incomplete Compensation and Pension Medical Examinations

exams are to be scheduled within three days of receipt of the exam request. On February 25, the appointment was canceled by the VA HCF clinic because the provider was not available. A new appointment was rescheduled for March 24, 2008; however, VA HCF personnel stated they did not contact the veteran to negotiate a rescheduled appointment time, and we saw no evidence that the veteran was notified. The C&P exam request was later canceled because the veteran failed to report for the rescheduled appointment. VA HCF personnel agreed that the delay in scheduling the initial exam appointment and the failure to negotiate a rescheduled appointment when the clinic was canceled was contrary to local VA HCF practice and caused the exam request to be returned to the VARO as incomplete.

Processing Errors by Personnel Caused Incomplete Exams
We identified 21 C&P exam requests (from 8 different VA HCFs) that were inappropriately canceled by VA HCF personnel. These exam requests were canceled after VA HCF personnel sent appointment notices to the wrong address, scheduled the wrong person for an exam, failed to schedule an exam requested by the VARO, or inadvertently canceled the exam request. In seven of these cases, VA HCF personnel sent veterans’ C&P exam appointment notices to the address of record listed in VistA; however, VARO personnel had provided updated addresses in the exam request. When mailing the appointment notification letters to veterans, VA HCF personnel failed to notice or did not use the updated addresses provided by the VAROs. This resulted in these seven requests being canceled and returned to the VAROs.
VA HCF officials indicated that these cancellations resulting from processing errors had multiple causes such as increased workload, lack of scheduling personnel, and the pressure to meet the 35-day time parameter to complete exam requests.
Policies did not Reasonably Accommodate Veterans
VSRs request more than one C&P exam, if necessary, when a veteran’s application contains multiple claimed conditions. However, VHA Procedure Guide 1601E.01 does not state how to handle a situation when a veteran fails to report for an initial C&P exam and has subsequent appointments scheduled under the same C&P exam request.
We identified five C&P exam requests (from four different VA HCFs) that were canceled after the veterans did not attend their initial appointment. VA HCF personnel canceled their subsequent appointments, scheduled on the same exam request, without contacting the veteran to determine why he or she missed their initial appointment or whether he or she planned to attend the subsequent appointments. For example, one veteran failed to report for a C&P exam scheduled for November 26, 2007. The veteran had a different C&P exam appointment scheduled for December 3, 2007. Because the veteran did not show up for the November 26 appointment, the VA HCF canceled the December 3 appointment. The VA HCF has a local policy that when a veteran fails to report for one appointment, all other C&P exam appointments on the request are canceled. The VA HCF stated this policy is communicated to veterans in the
VA Office of Inspector General 6 Audit of VA Incomplete Compensation and Pension Medical Examinations
appointment notification letter. Local VA HCF policies such as this appear to place more emphasis on meeting timeliness standards than on meeting the needs of veterans.
It is reasonable to expect that VA HCF personnel should not cancel all pending C&P exams without first contacting the veteran to determine why he or she missed the initial appointment or whether he or she plans to report for other scheduled C&P exams. Contacting the veteran, rather than canceling the appointments without direct communication would improve the service provided to veterans.
VBA Needs to Ensure Complete and Accurate Exam Requests Submitted to VA HCFs.
Exam Requests Submitted by VAROs Were Incomplete and Inaccurate
VBA needs to improve the quality of the C&P exam requests they submit to VA HCFs. The Memorandum of Understanding between Veterans Benefits Administration and Veterans Health Administration for Processing Compensation and Pension Examination Requests requires that exam requests submitted by VAROs contain the veteran’s last known address, last known telephone number, and the specific exam(s) required. VA Manual M21-1MR also clearly instructs that VARO personnel need to identify veteran employees and prevent their exam requests from being sent to the wrong VA HCF. We identified 53 canceled C&P exam requests that were preventable and within the control of the VAROs. Most of these (47 of 53) were canceled because the exam requests were incomplete or inaccurate.
Following are exam request deficiencies we identified during our case reviews.

