VA Claims Backlog Also Caused By High Error Rate, Not Only Processing Speed

by U.S. Medicine

June 7, 2012

By Stephen Spotswood

WASHINGTON — VA’s goal within two years is to have a claims-adjudication system that gets a first-time claim decision to a veteran within 125 days with 98% accuracy.

The agency has a long way to go.

It currently has nearly 900,000 claims backlogged in its system and an expected 1.3 million new claims to be filed by the end of 2012. About 65% of the 900,000 claims have been pending for more than 125 days and have an accuracy rate of 84%. In addition, there are 250,000 claims under appeal, with wait times as long as three years for adjudication.

Contributing to the backlog is VA’s relaxation of regulations for veterans filing PTSD-related benefits claims in 2010 as well as an increase in the number of service-connected claims for Agent Orange, Presumptive status recently was broadened for Vietnam veterans. The result has been a brighter spotlight on VA’s claims process, with many veterans’ advocates contending that

Claims_backlog_vaclaimchart1111.jpg

VA’s problem is lack of accuracy in adjudicating claims, not lack of manpower.

“The tidal wave of claims coming into VA is placing an unprecedented need on VA, and, in my opinion, VA does not have the resources to meet that demand,” said Paul Sullivan, managing director for public affairs at Bergmann and Moore, a Bethesda law firm representing veterans whose disability claims were denied before VA and the appeals court.

Sullivan told legislators at a recent House Veterans Affairs Committee hearing that, while he previously was working at VA, he “personally briefed VA leaders starting in 2003 about the surge in demands. And VA, at that time, decided not to pay attention to the train coming down the tracks.

“Now that there is a backlog, what effect does that have on an office?” Sullivan asked at the hearing. “The policy from Washington is usually [to focus on production] and to get the claims out as fast as possible. What that causes is for VA employees to take the easiest route to process a claim. That may not always be the best route.”

That quick-as-possible processing method may actually lead to the high error rate, which leads to more appealed claims — a process that sometimes takes 10 times as long to process as first-time claims.

PTSD Accuracy Rate Improves

In 2010, VA changed the rule on PTSD so that adjudicators no longer were  required to undertake extensive record review to corroborate that a veteran experienced the claimed in-service stressor.

When it comes to accuracy rate, that change and the resulting influx of PTSD cases may have actually helped the Veterans’ Benefits Agency (VBA), Sullivan said. VA’s error rate on PTSD claims prior to the regulation change was 25% or higher. After VA promulgated the regulation, the error rate decreased to about 10%.

“Streamlining the policies to reflect science actually improves VA’s accuracy rate,” Sullivan said.

He and veterans service organization (VSO) representatives agree that the answer includes more training, streamlined regulations reflecting current science, and more staff, especially who are familiar with veterans’ issues. A new employee unfamiliar with the military experience will need many months to acquaint themselves, and during that time could make poor claims decisions.

The benefit of having another veteran helping to guide the process is invaluable, said Randall Fisher, a service officer working with the American Legion in Kentucky who helps veterans navigate VBA red tape when submitting and following up on their claims. “Veterans know at a glance what all the information on a DD214 means,” Fischer noted. “We can picture exactly what’s happening in a report of action, because we’ve been there. We can speak to the veterans in a language they can understand.”

If VA wants to cut down on errors made by new employees, the agency should consider hiring more veterans to be claims processors, Fisher said. “Too often, we talk to VA employees who would never understand basic military concepts, such as the noise involved on a flight line or artillery range or that a position like military engineer might be attached as a support position to troops in the field. Understanding things like this is as basic as breathing to a veteran, but nonveterans miss things like this routinely.”

VA Claims Backlog Also Caused By High Error Rate, Not Only Processing Speed

Complexity of Claims

Tom Murphy, VBA’s director of compensation services, agreed that initial accuracy has a significant role in keeping the backlog down.

“If you’re having quality issues, it takes longer to work a case the second or third time than it takes to get it right the first time,” Murphy told the committee. “This ties back to the secretary’s goal of 98% accuracy.”

Recent years have seen the development of new complications to the claims process. A claim in the post-World War II era might have included approximately three contentions — an injured knee, a gunshot wound to the arm and an injured back, for example, Murphy pointed out.

A claim today has an average of 5.5 contentions, and sometimes that number is much higher. Also, those conditions can be much more complex and harder to assign a cause to than injuries in previous conflicts.

“It’s the nature of war today and the type of contentions,” Murphy said. “TBI and PTSD count as a single contention, and each is significantly more complex and takes much more time to evaluate than a relatively straightforward evaluation for a knee injury.”

While the loosening of PTSD claim regulations has helped PTSD-claim error rates, it also has tied up employees who otherwise would be helping winnow down the backlog.

Agent Orange claims also have kept the system clogged. VBA has 13 brokering centers around the country — centers filled with claims adjudicators who help with overflow from claims-processing centers nationwide. 

“For 14 of the last 16 months, those centers have been dedicated to working the new presumptive conditions that were granted a year ago for Agent Orange,” Murphy said. “Only now are those facilities returning to regular production.”

Most of these were reevaluations of previous claims, which take much longer. “We consumed 37% of our workforce that was working claims, in general, on grading those Agent Orange claims,” Murphy said.

Asked if VBA had done anything to prepare for the influx of appealed claims, Murphy said, “I don’t know that it’s necessarily a question of [being] prepared. The law required it.”

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