All Reports

The Under Secretary for Health implements corrective actions to ensure discharge instructions for veterans consistently include appointment locations in easy-to-understand language.

The Under Secretary for Health implements corrective actions to ensure discharge instructions for veterans who received inpatient mental health care include the purpose for each medication listed and do not include medical abbreviations.

The Under Secretary for Health implements corrective actions to ensure risk-benefit discussions occur for newly prescribed medications.

Update VA’s enterprise data strategy and spatial data strategy and other related policy documents to align with the goals and objectives of the National Spatial Data Infrastructure strategic plan for 2025–2035.

Update VA directives, handbooks, and standard operating procedures to ensure they are current and aligned with operational goals related to geospatial functions and responsibilities.

Develop a comprehensive plan to ensure the Office of Data Governance and Analytics and other related offices have the necessary resources to fulfill the responsibilities of effective geospatial data collection, production, and stewardship regarding related activities of the covered agency and, as necessary, support the activities of the Federal Geographic Data Committee.

Assess options to expand and optimize automation tools, including artificial intelligence–based solutions, for request for services processing to reduce manual steps and promote efficiency.

Address system limitations that prevent identification of whether actions specific to requests for services have been taken or are pending, such as the delegated clinician review.

Review and update national standard operating procedures for request for services processing to clarify roles and responsibilities, address inappropriate practices, and reduce processing delays.

Develop processes or controls to help improve the accuracy and consistency of the use of the actual receipt date as the official date the Veterans Health Administration received the request for services to maintain accurate timeliness tracking.

Make sure facilities provide accurate notifications to community providers and notify veterans at key processing stages.

Implement mechanisms to provide routine oversight of the request for services process, including assessing data accuracy and the timeliness of request processing, to reinforce accountability and support corrective action.

Confer with the VA Office of General Counsel to determine whether VA should assert a claim to recover the $11.2 million paid for services not received

Evaluate and take any needed actions to make sure policies and procedures require appropriate officials to accurately ascertain information security requirements for contracts that involve sensitive information prior to award.

Create and mandate standardized due process letters for clear and unmistakable errors and severance of service connection, drafted in compliance with 38 C.F.R. § 3.103.

Update procedures to require an enhanced level of review for all final decisions associated with proposed adverse actions resulting from clear and unmistakable errors so that decisions are compliant with 38 C.F.R. § 3.105 and the M21-1 Adjudication Procedures Manual.

Develop an automated report that periodically identifies proposed adverse actions without a final decision and applicable pending end product, and ensure identified cases are reviewed and resolved as appropriate, to maintain compliance with the M21-1 Adjudication Procedures Manual and the M21-4 Manual.

Correct all errors identified by this review as appropriate, so claim processing actions are compliant with 38 C.F.R. § 3.103 and 3.105, the M21-1 Adjudication Procedures Manual, and the M21-4 Manual.

Implement comprehensive national policy on how staff should process enrollment applications that are missing information—including a firm and clear requirement that they enter incomplete applications in the Veterans Health Administration Enrollment System.

Coordinate with the Veterans Benefits Administration to identify opportunities to further streamline enrolling veterans in both administrations.

Define and implement guidelines for applications received at community-based outpatient clinics to make certain that they are processed consistently and promptly across the Veterans Health Administration.

Ensure the Health Eligibility Center regularly evaluates medical center enrollment practices.

Establish and implement procedures to make sure enrollment staff adhere to requirements in reviewing the records of veterans who may qualify for higher‑priority groups.

Standardize how Veterans Integrated Service Networks assess whether medical facilities are complying with Veterans Health Administration enrollment policies.

Determine whether enrollment coordinators nationwide should employ the Health Eligibility Center’s audit tool, and if so, direct that its use is required.

Define in policy how medical facility enrollment coordinators should conduct oversight.

The Under Secretary for Health develops a process to identify patients with a diagnosis of heart failure with reduced ejection fraction and implements an action plan that ensures monitoring of compliance with evidence-based care.

The Under Secretary for Health reviews Veterans Health Administration’s compliance with American Heart Association/American College of Cardiology/Heart Failure Society of America guideline-directed medical therapy medications for the treatment of heart failure with reduced ejection fraction (stages C or D) in women veterans and implements an action plan to ensure compliance.