Incorrect Jurisdictions. In 33 cases (from 14 different VAROs), exam requests were canceled because VARO personnel submitted the requests to the incorrect VA HCF.
􀂃
In 23 of these cases, VARO personnel sent the exam requests to VA HCFs that were not the correct facility based on the veterans’ residence.
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In six other cases, the exam requests did not include the correct addresses for the veteran even though the correct addresses were available; therefore, the requests were sent to the wrong VA HCFs based on incorrect addresses.
􀂃
Four cases involved exam requests for VA employees. Contrary to VA policy, VARO personnel incorrectly sent these exam requests to the VA HCF where the veterans were employed. VA HCF personnel realized that these veterans were employed at their facilities, canceled the exam requests, and sent them back to the VAROs for submission to other VA HCFs. Since veterans’ claims folders and CAPRI identify veterans who are VA employees, VSRs should ensure they do not send C&P exam requests to the VA HCF where the veterans are employed.

Insufficient Information. In seven cases (from six different VAROs), exam requests were canceled because the requests did not contain sufficient information for the VA HCFs to schedule and complete them. Examples of these cases follow.

VA Office of Inspector General 7 Audit of VA Incomplete Compensation and Pension Medical Examinations
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In one case, the exam request did not identify the claimed medical conditions related to the exams requested.
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In another case, the VARO did not send the veteran’s claims folder to the VA HCF even though it was needed to complete the exam.

Incorrect Exams Requested. In seven cases (from five different VAROs), exam requests were canceled because VARO personnel requested incorrect exams. Examples of these cases follow.
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In one case, a genitourinary exam was ordered when a general medical exam was needed to address the veteran’s claim. Consequently, VA HCF personnel canceled the exam request.
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In another case, an audiology exam was ordered when an ear disease exam was needed to address the veteran’s claim. Consequently, VA HCF personnel canceled the exam request.

Miscellaneous Reasons. Six exam requests (from five different VAROs) were canceled for miscellaneous reasons. Examples of these cases follow.
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In one case, a C&P exam request was canceled because VARO personnel requested an exam that had already been completed. VARO personnel did not examine prior claims or C&P exam requests that indicated an exam related to the claimed condition had already been completed.
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In another case, a C&P exam request was canceled because adequate medical evidence was already on record to grant the veteran claimed pension benefits. Outpatient treatment records contained in the veteran’s claims folder were sufficient to grant pension benefits and it was not necessary to request a C&P exam.

