Veterans Health
 

Administration
 

Review of Cincinnati VA
 

Medical Center Beneficiary
 

Travel Office Allegations
 

OFFICE OF AUDITS AND EVALUATIONS

July 6, 2011
	

10-03292-217
	
ACRONYMS AND ABBREVIATIONS
	

BTO Beneficiary Travel Office 

OIG Office of Inspector General 

VAMC Veterans Affairs Medical Center 

VHA Veterans Health Administration 

VISN Veterans Integrated Services Network 

VistA Veterans Health Information Systems and Technology Architecture 

To Report Suspected Wrongdoing in VA Programs and Operations:
	

Telephone: 1-800-488-8244
	

E-Mail: vaoighotline@va.gov
 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
	
Report Highlights: Review of Cincinnati 

VA Medical Center Beneficiary Travel 

Office Allegations 

Why We Did This Audit 

The VA Beneficiary Travel program 

provides reimbursements to offset some of 

the travel costs associated with obtaining 

VA health care services. We reviewed the 

validity of allegations of mismanagement 

and fraud at the Cincinnati VA Medical 

Center (VAMC) Beneficiary Travel Office 

(BTO). 

What We Found 

We partially or fully validated four of nine 

allegations made, and in doing so, identified 

some processing inconsistencies in the 

Cincinnati VAMC’s Beneficiary Travel 

program operations. Specifically, we: 

	 Determined BTO staff approved 174 

travel reimbursement claims for medical 

appointments not completed. 

	 Identified 27 travel vouchers associated 

with cancelled (by patient) and no show 

appointments that the BTO preprinted 

prior to the beneficiaries’ appointments. 

	 Identified one occurrence where a 

beneficiary was inappropriately 

approved travel reimbursement to the 

Cincinnati VAMC instead of the nearest 

VA facility to the beneficiary’s 

residence. 

 Determined the former BTO supervisor 

improperly authorized wheelchair van 

services in FY 2010 under an expired 

contract. As a result, the VAMC could not 

legally reimburse the vendor for services 

received until the Head of the Contracting 

Activity ratified the unauthorized 

commitments in November 2010. 

We were unable to validate allegations of 

mileage reimbursements based on incorrect 

residence addresses or not personally 

incurring eligible expenses. We also could 

not validate allegations that BTO staff 

approved special mode of transportation 

services for ineligible beneficiaries. 

What We Recommended 

We recommended the Cincinnati VAMC 

Director improve controls and oversight of 

BTO operations and resolve remaining 

unpaid special mode of transportation 

invoices. 

Agency Comments 

The Cincinnati VAMC Director concurred 

with the report’s recommendations. Based 

on corrective actions taken, we consider all 

recommendations closed. 

BELINDA J. FINN
 

Assistant Inspector General
 

for Audits and Evaluations
 

i 
TABLE OF CONTENTS
	

Introduction......................................................................................................................................1
 

Results and Recommendations ........................................................................................................2
 

Review of Cincinnati VAMC Beneficiary Travel Program Hotline Allegations .......................2
 

Appendix A Scope and Methodology....................................................................................12 

Appendix B Background .......................................................................................................15 

Appendix C Potential Monetary Benefits in Accordance With Inspector General Act 

Amendments .....................................................................................................17 

Appendix D Cincinnati VA Medical Center Director Comments.........................................18 

Appendix E OIG Contact and Staff Acknowledgments........................................................22 

Appendix F Report Distribution ...........................................................................................23 

ii 
Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

Objective 

Complaint 

Program Overview 

INTRODUCTION 

We reviewed the validity of allegations of mismanagement, waste, and fraud 

at the Beneficiary Travel Office (BTO) located at the Cincinnati VA Medical 

Center (VAMC). 

On July 7, 2010, the VA Office of Inspector General (OIG) Hotline received 

anonymous allegations concerning the operations of the Cincinnati VAMC’s 

BTO section of Patient Business Services. The complainant alleged the BTO 

was responsible for mismanagement of funds, waste, and inconsistent 

processes and transactions supporting the Beneficiary Travel program. 

(See Appendix B for additional information.) 

The VA Beneficiary Travel program provides reimbursements to offset some 

of the travel costs associated with obtaining VA health care services. Under 

Title 38, United States Code, Section 111, Payments or Allowances for 

Beneficiary Travel, VA has the authority to pay the actual necessary expense 

of travel (including lodging and subsistence), or in lieu thereof an allowance 

based upon mileage traveled, to or from a Department facility or other place. 

VA may reimburse travel in connection with vocational rehabilitation or 

counseling or for the purpose of examination, treatment, or care. VHA may 

authorize special mode of transportation (for example, ambulance or 

wheelchair van) if medically necessary and approved before travel begins. 

Regulations permit exceptions to the special mode of transportation 

authorizations in cases of medical emergency where delay would be 

hazardous to life or health. 

Beneficiaries who are currently eligible to receive travel benefits include 

those with service-connected disabilities approved at 30 percent or more or 

are traveling for treatment of a service-connected condition. Travel benefits 

are also authorized for those who incur travel expenses in connection with a 

compensation or pension examination, are in receipt of a VA pension, or 

whose income does not exceed the maximum annual VA pension rate. 

