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VBA AND VHA INTERACTIONS: ORDERING 

AND CONDUCTING MEDICAL EXAMINATIONS 

HEARING 

BEFORE THE

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED THIRTEENTH CONGRESS 

SECOND SESSION 

Wednesday June 25, 2014 

Serial No. 113–77 

Printed for the use of the Committee on Veterans’ Affairs 

( 

Available via the World Wide Web: http://www.fdsys.gov 

http://www.house.gov/reform 


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COMMITTEE ON VETERANS’ AFFAIRS 

JEFF MILLER, Chairman 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida Vice-Chairman 

DAVID P. ROE, Tennessee 

BILL FLORES, Texas 

JEFF DENHAM, California 

JON RUNYAN, New Jersey 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

PAUL COOK, California 

JACKIE WALORSKI, Indiana 

DAVID JOLLY, Florida 

MICHAEL H. MICHAUD, Maine, Ranking 

Member 

CORRINE BROWN, Florida 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

ANN KIRKPATRICK, Arizona 

RAUL RUIZ, California 

GLORIA NEGRETE MCLEOD, California 

ANN M. KUSTER, New Hampshire 

BETO O’ ROURKE, Texas 

TIMOTHY J. WALZ, Minnesota 

Jon Towers, Staff Director 

Nancy Dolan, Democratic Staff Director 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Veterans’ Affairs are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 


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C O N T E N T S 

Page 

Thursday June 12, 2014 

VBA And VHA Interactions: Ordering And Conducting Medical Examinations 1 

OPENING STATEMENT 

Hon. Jeff Miller, Chairman 

Statement .......................................................................................................... 1 

Prepared Statement ......................................................................................... 3 

Hon. Mike Michaud, Ranking Minority Member 

Statement .......................................................................................................... 4 

Prepared Statement ......................................................................................... 5 

Hon. Ann Kirkpatrick 

Prepared Statement ......................................................................................... 7 

WITNESSES 

Mr. Thomas Murphy, Director Compensation Service, Veterans Benefits Administration, U.S. Department of Veterans Affairs 

Oral Statement ................................................................................................. 7 

Statement .......................................................................................................... 10 

Accompanied by: 

Ms. Beth McCoy, Acting Deputy Under Secretary for Field Operations, Veterans Benefits Administration, U.S. Department of Veterans Affairs 

Dr. Gerald M. Cross, Chief Officer Office of Disability and Medical Assessment, Veterans Health Administration, U.S. Department of Veterans Affairs 

Ms. Patricia D. Murray, Director Clinical Programs and Administrative Operations, Veterans Benefits Administration, U.S. Department of Veterans 

Affairs 

Mr. George C. Turek 

Oral Statement ................................................................................................. 17 

Statement .......................................................................................................... 19 

Exhibit 1 ............................................................................................................ 25 

Exhibit 2 ............................................................................................................ 27 

Exhibit 3 ............................................................................................................ 28 

Executive Summary ......................................................................................... 29 

APPENDIX 

STATEMENT FOR THE RECORD .................................................. 59 

Statement of Jeff Scarpiello 59 

VA Responses to Pre-Hearing Questions 62 

Mr. Turek’s Supplemental Testimony 70 


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VBA AND VHA INTERACTIONS: ORDERING 

AND CONDUCTING MEDICAL 

Wednesday, June 25, 2014 

U.S. HOUSE OF REPRESENTATIVES

COMMITTEE ON VETERANS’ AFFAIRS

WASHINGTON, D.C. 

The committee met, pursuant to notice, at 9:15 a.m., in Room 

334, Cannon House Office Building, Hon. Jeff Miller [chairman of 

the committee] presiding. 

OPENING STATEMENT OF CHAIRMAN JEFF MILLER 

The committee met, pursuant to notice, at 10:03 a.m., in Room 

334, Cannon House Office Building, Hon. Jeff Miller [chairman of 

the House Committee on Veterans’ Affairs] presiding. 

Present:Representatives Miller, Lamborn, Bilirakis, Roe, Flores, 

Denham, Runyan, Benishek, Huelskamp, Coffman, Wenstrup, 

Walorski, Michaud, Brown, Takano, Brownley, Titus, Ruiz, Negrete 

McLeod, Kuster, O’Rourke, and Walz. 

The *Chairman.* Good morning, everybody. During this morning’s full committee hearing entitled VBA and VHA Interactions: 

Ordering and Conducting Medical Examinations, we are going to 

examine the relationship that exists between VHA and VBA as to 

their respective efforts to conduct medical examinations on veterans’ claims for disability benefits known as C&P exams. There 

will be several reasons that we are going to focus on today and the 

reason that we are focusing on it is medical but non-treatment related VA functions that they perform. 