VBA does not have a process in place to ensure that VARO personnel include complete and accurate information on the C&P exam requests they send to VA HCFs. Without this information, VA HCF personnel cannot schedule and conduct the C&P exam appointments required for veteran’s disability claims. Ultimately, the payment of benefits for those veterans who are found to be entitled is unnecessarily delayed.
While we identified C&P exams requests that were incomplete or incorrect, there may be opportunities for more efficient processing of C&P exam requests if personnel at VA HCFs and VAROs improve their communication with each other. The January 2007 Memorandum of Understanding between Veterans Benefits Administration and Veterans Health Administration for Processing Compensation and Pension Examination Requests states that when a veteran submits a claim for compensation or pension, VHA and VBA have a shared responsibility to ensure the highest quality of service is delivered efficiently, compassionately, and with minimal inconvenience to the veteran. The respective roles of VHA and VBA in claims processing should be transparent to the veteran and the veteran’s experience will be that he or she is dealing with One VA.
VA Office of Inspector General 8 Audit of VA Incomplete Compensation and Pension Medical Examinations
While some VA HCF personnel indicated they did contact VARO personnel to resolve incomplete or incorrect C&P exam requests, some of the types of canceled C&P exam requests we identified may have been preventable with improved communication. For example, if a VARO sends a C&P exam request that does not request the correct exam, rather than canceling the request VA HCF personnel could contact VARO personnel to determine the correct exam. The Memorandum of Understanding states that in the best interest of the veteran, every effort should be made by VHA and VBA to avoid any unnecessary delays in processing a veteran’s request for examination. The receiving VA HCF should contact the requesting VARO to obtain any missing information or clarification. If this were done more consistently, the number of incomplete C&P exam requests could be reduced and service provided to veterans awaiting decisions on their claims could be improved.
CPEP Quality Assurance Reviews Need to Include Review of Incomplete Exam Requests.
VA’s quality assurance reviews of C&P exam requests do not include incomplete exam requests. The CPEP Office was established to improve and monitor the C&P exam process, and one goal of the office is to improve the quality of exam requests. CPEP personnel conduct quality assurance reviews of completed C&P exam requests; however, CPEP personnel have not extended their reviews to determine why some exam requests are canceled. Expanding quality assurance reviews to include incomplete C&P exam requests would allow CPEP to identify issues and causes that contribute to incomplete C&P exam requests and provide opportunities for continuous improvement.
CPEP Quality Assurance Review Processes Are Not Addressing the Reasons C&P Exam Requests Are Canceled
CPEP’s quality assurance reviews focus on the quality and timeliness of completed C&P exam requests. For their reviews, CPEP selects C&P exam requests that have been completed by VA HCFs and returned to the requesting VAROs. CPEP reports the results of these reviews to the applicable VAROs and VA HCFs for information purposes. However, CPEP does not review or capture data for those requests that were canceled. Thus, CPEP does not identify issues and causes that contribute to incomplete C&P exam requests. In order to be more effective, CPEP’s quality assurance reviews need to include incomplete C&P exam requests and recommend improvement actions to appropriate officials as needed.
Conclusion
C&P exams are necessary for VBA personnel to make decisions on veterans’ disability claims. VA’s ability to effectively complete C&P exams impacts whether or not veterans receive timely disability benefits and good customer service. In order to increase the number of completed C&P exams, VHA needs to improve their procedures for scheduling C&P exam appointments, and VBA needs to improve the quality of C&P exam requests submitted to VA HCFs. Additionally, CPEP needs to expand their quality
VA Office of Inspector General 9 Audit of VA Incomplete Compensation and Pension Medical Examinations
assurance review coverage to include incomplete C&P exam requests in order to identify issues and causes that contribute to incomplete C&P exam requests. If VA does not accomplish this, veterans will likely continue to experience delays in receiving their entitled disability benefits, and VA will miss opportunities to improve the service provided to veterans.
Recommendations
1.
We recommended the Under Secretary for Health establish requirements for VA healthcare facility personnel to contact veterans by telephone to schedule their compensation and pension examination appointments and reschedule appointments when a veteran requests postponement for a valid reason.
2.
We recommended the Under Secretary for Health provide guidance to ensure that VA healthcare facility personnel do not cancel subsequent appointments on the same request when a veteran does not attend their initial compensation and pension examination appointment without contacting the veteran to determine why he or she did not attend their initial appointment.
3.
We recommended the Under Secretary for Benefits establish a process at VA Regional Offices to ensure complete and accurate information is provided on compensation and pension examination requests.
4.
We recommended the Under Secretary for Health and the Under Secretary for Benefits jointly require the Compensation and Pension Examination Program Office’s quality assurance reviews include a routine review of incomplete compensation and pension examination requests, report identified deficiencies, and recommend improvement actions as needed.

