Louis Calderon:
This is Veteran Oversight Now, the Veterans Affairs Office of Inspector General official podcast. I’m your host, Louis Calderon.
The VA Office of Inspector General returned to Capitol Hill three times in February to testify before Subcommittees of the House Veterans’ Affairs Committee. In addition, we published seven reports and made significant developments in ongoing investigations. Here are some of the highlights. Find all the VA OIG’s work from February on our website—vaoig.gov.
In Dr. Julie Kroviak’s testimony before the HVAC Subcommittee on Health on February 12, she detailed the major themes highlighted in more than 50 OIG reports focused on community care. These themes included timeliness and coordination of care, inadequate oversight of the quality of care being delivered, staffing shortages, as well as substandard IT systems and inaccurate and incomplete data. In response to questions, Dr. Kroviak also noted that VA must clearly define roles and responsibilities to establish the authority needed to provide adequate internal oversight and to hold staff accountable. Let’s hear from her.
Dr. Julie Kroviak:
“What we have consistently found can be organized into four areas of concern. First, veterans may not experience timely and seamless coordinated care when they are referred to the community. Referrals designated as high risk must be consistently prioritized. Requests for additional services must be acted upon quickly to avoid interruptions to care, and results of that care must be appropriately uploaded in a patient's medical record to ensure care teams have up to date information and can take action that is needed. To do this, VHA must further develop administrative processes to get patients to the right provider in a timely manner, and then follow up to ensure veterans received the appropriate care. Second, VHA has inadequate oversight of community care providers and cannot ensure the quality of care that is being provided.
“Unlike care provided at VHA, the Community Care Program lacks robust quality assurance processes that monitor the performance of care specific to veterans, such as screenings for suicidal ideation and military sexual trauma, as well as real time oversight of opioid prescribing practices. For example, community care providers may not be complying with VHA's opioid safety initiative, risking the close monitoring of these prescriptions for veterans. When VA providers cannot even get timely access to basic clinical documentation detailing a community provider's management of a referred veteran, any opportunity to monitor that quality or address additional identified needs is lost. Basic qualifications of community providers must be thoroughly reviewed and verified prior to joining the Community Care Network. Third, VHA staffing shortages further undermine community care coordination efforts. Reliance on community providers is necessary, but as we have seen, it does not guarantee veterans will get the timely care they need. VHA must commit adequate staffing and resources to ensure community care is as seamless as it is in-house.
“Fourth, substandard IT systems and inaccurate and incomplete data significantly restrict VA's ability to manage community care payments. VA has a right and an obligation to recover community care treatment costs for conditions unrelated to military service from veterans’ private health insurers. The OIG has found that VHA has not enacted effective processes to do this, compounded further by the pause of the Program Integrity tool, which is used to identify billable claims. OIG teams will continue to conduct meaningful, independent oversight to ensure veterans receive the timely, high-quality care they deserve.”
Louis Calderon:
Later, on February 24, Acting Inspector General David Case testified before the HVAC Subcommittee on Technology Modernization. He spoke about the ongoing issues with the development and deployment of VA’s new electronic health record system. Here is an excerpt from his testimony:
Acting Inspector General David Case:
“While VA has addressed many OIG-identified patient safety issues, more work is needed to ensure that the veterans’ experience with the new EHR fulfills its promise of timely access to seamless, high-quality care. For example, the new EHR has had serious issues with handling scheduling changes and missed appointments. This includes VHA allowing mental health staff at new EHR sites to make fewer attempts to contact no-show patients compared to legacy sites, creating a different standard of care between sites. VHA should address barriers created by software deficiencies without compromising patient care and engagement standards.”
Louis Calderon:
Since 2020, the VA OIG has published 22 oversight reports covering VA’s implementation of the system. He reviewed the open recommendations from these reports, including issues with appointment scheduling, medication safety, and the absence of reliable information on the program’s cost and schedule. In response to questions, he reiterated that VA must develop an integrated master schedule to better understand whether it can properly deploy the new system safely and timely.
Now, here’s updates from the VA OIG’s Office of Investigations.
An investigation resulted in charges alleging that between September 2019 and January 2020, a former physician at the Atlanta VA Medical Center sexually assaulted four female patients during medical examinations at the facility by touching them inappropriately. The former physician was found guilty by a jury in the Northern District of Georgia of deprivation of rights under color of law and abusive sexual contact after a two-week trial. The jury found the physician guilty of charges related to one victim and acquitted him of charges pertaining to the other three victims. He was sentenced in the Northern District of Georgia to 24 months’ imprisonment and 15 years’ supervised release and is also prohibited from practicing medicine while on supervised release.
In another case, a multiagency investigation resulted in charges alleging that several individuals operated multiple compound pharmacies in North Texas and conspired with various doctors to charge medically unnecessary compound prescriptions, pain creams, scar gels, and multivitamins primarily to patients covered under the Office of Workers’ Compensation Program. A pharmacy owner was sentenced in the Northern District of Texas to 210 months’ imprisonment, 36 months’ supervised release, and ordered to pay restitution of more than $115 million after previously being found guilty at trial on various charges related to this scheme. The total loss to the government is approximately $62 million, including an approximately $7.5 million loss to VA.
Lastly, a VA OIG proactive investigation resulted in charges alleging that a veteran was receiving VA disability compensation benefits due to a 100-percent service-connected rating for legal blindness while maintaining a Florida driver’s license. The veteran allegedly made false statements to VA regarding his true visual acuity and did not disclose that he maintained an active driver’s license and worked as an armed guard at an elementary school. The loss to VA is approximately $1.3 million. The veteran was arrested after being indicted in the Middle District of Florida for theft of government funds.
Among the reports the OIG published in February is one titled Lapse in Fiduciary Program Oversight Puts Some Vulnerable Beneficiaries at Risk. VBA’s Fiduciary Program protects vulnerable beneficiaries who are unable to manage their own VA benefits. The program appoints and oversees fiduciaries to manage the benefit payments. Each beneficiary must have a record in the program’s case management system so that staff can assess beneficiaries’ well-being and protect benefits from misuse. The OIG found that VBA did not create records for 311 beneficiaries who received about $24.5 million in compensation and pension benefits without VBA oversight. VBA implemented the OIG’s three recommendations to establish records for the 311 beneficiaries, resume oversight activities to assess the well-being of beneficiaries and the use of funds, and implement controls to flag beneficiaries without records.
Another report describes a healthcare inspection the OIG conducted to assess clinic cancellation practices at a mental health clinic in Fort Wayne, Indiana. The OIG found that mental health leaders and a social work supervisor used a standard process to address the needs of patients of a social work mental health provider and transition the patients to alternate treatment following the provider’s sudden resignation. The OIG did not identify any concerns or adverse outcomes related to the cancellations but concluded that the chief of staff was not notified of urgent cancellations of the provider’s clinic, as required by policy. The OIG also found that the system failed to include social work providers assigned to mental health clinics in their review of short-notice clinic cancellations. The OIG made two recommendations to the system director.
Read more about the VA OIG’s oversight work in February 2025 on our website at vaoig.gov. Want to stay up to date? Sign up to receive email messaging from the VA OIG. Thanks for listening.