Department of
 

Veterans Affairs
 

Review of
 

Healthcare Services
 

and Benefits for Resident
 

U.S. Virgin Islands
 

Veterans

 May 5, 2011
	

10-03882-151
	

OFFICES OF AUDITS AND EVALUATIONS

AND HEALTHCARE INSPECTIONS
ACRONYMS AND ABBREVIATIONS 

C&P Compensation and Pension 

CBOC Community Based Outpatient Clinic 

OIG Office of Inspector General 

USMLE United States Medical Licensing Examination 

USVI U.S. Virgin Islands 

VACHS Veterans Affairs Caribbean Healthcare System 

VAMC Veterans Affairs Medical Center 

VARO Veterans Affairs Regional Office 

VBA Veterans Benefits Administration 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VistA Veterans Health Information Systems and Technology Architecture 

VSSC Veterans Support Service Center 

VSO Veterans Service Organization 

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)
	
TABLE OF CONTENTS
	

Executive Summary........................................................................................................................ ii
 

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

Results and Recommendations ....................................................................................................... 3
 

Issue 1 Language Barriers .............................................................................................. 3
 

Issue 2 Access to Healthcare .......................................................................................... 6
 

Issue 3 Timeliness of Care ........................................................................................... 10
 

Issue 4 Patient Satisfaction........................................................................................... 13
 

Issue 5 Disability Rating Decisions and Compensation and Pension Medical
 

Examination Cancelation Rates ....................................................................... 15
 

Issue 6 Beneficiary Travel Reimbursement ................................................................. 19
 

Issue 7 Income Guidelines That Determine Eligibility for VA Services ..................... 24
 

Appendix A Background ...................................................................................................... 26
 

Appendix B Scope and Methodology................................................................................... 27
 

Appendix C VHA Comments............................................................................................... 29
 

Appendix D VBA Comments............................................................................................... 33
 

Appendix E OIG Contact and Staff Acknowledgments....................................................... 34
 

Appendix F Report Distribution .......................................................................................... 35
 

i 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

EXECUTIVE SUMMARY 

Results 

In response to Congressional concerns, we fully or partially substantiated some allegations that 

veterans residing in the U.S. Virgin Islands (USVI) may be receiving disparate services and 

benefits in comparison to veterans residing in Puerto Rico. We substantiated the allegation that 

USVI veterans could face language barriers and problems communicating with non-direct 

patient care staff while at the VAMC in San Juan. However, we did not find that language 

barriers negatively impacted patient care. We also found that English language proficiency was 

not consistently documented in SF 52 Request for Personnel Action forms. 

We partially substantiated the allegation that USVI veterans do not have access to the same level 

of Veterans Health Administration (VHA) services as the veterans in Puerto Rico because VHA 

does not provide inpatient care, 24-hour emergency care, or outpatient specialty care in the 

USVI. VHA purchases these services from local providers and medical facilities through 

individual fee basis authorizations. Because the Veterans Affairs Caribbean Healthcare System 

(VACHS) allows USVI Community Based Outpatient Clinic (CBOC) providers liberal use of 

fee basis care, access to care for USVI veterans is not limited or less than that of the veterans in 

Puerto Rico. In addition, we confirmed that patient satisfaction was not measured at the local 

level for the USVI CBOCs as required. 

We could not confirm or refute the allegation that veterans must generally wait 3 months for a 

medical appointment. Appointments for new patients exceeded the VHA goal of less than 30 

days from the desired date of the appointment at the St. Thomas CBOC. However, established 

patients were generally seen within 30 days of the desired appointment date, and patients were 

consistently seen promptly by fee basis providers and within 30 days at the San Juan VAMC. 

We did not substantiate the allegation of disparate treatment of benefits claims filed by veterans 

residing in the USVI. No evidence suggested that VBA processed benefits claims differently 

based on a veteran’s residency. Further, the San Juan VARO processed benefit applications for 

USVI veterans on average 4 days sooner than benefit applications submitted by veterans residing 

in Puerto Rico. Additionally, veterans residing in the USVI had a higher rate of canceled 

Compensation and Pension (C&P) medical examinations (28 percent) compared to those 

veterans residing in Puerto Rico (10 percent). 

We could not determine whether VHA applied travel reimbursements unequally for claims 

submitted by veterans because there were no records of mileage reimbursement claims in VHA’s 

systems prior to October 2010. Veterans may not have submitted mileage reimbursement claims 

because, prior to January 2009, low mileage reimbursement rates and applicable deductibles 

negated potential reimbursements given the relatively short driving distances in the USVI. 

Veterans residing in the USVI also may not have submitted mileage reimbursement claims 

because the veterans were not provided with the information they needed regarding this 

allowance. We also verified that income guidelines used by VA to determine eligibility for 

VA Office of Inspector General ii 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

services for veterans from Puerto Rico and the USVI reflect the cost of living disparity between 

these locations. 

Recommentations 

We recommend that the Veterans Integrated Service Network 8 Director require the VA 

Caribbean Healthcare System Director to: 

	 Ensure that English language proficiency is documented in SF 52 forms for physicians, 

nurses, and residents, as required. 

	 Ensure that primary care appointments at the USVI CBOCs be available within the 

timeframes prescribed by VHA policy. 

	 Implement a mechanism to monitor the satisfaction of USVI veterans at the local level. 

	 Review the VA Caribbean Healthcare System patient advocate program for opportunities to 

facilitate complaint reporting for USVI veterans. 

	 Determine the feasibility of sending medical examiners to the USVI to perform 

Compensation and Pension examinations that do not require medical specialists or nonportable specialized medical equipment. 

	 Allow veterans residing in the USVI to submit mileage reimbursement claims retroactively 

for eligible visits completed between January 9, 2009, and September 30, 2010. 

	 Ensure the San Juan VAMC develops appropriate oversight mechanisms to review and 

monitor mileage reimbursement claims for the VA Caribbean Healthcare System. 

Management Comments and OIG Response 

The VISN and System Directors agreed with the findings and recommendation contained in the 

draft report and provided responsive implementation plans to address our recommendations. We 

will monitor progress and follow up on implementation until all proposed actions are completed. 

The Acting Under Secretary for Benefits stated that VBA appreciated the opportunity to review 

the draft report but offered no comments. Appendixes C and D contain the complete VHA and 

VBA comments on the draft report. 

BELINDA J. FINN JOHN D. DAIGH JR., M.D. 

Assistant Inspector General Assistant Inspector General 

for Audits and Evaluations for Healthcare Inspections 

VA Office of Inspector General iii 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Objective 

Background 

Congressional 

Concerns 

INTRODUCTION 

The VA Office of Inspector General (OIG) evaluated congressional concerns 

that veterans residing in the U.S. Virgin Islands (USVI) receive disparate 

healthcare services and benefits compared with veterans living in Puerto 

Rico. 

The VA Caribbean Healthcare System (VACHS), part of Veterans Integrated 

Service Network (VISN) 8, provides services to a population of 

150,000 veterans in Puerto Rico and the USVI. The VACHS includes the 

San Juan VA Medical Center (VAMC) in Puerto Rico, and seven outpatient 

clinics located throughout Puerto Rico and the USVI. According to 

2000 U.S. Census Bureau data, 5,152 veterans reside in the USVI. Currently 

two CBOCs are located in the USVI, one on St. Thomas and one on 

St. Croix. Contract primary care services through a local provider were 

scheduled to begin on St. John in January 2011. In addition to the CBOCs, 

through the use of non-VA providers, the USVI has comprehensive medical 

services and specialty providers available to veterans on St. Croix, 

St. Thomas, and St. John. The San Juan VA Regional Office (VARO) is 

responsible for delivering non-medical VA benefits and services to veterans 

and their families residing in Puerto Rico and the USVI. See Appendix A 

for additional background information. 

In June 2010, Donna M. Christensen, a Member of Congress that represents 

the USVI, sent a memorandum to the Inspector General in which she 

outlined her concerns about the unfair and discriminatory treatment of 

veterans residing in the USVI compared to veterans residing in Puerto Rico. 

Her concerns addressed the following issues: 

	 USVI veterans do not receive the same treatment at the VA hospital in 

Puerto Rico, often facing language barriers and problems communicating 

with personnel. 

	 USVI veterans do not have access to the same level of services as 

Puerto Rico veterans. USVI does not have a VA hospital, so USVI 

veterans must go to a private emergency department and are not always 

reimbursed for care received. 

