Federal Reports

The OIG conducted this review to assess the merits of two hotline complaints—one in March 2024 and one in April 2024—alleging Omaha VA Medical Center leaders manipulated the clinically indicated date for consults, thereby limiting veterans’ access to community care. The OIG substantiated the allegations, determining that from March 7, 2024, through April 11, 2024, facility leaders implemented a prohibited 29-day default for the clinically indicated date field that applied to referrals for specialty care and for some primary and mental health care. The default was implemented because clinically indicated dates for many specialty care consults were, in the chief of staff’s and medical facility director’s opinion, sooner than the patient’s condition warranted.

Before implementing the default, both the medical facility director and the chief of staff were made aware that there should not be a default. After implementing, they were also notified by an Omaha VA Medical Center employee that the default was not allowed and should be removed, but facility leaders took 19 days to remove the default. Furthermore, the OIG found providers were not given training on clinically indicated dates. In early November 2024—more than six months after the default was removed—training was provided.

The OIG made four recommendations: to clarify that automatically prepopulating the clinically indicated date field is prohibited; to determine whether any administrative action should be taken; to direct the medical facility director to provide education and training on the consult process; and to assess the actions the medical facility has taken to review consults potentially affected by the default and ensure veterans received the care they needed.

This report presents the results of our audit of the Postal Automated Redirection System. 

The Postal Automated Redirection System (PARS) was deployed in 2007 to handle letter mail that cannot be delivered to the name and address on the mailpiece. Mail sorting equipment can automatically intercept mail with an active Change of Address (COA), and PARS sorting equipment can forward it to the new destination, reducing additional mail handling. If mail that is undeliverable as addressed is not intercepted during the automated process, a carrier at the delivery unit can identify it as either forwardable — with a valid COA — or as return to sender and send it back to the plant for further processing. With the average American moving 11.7 times in their lifetime, the Postal Service must effectively handle PARS mail to ensure timely delivery of essential communications, such as bills, checks, and court documents. 

Our objective was to assess the effectiveness of procedures for processing and handling PARS mail. To accomplish our objective, we conducted interviews with U.S. Postal Service Headquarters management, obtained and analyzed PARS related data for fiscal years (FY) 2023 and 2024, and determined avoidable costs incurred due to identified issues. 

Our evaluation’s objective was to assess NTIA’s implementation of the Public Wireless Supply Chain Innovation Fund program. We determined the steps NTIA took to award and disburse program funds, the challenges NTIA faced while implementing the program, and the status of awards and disbursements. 

We found that although NTIA has taken steps to mitigate some challenges it faced when implementing the Innovation Fund program, it would benefit from developing a comprehensive strategic plan that would ensure the program’s success. We found that NTIA did not have a sufficient strategy for anticipating emerging industry challenges, had not fully developed program goals and strategic objectives that align with the program’s statutory objectives, and did not develop a comprehensive staffing plan before it began awarding grants. 

The lack of an adequate strategic plan limits NTIA’s ability to effectively measure the program’s performance and mitigate future challenges. With over $853 million in grant funds left to award, issues may continue to arise if NTIA does not improve its program planning.

VA asked the OIG to conduct an audit of a contractor whose billing practices were concerning. The contractor, which provided eligible veterans with wheelchair van and other nonemergency transportation services to and from medical appointments in a certain VA healthcare system, invoiced VA about $11.17 million between January 1, 2019, and December 31, 2021, under this contract.

The OIG conducted an assertion-based attestation examination and found the company may not have complied with contract terms related to billing for veteran transportation, resulting in an estimated $1.81 million in potential overbillings between January 1, 2019, and December 31, 2021. Of this amount, $1.34 million was related to unclear contract terms and the company’s methodology for billing remote trips with multiple stops as though each drop-off was a separate trip.

The OIG also found that the company used mileage estimates instead of miles traveled and may have misclassified trips, with those errors resulting in potentially overbilling VA by an additional $470,537. According to the contractor, VA did not object or instruct the company to bill differently. VA issued a contract modification in April 2022, addressing billing of remote trips. The OIG found that the vendor complied with the billing terms of the modification for trips identified as remote. Subsequently, VA set a flat fee for each pickup and drop-off, removing the requirement to calculate billings by trip.

Except for the potential overbillings giving rise to the qualified opinion, the OIG team found the company’s assertion that it billed in accordance with the terms and conditions of the contract was fairly stated in all material respects. The OIG recommended—and VA agreed—that VA should confer with its Office of General Counsel on whether any funds could or should be recouped.