Management Comments and OIG Response
The Acting Under Secretary for Health and the Under Secretary for Benefits agreed with the findings and recommendations in the report and provided acceptable implementation plans. (See Appendix C for the full text of the Acting Under Secretary for Health’s comments, and Appendix D for the full text of the Under Secretary for Benefits’ comments.)
VHA is addressing the issue of personal patient contact by facility personnel for all outpatient appointments, including those for C&P exams. A revised scheduling directive is in the final concurrence process and is expected to be published before the end of July 2009. The new directive provides guidance on the efforts that must be taken to establish contact with veterans throughout the scheduling process. In cases where telephone contact cannot be established, written correspondence must be sent requesting the veteran call within a specified time period to schedule an appointment. The directive will also require appropriate follow-up if a veteran fails to appear for a scheduled appointment. VHA has developed a training program for all personnel involved with scheduling, and
VA Office of Inspector General 10 Audit of VA Incomplete Compensation and Pension Medical Examinations VA Office of Inspector General 11
the training will be initiated when the revised directive is released. One emphasis of the training will be to ensure schedulers do not cancel subsequent appointments without adequate justification when an initial appointment is missed. In addition, VHA is revising their C&P handbook and procedure guide to incorporate these changes.
CPEP has revised their quality assurance review process to include a routine review of incomplete C&P exam requests. CPEP will assess the extent to which unclear, incorrect jurisdiction, or otherwise flawed exam requests submitted by VBA contribute to the number of incomplete C&P exam requests. VBA will develop an action plan to improve training of personnel who are responsible for ordering C&P exams, and establish workgroups involving both VBA and VHA personnel to help improve communication.
We consider these planned actions acceptable, and we will follow up on their implementation. We will close the recommendations when all proposed actions have been completed by VHA, VBA, and CPEP. Audit of VA Incomplete Compensation and Pension Medical Examinations Appendix A VA Office of Inspector General 12 Scope and Methodology
This audit addressed C&P exam requests VARO personnel submitted to VA HCFs that were canceled between October 1, 2007, and March 31, 2008. Of 303,005 C&P exam requests submitted during this six-month period, 249,884 (82.5 percent) were completed and 53,121 (17.5 percent) were canceled.
We conducted audit work from July 2008 to April 2009. To project the number and percentage of incomplete C&P exam requests that were preventable VA-wide, we developed a two-stage statistical sampling plan. (See Appendix B for additional details on the statistical sampling plan.) First, we randomly selected 21 VA HCFs (from a universe of 137 VA HCFs that conduct C&P exams). We then randomly selected 424 incomplete C&P exam requests from a total of 7,260 incomplete exam requests from the 21 facilities during the 6-month period of October 1, 2007, through March 31, 2008. We made onsite visits to four VHA locations-VA New Jersey Healthcare System (HCS) in East Orange, NJ; James A. Haley Veterans’ Hospital in Tampa, FL; VA Medical Center in Philadelphia, PA; and VA Salt Lake City HCS in Salt Lake City, UT. During our onsite reviews, we assessed the C&P exam request process and internal controls, and we conducted interviews with local C&P personnel at the VA HCFs. We also interviewed VBA personnel from the VAROs of jurisdiction for the four VA HCFs visited in Newark, NJ; St. Petersburg, FL; Philadelphia, PA; and Salt Lake City, UT. We reviewed related VA policies and procedures, including the January 2007 Memorandum of Understanding between Veterans Benefits Administration and Veterans Health Administration for Processing Compensation and Pension Examination Requests that was jointly signed by the Acting Under Secretary for Health and the Under Secretary for Benefits.
For each incomplete C&P exam request in our sample, we attempted to determine the reason(s) why the request was canceled and whether VA could have prevented it. For cases where we needed clarification in order to assess whether a canceled exam request was preventable, we provided written questions to C&P personnel, either at the VA HCFs and/or the VAROs of jurisdiction, and received written responses.
To obtain information on internal controls related to the C&P exam request process, we provided a questionnaire to C&P Program officials at the 21 VA HCFs and the 19 VAROs of jurisdiction. We also interviewed the Director of C&P Service concerning the C&P exam request process and the Acting Director of CPEP to assess CPEP’s involvement with and responsibilities for the C&P exam process. Our assessment of internal controls focused on those controls related to the audit objective.