	 Veterans must wait 3 months for a doctor’s appointment, unless the 

doctor at the USVI Community Based Outpatient Clinic approves 

expediting an appointment. 

	 Benefit applications are not given the same treatment, and if a veteran 

were to apply for benefits or disability claims, they would more likely get 

them if they applied through a mainland office instead of through Puerto 

Rico. 

VA Office of Inspector General 1 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

	 Travel reimbursements are not applied equally, given that a 40-mile 

distance traveled by car in Puerto Rico is reimbursed, yet the same 

distance from the Virgin Islands under similar conditions is not. 

Veterans must travel by air, land, and sea in order to be treated at the 

hospital in Puerto Rico. 

	 The income guidelines used to determine eligibility for services is the 

same despite the cost of living being much higher in the Virgin Islands 

than Puerto Rico. 

VA Office of Inspector General 2 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Issue 1 

English 

Proficiency 

Requirement 

San Juan VAMC 

Staff English 

Proficiency 

RESULTS AND RECOMMENDATIONS 

Language Barriers 

We substantiated that USVI veterans sometimes face language barriers and 

problems communicating with personnel when they come to the San Juan 

VAMC because Puerto Rico’s native language is Spanish. However, we 

found little evidence that language barriers negatively impacted the delivery 

of care. 

English language proficiency is a VA requirement for all direct patient care 

positions.1 Physicians, nurses, and other healthcare professionals at the 

San Juan VAMC must be able to read, write, speak, and understand English. 

A determination of English language proficiency is a part of the VAMC’s 

hiring process. Several criteria can be used to determine English language 

proficiency—the successful completion of portions of the interview 

conducted in English; graduation from any school in which the basic 

curriculum was conducted in English; and for physicians, certification by an 

American specialty board or successful completion of the United States 

Medical Licensing Examination (USMLE), which is written in English. 

VA Handbook 5005/7 states, “When a VA facility serves a substantial 

number of veterans with limited English-speaking ability, the Director must 

ensure the identification of sufficient numbers of staff members who are 

fluent in both the language most appropriate to these veterans and in 

English.” 

We reviewed the personnel records of all physicians, residents, and nurses 

appointed to work at the San Juan VAMC between March 2009 and 

March 2010 for evidence of English language proficiency. The VAMC 

utilizes the performance-based interview method to interview candidates for 

positions. 

Nurses. A panel conducts the interviews in English and Spanish in order to 

verify proficiency in both languages. The panel rates English language 

proficiency on a scale from 1 to 5 (least proficient to most proficient) for 

registered nurse positions. Candidates who score 1 or 2 are not selected. 

Physicians. For physician appointments, service chiefs complete a 

memorandum that includes if the candidate was proficient in English. 

1

VA Handbook 5005/7, Part II, Appendix I, English Language Proficiency states that “No 

person will be appointed under authority of 38 United States Code, Chapter 73 or 74, to 

serve in a direct patient-care capacity in VHA who is not proficient in written and spoken 

English.” 

VA Office of Inspector General 3 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Human Resources Management staff were unable to produce this document 

for the physician appointments we reviewed. However, we were provided 

with documentation of board certifications and/or degree programs taught in 

English for all of the physicians in our sample. 

Residents. No documentation existed to support the English language 

proficiency for residents appointed between March 2009 and March 2010. 

However, the San Juan VAMC satisfied the English proficiency requirement 

for the residents in our sample because all of them had passed the USMLE. 

In addition, the program directors of the psychiatry and internal medicine 

residency programs provided memorandums certifying English language 

proficiency of their residents. 

Documentation. VA Handbook 5005/7 also requires that “The determination 

that an employee is proficient in English will be documented on the 

appointment SF 52, Request for Personnel Action, which will be retained for 

the duration of VA employment.” We reviewed the SF 52 forms for 

registered nurses, physicians, and residents appointed to work at the San Juan 

VAMC between March 2009 and March 2010 for documentation of English 

language proficiency. For the 42 registered nurses appointed during this 

period, we found 39 (92 percent) SF 52 forms, and 33 (85 percent) of 39 had 

their English proficiency documented. For the 28 physicians appointed 

during this period, we found 26 SF 52 forms, but only 2 (8 percent) of 26 had 

the required English proficiency documentation. None of the 33 SF 52 

forms for residents appointed during this period had English language 

proficiency documented. 

Other Staff. Only staff with direct patient care capacity are required to 

demonstrate English language proficiency. This does not include personnel 

in non-direct patient care capacities who may encounter patients incidental to 

their primary job responsibilities.2 Since Spanish is the primary language in 

San Juan, and not all employees are required to speak English, it is likely 

that, on occasion, a USVI patient may encounter an employee with whom 

they cannot communicate. We reviewed patient advocate complaints from 

USVI veterans between March 2009 and March 2010. Only five complaints 

were recorded, and none of the five reported problems with communication. 

The VACHS Director told us that use of English is required at meetings, in 

e-mail correspondence, and in all administrative documentation. All medical 

record documentation is required to be in English. We learned that the 

System Director and other managers are proponents of encouraging the use 

of English in the workplace. We were told about one organized activity to 

support this effort—a voluntary informal meeting called English Cybercafé 

2

VA Handbook 5005/7, 2b. 

VA Office of Inspector General 4 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

where attendees discuss movies or current events in English to improve their 

skills. 

Conclusion	 We substantiated the allegation that USVI veterans could face language 

barriers and problems communicating with non-direct patient care staff while 

at the VAMC in San Juan. However, we did not find that language barriers 

negatively impacted patient care. We also found that English language 

proficiency was not consistently documented in SF 52 Request for Personnel 

Action forms. 

Recommendations	 1. We recommend that the Veterans Integrated Service Network 8 Director 

require the VA Caribbean Healthcare System Director to ensure that English 

language proficiency is documented in SF 52 forms for physicians, nurses, 

and residents, as required. 

Management	 The VISN and System Directors agreed with our findings and 

Comments and recommendation. All Human Resources staff have been instructed to 

OIG Response comply with this requirement. The Supervisor of Staffing and Recruitment 

will monitor ongoing compliance. The implementation plan is acceptable, 

and we will follow up on the planned actions until they are completed. 

VA Office of Inspector General 5 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Issue 2		 Access to Healthcare 

We partially substantiated the allegation that USVI veterans do not have 

access to the same level of Veterans Health Administration (VHA) services 

as the veterans in Puerto Rico. However, because of liberal use of fee basis 

authorizations for local care, USVI veterans’ care is not limited or less than 

that of the veterans in Puerto Rico. We substantiated that the cost of 

emergency care received at local hospitals was not always reimbursed; 

however, we found that these denials were appropriate. 

VHA does not provide 24-hour emergency services or inpatient services in 

the USVI. The VAMC closest to the USVI is in San Juan, Puerto Rico, 

which is 93 miles from St. Croix and 63 miles from St. Thomas by air. Both 

islands have airports, and flights to San Juan are frequent. Emergency and 

urgent inpatient services are fee based to local hospitals on both St. Thomas 

and St. Croix. Both hospitals provide comprehensive inpatient and 

outpatient healthcare services and have 24-hour emergency departments. 

VHA does provide outpatient services at two CBOCs located on St. Thomas 

and St. Croix. VHA established these CBOCs in 1994 to improve access to 

primary healthcare services for veterans in the USVI. The St. Croix CBOC 

is staffed with one physician, two nurses, a social worker, and two 

administrative staff. The St. Thomas CBOC is staffed with one physician, 

one nurse, a social worker, and two administrative staff. Both CBOCs 

provide outpatient primary care, laboratory, and nutrition and mental health 

telehealth services. The St. Thomas CBOC also has a monthly gynecology 

clinic, and the St. Croix CBOC has a pharmacist and pharmacy services 

onsite, with local pharmacy services available if needed. The St. Thomas 

CBOC provides patients with 10 days of medications through a local 

pharmacy as a bridge until medications are mailed to the patient through the 

VA outpatient medication distribution system. Both CBOCs fee base 

radiology services to local facilities. 

If the CBOC could not provide the necessary care, fee basis care was 

authorized by VA staff for initial outpatient evaluations and/or 

hospitalizations. The patients would be re-evaluated at the CBOC, and if 

further care was required, the patients were referred to the San Juan VAMC. 

In some cases, if the required follow-up care was frequent, a patient received 

authorization to continue care with local providers. If a patient was sent to 

the San Juan VAMC for care, flight arrangements were made by the VA at 

no cost to the veteran, in most cases. 