The first is based on that fact that VHA has failed. It has failed 

in its paramount mission and I quote, ‘‘to honor America’s veterans 

by providing exceptional healthcare that improves their health and 

their well-being.’’ The rampant corruption, dishonesty, and cowardice that has been brought to light by this committee shocks the 

very conscience of everyone in this room and certainly of the 

United States of America. This week’s newest whistleblower allegation regarding the falsification of deceased veteran records yet 

again underscores the bureaucratic arrogance that exists within 

this department. 

The consequences of VA’s failures did not fall on the unscrupulous or the willfully ignorant facility leadership. Instead the consequences fell squarely on the shoulders of those individuals who 

stood up and swore commitments to this nation. Commitments that 

center on fidelity, on honor, and on duty. And veterans have died. 


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Over the course of recent weeks this committee has held many 

hearing, targeted to address comprehensive VA reform and there 

are going to be more hearings to come. I still believe that the majority of VA’s workforce, the doctors, the nurses, the claims processes, and the veterans service representatives truly do endeavor 

to provide quality service to our veterans. But VA’s epidemic lack 

of accountability, and mission focus requires a wholesale, systematic reform of the Department. A massive, massive cultural shift is 

in fact necessary. 

I have listened to VA’s responses to this committee’s questions in 

recent weeks and what I hear are frequently institution-centered 

answers, not veteran-centered responses. In setting the tone for 

this hearing and future hearings, let me begin by cautioning that 

any equivocation, any excuse provided by VA that seeks to protect 

the establishment to the detriment of the veteran is going to fall 

on deaf ears. The time for excuses has long passed. 

Today’s hearing will explore the current division of labor between 

VBA and VHA on provision of C&P exams for disability adjudications, as well as the various contract tools that each administration 

uses. Given the recent VHA failures and issues raised by VHA to 

include space limitations and staff shortages, I want to hear your 

thoughts on whether the thousands of VHA employees assigned to 

performing C&P exams could be better used to treat veterans. VHA 

currently has nearly 8,200 registered and certified C&P examiners, 

which include physicians, nurse practitioners, physician assistants, 

and psychologists, as well as additional administrative support 

staff necessary to administer this function, many of whom work 

with VBA solely to perform C&P disability exams. Transferring 

some or all of the VHA C&P staff to treatment jobs would significantly increase the number of appointments available to veterans. 

I am aware that VHA has voiced some initial resistance to this 

concept and has objected on the basis that many C&P exam providers at VHA have either not maintained the necessary credentials to transition into patient treatment roles or that some prefer 

to work on a part-time schedule and thus must remain with a C&P 

examiner capacity at VHA. 

I would point out that this is a prime opportunity to demonstrate 

that culture shift that I have spoken about. The mission is to provide quality and timely healthcare to veterans, not to accommodate 

the status quo. And in any event, I am curious as to why VA does 

not require more than their healthcare providers to maintain their 

qualifications. Based on the high level of satisfaction with the contractors who perform medical disability examinations for purposes 

of adjudicating disability claims, VA has supported expansion of its 

contract authority in the past. However, we are also aware that 

VBA and VHA do not award or administer contracts uniformly. 

The ordering processes are different, the scheduling systems are 

different, the work flow processes are different, and the billing and 

collection processes are different. Accordingly, today we are going 

to take a detailed look at the big picture. We will look for sensible 

solutions and best practices to achieve both the most effective access to medical treatment as well as assurance of timely, high quality C&P exams for disability adjudication. 


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STATEMENT OF JEFF MILLIER, Chairman 

During this morning’s full committee hearing entitled, ‘‘VBA and 

VHA interactions: ordering and conducting medical examinations’’ 

we will examine the relationship that exists between VHA and 

VBA as to their respective efforts to conduct medical examinations 

on veterans’ claims for disability benefits, known as ‘‘C&P exams.’’ 

And there are several reasons that we will focus on this specific 

medical, but non-treatment related, VA function. 

The first is based upon the fact that VHA has failed . . . it has 

failed its paramount mission, I quote, ‘‘to honor America’s veterans 

by providing exceptional health care that improves their health and 

well-being.’’ 

The rampant corruption, dishonesty, and cowardice brought to 

light by this committee shocks the conscience of everyone in this 

room, and of this Nation. 

This week’s newest whistle-blower allegation, regarding the falsification of deceased veterans’ records, yet again underscores the 

bureaucratic arrogance that subsists within this department. 

