Veteran Oversight Now is an official podcast of the Department of Veteran Affairs, Office of Inspector General. Each episode features interviews with key stakeholders, discussions on high-impact reports, and highlights of recent oversight work. Listen regularly for the inside story on how the VA OIG investigates crimes and wrongdoings, audits programs that provide benefits and services to veterans, and inspects medical facilities to ensure our nation’s veterans receive safe and timely health care.
Amanda
Welcome back to another episode of Veteran Oversight Now, an official podcast of the VA Office of Inspector General. I’m your host, Amanda Simmons.
Each month on this podcast, we’ll bring you highlights of the OIG’s recent oversight activities and interview key stakeholders in the office’s critical work for veterans.
Joining us today is VA’s Inspector General Michael J. Missal. He’ll discuss the OIG’s latest Semiannual Report to Congress, which covers the second half of the fiscal year 2024 from April 1st to September 30th.
Mr. Missal, welcome.
IG Missal
Thanks so much, Amanda, and thanks for hosting this podcast. I understand this is your inaugural podcast, so I’m excited to be here and to share information about our work over the past six months.
Amanda
Thank you so much, Mr. Missal. This is the VA OIG’s 92nd Semiannual Report to Congress, and according to the report, the OIG identified more than $5.1 billion in monetary impact during the six month reporting period, which brings the fiscal year total to nearly $6.6 billion. This is the highest amount since 2017, which was your first year as inspector general.
IG Missal
Yes. Amanda, as I’ve said many times before, I am focused on the qualitative impact of our work. How we help VA improve its programs and operations for veterans and their loved ones is something that is critically important to our office. However, the quantitative data does help tell a story of how we’re doing, and we did have a very strong return on investment in fiscal year 2024. Some of the monetary impact relates to the great work of our investigations office, which works closely with external federal partners, like the Department of Justice, on law enforcement actions that are at times large scale and complex.
Amanda
I did notice that the report highlights the VA OIG’s participation in a nationwide effort led by the DOJ.
IG Missal
Correct. In June, our Office of Investigations took part in the Justice Department’s 2024 National Health Care Fraud Enforcement Action, which was a coordinated effort against healthcare fraud and opioid abuse schemes that involve multiple law enforcement agencies. FBI, DEA, Homeland Security Investigations, Defense Criminal Investigative Services, HHS OIG, and several others were all involved. The action resulted in criminal charges against a total of 193 defendants for their alleged participation in these schemes, which included over $2.75 billion in fraudulent claims.
VA OIG special agents conducted six different investigations in connection with this action, and these investigations involve 10 defendants, including four licensed medical professionals. These 10 defendants allegedly took part in illegal kickback schemes involving durable medical equipment, wound care products, generic testing, compound pharmacy prescription, and medical imaging services.
Amanda
Another impactful effort highlighted in the report that identified over $1 billion question costs was a review by the Office of Audits and Evaluations, titled VBA Did Not Identify All Vietnam Veterans Who Could Qualify for Retroactive Benefits. Could you summarize the review for our listeners?
IG Missal
Sure. Going back to 1986, a class action lawsuit, Nehmer vs. the US Department of Veterans Affairs, was filed by Vietnam War veterans who believed the VA improperly denied their compensation claims for disabilities caused by herbicide exposure during their service. As a result of the lawsuit, VA was required to readjudicate their denied claims. In 2021, Congress expanded the list of health conditions that, in the intervening time, were found to be connected to herbicide exposure. This required VA to conduct another review of about 70,000 veterans and survivors who may now be eligible for disability compensation. While thousands of newly eligible veterans started receiving their benefits, the purpose of our review was to find out if VBA missed anyone.
Amanda
And did they miss anyone?
IG Missal
Yes, unfortunately they did. We projected it was over 36,000 veterans that were missed. The unpaid benefits to these veterans were estimated at about $844 million at the time of the review, but we also estimated that another $183 million could go unpaid over the next three years if VBA doesn’t take corrective action.
Amanda
Do we know if they’ve started to take corrective action?
