"We must have a plan to keep vets safe but also keep claims moving forward.”

Hundreds of thousands of veterans are stuck in limbo in regards to their disability compensation because the novel coronavirus (COVID-19) pandemic has delayed compensation and pension (C&P) exams, which vets need to take in order to receive a disability rating.

The exams are usually conducted in-person, but the Department of Veterans Affairs paused over 230,000 in-person C&P exams on April 2nd to prevent the spread of COVID-19, the VA told Task & Purpose.

Since few C&P exams can be conducted over the phone or online, many veterans are stuck on hold in terms of determining their compensation levels — and that’s attracted the attention of Congress.

“This abrupt pause to the C&P exam process has left some veterans to wonder when and how their claim will move forward,” said Rep. Elaine Luria (D-Va.) during a virtual forum on May 27 with experts from veteran service organizations.

While the congresswoman said she understood VA’s reasons for halting in-person C&P exams due to the spread of COVID-19, she argued that there also needs to be better procedures in place for ensuring a backlog doesn’t build up. According to the VA, claims pending for 125-plus days are considered “backlog.”

The build-up is made worse by logistical problems at the VA, several VSO experts said.

Matthew Doyle, associate director for the national legislative service for the Veterans of Foreign Wars (VFW), said that several veterans’ exams were cancelled due to COVID-19, but they were still marked as no-shows by the VA. The veterans then received a notification saying that their claim had been denied due to lack of evidence.

“During the 48-hour review period, our service officers noticed that VA drafted a rating decision in which every single condition the veteran claimed was denied because ‘we have been informed that you have canceled the VA examination scheduled in support of your claim,’” Doyle said of one such incident.

Rep. Mark Takano (D-Calif.), chairman of the House Veterans Affairs Committee, lamented a lack of transparency from the VA on what it was doing to address the C&P exam disruptions.

“Unfortunately, despite this looming backlog, VA chose not to participate today,” Takano said at the forum last week. “That decision prevents Congress from learning how VA plans to resume these exams and denies veterans the opportunity to hear first-hand from the agency in charge of the process.”

The VA seems to have been listening: the day after the forum, the department announced it would resume in-person C&P exams at select locations. The department also said that it would not take a final action on a claim while a required in-person exam is pending.

However, it was unclear what VA would do to address some of the other concerns shared by VSO experts.

When in-person exams are inadvisable

For example, both VFW and the Wounded Warrior Project warned that in-person exams may not be ideal for veterans who want to avoid traveling for fear of contracting COVID-19, or for veterans who cannot go to a VA facility easily.

“Often, one disability packet can require multiple exam visits which in turn requires the veteran to take off several days from work,” said Derek Fronabarger, government affairs director for WWP. “We believe that virtual C&P exams may resolve these challenges and will decrease barriers for veterans who are employed – or have mobility or transportation challenges.”

VA wrote in its press release that veterans outside of the in-person exam areas, or who do not yet feel comfortable receiving in-person exams, can schedule their exam for a later date, or be served through telehealth appointments.

However, virtual or telehealth C&P exams come with their own limitations, VSO experts said. Many of the C&P exams cannot be performed completely virtually.

Earlier in the pandemic, the Veterans Benefits Administration increased the number of authorized tele-C&P exam Disability Benefit Questionnaires (DBQs) from 16 to 29, Fronabarger said.

While the WWP expert applauded that move, he pointed out that only one of the 29 exams, the supplemental claims for already-established PTSD, can be performed completely virtually.

For the 28 other exams, VA requires an ‘in-home tele-practitioner,’ to assist the medical specialist performing the virtual exam, Fronabarger explained, which is a challenge when the whole point of staying home during COVID-19 is to avoid contact with other people.

“This is obviously the largest barrier we have identified in transitioning from in-person exams to a virtual model,” he said.

To remove that barrier, Fronabarger recommended VA review all 29 DBQs and waive some of the in-home tele-practitioner requirements. For example, some of the C&P exams require the tele-practitioner just to check blood pressure and temperature, which could be dropped from the exam requirements when possible, Fronabarger wrote.

Fronabarger also recommended VA work with third-party contractors or possibly VSOs to have mobile practitioners who could assist with virtual exams when practitioner requirements are not waivable. WWP’s Independence Program already provides in-home assistance for veterans with limited mobility, so that could be used to help administer C&P exams, he said.

“This would also help those who have limited mobility even after the COVID-19 pandemic is over,” he wrote.