The consequences of VA’s failures did not fall on the unscrupulous manager, or the willfully ignorant facility leadership; instead, 

the consequences fell squarely on the shoulders of those individuals 

who stood up and swore commitments to this nation . . . commitments that center on fidelity, honor, and duty. 

And, veterans died. 

Over the course of recent weeks, this committee has held many 

hearings targeted to address comprehensive VA reform, and there 

will be more hearings to come. 

I still believe that the majority of VA’s workforce - the doctors, 

nurses, claims processors, and veteran service representatives - 

truly do endeavor to provide quality service to veterans. But, VA’s 

epidemic lack of accountability —- lack of mission focus—- requires 

a wholesale systematic reform of the department . . . a massive, 

massive, cultural shift is necessary. 

I have listened to VA’s responses to this committee’s questions in 

recent weeks . . . and what I hear are frequently institution-centered, not veteran-centered, responses. And so, in setting the tone 

for this hearing, and future hearings, let me begin by cautioning 

that any equivocation —- any excuse —- provided by VA that seeks 

to protect the establishment, to the detriment of the veteran, will 

fall on deaf ears. The time for excuses is long past. 

Today’s hearing will explore the current division of labor between 

VBA and VHA on provision of C&P exams for disability adjudications, as well as the various contract tools that each administration 

maintains. 

Given the recent VHA failures, and issues raised by VHA to include space limitations, and staff shortages, I would like to hear 

your thoughts on whether the thousands of VHA employees assigned to performing C&P examinations could be better used to 

treat veterans. 

VHA currently has nearly eight thousand two hundred registered 

and certified C&P examiners, which include physicians, nurse practitioners, physician assistants, and psychologists, as well as additional administrative support staff necessary to administer this 


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function, many who work closely with VBA solely to perform C&P 

disability examinations. 

Transferring some or all of the VHA C&P staff to treatment jobs 

would significantly increase the number of appointments available 

to veterans. 

Now, I am aware that VA has voiced some initial resistance to 

this concept, and has objected on the basis that many C&P exam 

providers at VHA have either not maintained the necessary credentials to transition into patient treatment roles, or that some prefer 

to work on a part-time schedule, and thus must remain within a 

C&P examiner capacity at VHA. I would point out that this is a 

prime opportunity to demonstrate that culture shift I spoke about: 

The mission is to provide quality and timely healthcare to veterans, not to accommodate the status- quo. And, in any event, I am 

curious why VA does not require more of their healthcare providers 

to maintain their qualifications. 

Based on the high level of satisfaction with the contractors who 

perform medical disability examinations for purposes of adjudicating disability claims, VA has supported expansion of its contract 

authority in the past. 

However, we are also aware that VBA and VHA do not award 

or administer contracts uniformly; the ordering processes are different, the scheduling systems are different, the workflow processes 

are different, and the billing and collection processes are different. 

Accordingly, today we are going to take a detailed look at the big 

picture. 

We will look for sensible solutions, and best practices, to achieve 

both the most effective access to medical treatment, as well as assurance of timely, high-quality C&P exams for disability adjudication. 

With that, I want to recognize the Ranking Member Mr. Michaud 

for his opening statement. 

OPENING STATEMENT OF MIKE MICHAUD, RANKING MEMBER 

Mr. MICHAUD. Thank you very much, Mr. Chairman, for holding 

this hearing today on behalf of our nation’s veterans. Mr. Chairman, I appreciate your taking the time during our extensive oversight of the VA to focus on something that the VA is improving 

upon, processing claims. 

As of today the VA has reduced the backlog by more than 50 percent from the highest point in March of 2013. We are not even 

close to the finish line but we are starting to see increase in productivity as a result of VBA’s long overdue shift from paper to an 

electronic processing system. All 56 offices have moved into this 

electronic processing system and into a new organizational model 

that appears to be showing positive results. Some of our high performing regional offices are nearing the point at which the backlog 

will be eliminated. 

While we have heard of the scheduling challenges that the veterans face in receiving clinical appointments, I am happy to hear 

that VA has been providing timely medical examinations to determine a veteran’s entitlement for VA benefits. Currently VA’s national average for medical examinations for benefits purposes is 24 


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days, which is six days better than their goal of 30 days. VA seems 

to believe that they have a solid handle on their mix of contract 

versus non-contract examination. We have heard VA suggest that 

in an ideal world they would prefer non-contract examinations over 

contract examinations because they believe it will provide a better 

continuum of care for our veterans. We have generally heard the 

same things from veterans, who suggest that when they have access VA quality of care is second to none. 