After attending VA health care appointments, claimants for beneficiary 

travel may apply for travel expense reimbursements orally or in writing 

through the BTO. Travel clerks complete an electronic version of VA Form 

70-3542d on the claimant’s behalf using the information in the Veterans 

Health Information Systems and Technology Architecture (VistA). The 

beneficiary signs and dates the voucher. Beneficiaries receive payment 

through the local agent cashier in person, or in cases where the form is 

completed and signed by the beneficiary and mailed, BTO staff process the 

voucher and will forward the voucher to the agent cashier for payment by 

check. 

VA Office of Inspector General 1 
Allegation 1 

Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

RESULTS AND RECOMMENDATIONS 

Review of Cincinnati VAMC Beneficiary Travel Program 

Hotline Allegations 

We partially or fully validated four of nine allegations made, and in doing so, 

identified some processing inconsistencies in the Cincinnati VAMC’s 

Beneficiary Travel program operations. Although VAMC management 

reported having strong controls over special mode of transportation contracts 

and benefits, the VAMC’s Beneficiary Travel program lacked adequate 

monitoring and oversight of travel reimbursements, and therefore, was more 

susceptible to improper transactions. 

We made recommendations to the Cincinnati VAMC Director to improve 

controls and oversight of BTO operations, and to ensure Beneficiary Travel 

program travel reimbursement activities are compliant with applicable 

policy. We also recommended the Cincinnati VAMC Director ensures the 

Head of Contracting Authority reviews and resolves remaining unpaid 

invoices for special mode of transportation services. 

BTO improperly reimbursed beneficiaries for mileage to VA facilities 

from addresses where they do not live or have never have lived. 

We could not substantiate the allegation that BTO staff reimbursed 

beneficiaries for mileage from their residences to VA medical facilities based 

on fictitious or incorrect addresses in order to obtain a larger reimbursement. 

Although the complainant indicated that this occurred regularly, sufficient 

evidence did not exist to review or support the allegation. 

However, we concluded the Veterans Health Administration (VHA) policies 

do not proscribe a process for Beneficiary Travel operations to determine 

when to validate beneficiaries’ addresses when processing travel 

reimbursement claims. According to VHA policy, VAMC staff have the 

authority to request any additional information needed to determine the 

validity of beneficiary travel claims. However, VHA policy does not provide 

examples of specific circumstances when to request the additional 

information. While Cincinnati BTO staff have the discretion to request 

additional information from the beneficiary to confirm the address used to 

calculate a travel reimbursement, the local policy was not in writing and staff 

reported not being clear as to when to ask for proof of residence from a 

beneficiary. 

The VAMC Director stated that Eligibility Office staff have the primary 

responsibility in the VAMC for any address changes, not the BTO staff. The 

Director also emphasized that were no electronic tools available to identify 

VA Office of Inspector General 2 
Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

Allegations 

2, 3, and 4 

fraud or nationally developed procedures for addressing suspicions of fraud 

related to reimbursement claims based on inaccurate addresses. The VAMC 

Director stated that veterans may now change addresses in VistA through 

portals such as “MyHealtheVet” without verification. 

VAMC officials indicated that initiatives are underway to address this 

control weakness. The VAMC’s Eligibility Office will monitor address 

changes requested on VA Form 10-10EZ, “Application for Health Benefits,” 

and will monitor compliance for requesting and receiving proper 

documentation to support address changes. 

Beneficiaries improperly received mileage reimbursements without 

incurring eligible travel costs to VA facilities. 

The complainant alleged beneficiaries improperly received mileage 

reimbursements although they did not personally incur eligible costs while 

traveling to VA facilities. We found only anecdotal and testimonial evidence 

to support these allegations. Ultimately, the BTO approves travel 

reimbursement claims based on the written representations made by the 

beneficiary. 

The complainant alleged that beneficiaries carpooled and each beneficiary 

claimed and received reimbursement for round trip mileage. When 

beneficiaries carpool, the total amount paid should not exceed the amount 

equal to the mileage paid to one beneficiary for the entire trip. The 

complainant also alleged that spouses, who were also beneficiaries, traveled 

to VA facilities together to obtain VA health care services and both claimed 

and received round trip mileage reimbursements. However, the BTO staff 

provided evidence of only one married couple claiming individual mileage 

reimbursements for appointments both attended at the VA facility on 

44 different occasions. On separate dates between January 1 through 

September 16, 2010, each spouse had 44 medical appointments at the same 

VA facility on the same day and claimed 88 mileage reimbursements (1 each 

for each day), totaling $1,385. If this couple traveled together, they would 

have been entitled to half that amount. When BTO staff questioned the 

spouses, they denied traveling to the facility together in the same vehicle. 

Using information from VHA’s VistA system, we identified a small number 

of other beneficiaries residing at the same addresses that the BTO approved 

reimbursement claims for mileage on the same day. Within a universe of 

22,832 approved travel reimbursements, we identified 12 claimants living at 

6 addresses that had appointments on the same day associated with 

52 approved travel reimbursements valued at $1,307. These reimbursements 

represented only 0.2 percent of the travel reimbursements for the period 

January 1 through September 16, 2010. Therefore, we concluded that while 

isolated instances of beneficiaries traveling together and improperly claiming 

VA Office of Inspector General 3 
Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

and misrepresenting mileage reimbursements may be occurring, sufficient 

evidence does not exist to support that these abuses are a systemic problem at 

the Cincinnati VAMC. 

The complainant also alleged some beneficiaries claimed and received 

mileage reimbursements for travel to VA facilities despite using public 

transportation and other sources that provide free transportation, such as 

Veterans Service Organizations and nursing homes. However, sufficient 

controls do not exist to allow the BTO to routinely and accurately identify 

instances whereby beneficiaries carpool or use public or free community 

transportation to and from VA facilities. In addition, data does not exist to 

routinely and accurately identify beneficiaries who use public transportation 

and claim mileage reimbursements. 