Fee Basis Care	 VA policy states that VA facilities should have local policy and procedures 

regarding the request, approval, and authorization of non-VA care and 

VA Office of Inspector General 6 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Fee Basis 

Outpatient Care 

services.3 Furthermore, a consult referral template should be established at 

each facility to manage and oversee non-VA services. This consult template 

should include reasons that justify the decision to seek non-VA care. A 

consult template is in place at the USVI CBOCs, but no local policies 

regarding fee basis care existed. However, VACHS provided a statement 

that “if services for a specialty clinic are required and there is a local 

provider available, a voucher will be prepared for that particular service. If 

that specialty is not available in the community, then the primary care 

provider will originate a consult to San Juan for the specialty needed.” 

While the CBOCs had no contracts or memorandums of understanding with 

non-VA providers in the USVI, we were provided with a list of approved 

vendors for a wide range of services. 

USVI CBOC staff told us that, generally, local providers would take VA 

patients for all available services with the exception of gastroenterology and 

ophthalmology services. Consults are sent to the San Juan VAMC for 

patients needing these services. After being seen by a fee basis provider, the 

veteran is to return to the USVI CBOC for further disposition. If further care 

is needed, the CBOC provider decides if that care can be provided in the VA 

system. USVI providers generated 2,089 consults for local fee basis care 

from October 1, 2009–May 31, 2010. Table 1 shows the number of USVI 

patients that received fee basis outpatient care and the amount spent for these 

services during the last 5 fiscal years. 

Table 1 USVI Outpatient Fee Basis Payments for FYs 2006–2010 

USVI Outpatient 

Fee Basis Payments FY 06 FY 07 FY 08 FY 09 FY 10 

Unique Patients 963 1003 966 1101 1087 

Disbursed Amount 

Per Unique Patient $647.30 $615.95 $688.46 $881.84 $1,027.19 

Disbursed Amount 

Per Outpatient Visit $156.03 $169.49 $168.92 $200.60 $185.11 

Disbursed Amount $623,345.22 $617,800.33 $665,052.49 $970,908.89 $1,116,559.30 

Source: VA Caribbean Healthcare System. 

3

Memorandum, Deputy Under Secretary for Health for Operations and Management (10N) 

(webcams #441408), Documenting Justification for Non-VA Health Care and Services in 

CPRS, November 23, 2009. 

VA Office of Inspector General 7 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Fee Basis 

Inpatient Care 

Fee Basis 

Emergency Care 

Review of 

Emergency Care 

Claims 

We reviewed 100 patient medical records for timeliness of fee basis care and 

found that in most cases, the patients were seen within days of the initial fee 

basis request. 

Title 38 of the United States Code § 17.52 addresses VA’s responsibility in 

providing hospital care and medical services in non-VA facilities. When VA 

facilities are not capable of furnishing economical hospital care or medical 

services because of geographic inaccessibility or they are not capable of 

furnishing care or the services required, VA may contract with non-VA 

facilities for care or individual authorizations may be used. USVI veterans 

requiring immediate inpatient care are sent to local hospitals for fee basis 

care until arrangements can be made to transfer the patient to a VA facility, if 

indicated. In FY 2010, 100 veterans were hospitalized in USVI facilities at a 

cost to the VA of $473,659.30. 

Title 38 of the United States Code § 1725 also addresses reimbursement for 

emergency treatment of veterans at non-VA facilities. Generally, if a veteran 

seeks emergency care at a non-VA facility, it is reimbursable if the veteran is 

actively enrolled in the VA healthcare system, has received care at the VA 

within the last 24 months prior to the emergency treatment, does not have 

other payer sources, and the care rendered was not feasibly available 

elsewhere and of an emergent nature. 

The USVI CBOCs are operational during typical business hours. If 

emergency care is required, USVI veterans must go to a local hospital with a 

24-hour emergency department. If a bill is submitted to the VACHS for 

payment, medical records are requested and reviewed by clinical and 

administrative staff at the VAMC, and payment is authorized based on the 

nature of the complaint, treatment, and the veteran’s eligibility. While no 

local policies are in place to describe this process, system managers gave us 

a document developed by the physician responsible for reviewing fee basis 

emergency care claims. 

The document outlines how claims are to be reviewed for approval or denial 

of payment. Information provided to us showed that in FY 2010, 

35 (38 percent) of 92 claims submitted for non-VA emergency treatment 

were disapproved for reimbursement. Reasons for disapproval included nonemergent care (15), other insurance benefits (14), and no VA treatment in the 

past 24 months (6). The reasons for denial of payment were consistent with 

federal regulations. We reviewed documents associated with two of the 

disapprovals and found medical record documentation to support the 

disapproval decisions. 

VA Office of Inspector General 8 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

USVI Veteran 

Consults to the 

VACHS 

Conclusion 

Management 

Comments and 

OIG Response 

Providers at the USVI CBOCs told us that consults are sent to the VAMC for 

patients requiring further evaluation and/or treatment after a fee basis 

outpatient appointment, inpatient care, or surgical intervention. Consults 

received from USVI CBOCs are sent to the consulted service for review and 

disposition. If an appointment is approved, it is scheduled by the specialty 

clinic consult coordinator. A physician must request the initial consult, and 

according to CBOC staff, consults are prioritized and scheduled according to 

urgency. 

From October 1, 2009–May 31, 2010, 1,509 unique USVI veterans had 

5,758 visits at the VAMC. The USVI CBOC and/or San Juan VAMC staff 

make travel arrangements to San Juan, and if VA does not cover the airfare 

due to patient ineligibility, the USVI Veterans Service Organization (VSO) 

provides funding for the ticket, in some cases. The San Juan VAMC 

provides shuttle services to and from the airport as well as hotel 

accommodations, if required. A San Juan VAMC coordinator oversees the 

arrangements and follows the course of care while the veterans are in 

San Juan. 

We partially substantiated the allegation that USVI veterans do not have 

access to the same level of VHA services as the veterans in Puerto Rico 

because VHA does not provide inpatient care, 24-hour emergency care, or 

outpatient specialty care in the USVI. VHA purchases these services from 

local providers and medical facilities through individual fee basis 

authorizations. Because VACHS allows USVI CBOC providers liberal use 

of fee basis care, access to care for USVI veterans is not limited or less than 

that of the veterans in Puerto Rico. 

The VISN 8 Director provided no comments concerning the OIG’s analysis 

or conclusions concerning this issue. 

VA Office of Inspector General 9 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Issue 3
	

CBOC 

Appointments 

USVI CBOC 

Capacity 

Timeliness of Care 

We could not confirm or refute the allegation that veterans generally 

experienced a 3-month wait for a doctor’s appointment at the USVI CBOCs. 

However, we found that next available appointment times for new patients 

exceeded the VHA 30-day requirement at the time of our visit, and wait 

times for new patient appointments in St. Thomas reflected poor access to 

care in FY 2010. Providers decide when established patients need to return 

for follow-up. A routine follow-up in 3 to 6 months can be entirely 

appropriate. It was not clear from the complaint whether the concerns were 

related to wait times for an appointment at the USVI CBOC, at the San Juan 

VAMC, or for new or established patients. Therefore, we reviewed data on 

wait times for the primary care clinics at the USVI CBOCs for new and 

established patients and timeliness of initial appointments for USVI veterans 

at specialty clinics at the San Juan VAMC. We also reviewed provider panel 

sizes and clinic capacity for the USVI CBOCs.4,5 

Veterans Support Service Center (VSSC) “New and Established Patient Wait 

Times for Completed Appointments” report data reflected that 95 percent of 

new patients from October 1, 2009–May 31, 2010, were seen within 30 days 

of the desired appointment date at the St. Croix CBOC, and 64 percent were 

seen within 30 days of the desired appointment date at the St. Thomas 

CBOC. The same data source showed that 99 percent of established patients 

at the St. Croix CBOC and 96 percent of established patients at the 

St. Thomas CBOC were seen within 30 days of the desired appointment date. 

While we were onsite at the USVI CBOCs during the week of 

October 25, 2010, we asked for the next available primary care appointment 

dates for new patients. The first available appointment for new patients at 

the St. Thomas CBOC was December 29 (65 days). The first available new 

patient appointment at the St. Croix CBOC was December 27 (63 days). 

CBOC staff told us that the influx of veterans to the USVI during winter 

months caused wait times for appointments to exceed the current VHA goal 

of less than 14 days from the desired date. 