However, with regards to contract examination it seems that the 

logical way forward continues to be a mix based on clear standards 

as to when and where they should or should not be used. That said, 

I have some overarching concerns with VBA’s transformation efforts. Foremost, the all in focus on the backlog is starting to come 

at the cost of increased delays from other benefits. Management by 

crisis is not a long term viable solution. We cannot afford to solve 

one critical issue by taking our attention off another. 

I urge VA to reallocate resources to process non-rating claims 

and appeals in a timely fashion. Appeals in non-rating claims are 

also part of the backlog and deserve to be adequately resourced to 

provide timely and accurate decisions to our veterans. 

There will be no victory laps until VBA has eliminated their entire overdue inventory. If we have learned anything from this 

healthcare debacle it should be that serving veterans, not performing metrics, is a way to do business. Along these lines I would 

encourage VBA to ask itself are we oriented towards a specific set 

of performance metrics at the expense of identifying how to best 

serve our veterans? These are the types of questions we must answer as we move forward and I hope to hear them discussed in today’s hearing in more detail. 

I want to thank all of you for coming here today, joining us, and 

look forward to the hearing, your testimony, as well. With that, Mr. 

Chairman, I yield back. 

STATEMENT OF MIKE MICHAUD, Ranking Member 

Thank you, Mr. Chairman for holding this hearing today on behalf of our nation’s veterans. 

Mr. Chairman, I appreciate you taking the time during our extensive oversight of the VA to focus on something that the VA is 

improving upon: processing claims. 

As of today, the VA has reduced the backlog by more than 50 

percent from its highest point in March of 2013. 

We are not even close to the finish line, but we are starting to 

see increases in productivity as a result of VBA’s long overdue shift 

from paper to an electronic processing system. 

All 56 offices have moved into this electronic processing system 

and into a new organizational model that appears to be showing 

positive results. 

Some of our high-performing regional offices are nearing the 

point at which the backlog will be eliminated. 

While we have heard of the scheduling challenges that veterans 

face in receiving clinical appointments, I am happy to hear that VA 

has been providing timely medical examinations to determine a 

veteran’s entitlement for VA benefits. 


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Currently VA’s national average for medical examinations for 

benefits purposes is 24 days, which is six days better than their 

goal of 30 days. 

VA seems to believe that they have a solid handle on their mix 

of contract versus non-contract examinations. 

We have heard VA suggest that in an ideal world they would 

prefer non-contract examinations over contract examinations because they believe it provides a better continuum of care for veterans. 

We have generally heard the same thing from veterans, who suggest that when they have access, VA quality of care is second to 

none. 

However, with regards to contract examinations, it seems that 

the logical way forward continues to be a mix based on clear standards as to when and where they should or should not be used. 

That said, I have some overarching concerns with VBA’s transformation efforts. 

Foremost, the ‘‘all-in’’ focus on the backlog is starting to come at 

the cost of increased delays for other benefits. 

Management-by-crisis is not a long-term viable solution - We 

cannot afford to solve one critical issue by taking our attention off 

another. 

I urge VA to reallocate resources to process non-rating claims 

and appeals in a timely fashion. 

Appeals and non-rating claims are also part of the backlog and 

deserve to be adequately resourced to provide timely and accurate 

decisions to our veterans. 

There will be no victory laps here until VBA has eliminated their 

entire overdue inventory. 

If we have learned anything from this healthcare debacle, it 

should be that serving veterans, not performance metrics, is the 

way to do business. 

Along these lines, I would encourage VBA to ask itself, are we 

oriented toward a specific set of performance metrics at the expense of identifying how to best serve our veterans? 

These are the types of questions we must answer as we move forward, and I hope to hear them discussed in today’s hearing in a 

bit more detail. 

The *Chairman.* Thank you very much, Mr. Michaud. And if you 

have a telephone on in this room, turn it off. Thank you very much. 

I would ask all members to waive their opening statement as per 

the Committee’s custom. Thank you for appearing before us today 

as witnesses. We are going to hear from Mr. Tom Murphy, Director 

of Compensation, Veterans Benefits Administration, Department of 

Veterans Affairs. He is accompanied by Ms. Beth McCoy, Acting 

Deputy Under Secretary for Field Operations, Veterans Benefits 

Administration, Department of Veterans Affairs; Dr. Gerald Cross, 

Chief of the Office of Disability and Medical Assessment, Veterans 

Health Administration, Department of Veterans Affairs; and Ms. 

Patricia D. Murray, Director of Clinical Programs and Administrative Operations, Veterans Health Administration, Department of 

Veterans Affairs. And we also will hear from Mr. George Turek, 

Founder, Owner, Chairman, and Chief Executive Officer for VetVerDate Aug 31 2005 06:39 Oct 30, 2014 Jkt 000000 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 C:\PDF\89376.TXT PAT

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erans Evaluation Services. I ask all the witnesses now if you would 

please rise and raise your right hand? 