According to BTO staff, they receive passenger manifests from only one of 

multiple sources providing free transportation for patients to the Cincinnati 

VAMC. BTO staff stated that prior to processing mileage reimbursement 

claims, these manifests are checked to ensure beneficiaries provided free 

transportation are not reimbursed for mileage. However, the BTO lacks 

authority to direct service providers, public or other, to routinely forward 

passenger manifests to the BTO. Generally, public providers do not provide 

passenger manifests and logs to the BTO for beneficiary verification 

purposes. Further, the BTO lacks the resources to effectively identify the 

mode of transportation each beneficiary uses to travel to and from the 

VAMC. 

Only limited controls exist at the Cincinnati VAMC to help prevent the types 

of concerns in allegations 2, 3, and 4. For example, the VAMC Director 

reported that the act of a veteran signing VA Form 70-3542d, “Voucher for 

Cash Reimbursement of Beneficiary Travel Expenses,” certifying in writing 

that he or she personally incurred eligible costs claimed for reimbursement, 

constitutes a control. In addition, the VAMC Director noted that there are 

posters and brochures in the Travel Office that remind veterans of the 

consequence for submitting a fraudulent reimbursement claim. In addition, 

the VAMC Director reported that, in some cases, BTO staff will alert their 

supervisor or VA Police, if they suspect fraudulent activity. 

The Chief of Patient Business Services stated the BTO intends to request 

additional transportation manifests from some available sources that do not 

currently provide them to the BTO. Factors such as cost/benefit and other 

practical limitations affect the VAMC’s management from implementing 

additional controls to address some of these allegations related to gaining 

reasonable assurance that beneficiaries are not misrepresenting their travel 

costs. 

VA Office of Inspector General 4 
Allegation 5 

Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

BTO staff approved “special mode” transportation for ineligible 

beneficiaries. 

We could not substantiate the allegation that ineligible beneficiaries received 

approval for special modes of transportation, such as ambulance or 

wheelchair van services, in connection with service or care at VA medical 

facilities. A Veterans Integrated Services Network (VISN) 10 policy and a 

locally developed form to request and approve special modes of 

transportation for patients caused confusion among staff and made it more 

difficult to determine the eligibility for some beneficiaries. 

According to VHA Procedure Guide 1601B.05, VHA health care clinicians 

determine medical necessity for special modes of transportation. The Guide 

also states that for beneficiaries to qualify for special modes of 

transportation, they must: 

	 Have a medical condition as determined by a VA provider that requires 

an ambulance or specially equipped van, 

	 Meet the administrative requirements of eligibility for beneficiary travel, 

and 

	 The travel must be pre-authorized. 

VHA policy states that a VHA health care clinician determines that special 

mode of transportation is required. VHA policy is silent on the 

circumstances or medical conditions that must be present to provide this 

benefit to patients. Because the national policy is vague, a VHA official 

stated that VHA allows VISNs and VHA facilities to develop local policies 

specific to their customers. 

However, policy developed by VISN 10, and an approval form based on this 

policy, caused confusion among BTO staff concerning the eligibility of some 

patients for this benefit. VISN 10 policy provides a highly restrictive 

definition of those eligible for this benefit, stating that beneficiaries must 

require a stretcher for transport, be unable to transfer on their own from a 

wheelchair, or require a medical escort to qualify for special mode of 

transportation. Based on VISN 10 policy, VAMC staff developed a form for 

clinicians to request special mode of transportation for patients. When 

clinicians indicated on the forms that beneficiaries could transfer themselves 

from a wheelchair without assistance, BTO staff understood this as meaning 

beneficiaries were not medically eligible for special mode of transportation. 

We concluded the form used was the basis for confusion about patient 

eligibility for this benefit. We noted examples where BTO staff denied 

special mode requests reportedly due to the confusion concerning the request 

form and associated VISN policy. 

VA Office of Inspector General 5 
Allegation 6 

Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

We reviewed 41 special mode of transportation request forms processed 

from June 2009 through April 2010 that current BTO staff identified and 

believed were erroneously approved. Based on information available on the 

forms, we were unable to determine if beneficiaries were medically eligible 

for special modes of transportation. In all cases, clinicians used these forms 

to support the need for special mode of transportation for patients. The 

clinicians’ requests provided strong support that the clinicians believed that 

the patients required transportation to VA medical facilities for service and 

treatment. 

The Cincinnati VAMC incurred $2.4 million in special mode of 

transportation expenses in FY 2010, more than three times the amount paid 

to beneficiaries for travel expenses to VA facilities, approximately $778,000. 

The significant cost associated with special mode of transportation services 

increases the risk of waste and fraud and necessitates aggressive oversight of 

service authorizations by the BTO and clinicians. 

VAMC officials stated they will undertake initiatives to improve oversight of 

special mode of transportation requests. The approval form will be changed 

to include a second line of approval by the Chief of Primary Care or 

designee. In addition, VAMC management will establish training for 

clinicians regarding criteria for and approving special mode of transportation 

of patients. 

Beneficiaries received unauthorized travel reimbursement to the 

Cincinnati VAMC although other VA Medical Centers closer to their 

residences could provide the care or services. 