IG Missal
Well, VBA actually disagreed with parts of our analysis but, in fact, is convening a workgroup to improve methods for identifying eligible veterans. They also agreed to send outreach letters to potential beneficiaries, improve claim processors’ identification of claims possibly warranting a readjudication, and update procedures so that staff can consider whether veterans’ medical records in VBA claims folders show a diagnosis of the now-covered herbicide-related diseases during prior disability benefits claims.
Amanda
That’s really good to hear. Fixing this process would make a real financial difference in the lives of thousands of veterans.
IG Missal
Exactly. And that holds true for our investigative work as well. To take another example highlighted in the report, we investigated a VA doctor, the former chief of medicine at a VA medical center in Louisiana, who was ultimately found guilty of defrauding several healthcare benefits programs. The loss to the government was about $5.4 million. And while he may have to pay the money back—he’s still awaiting sentencing—the more meaningful impact is that veterans will no longer interact with such a corrupt doctor, whose fraud scheme involved giving opioids to patients without a legitimate medical purpose. And again, this was the chief of medicine at the medical center.
Amanda
Well, that segues nicely into our Office of Healthcare Inspections, which emphasizes the importance of leadership and culture throughout VA medical facilities.
IG Missal
Absolutely. Having dedicated and engaged leaders has never been more crucial to the success of VHA. In fact, our findings across all OHI reviews—that’s the Office of Healthcare Inspections—have reinforced the connection between the culture created by leaders and the safety of patients and quality of care provided by staff.
Amanda
OHI published 65 reports during this reporting period. Is there a specific report you’d like to highlight?
IG Missal
Yeah, I think one of the best examples of leadership’s impact on patient safety from our Office of Healthcare Inspections is our latest report on the VA medical center in Hampton, Virginia. In fact, this was our third report on Hampton that stemmed from complaints by facility personnel or veterans receiving care. In each instance, the person who made the complaint asserted the facility leaders were either not cognizant of certain problems or had not properly responded to problems that they knew about. The first and second reports, which were published in 2022 and 2023, focused on Hampton’s quality assurance and oncology departments.
The latest report, published in July of 2024, focused on their surgical services. In short, we received complaints that multiple patients received poor surgical care, and that leadership at Hampton was aware of the concerns but did not address them. Our inspection found a number of problems, including the mishandling of the professional practice evaluations of surgeons, the Surgical Service’s quality management, and the failure to make institutional disclosures to patients or their representatives of an adverse event that resulted in harm.
Amanda
All of these issues at Hampton seem to be related to deficient leadership.
IG Missal
Yeah, I think that’s what our ultimate conclusion is. VHA has recently made changes to the leadership team at the Hampton facility, and we recognize that the course correction and change in culture may take some time.
Amanda
I’m so glad to hear they’re moving in the right direction. Mr. Missal, thank you for your time today. Is there anything else you would like to add before you sign off?
IG Missal
First, I appreciate you hosting this podcast. And I’d also like to thank our outstanding OIG staff who continue to conduct challenging and complex oversight projects during a period of great change at the highest levels of our nation and at VA. More change is forthcoming with Secretary McDonough previously announcing plans to leave VA in early 2025, and then there will be a change in administration.
Amid this changing landscape, I believe our work is more vital than ever. We continue to meet the challenge by improving as an organization and focusing our priorities on the areas that pose the greatest risk to veterans, VA, and taxpayers. For example, we’ve expanded the reach of our investigative efforts, launched new healthcare inspection programs, invested in systems and tools to improve effectiveness and efficiency, and so much more. I’m extremely proud of all the enhancements we’ve made and the exceptional improvements we helped to bring about for VA’s programs and operations, which ultimately improve the lives of veterans and their family members.
I encourage everyone to check out the semiannual report, as well as our website— www.vaoig.gov—to read more about all the impactful work we have done. There’s certainly more to come in 2025 and beyond.
Amanda
Thank you, Mr. Missal. Next up we have a recap of our monthly highlights.