The Under Secretary for Health ensures women veterans with a diagnosis of heart failure with reduced ejection fraction who are not receiving guideline-directed medical therapy medications have a documented rationale for the exception and implements an action plan to ensure compliance.

Ensure the Veterans Benefits Administration updates its Toxic Exposures Fund cost estimation methodology to reflect how it plans to use the funds.

Implement monitoring procedures to ensure Veterans Health Administration expenditure transfers follow statutes.

Assess lessons learned and establish standard operating procedures to integrate oversight roles, responsibilities, and clear guidance for reconciling Toxic Exposures Fund costs.

Make certain that the Veterans Benefits Administration’s Office of Financial Management and Office of Human Capital Services validate the actual number of Toxic Exposures Fund–supported employees and properly code them in VA’s HR Smart.

Update the Adjudication Procedures Manual to require documentation of each specific action taken when staff certify mail as unidentifiable.

Provide all employees who process unidentified mail appropriate access to all systems and resources necessary to identify a claimant.

Implement a plan to ensure all Veterans Benefits Administration contact and correspondence with claimants is documented and stored as required by the Adjudication Procedures Manual. As part of this plan, ensure documentation is easily accessible to appropriate staff.

Provide claims assistants who process unidentified mail with consistent quality reviews specific to their handling of unidentified mail.

Consider implementing a training module on processing unidentified mail, including guidance on appropriate work credit for claims assistants, and incorporating it into the national training curriculum. This training could be beneficial for all personnel involved in mail processing, including supervisors and records management officers.

Develop and maintain a Benefits Enterprise Platform modernization program schedule that (1) captures both agile and nonagile tasks and (2) documents the time frame for the delivery of all system modernization requirements.

Ensure staff follow VA’s Product (Line) Accountability and Reporting System Guide to include all program schedule information in the System.

Develop reliable, validated life cycle cost estimates for the Benefits Enterprise Platform modernization program that support planning and budgeting as required by Office of Management and Budget Circulars A-130 and A‑11.

Include all Benefits Enterprise Platform modernization costs in the VA’s Product (Line) Accountability and Reporting System as required by the Veteran-Focused Integration Process Guide, and track Cost of War Toxic Exposures Fund obligations and expenditures in the Office of Information and Technology PACT Act Dashboard consistent with VA financial policy.

Establish a mechanism for enforcing VA policy that requires minor applications to include an approved security assessment before being placed on VA’s network.

Consider the need for adjustments to current or for future contractual requirements that would improve mental health appointment timeliness by third-party administrators.

Identify and disseminate best practices used by healthcare systems to contact veterans, evaluate barriers to broader adoption of those practices, and implement a plan that supports consistent use of those best practices to improve scheduling timeliness.

Ensure that systems used to identify available community providers capture the full range of preferences that matter to veterans, so scheduling can better align with their individual needs and expectations for care.

Evaluate whether the third-party administrator’s network adequacy standards for mental health providers meet demand for both in person and telehealth, and if needed, modify the language to explicitly require sufficient availability of both in‑person and telehealth mental health providers to meet veteran demand.

Conduct a review to determine the best approach for increasing external use of available systems by community providers to streamline communication between the Veterans Health Administration and community providers and develop, implement, and monitor an action plan based on the review’s findings.

Assess the need for standardized guidance or contractual requirements that prohibit community mental health providers from requesting additional forms containing information already provided in the Veterans Health Administration referral documentation and implement measures to ensure compliance.

The Under Secretary for Health reviews Veterans Health Administration’s compliance with requirements for postpartum care coordination contacts by the maternity care coordinator and implements an action plan to ensure sustained compliance.

The Under Secretary for Health reviews Veterans Health Administration maternity care coordinators’ compliance with requirements for postpartum screenings and implements an action plan to ensure sustained compliance.

The Under Secretary for Health evaluates concerns regarding community care billing and billing resolution processes for maternity care and implements an action plan as warranted.

The Under Secretary for Health evaluates the scheduling and completion of postpartum primary care appointments within three months of delivery and implements an action plan to ensure sustained compliance.