We partially confirmed the allegation the BTO approved mileage 

reimbursements to beneficiaries traveling to the Cincinnati VAMC when a 

closer VA facility could have provided the needed care or services. Unless 

otherwise allowed by Title 38, Code of Federal Regulations, Section 

70, VHA Beneficiary Travel, payment is limited to travel from the 

beneficiary's residence to the nearest VA or non-VA facility where the care 

or services could be provided and from such facility to the beneficiary’s 

residence. 

We randomly selected and reviewed 30 of the 1,147 travel claims processed 

by the BTO from January 1 through September 16, 2010, for a one-way 

travel distance of 100 miles or more. We identified one claim of the 30 

sampled (3 percent) where the BTO approved travel expenses to the 

Cincinnati VAMC when a closer VA facility could have provided the needed 

care or services. The value of this claim was $235. 

The VAMC Director explained that because a physician provided a referral 

for treatment to the Cincinnati VAMC, the BTO correctly approved the 

VA Office of Inspector General 6 
Allegation 7 

Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

travel reimbursement claim. However, 38 CFR, Part 70, states travel 

reimbursement is limited from the beneficiary’s residence to the closest VA 

facility that can provide the needed care or services. According to Cincinnati 

VAMC staff, Cleveland VAMC was the closest VA facility that could have 

provided the needed care or service to the beneficiary. The physician’s 

medical notes associated with the referral states the beneficiary requested to 

receive the services from the Cincinnati VAMC. The referral did not 

indicate the services could only be provided by the Cincinnati VAMC. 

While the patient received treatment at the Cincinnati VAMC, the BTO 

should have approved travel reimbursement only for the distance from the 

patient’s home to the nearest VA facility that could have provided the needed 

service. 

Furthermore, VHA policy in place during 2010 did not include exceptions 

made based on physician referrals. However, in January 2011, VHA issued 

guidance that allows reimbursement from a beneficiary’s residence to a VA 

facility other than the one closest to the residence if a clinician provides a 

referral to the veteran. 

Beneficiaries received mileage reimbursements without completing 

medical appointments at VA facilities. 

We substantiated the allegation beneficiaries received mileage 

reimbursements without completing appointments at VA medical facilities, 

although we also considered the number of instances identified to be low and 

generally insignificant. Using VistA data for beneficiary travel claims 

approved from January 1 through September 16, 2010, we initially identified 

268 (1 percent) of 22,832 beneficiary travel claims, totaling $5,400, 

approved for reimbursement by the BTO for beneficiary-cancelled or no 

show appointments. 

After review, VAMC officials acknowledged that 174 of these 

reimbursements, valued at about $3,500, were erroneously approved. 

According to VHA policy, VA reimburses beneficiary travel expenses “upon 

completion of examination, treatment, or care.” The VAMC Director 

advised us that those veterans who were identified as being incorrectly paid 

travel reimbursements will be issued a bill of collection. 

The Chief of Patient Business Services could not explain why BTO staff 

processed travel reimbursements for beneficiary-cancelled or no-show 

appointments. BTO staff indicated they were aware beneficiaries should 

receive travel claims only if they attended their appointments or if the 

beneficiary did not receive a timely notice of appointment cancellation. The 

Chief explained that medical staff do not consistently update VistA to show 

completed appointments before the patient applies for travel reimbursement. 

VA Office of Inspector General 7 
Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

Allegation 8 

Allegation 9 

In addition, a VAMC official told us that BTO staff members routinely 

process travel reimbursement claims despite the absence of completed 

appointment information in VistA. VAMC officials also told us that BTO 

staff sometimes accept verbal declarations by beneficiaries that health care 

appointments were completed. The Chief stated that, in those cases, BTO 

staff could attempt to recoup the funds later instead of denying a 

beneficiary’s travel reimbursement claim. 

These types of practices, however, do not constitute an effective control and 

provide unnecessary opportunities for inaccurate or fraudulent payments for 

appointments that were not completed and additional work tracking and 

managing collections. Clinic staff’s timely input of clinic appointment 

information into VistA is necessary to gain reasonable assurance that the 

travel reimbursements payments are proper. 

BTO staff provided preprinted travel vouchers to patients prior to 

completion of scheduled appointments. 

We confirmed that a former BTO staff member preprinted some 

reimbursement vouchers for travel to and from the Cincinnati VAMC, 

including some cases where the VAMC Beneficiary Travel program 

approved travel reimbursement for patients who did not complete scheduled 

appointments. We found 27 (15 percent) of 174 travel vouchers associated 

with cancelled (by patient) and no show appointments that were preprinted 

prior to the beneficiaries’ appointment times. VHA policy requires travel 

vouchers be processed only after care or services have been provided. 

The former BTO staff admitted to creating electronic travel vouchers at the 

beginning of each workday, but indicated beneficiaries received the vouchers 

only after verifying they completed scheduled appointments. The former 

staff member stated the former BTO supervisor approved this practice. The 

VAMC Director stated that this was done to expedite processing of payment 

vouchers and to improve veteran satisfaction with the BTO. The VAMC 

Director also advised that this practice was immediately stopped by 

management upon discovery, and prior to the Hotline allegation. Senior 

Cincinnati VAMC management advised us that the BTO stopped issuing 

preprinted travel vouchers in April 2010. 

VHA has not paid special mode of transportation vendors due to a 

variety of contract issues. 