To achieve the audit objective, we relied on computer-processed data contained in VistA and CAPRI. We assessed the reliability of this data and found it to be adequate. We also obtained facility-level data from each of the 21 VA HCFs in our statistical sample. Each VA HCF provided an electronic report listing all incomplete C&P exam requests that were canceled between October 1, 2007, and March 31, 2008. To test data reliability for Audit of VA Incomplete Compensation and Pension Medical Examinations Appendix A VA Office of Inspector General 13
each incomplete exam request in our sample for the four site visits, we determined whether electronic data recorded in CAPRI and VistA matched hardcopy documentation maintained in veterans’ claims folders. Based on these tests and assessments, we concluded the data was sufficiently reliable to meet the audit objective.
Public Law 108-183 authorized VBA to contract for C&P exams. Our review did not include C&P exams conducted by VBA contractors because data on exams conducted by VHA personnel and the VBA contractors is not contained in a single system. However, we noted that QTC Medical Services, Inc. (QTC) conducts C&P exams for 10 VAROs and MES Solutions (MES) performs C&P exams for 6 other VAROs. During the first half of FY 2008, VA sent a total of 55,779 C&P exam requests to QTC, of which about 3 percent were canceled. Also, during the 6-month period, about 10 percent of scheduled C&P exams were not completed because veterans failed to attend their appointments. MES did not conduct any C&P exams during the time period of the audit because the contract was not awarded until May 2, 2008.
We conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objective. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objective. Audit of Incomplete Compensation and Pension Medical Examinations Appendix B VA Office of Inspector General 14 Sampling Methodology and Estimates
Universe
The audit universe consisted of 53,121 incomplete C&P exam requests canceled between October 1, 2007, and March 31, 2008. The universe was made up of all C&P exam requests canceled during this 6-month time period by the 137 VA HCFs that conduct C&P exams. The source of universe data was incomplete C&P exam request statistics reported on the VHA CBO’s Performance and Operational Web-Enabled Reports for each VA HCF.
Sample Design
We designed a two-stage statistical sampling plan to compute the error rate of incomplete C&P exam requests that were preventable by VA. In order to improve efficiency of our estimates, we divided the sampling universe of 21 VA HCFs into three strata of seven VA HCFs each based on volume (represented by the total number of exam requests per VA HCF). Total exam requests were calculated by adding the number of incomplete C&P exam requests and the number of completed C&P exam requests for the 6-month period. The results of our audit for all sampled strata were combined and projected to the universe to calculate weighted point estimates and associated margins of error at the 90 percent confidence level.
In the first stage of sampling, we randomly selected 21 VA HCFs (7 from each strata) for review. For the second stage of the sample, we selected a simple random sample of 424 canceled C&P exam requests. See Tables 2 through 5 for more details.
Table 2. Strata 1-High Volume VA HCFs
Station  Number     Station Name     Requests  Completed     Requests  Incomplete     Total  Requests     Incomplete  Percentage     Sample
436     Montana     2,313     255     2,568     9.9%     14
554     Denver     4,277     813     5,090     16.0%     45
561     New Jersey     2,638     620     3,258     19.0%     42
603     Louisville     2,374     484     2,858     16.9%     27
636     Central Plains     7,487     1,180     8,667     13.6%     65
642     Philadelphia     3,739     167     3,906     4.3%     11
673     Tampa     3,184     721     3,905     18.5%     50
Strata Totals     26,012     4,240     30,252     14.0%     254
Audit of Incomplete Compensation and Pension Medical Examinations Appendix B VA Office of Inspector General 15
Table 3. Strata 2-Medium Volume VA HCFs
Station  Number     Station Name     Requests  Completed     Requests  Incomplete     Total  Requests     Incomplete  Percentage     Sample
358     Manila     1,059     353     1,412     25.0%     19
463     Anchorage     1,118     363     1,481     24.5%     20
550     Danville     967     291     1,258     23.1%     16
621     Mountain Home     1,785     336     2,121     15.8%     18
629     New Orleans     1,550     427     1,977     21.6%     23
657A5     Marion     1,621     231     1,852     12.5%     13
660     Salt Lake City     1,091     339     1,430     23.7%     23
Strata Totals     9,191     2,340     11,531     20.3%     132