The VSSC target for the number of patients expected to be assigned to a 

primary care provider is 90 to 105 percent of panel size capacity. We found 

that the St. Croix CBOC provider panel size was at 99 percent of capacity, 

but the St. Thomas CBOC provider panel size was only 72 percent of 

capacity, significantly below the target. As panel size was not near capacity 

4

Panel size is the number of patients currently assigned to a healthcare provider.

5

Clinic capacity is the maximum number of patients that can be assigned to a healthcare 

provider. 

VA Office of Inspector General 10 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

at the St. Thomas CBOC, it is unclear why only 64 percent of new patients 

were seen within 30 days of the desired appointment date. 

According to the Chief of Primary Care for the VACHS, as of 

October 26, 2010, the primary care provider at the St. Croix CBOC had 

924 patients assigned, and the clinic capacity was 981 for this 

location/provider combination. The primary care provider at the St. Thomas 

CBOC had 743 patients assigned with a clinic capacity of 981 for this 

location/provider combination, yet the next available new patient 

appointments were 65 days out. 

We also reviewed missed opportunity reports for the St. Thomas and 

St. Croix CBOCs for the last 3 FYs (Table 2). Missed opportunities include 

no-shows and patient and/or clinic cancelations after the date of the 

appointment. 

Table 2 USVI Missed Opportunity Rates from FY 2008-FY 2010 

Clinic Location FY 08 FY 09 FY 10 Target 

St. Croix 12.96% 11.46% 9.21% 11.61% 

St. Thomas 17.38% 12.34% 13.51% 11.61% 

VAMC 

Appointments 

Source: VSSC Missed Opportunities Report. 

The missed opportunity rates at St. Thomas consistently exceeded the target 

rate for the last 3 FYs. While we noted improvement since FY 2008, a high 

percentage of missed opportunities reflects less than optimal clinic utilization 

and could contribute to delays in scheduling appointments within target 

dates. 

From October 1, 2009–May 31, 2010, USVI CBOC providers generated 

569 consults for specialty care services at the VAMC. Of those, 426 were 

completed, 108 were canceled, 30 were discontinued, 4 were scheduled for 

future appointments, and 1 was pending. Further review showed that of the 

138 canceled and discontinued consults, 102 were canceled or discontinued 

by the receiving service. Of those, 42 were canceled or discontinued because 

further patient evaluation was required prior to consulting the specialty 

service, as specified by service agreements between primary care and 

specialty services. We also found that 25 consults were canceled or 

discontinued because the patient was not eligible for the requested service. 

Consults canceled or discontinued due to need for further evaluation must be 

re-submitted and re-processed after the preliminary evaluations are 

completed, creating extra work and adding to delays in obtaining specialty 

care appointments at the San Juan VAMC. 

VA Office of Inspector General 11 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Conclusion 

Recommendation 

Management 

Comments and 

OIG Response 

We reviewed the medical records of 100 USVI veterans seen at the San Juan 

VAMC specialty clinics. USVI CBOC providers requested these 

appointments through consults between October 1, 2009–May 31, 2010. We 

found that 91 (91 percent) of 100 veterans were seen within 30 days after the 

consult was initiated. 

We found that the only wait time for appointments that exceeded the VHA 

target was new patient appointments at the St. Thomas CBOC. Established 

patients were generally seen within 30 days of the desired appointment date 

at both CBOCs, and patients were consistently seen promptly by fee basis 

providers and within 30 days at the San Juan VAMC. 

We could not confirm or refute the allegation that there is generally a 

3-month wait for a medical appointment. Appointments for new patients 

exceeded the VHA goal of less than 30 days from the desired date of the 

appointment at the St. Thomas CBOC. However, established patients were 

generally seen within 30 days of the desired appointment date, and patients 

were consistently seen promptly by fee basis providers and within 30 days at 

the San Juan VAMC. 

2. We recommend that the Veterans Integrated Service Network 8 Director 

require the VA Caribbean Healthcare System Director to ensure that primary 

care appointments at the U.S. Virgin Islands Community Based Outpatient 

Clinics be available within the timeframes prescribed by VHA policy. 

The VISN and System Directors agreed with our findings and 

recommendation. Standard Operating Procedures for disposition of patient 

appointments will be established and Case Managers will monitor 

compliance. The implementation plan is acceptable, and we will follow up 

on the planned actions until they are completed. 

VA Office of Inspector General 12 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Issue 4		 Patient Satisfaction 

We interviewed Customer Service staff at the San Juan VAMC and reviewed 

patient advocate reports related to USVI CBOCs. No patient advocates were 

specifically assigned to the USVI CBOCs. USVI veterans must call the 

San Juan VAMC to voice their concerns. During our tours of the CBOCs, 

we noted that patient advocate contact information was not posted. 

Customer Service managers at the San Juan VAMC told us that they meet 

with the VSO representatives from the USVI quarterly. The VSO 

representatives we interviewed told us that veterans often call their office 

when they have concerns about their care. Then the VSO representative 

contacts Customer Service in San Juan or the USVI CBOC staff to attempt to 

resolve the issue. As VSO representatives are not VA staff, they do not have 

access to information available to VA patient advocates. 

We also learned that, because of the low survey return rate, “VHA Survey of 

Healthcare Experiences of Patients” data was not available for USVI 

CBOCs. If the response is less than 10 surveys, data is not reported. 

VHA Handbook 1003.1 section 7b6 states that satisfaction must be measured 

at the local level, including patient waits and staff courtesy, through a variety 

of mechanisms such as focus groups and comment cards. VACHS managers 

told us that despite the fact that “VHA Survey of Healthcare Experiences of 

Patients” data was not available, no other means were utilized to capture the 

concerns of the USVI veterans regarding their care. 

Conclusion	 Patient satisfaction was not measured at the local level for the USVI CBOCs 

as required. 

Recommendation	 3. We recommend that the Veterans Integrated Service Network 8 Director 

require the VA Caribbean Healthcare System Director to implement a 

mechanism to monitor the satisfaction of U.S. Virgin Islands veterans at the 

local level. 

4. We recommend that the Veterans Integrated Service Network 8 Director 

require the VA Caribbean Healthcare System Director to review the VA 

Caribbean Healthcare System patient advocate program for opportunities to 

facilitate complaint reporting for U.S. Virgin Islands veterans. 

6

VHA Handbook 1003.1, Key Elements of VHA’s Veteran Customer Service Program, 

August 6, 2003. 

VA Office of Inspector General 13 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Management 

Comments and 

OIG Response 

The VISN and System Directors agreed with our findings and 

recommendations. A Quick Card patient satisfaction survey tool will be 

implemented in the CBOCs. Patient Advocates at both St. Thomas and 

St. Croix will be identified and trained, and posters with their pictures will be 

placed in the clinics. A notice outlining the complaint process will be sent to 

VSOs and stakeholders. The implementation plan is acceptable, and we will 

follow up on the planned actions until they are completed. 

VA Office of Inspector General 14 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Issue 5
	

Claims Processing 

Similar for 

Veterans in Both 

Locations 

Claims Processing 

Error Rates 

Similar 

Disability Rating Decisions and Compensation and 

Pension Medical Examination Cancelation Rates 

We could not substantiate the allegation of disparate treatment of benefits 

claims filed by veterans residing in the USVI. Evidence did not suggest that 

the Veterans Benefits Administration (VBA) San Juan VARO processed 

disability compensation claims differently for veterans residing in the USVI 

compared to those residing in Puerto Rico. However, we noted that 

Compensation and Pension (C&P) canceled C&P medical examinations for 

veterans residing in the USVI at a higher rate than exams for veterans 

residing in Puerto Rico. 

The San Juan VARO completed disability compensation claims for veterans 

residing in Puerto Rico on average of 149 days with an 8 percent error rate. 

For veterans residing in the USVI, the San Juan VARO completed disability 

compensation claims on average of 145 days (4 days sooner) with a slightly 

higher error rate of 10 percent. 

We reviewed 120 claims folders requiring a rating decision—60 claims 

folders for veterans residing in Puerto Rico and 60 claims folders for 

veterans residing in the USVI. The San Juan VARO Veterans Service 

Center Manager informed us that they generally processed benefit 

applications in date of claim order, from oldest to newest. Although we 

reviewed 2 percent of the population of completed claims, we did not find 

disparity in the processing of these benefits by the San Juan VARO. 

Regardless if the claimed disability was granted or denied, we determined 

109 of 120 decisions were accurate. 

