Highlights from VA OIG's 93rd Semiannual Report to Congress

This Semiannual Report to Congress summarizes the independent oversight efforts of the VA Office of Inspector General (OIG) from October 1, 2024, through March 31, 2025.

Visit the VA OIG's website to read the full report.
 

For this six-month period, the VA OIG identified nearly $3.3 billion in monetary impact for a return on investment of $28 for every dollar spent on oversight. These figures do not include the inestimable value of the healthcare oversight work completed to help save the lives of veterans and ensure their access to top-level medical care.

During this period, the Office of Investigations opened 256 cases and closed 213 (most opened in prior reporting periods), with efforts leading to 144 arrests. The OIG hotline staff triaged more than 17,000 contacts to help identify wrongdoing and address concerns with VA activities. The related work resulted in 598 administrative sanctions and corrective actions.

The Office of Audits and Evaluations (OAE) produced 47 work products, including one VA management advisory memoranda on VA’s progress related to reducing overdose deaths. Also included were 16 oversight reports and 30 preaward and postaward contract audits and reviews to help VA obtain fair and reasonable pricing on products and services. OAE reports for the six-month period resulted in 146 recommendations for VA improvements.

The Office of Healthcare Inspections (OHI) continued to provide the oversight necessary to assess VHA's delivery of high-quality care and leaders' efforts to build and uphold a culture that prioritizes patient safety. Of the 36 oversight products OHI published in the last six months, 10 were for-cause reports responsive to OIG hotline complaints. In addition to seven national reviews, OHI released 14 healthcare facility inspections, three care-in-the-community inspections, one mental health inspection, and one vet center inspection.

The Office of Special Reviews (OSR) conducted 21 investigative interviews and issued one report addressing VA’s lapses in oversight of a grantee providing transitional housing services to veterans at risk for homelessness. Also during this period, OSR reviewed 12 allegations of possible whistleblower retaliation involving VA contractor's employees or grantees.

What is Veteran Oversight Now?

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.

Welcome back to another episode of Veteran Oversight Now, an official podcast of the VA Office of Inspector General. I’m your host, Louis Calderon.
The OIG published our 93rd Semiannual Report to Congress on May 22. This report covers the first half of fiscal year 2025 from October 1, 2024, through March 31, 2025. During this reporting period, the OIG identified nearly $3.3 billion in monetary impact for a return on investment of $28 for every dollar spent on oversight. We published 103 reports and other products with 342 recommendations for VA to take corrective actions.
OAE dedicated significant attention to reviewing what led to the projected budget shortfalls and related requests for supplemental funding that VHA and VBA claimed were needed for fiscal years 2024 and 2025 to cover veterans’ health care and benefits.
In July 2024, VHA informed Congress it might need an additional $12 billion (later revised down to $6.6 billion) in medical care funding for the rest of fiscal year 2024 and all of fiscal year 2025. The OIG found that the fiscal year 2025 advance appropriations relied on outdated data and assumptions, including lower-than-actual costs for new medications and both direct VA and community care. VHA also believed it could stay under a governing legislative funding cap but failed to remain within its budget despite actions to cut obligations.
Similarly, in July 2024, VA announced to Congress that VBA needed about $2.9 billion to avoid delayed payments for disability compensation, pension, and readjustment benefits to over seven million veterans through September 2024. VA officials later reported to Congress that supplemental funds were not needed. The OIG found that monthly congressional reports would have shown a reduced risk of a shortfall if VBA had included realized prior-year recoveries in status of funds calculations throughout the year. Find these two reports, published on March 27, on our website.
OHI continued its oversight activities by conducting cyclical inspections of programs and facilities as well as inspections prompted by reported allegations regarding patient safety and care, and national reviews. This included oversight of the implementation of the PACT Act.
A national review of VHA’s implementation of toxic exposure screenings and required training for clinical staff mandated by the PACT Act of 2022 found that VHA complied with the legislation, screening over four million of the nine million enrolled veterans as of November 30, 2023. VHA also complied with the requirements to train clinical staff on toxic exposure. Despite VHA issuing memoranda requiring additional toxic exposure screening training for VHA clinical staff, the review team found that just 21.4 percent of them completed training before performing screenings from November 8, 2022, through January 9, 2023.
On the investigations side, OIG special agents opened 256 investigations and closed 213. These investigations led to 144 arrests, 137 convictions, and more than $1.8 billion in monetary benefits for VA during the reporting period.
For example, a VA OIG investigation resulted in charges alleging the owner of a non-college-degree school and its certifying official conspired to submit fraudulent information to conceal noncompliance with the rules and regulations of the Post-9/11 GI Bill Program. The owner was sentenced in the District of New Hampshire to 12 months’ home detention and 36 months’ probation and ordered to pay restitution of approximately $200,000 after previously pleading guilty to conspiracy to make false statements.
As the result of another investigation by the VA OIG and multiple other agencies, four defendants pleaded guilty to conspiracy to pay and receive healthcare kickbacks after it was revealed that they fraudulently billed federal and private healthcare insurance programs over $110 million for expensive compounded medication in exchange for more than $6 million in payments.
In addition, text drafted with the assistance of OI investigators and other OIG staff was included in the Senator Elizabeth Dole 21st Century Veterans Healthcare and Benefits Improvement Act, signed by the president in January, to strengthen VBA’s compensation and pension program.
During this six-month reporting period, OIG leaders were also expert witnesses in four congressional hearings on protecting VA data and related systems, ensuring accountability in VA, reviewing VA’s oversight of community care, and restarting the electronic health record modernization project. These hearings highlight the integrity and impact of OIG work and the demand for independent, expert oversight. OIG testimony helps identify areas for congressional action and elevates national attention on topics of concern within the veteran community.
Check out the semiannual report under the reports tab on our website, www.vaoig.gov, to read more about all the impactful work we have done so far in fiscal year 2025.