We substantiated the allegation that Cincinnati VAMC had not paid a 

transportation contractor for services rendered in FY 2010. This occurred 

because the former BTO supervisor improperly authorized wheelchair van 

services under an expired contract. As a result, the VAMC could not legally 

VA Office of Inspector General 8 
Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

Travel 

Reimbursement 

Processes Not 

Regularly 

Reviewed 

Conclusion 

reimburse the vendor for services received until VHA ratified the 

unauthorized commitments in November 2010. 

The transportation contractor provided wheelchair van services to the 

Cincinnati VAMC during FY 2009 under a valid contract. However, VAMC 

staff awarded a new contract for these transportation services in FY 2010 to a 

different vendor. However, the BTO Supervisor continued to process 

invoices for the previous vendor using a FY 2009 Purchase Order instead of 

submitting a request for a new Purchase Order for FY 2010. The BTO 

Supervisor made the unauthorized commitments to ensure the continuation 

of wheelchair van services during the transition period for the new 

contractor. 

Although services were contractually unauthorized, the vendor sent invoices 

to the Cincinnati VAMC for services rendered from October through 

December 2009 totaling $100,242. Once the VHA Head of Contracting 

Activity ratified the unauthorized commitments in November 2010, VAMC 

staff made payments to the contractor totaling $83,536. We are not offering 

a recommendation to hold the former BTO supervisor accountable for the 

unauthorized commitments since this individual no longer works in the BTO. 

Although VAMC management reported having strong controls over special 

mode of transportation contracts and benefits, the VAMC lacked adequate 

monitoring and oversight of travel reimbursements, and, therefore, were 

more susceptible to improper transactions. Travel reimbursement processes 

in the BTO were not subject to routine quality reviews. 

After the OIG announced this review of BTO program operations, BTO 

management provided the review team with a list of planned initiatives to 

address deficiencies in Beneficiary Travel program operations. For example, 

the BTO will compare the list of patients collecting travel reimbursement to 

a list of patients who checked into the Emergency/Urgent care area of the 

VAMC. In addition, the BTO intends to review all travel reimbursements 

over $20. The BTO also intends to maintain an electronic list of 

beneficiaries suspected of fraud and coordinate with the VAMC’s police for 

potential investigation and surveillance. In our opinion, if implemented, 

these changes will strengthen management controls over the program and 

help identify potential fraud in Beneficiary Travel program claims. 

We partially or fully validated four of nine allegations made, and in doing so, 

identified processing inconsistencies in the Cincinnati VAMC’s Beneficiary 

Travel program operations that place the BTO at increased risk of approving 

improper travel reimbursements. Factors such as cost/benefit and other 

practical limitations affect the VAMC’s management from implementing 

controls to address some of the allegations we examined, especially those 

allegations related to gaining reasonable assurance that beneficiaries are not 

misrepresenting their travel costs. Although VAMC management reported 

VA Office of Inspector General 9 
Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

Recommendations 

Management 

Comments and 

OIG Response 

having strong controls and oversight concerning special mode of 

transportation contracts, the VAMC’s Beneficiary Travel program lacked 

adequate monitoring and oversight of travel reimbursements. VAMC staff 

could have detected problems related to travel reimbursements and taken 

corrective actions to independently review information readily available in 

the VAMC medical information systems along with providing more 

aggressive oversight and monitoring of travel reimbursement activities. 

The current VAMC and BTO management are addressing known control 

weaknesses. Although planned management control improvements are 

overdue, the Cincinnati VAMC management is taking positive steps to 

address identified BTO operational weaknesses. 

1.	 We recommend the Cincinnati VA Medical Center Director enhance 

management oversight of Beneficiary Travel Operations by 

implementing a quality assurance program to ensure Beneficiary Travel 

program travel reimbursement activities are compliant with applicable 

policy. 

2.	 We recommend the Cincinnati VA Medical Center Director direct the 

Beneficiary Travel Office staff to immediately stop processing mileage 

reimbursements without evidence of medical appointments, and take 

actions to collect unsupported payments. 

3.	 We recommend the Cincinnati VA Medical Center Director ensure the 

Head of Contracting Authority reviews and resolves remaining unpaid 

special mode of transportation invoices. 

The Cincinnati VAMC Director concurred with the recommendations contained 

in the draft report, and provided responsive implementation plans to address 

our recommendations. The VAMC Director stated that the VAMC’s Patient 

Business Services office implemented routine audits beginning in January 

2011 of payable claims reports to ensure mileage reimbursements are 

compliant with VA regulations and to identify the need for further process 

improvement or the re-training of any staff. 

In addition, the Director advised that the existing Beneficiary Travel 

program handout is being revised to inform veterans that they will be billed 

for fraudulent or improper travel claims. BTO staff have been retrained to 

assure that appointments are checked out in the computer before approving 

mileage reimbursements. If veterans have not been checked out at the time 

they report to the BTO, BTO staff will ask the veteran to sign the claim form 

and a check will be mailed after the BTO verifies the completed 

appointment. A lead clerk has been delegated the responsibility for assuring 

that the appointments were completed before she authorizes payment by 

check to the beneficiaries. 

VA Office of Inspector General 10 
Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

Furthermore, the Director stated that the VAMC has paid previously unpaid 

invoices from FY 2010 associated with one special mode of transportation 

contractor. The Director stated the actions for this recommendation were 

completed at the time of the OIG review, but that documentation necessary 

to verify status of the paid claims was unavailable at the time. In May 2011, 

VAMC officials provided documentation of paid claims to the OIG. 

Based on actions taken and plans to take additional actions in these areas, 

we consider all recommendations closed. See Appendix D for the text of the 

Cincinnati VAMC Director’s comments. We modified the text to show 

actions completed instead of target dates. 