In addition, we compared the San Juan VARO’s disability claims processing 

accuracy rate with that of mainland VAROs for FY 2010. Although the 

San Juan VARO’s accuracy rate was slightly lower than the national 

average, our review revealed a veteran’s residence did not influence or affect 

the accuracy or timeliness of benefits processed at the San Juan VARO. 

San Juan VARO staff incorrectly processed 5 (8 percent) of 60 claims for 

veterans residing in Puerto Rico and 6 (10 percent) of 60 claims for veterans 

residing in the USVI. Of the 11 combined claims processing errors, two 

affected benefits for veterans residing in Puerto Rico and two affected 

benefits for veterans residing in the USVI. The OIG provided claims 

processing errors identified during the review to the San Juan VARO 

Veterans Service Center Manager for appropriate action. Table 3 shows the 

errors affecting veterans’ benefits. 

VA Office of Inspector General 15 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Table 3 Benefit Claims Processing Errors 

Residence 

of 

Veteran 

Number 

of Claims 

Reviewed 

Number of 

Processing 

Errors 

Number 

of Errors 

Affecting 

Veterans’ 

Benefits 

Total 

Overpayments 

Total 

Underpayments 

Puerto 

Rico 60 5 2 $39,182 $1,536 

USVI 60 6 2 0 $7,921 

TOTAL 120 11 4 $39,182 $9,457 

C&P Medical 

Examinations 

Meet VHA 

Timeliness 

Standard 

USVI Veterans 

Had Higher Rates 

of Canceled C&P 

Medical Exams 

In addition, VHA has a national time standard of 35 calendar days after 

receipt of the medical examination request to complete the exams and 

required tests. Examinations for veterans in Puerto Rico and the USVI on 

average met this standard. Of the 120 claims reviewed, VARO staff 

requested medical exams for 77 veterans—36 veterans residing in Puerto 

Rico and 41 veterans residing in the USVI. The medical exams for veterans 

residing in Puerto Rico took an average of 17 days to complete. Of the 

41 veterans in the USVI, four did not complete requested examinations. The 

examinations for the remaining 37 USVI veterans took 32 days on average to 

complete. Although it took 15 days longer to complete the exams scheduled 

for veterans in the USVI, the delays did not negatively impact the overall 

time to complete their claims. 

We also noted that veterans residing in the USVI had a higher rate of 

canceled C&P medical exams compared to veterans residing in Puerto Rico. 

San Juan VARO staff requested 132 C&P examinations for the 77 benefits 

claims—68 exams for veterans in Puerto Rico and 64 exams for veterans in 

the USVI. Veterans residing in Puerto Rico had 7 (10 percent) of 68 medical 

exams canceled compared to 18 (28 percent) of 64 for USVI veterans. 

Table 4 on the next page indicates the number of canceled medical exams in 

relationship to the veteran’s residence. 

Table 4 Canceled Medical Examinations by Location 

Residence of 

Veteran 

Number of Claims 

Requiring a C&P Exam 

Number of Exams 

Requested 

Number of 

Exams Canceled 

Puerto Rico 36 68 7 

USVI 41 64 18 

Total 77 132 25 

VA Office of Inspector General 16 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

C&P Exams Not 

Conducted in the 

USVI 

Conclusion 

Recommendation 

C&P medical examination cancelation notices revealed that 11 (61 percent) 

of 18 USVI cancelations resulted from those veterans that did not report for 

their scheduled examinations. The Clinical Supervisor for the C&P Exam 

Clinic at the San Juan VAMC could not explain the disparity in cancelation 

rates. The Clinical Supervisor said, “Aside from the general category of 

examination cancelations known as Failure to Report, the hospital does not 

capture or maintain detailed information on why a veteran does not report for 

an examination.” Further, the Clinical Supervisor indicated that because 

veterans residing in the USVI must go to the San Juan VAMC for C&P 

examinations, the travel required might be a reason for the high number of 

veterans that fail to report for their examinations. As a result, the San Juan 

VAMC could use the allotted time for those examinations to treat other 

veterans. 

We asked the Clinical Supervisor for C&P examinations if the San Juan 

VAMC had any initiatives to send physicians to the USVI to perform 

examinations. The Clinical Supervisor indicated no plans currently exist. 

Further, the Clinical Supervisor informed us that C&P exams may require a 

medical specialist, specific medical equipment, or diagnostic testing 

currently not available at the CBOC in the USVI. 

VA policy states that specialists routinely perform medical examinations 

involving hearing, vision, dental, and psychiatric conditions. Our analysis of 

the 18 canceled examinations revealed only one, an audiology examination, 

may have required a specialist to complete. Therefore, approximately 

10 veterans residing in the USVI might have benefited from C&P medical 

examinations performed at the local CBOC. 

We did not substantiate the allegation of disparate treatment of benefits 

claims filed by veterans residing in the USVI. No evidence suggested that 

VBA processed benefits claims differently based on a veteran’s residency. 

Further, the San Juan VARO processed benefit applications for USVI 

veterans on average 4 days sooner than benefit applications submitted by 

veterans residing in Puerto Rico. Veterans residing in the USVI had a higher 

rate of canceled C&P medical examinations (28 percent) compared to those 

veterans residing in Puerto Rico (10 percent). 

5. We recommend the Veterans Integrated Service Network 8 Director 

require the VA Caribbean Healthcare System Director to determine the 

feasibility of sending medical examiners to the U.S. Virgin Islands to 

perform Compensation and Pension examinations that do not require 

medical specialists or non-portable specialized medical equipment. 

VA Office of Inspector General 17 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Management The VISN 8 Director concurred with the recommendation and stated that 

Comments and actions will be taken to perform Compensation and Pension non-specialty 

OIG Response examinations in the USVI. The Acting Under Secretary for Benefits 

provided no comments concerning the OIG’s analysis or conclusions 

concerning this issue. 

VA Office of Inspector General 18 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Issue 6
	

Beneficiary Travel 

Program 

Beneficiary Travel Reimbursement 

We could not determine whether VHA applied travel reimbursements 

unequally for claims submitted by veterans because there were no records of 

mileage reimbursement claims in VHA’s systems prior to October 2010. A 

San Juan VAMC official indicated that eligible USVI veterans were not 

denied the benefits nor were discouraged from applying for mileage 

reimbursement. The official stated that veterans did not submit mileage 

reimbursement claims because, prior to January 2009, low mileage 

reimbursement rates and applicable deductibles negated potential 

reimbursements given the relatively short driving distances in the USVI. We 

also concluded that veterans in the USVI may not have submitted mileage 

reimbursement claims from January 2009 through September 2010 for the 

following reasons: 

	 Inadequate communication about travel benefits to veterans residing in 

the USVI. 

	 Insufficient beneficiary travel benefits training of VA staff at CBOCs 

located in St. Thomas and St. Croix. 

	 Inadequate oversight by the San Juan VAMC that would have detected 

the lack of mileage reimbursement claims for USVI. 

The purpose of VA travel reimbursement is for VHA to make payments for 

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

persons obtain care of services from VHA. Under section 111, Title 38 of 

the United States Code, Payments or Allowances for Beneficiary Travel, VA 

has the authority to pay the actual necessary expenses of travel, including 

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 for certain eligible veterans. 

Reimbursements may also include ferry fares and tolls for bridges, roads, and 

tunnels. 

The San Juan VAMC Beneficiary Travel Office administers VA’s 

Beneficiary Travel program for veterans residing in the USVI. Staff at the 

CBOCs in coordination with VAMC staff make arrangements and pay for 

eligible USVI veterans to travel via commercial airline from the USVI to the 

San Juan VAMC for authorized treatment. In addition, CBOC personnel 

assist veterans residing in the USVI to submit travel reimbursement claims. 

When veterans seek treatment in the USVI (such as going to a CBOC located 

in St. Thomas or St. Croix) and are eligible for mileage reimbursement, 

clerks located in the CBOC verify the mileage, complete the claim in 

VA Office of Inspector General 19 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Mileage 

Reimbursement 

Claims Not 

Submitted or 

Processed 

Veterans Health Information Systems and Technology Architecture (VistA),7 

and send the signed form to the San Juan VAMC. The San Juan VAMC 

processes mileage reimbursement claims and sends compensation to the 

veteran via a check by mail. 