More and more paperwork

VFW pointed out even more problems. For example, in late April, the VA ended the decades-long practice of giving VSOs 48 hours to help veterans review their benefits decisions for accuracy before being finalized, Connecting Vets reported.

Getting rid of that window is bad news for vets, VFW said.

“Veterans will now receive these kinds of erroneous decisions and have to file more paperwork to fix this problem,” Doyle said. “Moreover, our advocates must use complex workarounds and tracking methods outside of [veterans benefits management system] in the hopes of finding all of our recent decisions, in order to conduct a proper quality review.”

Related: The VA is supposed to reimburse vets through ‘community care,’ but they’re behind on 2.5 million payments

The VA made things even more difficult by removing public-facing DBQs from its website in April, Doyle added. Veterans often consult private medical providers to get an independent opinion about their service-connected disabilities, and DBQs filled out by a private medical provider help strengthen a veteran’s claims, he explained.

However, that can no longer be done now.

“[The] VA’s removal of public-facing DBQs amidst the crisis, was both imprudent and incomprehensible,” said Doyle, who endorsed Rep. Andy Barr (R-Ky.)’s “Veterans Benefits Fairness and Transparency Act” as a way to correct the problem.

Contractor headaches

However, there are still more problems with telehealth C&P exams, namely that the contractors VA hires to conduct its virtual C&P exams have a spotty track record.

Rich Loeb, senior policy counsel for the American Federation of Government Employees (AFGE), said exams conducted by private contractors are more likely to have errors in them, which slows down the process by requiring follow-up exams.

In contrast, VA clinicians have specialized knowledge, skills and experience that reduce the likelihood of such errors, Loeb said.

“This specialized workforce benefits veterans in several ways, including by using and developing examiners who know exactly what to look for during C&P exams, often leading to more thorough examinations that are less likely to be sent for a costly re-examination,” Loeb wrote in a statement.

Elizabeth Curda, a director in the Government Accountability Office’s Education, Workforce and Income Security team, confirmed some of Loeb’s claims about the reliability of VA’s C&P exam contractors. In 2018, her office published a report on how the VA needed to increase its oversight of private contractors that conduct medical exams.

“We found the agency does not know the extent to which contractors are meeting the exam contract’s quality and timeliness standards,” GAO wrote at the time. “The agency identified some contractor performance problems, but the incomplete information gathered on performance highlights the inadequacy of VBA’s oversight.”

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In September, the Government Accountability Office published a report on how VBA was implementing its recommendations for improving oversight. On the plus side, the agency had made fixes to its exam management system and begun auditing training for contract examiners to ensure the contractors were meeting training requirements, Curda said.

However, none of the GAO’s recommendations had been fully implemented, “so we do have some concerns about their ability to fully oversee the contracted examiners, especially under these circumstances where a large backlog of claims is building,” Curda said in the virtual forum.

For example, VA still hasn’t fully resolved its exam management system issues, which it needs in order to track the completion of exams and the payment of contractors, Curda explained. Without that system, VA will also have a hard time analyzing the exam backlog and coming up with ways to fix it.

Cutting down the backlog

Keeping track of its contractors is a vital step for VA, since 61% of all C&P exams are conducted by VBA contractors, Luria said at the forum. The inability to conduct in-person exams has also heavily increased the burden on contractors, she explained, and the backlog has increased with it.

Between April 11 and May 16, VA public data showed that backlogged claims went up from 75,000 to 100,000, she said.

“This means in the first month without in-person C&P exams we’ve seen a huge spike in the backlog,” Luria said. “This tells me we must have a plan to keep vets safe but also keep claims moving forward.”

The number of pending exams could reach more than a million by December if things remain unchanged, Luria said. However, that was before VA said on Thursday that it would resume in-person C&P exams at select locations.

Fronabarger said he was encouraged by the move, and he was confident VA would improve its telehealth C&P exams.

“The moves that have been made to digital for healthcare options, diagnosis, and treatment, is new territory for many health organizations, including the Department of Veterans Affairs,” he told Task & Purpose. “There will be growing pains and some trial and error as this gets fine-tuned. But we’ve seen a willingness from the VA to evolve, grow, and modernize their systems and processes during the COVID-19 crisis.”

Fronabarger says he hopes the telehealth adjustment will continue post-pandemic.

“It makes sense for some veterans to utilize a digital offering or telehealth option instead of driving three-to-four hours to the nearest capable VA facility,” he wrote.