VA Office of Inspector General 11 
Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

Appendix A Scope and Methodology 

We observed and reviewed the Cincinnati VAMC Beneficiary Travel 

program from September 13 through 16, 2010. We interviewed and 

corresponded with key personnel responsible for overseeing the Beneficiary 

Travel program from the Cincinnati VAMC, VHA Headquarters, and 

VISN 10. We examined Beneficiary Travel program documentation and 

related supplementary records and reports from VHA information systems. 

We also reviewed applicable laws, policies, and procedures. Our universe 

consisted of almost 23,000 mileage reimbursements for the period from 

January 1 through September 16, 2010. 

Allegation 1	 For Allegation 1, we interviewed VAMC personnel to determine the local 

process for address change requests and related recordkeeping and address 

validation procedures applicable to beneficiary travel claims. We obtained 

data for address changes recorded in VistA for each beneficiary who was 

approved travel reimbursements from January 1 through September 16, 

2010. We reviewed the data for evidence of address changes made 

immediately before and after a health care appointment. 

Allegations For Allegation 2, we interviewed personnel to determine the local process for 

2, 3, and 4 mitigating risks applicable to beneficiaries traveling together and 

fraudulently claiming travel reimbursement. We obtained and reviewed 

VistA data for approved travel beneficiary claim recipients residing at the 

same address on the same date claims were processed. For Allegation 3, 

based on a specific referral from BTO staff, we obtained and reviewed 

VistA electronic record data of all travel beneficiary approved for a married 

couple for the same dates. For Allegation 4, we interviewed knowledgeable 

personnel and a Cincinnati VAMC detective to obtain evidence of 

beneficiaries using public and community transportation and collecting 

mileage reimbursement. 

Allegation 5	 For Allegation 5, we interviewed personnel to determine the local process for 

special mode of transportation requests and approvals. In addition to 

reviewing VHA policy, we reviewed the VISN 10 policy specific to special 

modes of transportation. We also obtained and reviewed 41 special mode of 

transportation request forms submitted for approval to the BTO that BTO 

staff believed were erroneously approved. We reviewed the forms to 

determine whether the Cincinnati VAMC approved special mode of 

transportation in accordance with VHA and VISN 10 policy. 

VA Office of Inspector General 12 
Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

Allegation 6 

Allegation 7 

Allegation 8 

Allegation 9 

Reliability of 

ComputerProcessed Data 

To substantiate Allegation 6, we interviewed personnel to determine the local 

process for identifying veterans eligible for travel reimbursement to the 

Cincinnati VAMC although residing closer to other VA facilities. We 

obtained data from VistA to identify beneficiaries who were approved travel 

reimbursement for a one-way travel distance of 100 miles or more. From 

this list, we randomly selected and reviewed a sample of 30 travel claims. 

We then used the Compensation and Pension Records Interchange system to 

identify patients with evidence of a referral from a physician directing travel 

to Cincinnati VAMC. 

For Allegation 7, we interviewed personnel to determine the local process for 

identifying mileage reimbursement claims associated with beneficiaries who 

did not complete appointments at the Cincinnati VAMC. We also compared 

the distribution of digits that made up the claimed amounts to the expected 

distribution under Benford’s Law. This analysis was appropriate since the 

values for the claims had no imposed lower or upper limits. We did not 

identify unusual patterns associated with these exceptions that merited 

further examination. We are questioning the costs of these reimbursements 

and making a recommendation to the Director of the Cincinnati VAMC to 

research and collect unsupported payments. 

For Allegation 8, we interviewed personnel to determine whether BTO travel 

clerks preprinted travel vouchers for beneficiaries prior to completion of the 

appointments. We obtained data from VistA for all travel reimbursements 

approved for beneficiaries on the same date that VistA indicated a no show 

appointment. We then compared no show appointment times to the times the 

BTO printed travel vouchers to identify vouchers printed prior to scheduled 

appointment times made, but not kept, by patients. 

For Allegation 9, we interviewed key Cincinnati VAMC personnel and 

obtained and reviewed applicable special mode of transportation contracts 

and invoices. We identified a series of payments associated with one special 

mode transportation provider that occurred 15 months after the BTO made 

unauthorized obligations under an expired contract. We coordinated with 

VAMC personnel to identify steps VAMC staff took to ratify the contract 

and to determine if outstanding invoices associated with the unauthorized 

obligations remained. 

We assessed the reliability of VA data by randomly selecting VistA 

beneficiary travel records and comparing those records to associated medical 

appointment and physician consult information found in the Compensation 

and Pension Records Interchange system. Based on these tests and 

assessment, we concluded the data were sufficiently reliable for the purposes 

used. 

VA Office of Inspector General 13 
Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

Compliance With 

Government Audit 

Standards 

We conducted this review from September through November 2010 in 

accordance with the Council of Inspectors General on Integrity and 

Efficiency standards. These standards guide the conduct of all inspection 

work performed by Offices of Inspector General. Accordingly, based on our 

review objectives, we believe the evidence obtained provides a reasonable 

basis for our findings and conclusions. 