Lauren
Thanks, Amanda. October marks the start a new fiscal year at the VA OIG. Fourteen investigations had updates this month.
One investigation found that between 2016 and 2020, a purchasing agent employed at the Jesse Brown VA Medical Center in Chicago, Illinois, conspired to rent medical equipment from a vendor in exchange for kickbacks of at least $220,000. The vendor received about $2.8 million in VA purchase card orders from the purchasing agent, of which approximately $1.3 million was fraudulent. The vendor was sentenced to 60 months in prison and more than $1.3 million in restitution, and fined $10,000 after being found guilty on charges of wire fraud. The former VA purchasing agent previously pleaded guilty to wire fraud.
Meanwhile, a multiagency investigation resulted in charges alleging that a veteran received about $200,000 in VA compensation benefits based on fraudulent claims that he suffered from posttraumatic stress disorder and other ailments due to combat service in Iraq. His military records, however, showed no indication that he ever served outside the United States. The charges also alleged that he was a patient at an Army hospital in Hawaii during the period that he claimed to have been deployed to Iraq. The veteran was arrested in the District of Rhode Island after being charged with making false statements and false statements relating to healthcare matters. The VA OIG, VA Police Service, and Defense Criminal Investigative Service conducted this investigation.
Another VA OIG investigation resulted in charges alleging that a veteran voiced numerous threats while communicating with the Veterans Crisis Line regarding killing and harming employees at the New Orleans VA Medical Center. The veteran was indicted in the Eastern District of Louisiana on charges of making interstate threat communications.
The VA OIG published two reports in October.
One report detailed an inspection team’s review of allegations involving the heart transplant program as well as the performance and behavior of the cardiothoracic section chief at the Richmond VA Medical Center in Virginia. The team also reviewed the temporary inactivation of the heart transplant program, factors associated with its reactivation, and the response of VISN and facility leaders to staff concerns about the program.
While the cardiothoracic section chief was found to have repeatedly exhibited unprofessional conduct toward staff, the inspection could not substantiate that the section chief’s surgical patient outcomes statistically varied from national averages, nor that the chief had long cardiopulmonary bypass times. In addition, VISN leaders did not ensure a timely quality of care review of cardiothoracic cases, and facility leaders failed to create a culture of safety in which staff felt comfortable reporting concerns. VA concurred with the OIG’s six recommendations related to oversight of the transplant program; clinical care reviews; and assessments of the section chief’s conduct, staff’s concerns, as well as the facility’s culture.
We also published a healthcare facility inspection report. The OIG’s Healthcare Facility Inspection Program, also known as HFI, reviews VHA medical facilities approximately every three years to measure and assess the quality of care provided. The inspections incorporate VHA’s high reliability organization principles to provide context for facility leaders’ commitment to a culture of safety and reliability, in addition to the well-being of patients and staff. October’s HFI report examined the VA Northeast Ohio Healthcare System in Cleveland.
Thanks for listening. To read the entire October monthly highlights, go to the reports section of our website: www.vaoig.gov.
Amanda Simmons is a retired Marine veteran and a public affairs specialist with the VA Office of Inspector General. Amanda spent 20 years with “The President’s Own” United States Marine Band where she served as the communications strategy chief.
Lauren O’Connor is a career writer-editor with the federal government. Here at the VA Office of Inspector General, she works to help veterans like her father, who graduated from the US Naval Academy and served on submarines before teaching at the Naval War College in Newport, Rhode Island.
This has been an official podcast of the VA Office of Inspector General. Veteran Oversight Now is produced by the Office of Communications and Public Affairs. Tune in monthly to hear how the VA OIG serves veterans, their families, and caregivers through meaningful independent oversight. Report potential crimes related to VA waste or mismanagement; potential violations of laws, rules, or regulations; or risks to patients, employees, or property to the OIG online at vaoig.gov or call the hotline at 1-800-488-8244.
If you are a veteran in crisis or concerned about one, call the Veterans Crisis Line at 988, press 1, and speak with a qualified responder now.