The San Juan VAMC did not reimburse eligible veterans residing in the 

USVI for travel mileage associated with VA healthcare because VistA did 

not contain data to indicate that veterans submitted mileage reimbursement 

claims from October 1, 2008–May 31, 2010. A VISN official confirmed that 

no mileage reimbursement claims were processed for USVI veterans prior to 

October 1, 2010. However, records indicate that at least 6,110 visits would 

have been eligible for mileage reimbursements during this time period. In 

comparison, eligible veterans in Puerto Rico in Priority Group 1 and Priority 

Group 28 made 252,111 eligible visits and submitted 79,415 mileage 

reimbursement claims during the same period. There is no evidence that 

veterans residing in the USVI submitted mileage reimbursement claims until 

October 1, 2010, after the OIG contacted San Juan VAMC and 

VISN 8 officials concerning our review. 

According to a San Juan VAMC official, until recently, little incentive 

existed for veterans residing in the USVI to claim mileage reimbursements 

due to relatively short travel distances in the USVI, low mileage 

reimbursement rates, and applicable deductibles. The official also indicated 

that eligible USVI veterans were not denied the benefits nor were 

discouraged from applying for mileage reimbursement. A San Juan VAMC 

Travel Clerk indicated that, in the past, some USVI veterans inquired about 

mileage reimbursement and when told that the reimbursement was relatively 

small, would not complete the claim process. The maximum one-way 

distance to the airport or the CBOC is 9 miles in St. Thomas and 17 miles in 

St. Croix. Table 5 summarizes the changes in mileage reimbursement rates 

and deductibles. 

7

VistA is an enterprise-wide information system used for a variety of clinical and 

administrative functions. 

8

VA assigns veterans to a Priority Group based on their eligibility status. Priority Groups 

range from 1–8 with 1 being the highest priority for enrollment in the VA healthcare 

program. 

VA Office of Inspector General 20 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Table 5 Beneficiary Travel Mileage Reimbursements and Deductibles 

Effective 

Date 

Mileage 

Reimbursement 

Rate 

(per mile) 

Deductible Maximum 

Deductible 

(per calendar month) 

Prior to 

February 2008 11.0¢ $3.00 one-way 

($6 round trip) 

$18.00 

February 2008 28.5¢ $7.77 one-way 

($15.54 round trip) $46.62 

July 2008 28.5¢ $7.77 one-way 

($15.54 round trip) 

$46.62 

(or six one-way 

trips, whichever 

occurs first) 

November 2008 41.5¢ $7.77 one-way 

($15.54 round trip) 

$46.62 

(or six one-way 

trips, whichever 

occurs first) 

January 2009 41.5¢ $3.00 one-way 

($6 round trip) 

$18.00 

(or six one-way 

trips, whichever 

occurs first) 

Inadequate 

Communication 

and Training 

Despite the November 2008 increase in the mileage rate and reduction in the 

January 2009 deductible rates, there is no evidence that eligible veterans 

residing in the USVI submitted mileage reimbursement claims until 

October 1, 2010. The San Juan VAMC processed 34 claims from veterans 

residing in the Virgin Islands from October 1–22, 2010. These claims were 

for mileage reimbursements totaling $158.13 with $42.85 paid after reducing 

the payments by the required deductibles through the St. Croix and St. 

Thomas CBOCs. 

Veterans residing in the USVI may not have submitted mileage 

reimbursement claims because the veterans were not provided with the 

information they needed regarding this allowance, and CBOC-based staff 

who assist veterans with their benefits had not received training specifically 

related to beneficiary travel mileage reimbursements until after the OIG 

contacted San Juan VAMC and VISN 8 officials concerning our review. The 

Internet pages for the VA Caribbean Healthcare System and the St. Thomas 

and St. Croix CBOCs do not provide information concerning beneficiary 

travel benefits. In comparison, other VAMC Internet pages provide 

information on the Beneficiary Travel program. The CBOCs also did not 

have brochures available to explain the benefits. In addition, the San Juan 

VAMC did not communicate to veterans about the November 2008 mileage 

VA Office of Inspector General 21 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

VISN 8 and 

San Juan VAMC 

Officials Unaware 

of Problem 

Projection of 

Reimbursement 

Claims 

rate increase and January 2009 deductible decrease. The VSO 

representatives interviewed were also unaware of key provisions of the 

Beneficiary Travel program. 

Following the VA OIG inquiry regarding travel benefit issues related to 

veterans residing in the USVI, the San Juan VAMC took steps to remedy the 

lack of adequate communication regarding travel benefits. The VAMC 

mailed an informative postcard pertaining to travel benefits to almost 

1,900 veterans residing in the USVI. In addition, clerks at the VA clinics in 

St. Thomas and St. Croix reported they have begun proactively asking 

eligible veterans if they would like to claim a mileage reimbursement. The 

St. Thomas and St. Croix CBOCs posted a flyer concerning beneficiary 

travel benefits in the patient waiting area. Given that the San Juan VAMC 

has processed mileage reimbursements beginning in October 2010, it would 

appear that these steps have been effective in making veterans residing in the 

USVI more aware of the Beneficiary Travel program. 

In addition, training for staff administering mileage reimbursement to 

veterans residing in the USVI was inadequate. San Juan VAMC Beneficiary 

Travel Office staff and USVI-based CBOC clerks that process mileage 

reimbursement claims receive only on-the-job training and rely on the 

knowledge of current staff. A supervisor noted that training was insufficient 

and some of the information provided in the past was incorrect. 

CBOC-based staff stated that the San Juan VAMC provided training on 

beneficiary travel benefits and processing for the first time in 

September 2010. Despite this recent training, CBOC staff were unaware of 

some provisions of VA travel reimbursement benefits, such as deductible 

waivers. 

In addition, VISN 8 and San Juan VAMC officials were unaware that no 

mileage reimbursement claims were processed for veterans residing in the 

USVI. Therefore, these officials took no steps to address the situation until 

after the OIG review was announced. A San Juan VAMC official stated that 

oversight of mileage reimbursements were not considered a high priority. 

Instead, their focus was on other aspects of beneficiary travel (such air fares 

associated with bringing veterans to San Juan for treatment) that were more 

costly. The official advised that the San Juan VAMC spends approximately 

$100,000 per month on airfare associated with bringing veterans residing in 

the USVI to San Juan for treatment. 

Between October 1, 2009–May 31, 2010, veterans residing in Puerto Rico 

eligible for beneficiary travel completed 252,111 visits and claimed 

79,415 mileage reimbursements, or 32 percent of visits. Veterans residing in 

the USVI eligible for beneficiary travel completed 6,110 visits during the 

same period. Based on the rate of mileage reimbursement claims by veterans 

residing in Puerto Rico between October 2009–May 2010, we estimate 

VA Office of Inspector General 22 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Conclusion 

Recommendations 

Management 

Comments and 

OIG Response 

veterans residing in the USVI might have claimed, at minimum, 

1,955 mileage reimbursements if they had been more aware of their 

eligibility, the possibility of obtaining waivers, and the increased mileage 

reimbursement rates. 

The San Juan VAMC did not reimburse eligible veterans residing in the 

USVI for mileage costs associated with obtaining VA healthcare services 

because we were told that veterans did not submit mileage reimbursement 

claims. In contrast, veterans residing in Puerto Rico submitted mileage 

reimbursement claims for incurred travel costs associated with obtaining VA 

healthcare. Veterans residing in the USVI may not have submitted mileage 

reimbursements because of relatively short driving distances in the USVI, the 

low mileage reimbursement rate, and applicable deductibles that provided 

little or no compensation. VISN 8 and San Juan VAMC officials were 

unaware that no mileage reimbursement claims were processed for veterans 

residing in the USVI. San Juan VAMC and VISN 8 officials also did not 

ensure VA staff located at CBOCs in the USVI were sufficiently trained to 

assist veterans residing in the USVI with beneficiary travel claims. 

6. We recommend that the Veterans Integrated Service Network 8 Director 

require the VA Caribbean Healthcare System Director to allow veterans 

residing in the U.S. Virgin Islands to submit mileage reimbursement claims 

retroactively for eligible visits completed between January 9, 2009, and 

September 30, 2010. 

7. We recommend the Veterans Integrated Service Network 8 Director 

require the VA Caribbean Healthcare System Director to ensure the San Juan 

VAMC develop appropriate oversight mechanisms to review and monitor 

mileage reimbursement claims for the VA Caribbean Healthcare System. 

The VISN 8 Director concurred with our analysis and recommendation and 

stated that actions are being taken to notify eligible USVI veterans to submit 

mileage reimbursement claims retroactive from January 2009. He further 

stated that a notification letter will be developed and mailed to eligible USVI 

veterans informing them of their ability to submit a claim for mileage 

reimbursement, and claims will be processed upon receipt. In addition, the 

VISN 8 Director stated that enhancements were made in October 2010 to 

specifically track and monitor USVI mileage reimbursement claims. We 

concur with the VISN’s planned actions and will monitor their 

implementation. 