VA Office of Inspector General 14 
Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

Appendix B 

Beneficiary Travel
 

Program Overview
 

Travel 

Reimbursement 

Process 

Background 

Under Title 38, United States Code, Section 111, “Payments or Allowances 

for Beneficiary Travel,” VA has the authority to pay the actual necessary 

expense of travel (including lodging and subsistence), or in lieu thereof an 

allowance based upon mileage traveled, to or from a Department facility or 

other place in connection with vocational rehabilitation or counseling or for 

the purpose of examination, treatment, or care. Reimbursements may also 

include ferry fares and tolls for bridges, roads, and tunnels. VHA may 

authorize special mode of transportation, for example, ambulance or 

wheelchair van, if medically necessary and approved before travel begins. 

Exception to this would be in cases of medical emergency where delay 

would be hazardous to life or health. 

Title 38, Code of Federal Regulations, Part 70, “VHA Beneficiary Travel 

Under 38 U.S.C. 111,” provides a mechanism for VHA to make payments 

for travel expenses incurred in the United States to help veterans and other 

persons obtain care or services from VHA. VHA Handbook 1601B.05, 

Beneficiary Travel, July 23, 2010, provides additional information and 

guidance on the Beneficiary Travel program. 

A claimant may apply for beneficiary travel benefits orally or in writing and 

must apply for reimbursement within 30 calendar days after completing 

beneficiary travel. For beneficiary travel that includes a special mode of 

transportation, a claimant must apply for payment of beneficiary travel and 

obtain approval from VA prior to travel in most cases. Claimants for 

beneficiary travel must submit information to the Chief of the Business 

Office, or other designee, at the VA facility responsible for the medical care 

or services provided and for which travel is required. 

Beneficiaries use VA Form 70-3542d when completing mileage allowance 

claims. BTO travel clerks complete an electronic version of VA Form 

70-3542d on the claimant’s behalf using VistA. Policy requires that BTO 

travel clerks record claimant’s information and determine if the beneficiary 

is eligible before processing the travel reimbursement claim in VistA. Upon 

successful processing, VistA generates a travel voucher, which VHA pays by 

cash or by check. By signing and dating the travel voucher, the beneficiary 

certifies the following: 

I have neither obtained transportation at Government expense 

nor through the use of Government request, tickets, or tokens; 

and have not used any Government-owned conveyance or 

incurred any expenses which may be presented as charges 

against the Dept. of Veterans Affairs for transportation, meals, 

or lodging in connection with my authorized travel that is not 

herein claimed. I hereby claim the amount entered in Item 14 

VA Office of Inspector General 15 
Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

above. I certify that the claim is correct and just and that 

payment has not been received. 

I hereby acknowledge receipt, in cash or check to be mailed, of 

the amount in Item 14 above, in full payment of this claim. 

Beneficiary Travel	 On July 7, 2010, the VA OIG Hotline received the following anonymous 

Office Allegations	 allegations concerning the operations of the Cincinnati VAMC’s BTO 

section of Patient Business Services. The complainant alleged the BTO was 

responsible for mismanagement of funds, waste, and inconsistent processes 

and transactions supporting the Beneficiary Travel program. 

1.	 Beneficiaries were reimbursed for mileage from addresses where they do 

not reside and/or never have resided. 

2.	 Beneficiaries were sharing rides to VA facilities for medical 

appointments and both were claiming mileage reimbursements. 

3.	 Spouses were sharing rides to VA facilities for medical appointments and 

both were claiming mileage reimbursements. 

4.	 Beneficiaries were using community and other public transportation and 

collecting mileage reimbursements. 

5.	 BTO staff approved some patients for special mode of transportation 

benefits who were not eligible for this benefit. 

6.	 Beneficiaries received unauthorized travel reimbursements to the 

Cincinnati VAMC although other VA facilities, which could provide the 

care or services, were closer to their residences. 

7.	 BTO staff provided travel reimbursement to some patients for unattended 

medical appointments. 

8.	 BTO staff provided preprinted travel vouchers to patients prior to their 

completion of scheduled appointments. 

9.	 VHA had not paid a special mode of transportation vendor due to a 

variety of contract issues. 

VA Office of Inspector General 16 
Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

Appendix C Potential Monetary Benefits in Accordance With 

Inspector General Act Amendments 

Better Use Questioned Recommendation Explanation of Benefits of Funds Costs 

3	 174 travel reimbursements $0 $3,500 

approved without evidence of 

completed medical appointments 

Total $0 $3,500 

VA Office of Inspector General 17 
Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

Appendix D Cincinnati VA Medical Center Director Comments 

Department of Memorandum Veterans Affairs 

Date: June 6, 2011 

From: Network Director, VA Healthcare System of Ohio (10N10) 

Subj: Cincinnati VA Medical Center Beneficiary Travel Office Allegations 

To: Director, St. Petersburg Audit Operations Division (52SP) 

Director, Management Review Service (Management Review VHA 10A4A4) 

1.	 I have reviewed the recommendations and concur with responses and action plans 

submitted by the Cincinnati VA Medical Center 

2.	 If you have any questions or require additional information, please feel free to contact 

me at (513) 247-4610. 

(original signed by:) 

Jack G. Hetrick, FACHE 

VA Office of Inspector General 18 
Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

Department of Memorandum Veterans Affairs 

Date:	 June 3, 2011 

From:	 Medical Center Director, Cincinnati, OH (539/00) 

Subj:	 Draft Report, Veterans Health Administration: Review of Cincinnati VA Medical Center 

Beneficiary Travel Office Allegations 

To: Network Director (10N10), VA Healthcare System of Ohio, Cincinnati, OH 

1.	 Attached are my comments and implementation plans in response to the 

recommendations identified in the OIG Review conducted on July 7, 2010 at the 

Cincinnati VA Medical Center. I concur with the recommendations, but suggested 

several changes in the wording of the findings. 