Table 4. Strata 3-Low Volume VA HCFs
Station  Number     Station Name     Requests  Completed     Requests  Incomplete     Total  Requests     Incomplete  Percentage     Sample
438     Sioux Falls     987     219     1,206     18.2%     12
590     Hampton     235     61     296     20.6%     3
600     Long Beach     69     60     129     46.5%     3
637     Asheville     28     11     39     28.2%     1
663     Puget Sound     230     140     370     37.8%     8
675GA     Brevard     945     142     1,087     13.1%     8
687     Walla Walla     238     47     285     16.5%     3
Strata Totals     2,732     680     3,412     19.9%     38

Table 5. Sample Summary Data
Requests  Completed     Requests  Incomplete     Total  Requests     Incomplete  Percentage     Sample
Sample Totals     37,935     7,260     45,195     Avg. 16.1%     424
Universe Totals     249,884     53,121     303,005     Avg. 17.5%

Sample Results
We analyzed 424 incomplete C&P exam requests to determine if the canceled requests were preventable by VA. In total, we determined that 97 of 424 incomplete C&P exam requests could have been prevented by VA. We projected nationwide that about 12,000 Audit of Incomplete Compensation and Pension Medical Examinations Appendix B VA Office of Inspector General 16
incomplete C&P exam requests canceled during the first half of FY 2008 could have been prevented by VA. Based on this projection, we estimated 24,000 incomplete C&P exam requests could have been prevented during FY 2008.
Table 6. Summary of Projections for Incomplete C&P Exam Requests
Preventable  by VA     Sample     Projected     Lower  90%     Upper  90%     Projected  Percentage     Margin of  Error
No     327     41,067     39,239     42,895     77.3%     3.4%
Yes     97     12,054     10,226     13,882     22.7%     3.4%
Total     424     53,121     53,121     53,121     100.0%

We computed these projections from a sample of incomplete C&P exam requests. The margins of error in this report give the upper and lower bounds of a 90 percent confidence interval for each projection, as shown in Table 6. This means that 90 percent of the possible samples we could have selected of the same size and design would have resulted in an estimate within these bounds. Audit of VA Incomplete Compensation and Pension Medical Examinations Appendix C
Acting Under Secretary for Health Comments Audit of VA Incomplete Compensation and Pension Medical Examinations Appendix C Acting Under Secretary for Health Comments VA Office of Inspector General 18 Audit of VA Incomplete Compensation and Pension Medical Examinations Appendix C Audit of VA Incomplete Compensation and Pension Medical Examinations Appendix C Audit of VA Incomplete Compensation and Pension Medical Examinations Appendix C VA Office of Inspector General 22 Audit of VA Incomplete Compensation and Pension Medical Examinations Appendix D
Under Secretary for Benefits Comments Audit of VA Incomplete Compensation and Pension Medical Examinations Appendix D VA Office of Inspector General 24 Audit of VA Incomplete Compensation and Pension Medical Examinations Appendix E OIG Contact and Staff Acknowledgments
OIG Contact     Nick Dahl (781) 687-3120
Acknowledgments     Maureen Barry  Stephen Bracci  Lee Giesbrecht  David Orfalea  Grace Terranova  Joseph Vivolo

VA Office of Inspector General 25 Audit of VA Incomplete Compensation and Pension Medical Examinations Appendix F Report Distribution VA Distribution
Office of the Secretary
Veterans Health Administration
Veterans Benefits Administration
National Cemetery Administration
Assistant Secretaries
Office of General Counsel Non-VA Distribution
House Committee on Veterans’ Affairs
House Appropriations Subcommittee on Military Construction, Veterans Affairs, and Related Agencies
House Committee on Oversight and Government Reform
Senate Committee on Veterans’ Affairs
Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and Related Agencies
Senate Committee on Homeland Security and Governmental Affairs
National Veterans Service Organizations
Government Accountability Office
Office of Management and Budget
This report will be on the VA OIG web site and remain on the OIG web site for at least two fiscal years after it is issued: http://www.va.gov/oig/publications/reports-list.asp.
VA Office of Inspector General 26

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