VA Office of Inspector General 23 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Issue 7
	

Veterans 

Assigned to Some 

Priority Groups 

Based on 

Financial Factors 

Income Guidelines Determine Eligibility for VA Services 

We verified that VA uses the National Income and National Geographic 

Income Thresholds to assign veterans to Priority Groups, when appropriate, 

and that the National Geographic Income Thresholds reflect differences in 

the cost of living between the USVI and Puerto Rico. 

Eligibility for VA healthcare services is dependent upon a number of 

variables, which may influence the final determination of the services for 

which a veteran qualifies. VA assigns veterans to a Priority Group based on 

their eligibility status. Priority Groups range from 1–8 with assignment to 

certain Priority Groups dependent on income and cost of living factors. For 

example, Priority Group 5 is comprised of nonservice-connected veterans 

and non-compensable service-connected veterans rated 0 percent disabled by 

VA with an annual income and/or net worth below the VA National Income 

Thresholds. 

Recognizing that the cost of living can vary significantly from one 

geographic area to another, Public Law 107-135, the Department of Veterans 

Affairs Health Care Programs Enhancement Act of 2001, directed VA to 

implement a geographic-based means test to help determine VA healthcare 

eligibility. VA identifies veterans living in high cost areas who may qualify 

for the reduced inpatient co-pay rate by the addition of the VA National 

Geographic Income Thresholds. VA uses the Department of Housing and 

Urban Development "low-income" geographic-based income limits (used as 

a basis for housing assistance) as the basis for VA's thresholds. The 

Department of Housing and Urban Development updates these limits 

periodically. 

Placement in Priority Group 7 is determined by comparing a veteran's 

income from the previous year with the appropriate geographic-based means 

test threshold for the previous calendar year. Priority Group 7 veterans have 

an income and/or net worth above the VA National Income Thresholds and 

below the VA National Geographic Income Thresholds. As of 

September 30, 2010, VA data indicated that 500 veterans residing in the 

USVI were enrolled in Priority Group 5 and 12 veterans were enrolled in 

Priority Group 7. In addition, certain veterans that have income exceeding 

the geographically adjusted income thresholds for their resident area (by 

10 percent or less) are eligible for Priority Group 8 enrollment in the 

VA Healthcare System. Data provided by the San Juan VAMC showed 

516 veterans residing in the USVI enrolled in Priority Group 8. 

VA Office of Inspector General 24 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Geographic 

Thresholds 

Reflect Cost of 

Living Differences 

Conclusion 

Management 

Comments and 

OIG Response 

The VA National Geographic Income Thresholds reflect the difference in 

cost of living between Puerto Rico and the USVI. For example, the 

VA National Geographic Income Thresholds for St. Thomas establishes a 

median family income threshold of $41,500 and varies from $32,150 for a 

veteran with no dependents and from $36,700 to $60,600 for a veteran with 

one to seven dependents. In comparison, the 2010 VA National Geographic 

Income Thresholds for San Juan establishes a median family income 

threshold of $26,500 and varies from $17,000 for a veteran with no 

dependents and from $19,400 to $32,000 for a veteran with one to seven 

dependents. 

Concerns that income guidelines used to determine eligibility for services are 

the same despite the cost of living being much higher in the USVI than in 

Puerto Rico are not founded. VA’s National Geographic Income Thresholds 

used by VA to determine eligibility for services reflect the difference in cost 

of living between Puerto Rico and the USVI. 

The VISN 8 Director did not provide comments related to the OIG analysis 

and conclusions concerning this issue. 

VA Office of Inspector General 25 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Appendix A Background 

The VA Caribbean Healthcare System, part of VISN 8, provides services to a 

population of 150,000 veterans in Puerto Rico and the USVI. The VACHS 

includes the VAMC in San Juan, Puerto Rico, and seven outpatient clinics 

located throughout Puerto Rico and the USVI. According to 2000 Census 

Bureau data, 5,152 veterans reside in the USVI. Of those, 2,489 live on 

St. Croix, 2,412 on St. Thomas, and 251 on St. John. In addition, 

1,572 USVI veterans are enrolled in the VACHS—859 from St. Croix, 

666 from St. Thomas, and 47 from St. John. Two CBOCs are currently 

located in the USVI. The CBOC on St. Thomas, staffed by VA personnel, is 

located in leased space in Charlotte Amalie, USVI. The CBOC on St. Croix 

is also staffed by VA personnel and is located in leased space in Kings Hill, 

USVI. Both CBOCs also have dedicated space for Vet Center personnel. 

In addition to the VA CBOCs, the USVI has comprehensive medical services 

and specialty providers available to veterans on St. Croix, St. Thomas, and 

St. John. Contract primary care services through a local provider were 

scheduled to begin on St. John in January 2011. 

The Schneider Regional Medical Center is a healthcare system with three 

facilities located on St. Thomas and St. John. St. Thomas has the Roy Lester 

Schneider Hospital—a Joint Commission accredited facility with a full range 

of inpatient and outpatient services, including a 24-hour emergency 

department and the Charlotte Kimelman Cancer Institute. The Myrah 

Keating Smith Community Health Center, a 24-hour outpatient health center 

with emergency, primary, and preventative care services, is located on 

St. John. The Governor Juan F. Luis Hospital, located on St. Croix, is Joint 

Commission accredited and has a 24-hour emergency department and a full 

range of inpatient and outpatient services. The Charles Harwood Memorial 

Hospital, an outpatient facility with limited laboratory and medical services, 

is also located on St. Croix. 

The San Juan VARO is responsible for delivering non-medical VA benefits 

and services to veterans and their families in Puerto Rico and the USVI. 

Examples of the benefits and services administered by the VA Regional 

Office are as follows: 

 Disability compensation, including death compensation benefits to 

eligible survivors 

 Disability and death pensions for veterans and their dependents 

 Vocational rehabilitation and employment assistance 

 Special benefits for the disabled 

 Outreach 

 Certain burial benefits 

VA Office of Inspector General 26 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Appendix B Scope and Methodology 

We reviewed pertinent laws and regulations related to VA; VHA and local 

policies and procedures; and information and data provided by the VACHS 

and VISN 8 on fee basis care, access to care, VA benefits, and USVI 

demographics. We reviewed VSSC data, personnel files, and other relevant 

documents. We also reviewed the medical records of 200 USVI veteran 

patients. We conducted interviews with VISN and VACHS leadership and 

VAMC and USVI CBOC staff. We also met with VSO leaders in the USVI 

and several USVI veteran patients. We conducted site visits at the VAMC in 

San Juan and the USVI CBOCs on St. Thomas and St. Croix from 

October 25–28, 2010. 

We conducted our onsite review of the treatment of benefits claims by 

veterans residing in the USVI at the San Juan VARO from 

September 27–29, 2010. To address the concerns of disparate treatment 

towards veterans residing in the USVI, we reviewed 120 claims completed 

by the San Juan VARO during the period of May 2009–May 2010. This 

sample consisted of 60 claims completed for veterans residing in Puerto Rico 

and 60 claims completed for veterans residing in the USVI. We reviewed 

these claims to determine if disparity existed in the accuracy and timeliness 

of claims processing, as well as the timelines of C&P medical examinations, 

between veterans residing in Puerto Rico and veterans residing in the USVI. 

The total population of claims completed during this period was 7,110 for 

veterans residing in Puerto Rico and 153 for veterans residing in the USVI. 

We conducted the onsite review of Beneficiary Travel program mileage 

reimbursement claims from October 25–28, 2010. We visited and 

interviewed key personnel from VHA Headquarters; VISN 8; the VA 

Caribbean Healthcare System’s main facility in San Juan, Puerto Rico; and 

CBOCs located in St. Croix and St. Thomas. We collected and examined 

Beneficiary Travel program documentation and related supplementary 

records and reports from VHA’s information systems. We also reviewed 

applicable laws, policies, and procedures. 

Utilizing data from the San Juan VAMC VistA, we identified: (1) veterans 

residing in Puerto Rico and the USVI in VA Enrollment Priority 

Groups 1 and 2 which met VA’s eligibility requirements for beneficiary 

travel benefits, (2) completed healthcare appointments between 

October 1, 2009–May 31, 2010, and (3) claimed mileage reimbursements 

between October 1, 2009–May 31, 2010. Based on differing factors, 

veterans may or may not be eligible for beneficiary travel reimbursements in 

VA Enrollment Priority Groups 3–8 and could not be identified using VistA. 

