Federal Reports

The VA Office of Inspector General (OIG) reviewed the Systematic Technical Accuracy Review (STAR) program, which helps the Veterans Benefits Administration (VBA) provide timely and accurate disability compensation benefits to veterans and their beneficiaries. VBA’s STAR analysts perform quality reviews on randomly selected claims for disability compensation to identify errors and deficiencies in how claims were processed and to provide feedback to personnel to improve decision-making. The OIG review team examined whether STAR staff conducted accurate quality reviews of claims decisions, had adequate procedures to ensure corrective actions were timely and correct, and provided feedback to managers and staff to improve decision-making. The OIG found that STAR analysts were generally identifying benefit entitlement errors but not placing as much emphasis on finding procedural deficiencies. The OIG team determined there was no formal secondary review process for procedural deficiencies. An estimated 55 percent of claims had deficiencies (including benefit entitlement errors that could affect veterans’ disability compensation payments) and procedural deficiencies (such as veterans having to report for an unnecessary medical examination). Problems were also noted with the process for correcting errors that resulted in untimely and inaccurate actions, as well as with outdated or inaccessible feedback from reviews that did not enhance the quality of claims decisions. The OIG made six recommendations for ensuring STAR analysts follow the quality review checklist. Improvements to the second senior review process were also recommended for both analyst-identified deficiencies and to scan for errors missed by analysts, as well as advancing the processes to correct errors. In addition, VBA was called on to assess the training requirements for STAR staff; establish adequate policies, procedures, and monitoring to ensure corrections are completed timely and accurately; and to develop a plan to provide quality review data and feedback to assist managers in improving decision-making on claims.

Quality review team (QRT) program specialists oversee employees in the Veterans Benefits Administration (VBA) who process disability compensation claims. The VA Office of Inspector General (OIG) examined whether QRT specialists conducted accurate quality reviews; regional office managers decided employee requests for reconsideration of errors appropriately; and employees corrected claims-processing errors based on established standards. The OIG found that QRT specialists, who are supposed to identify claims-processing errors made by employees, missed errors in approximately 9,900 of the 28,400 quality reviews (35 percent) completed during the review period. Furthermore, the process in which QRT specialists review one another’s work was inadequate to identify errors missed during the initial quality review. Performance reviews of QRT specialists also did not ensure competency for identifying errors. Regional office managers did not follow VBA procedures by overturning errors identified by QRT specialists. The OIG estimated that during the review period, regional office managers inappropriately overturned errors in 430 of 870 quality reviews (about 50 percent) where claims processors requested a reconsideration of QRT specialist- identified errors. Finally, VBA has not established adequate oversight or accountability to ensure the timeliness of error corrections. The OIG estimated that during the review period 2,000 of 4,400 identified errors (45 percent) were not corrected in a timely manner and 810 of 4,400 identified errors (18 percent) were not corrected at all. The OIG recommended the under secretary for benefits (1) revise the current peer review process to make certain all errors are identified during quality reviews, (2) revise the QRT specialist performance review process to for competency in identifying errors, (3) revise the error reconsideration process to adhere to VBA procedures and promote objectivity, and (4) improve oversight of the error correction process.

Under the prospective payment system (PPS), Medicare pays home health agencies (HHAs) for each 60 day episode of care that beneficiary receives, called a payment episode. During our audit period, if an HHA provided four or fewer visits in a payment episode, Medicare paid the HHA a standardized per-visit payment. Claims for these types of payments are called Low Utilization Payment Adjustment (LUPA) claims. Once a fifth visit was provided during the payment episode (i.e., above the LUPA threshold), Medicare paid an amount for the services provided that was, in general, substantially higher than the per-visit payment amount. Because of the large payment increase starting with the fifth visit, HHAs have an incentive to improperly bill claims with visits slightly above the LUPA threshold.