2.	 I appreciate the opportunity for this review as a continuing process to improve care 

to Veterans. 

3.	 Should you have any questions or require further information, please contact me at 

(513) 475-6300. 

(original signed by:) 

Linda D. Smith, FACHE 

Attachment 

VA Office of Inspector General 19 
Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

Comments to Office of Inspector General’s Report
	

The following Director’s comments are submitted in response to the recommendations 

in the Office of Inspector General report: 

OIG Recommendations 

Recommendation 1. We recommend the Cincinnati VA Medical Center Director 

enhance management oversight of Beneficiary Travel Operations by implementing a 

quality assurance program to ensure Beneficiary Travel Program travel reimbursement 

activities are compliant with applicable policy. 

Concur 

Action Completed: 5/16/11 

Facility Response: The medical center’s Patient Business Services (PBS) office 

implemented routine audits in January 2011 of payable claims reports to ensure 

mileage reimbursements are compliant with VA regulations and to identify the need for 

further process improvement or the re-training of any staff. The initial review is being 

conducted on 100% of travel claims. PBS has also requested additional transportation 

manifests from sources that do not currently provide the manifests to the BTO. Both of 

these actions are in addition to the follow up done by BTO and Police and Security 

Service when there is a suspicion of a fraudulent claim. The BTO is also being 

reorganized. One full-time clerk is paying all special mode bills, managing the fund 

control point, processing unauthorized claims and auditing mileage claims. Audits will 

be tracked through the medical center’s Compliance Committee. These actions have 

been completed and incorporated to ongoing business practices. We request this 

recommendation to be closed at this time. 

Recommendation 2. We recommend the Cincinnati VA Medical Center Director direct 

the Beneficiary Travel Office staff to immediately stop processing mileage 

reimbursements without evidence of medical appointments and take actions to collect 

unsupported payments. 

Concur 

Target Date for Completion: 6/30/11 

Facility Response: The existing Beneficiary Travel handouts are being revised to 

inform Veterans that they will be billed for fraudulent or improper travel claims. Staff in 

the Beneficiary Travel Office have been retrained to assure that appointments are 

checked out in the computer before paying cash reimbursements for mileage. This had 

been an issue primarily in mental health group clinics due to the time involved to 

complete notes for all the Veterans in the group. If Veterans have not been checked 

VA Office of Inspector General 20 
Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

out at the time they report to the BTO, they will be asked to sign the claim form and a 

check will be mailed when the completed appointment can be verified. A lead clerk has 

been delegated the responsibility for assuring that the appointments were completed 

before she authorizes payment by check to the Veterans. 

Recommendation 3. We recommend the Cincinnati VA Medical Center Director 

ensure the Head of Contracting Authority reviews and resolves remaining unpaid 

special mode of transportation invoices. 

Concur 

Action Completed: 1/21/11 

Facility Response: Fiscal Service has confirmed that the final payment to Med Corp 

occurred on January 21, 2011. Med Corp, the interim Special Mode transportation 

provider who transported Veterans while American Ambulance was ramping up to 

provide new contract service, advised the medical center by email that the company 

had been fully paid. The actions for this recommendation were completed at the time of 

the review, however documentation to verify status of the paid claims was unavailable 

at the time. The documentation of paid claims has since been provided to the OIG. We 

request that this recommendation be closed at this time. 

Other Issues Identified from the Draft Report “Review of Cincinnati VA Medical 

Center Beneficiary Travel Office Allegations” 

Issue 1: On page 2 of the OIG draft report, the OIG indicates that “While Cincinnati 

BTO staff has the discretion to request additional information from the beneficiary to 

confirm the address used to calculate a travel reimbursement, the local policy was not 

in writing and staff reported not being clear as to when to ask for proof of residence 

from a veteran. 

Facility Response: Eligibility staff has the primary responsibility in the medical center 

for any address changes. This was not the responsibility of the BTO staff. Eligibility 

staff has a clear process for change of address that includes documentation in the 

remarks section of the demographic update in VistA providing the date of the address 

change. They also require that the Veteran document the address change on the 

1010EZ. 

Issue 2: On page 8 of the OIG draft report, the OIG indicates that “BTO staff admitted 

creating electronic travel vouchers at the beginning of each workday . . .” 

Facility Response: There was a single BTO staff member who preprinted travel 

vouchers for a short period of time in 2010. This practice was reported to management 

but the employee had already taken another position in the medical center so no further 

action was required. 

VA Office of Inspector General 21 
Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

Appendix E OIG Contact and Staff Acknowledgments
	

OIG Contact	 For more information about this report, please 

contact the Office of Inspector General at 

(202) 461-4720. 

Acknowledgments Timothy J. Crowe, Director 

Johnny McCray 

Bryan Shaw 

Craig Ward 

VA Office of Inspector General 22 
Review of Cincinnati VAMC Beneficiary Travel Office Allegations 

Appendix F Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Director, Cincinnati VA Medical Center 

Director, VA Healthcare System of Ohio 

Veterans Health Administration Chief Business Officer 

Assistant Secretaries 

Office of General Counsel 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans 

Affairs, and Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans 

Affairs, and Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

This report will be available in the near future on the OIG’s Web site at 

http://www.va.gov/oig/publications/reports-list.asp. This report will remain 

on the OIG Web site for at least 2 fiscal years. 

VA Office of Inspector General 23