VA Office of Inspector General 27 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Reliability of 

ComputerProcessed Data 

Compliance with 

Government Audit 

Standards 

We utilized the data received from the San Juan VAMC to determine the rate 

at which veterans residing in Puerto Rico that completed VA or 

VA-approved healthcare visits claimed mileage reimbursements. We 

determined the rate at which veterans residing in Puerto Rico claimed 

mileage reimbursements as a basis to estimate the total number of veterans 

residing in the USVI that may have claimed mileage reimbursements during 

our review period. 

We also reviewed VA policies and directives concerning National and 

Geographically-Adjusted Income Thresholds for enrollment in VA’s 

Healthcare System. We verified this information with a VHA official. To 

verify VA was placing veterans into Priority Groups largely determined by 

financial factors, we obtained data to indicate the numbers of veterans 

residing in Puerto Rico and the USVI enrolled in Priority Groups 5, 7, and 8. 

We assessed the reliability of VA data by comparing qualifying 

appointments from VA’s Computerized Patient Record System with data 

obtained from VistA. Based on this test and assessment we concluded the 

data were sufficiently reliable for the purpose used. 

We conducted this review between September 2010–November 2010 in 

accordance with the Council of Inspectors General on Integrity and 

Efficiency. Based on our review objectives, we believe the evidence 

obtained provides a reasonable basis for our findings and conclusions. 

VA Office of Inspector General 28 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Appendix C VHA Comments 

Department of Memorandum Veterans Affairs 

Date: March 25, 2011 

Director, VA Sunshine Healthcare Network (10N8) From: 

Review of Healthcare Services and Benefits for Resident U.S. Virgin Island Subj: 

Veterans, Project Number 2010-03081-HI-0324 

To:	 Director, Bay Pines Office of Healthcare Inspections (54SP)
 

Director, Management Review Office (10B5)
 

I have reviewed and concur with the findings and recommendations contained in 

the Healthcare Inspection report, as it relates to the Review of Healthcare 

Services and Benefits for Resident U.S. Virgin Island Veterans. 

1. 

Appropriate action has been initiated and/or completed, as detailed in the 

attached report. 

2. 

Nevin M. Weaver, FACHE 

VA Office of Inspector General 29 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Department of Memorandum Veterans Affairs 

March 25, 2011 Date: 

Director, VA Caribbean Healthcare System (672/00) From: 

Subj:	 OIG Draft Report—Review of Healthcare Services and Benefits for Resident U.S. 

Virgin Island Veterans, Project Number 2010-03081-HI-0324 

To: Director, VA Sunshine Healthcare Network (10N8) 

1.	 On behalf of the VA Caribbean Healthcare System, I want to express my 

appreciation to the Office of Inspector General (OIG), Office of Healthcare 

Inspections for their professional and comprehensive Review of Healthcare 

Services and Benefits for Resident U.S. Virgin Island Veterans. 

2. I concur with the findings and recommendations of this Office of Inspector General 

report. The VA Caribbean Healthcare System welcomes the external perspective 

provided by this report. 

3.	 Attached is the VA Caribbean Healthcare System’s reply outlining corrective 

actions. 

Wanda Mims, MBA 

VA Office of Inspector General 30 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

VISN and System Directors’ Comments
	

To Office of Inspector General’s Report
	

The VISN and System Directors concur with the findings in OIG’s draft report and
 

provide the following comments in response to the recommendations.
 

Recommendation 1: Ensure that English language proficiency is documented in SF 52
 

forms for physicians, nurses, and residents, as required.
 

Concur: English language proficiency will be documented in SF 52 forms for
 

physicians, nurses, and residents, as required.
 

Status: All HR Staff have been instructed to comply with this requirement. The
 

Supervisor, Staffing & Recruitment will monitor ongoing compliance.
 

Target Completion Date: Completed 

Recommendation 2: Ensure that primary care appointments at the USVI CBOCs be 

available within the timeframes prescribed by VHA policy. 

Concur: Every effort is made to schedule patients within the required time frames as 

prescribed by VHA policy. 

Status: Standard Operating Procedures for disposition of patient appointments will be 

established and Case Managers will monitor compliance. Access and coordination of 

care is expected to improve with the implementation of the Patient Aligned Care Team
 

delivery model scheduled for July 2011.
 

Target Completion Date: July 2011
 

Recommendation 3: Implement a mechanism to monitor the satisfaction of USVI
 

Veterans at the local level.
 

Concur: Local survey tool will be implemented.
 

Status: A Quick Card survey tool will be implemented to assess patient satisfaction
 

recurrently. Results will be evaluated and appropriate actions taken.
 

Target Completion Date: May 2011
 

Recommendation 4: Review the VA Caribbean Healthcare System patient advocate
 

program for opportunities to facilitate complaint reporting for USVI Veterans.
 

Concur: Actions will be taken to facilitate complaint reporting for USVI Veterans.
 

VA Office of Inspector General 31 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Status: Patient Advocates at both St Thomas and St Croix will be identified and trained, 

and posters with their pictures will be placed in the clinics. Complaints will continue to 

be tracked through the Patient Advocate tracking system. In addition, a notice outlining 

the complaint process will be sent to VSO’s and stakeholders. 

Target Completion Date: April 2011 

Recommendation 5: Determine the feasibility of sending medical examiners to the 

USVI to perform Compensation and Pension examinations that do not require medical 

specialists or non-portable specialized medical equipment. 

Concur: Actions will be taken to perform Compensation and Pension non-specialty 

examinations in the USVI. 

Status: Efforts are underway to identify an internist to visit the U.S. Virgin Islands at 

least monthly, to perform non-specialty Compensation and Pension exams. 

Target Completion Date: June 2011 

Recommendation 6: Allow Veterans residing in the USVI to submit mileage 

reimbursement claims retroactively for eligible visits completed between January 9, 

2009, and September 30, 2010. 

Concur: Actions are being taken to notify eligible USVI veterans to submit mileage 

reimbursement claims retroactive from January 2009. 

Status: A notification letter will be developed and mailed to eligible USVI veterans 

informing them of their ability to submit a claim for mileage reimbursement, and claims 

will be processed upon receipt. 

Target Completion Date: April 2011 

Recommendation 7: Ensure the San Juan VAMC develops appropriate oversight 

mechanisms to review and monitor mileage reimbursement claims for the VA 

Caribbean Healthcare System. 

Concur: Monitors have been in place to review and monitor mileage reimbursement 

claims for the VA Caribbean Healthcare System. 

Status: Enhancements were made in October 2010 to specifically track and monitor 

USVI mileage reimbursement claims. 

Target Completion Date: Completed 

VA Office of Inspector General 32 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Appendix D VBA Comments 

Department of Memorandum Veterans Affairs 

April 1, 2011 Date: 

Acting Under Secretary For Benefits (20) From: 

OIG Draft Report—Review of Healthcare Services and Benefits for Resident U.S. Subj: 

Virgin Island Veterans [Project No. 2010-03081-HI-0324]—VAIQ 7096440
 

To: Assistant Inspector General for Audits and Evaluations (52)
 

This is in response to your request for VBA’s review of OIG Draft Report—Review 

of Healthcare Services and Benefits for Resident U.S. Virgin Island Veterans. 

1. 

2. VBA appreciates the opportunity to review this report and provides no comments. 

3. Questions may be referred to Catherine Milano, Program Analyst, at 461-9216. 

Michael Walcoff 

VA Office of Inspector General 33 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

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 Crowe, Project Leader (Audits & Evaluations) 

Christa Sisterhen, Project Leader (Healthcare Inspections) 

Brent Arronte 

Berry “Craig” Ward 

Carol Torczon 

Danny Clay 

Kristine Abramo 

Douglas Henao 

Lisa Van Haeren 

Kerri Leggiero-Yglesias 

Johnny McCray 

Bryan Shaw 

Karen Sutton 

VA Office of Inspector General 34 
Review of Healthcare Services and Benefits for Resident U.S. Virgin Islands Veterans 

Appendix F Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Director, Veterans Integrated Service Network 8 

Director, VA Caribbean Healthcare System 

Veterans Benefits Administration 

Office of General Counsel 

Non-VA Distribution 

Donna M. Christensen, United States Virgin Islands Delegate to Congress 

Pedro Pierluisi, Resident Commissioner for Commonwealth of Puerto Rico 

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 35