STATEMENT OF THE HON. ANN KIRKPATRICK 

Veterans are waiting too long—for medical appointments and for 

their disability claims to be processed. This week, the VA claims 

backlog stands at 562,968. This number only reflects the number 

of claims that have been filed and have been pending for longer 

than 125 days. If veterans are waiting just to get that examination 

to file a claim, this adds to the wait time. 

Appointment scheduling and wait time data for compensation 

and pension examinations should be carefully scrutinized in light 

of report after report of VA medical facilities covering up long patient wait times. Any additional reviews of appointment scheduling 

should include an examination of patient wait times for these 

exams as well. It is imperative that accurate data be reported so 

that the VA is able to serve the growing number of veterans that 

are seeking care. 

Major reforms in the VA are sorely needed. The VA and Congress must work together to strip away the layers of bureaucracy 

and cut through the red tape so that the VA is able to efficiently 

meet the needs of our veterans. While contracting out compensation and pension examinations gives VA primary care doctors more 

time to see patients, we cannot sacrifice quality for efficiency. We 

have received several reports of compensation and pension exams 

being performed by contract doctors that do not have the licenses 

or credentials to perform these exams—which can lead to wrongfully denied claims, and the growing backlog of appealed claims. 

[Witnesses sworn.] 

The *Chairman.* Thank you very much. Please be seated. Each 

of your written statements will be entered into the record and Mr. 

Murphy, you are now recognized for five minutes. 

STATEMENT OF THOMAS MURPHY 

Mr. MURPHY. Chairman Miller, Ranking Member Michaud, and 

committee members, thank you for providing me the opportunity to 

discuss the VA’s C&P examination process. 

The Department of Veterans Affairs is committed to providing 

timely, high quality healthcare and other benefits that veterans deserve and have earned through their service. An important part of 

accurately determining those healthcare and other benefits for 

which a veteran is eligible is through a C&P examination. For this 

reason it is important that C&P exams are performed under stringent clinical requirements and credentialing criteria for both the 

elements of the exam as well as the clinicians who perform them. 

These requirements are the same whether the exam is conducted 

by a VA provider or a VA contracted community health provider. 

A case has been identified where 51 veterans were previously examined by a VA contractor need to be reexamined by VA to ensure 

the required standard was upheld. These 51 veterans are being 

contacted individually and their appointments scheduled at their 

earliest convenience. VA benefits staff members are standing by to 


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expedite processing of these C&P exams and inform veterans of 

their benefits for which they may be eligible. 

VA is working with the contractor to rectify the current situation 

and prevent any recurrences. In addition, VA contacted all DEM 

vendors and reviewed requirements for training and certifying providers that conduct C&P exams. VA required that all DEM vendors 

verify they are following these requirements. 

VHA conducts disability exams at the request of VBA. A medical 

exam or opinion is required in claims when, after the development 

of all other relevant evidence, there is not sufficient medical evidence to make a rating decision on the claim. To trigger the requirement for the examination there must be evidence of a current 

disability, evidence of an event, injury, or disease in service, and 

a nexus between the two. 

VBA and VHA have instituted several initiatives to improve the 

timeliness and accuracy of claims processing based on medical evidence. For example, DBQs are designed to efficiently gather medical evidence by capturing all information needed to rate a claim 

for a specific condition. A total of 81 DBQs are available for VHA 

clinicians, including 71 DBQs that can be completed by private doctors. Similarly, in the ACE VHA initiative, clinicians review existing medical evidence and determine whether that evidence can be 

used to complete a DBQ. For many veterans this means they no 

longer need to travel and take time off to complete an examination. 

VHA is providing certified C&P clinicians at all 56 VBA regional 

offices and two DRAS sites. The clinicians provide medical opinions, answer staff questions, correct insufficient examinations, and 

serve as a key communication link between VBA and VHA. No examinations are conducted at the regional offices. 

VHA and VBA joint analytics team work closely together to track 

C&P examination metrics as well as to analyze data to be able to 

identify trends, strengths, and weaknesses and project future workload. 

VHA’s DMA is a national office that facilitates the disability examination process to support field C&P clinics. Nearly 8,200 VHA 

registered and certified V&P examiners, which included full-time 

and part-time VHA employees, residents, fee for service examiners, 

VHA contract vendors, locum tenens, and specialty providers. 

In 2011 VHA established a nationwide medical examination contract with additional overseas capability. The contract is held by 

four vendors who provide their services to meet VHA standards. 

In addition to DEM contract services, VHA provided VA medical 

centers a number of tools. Examples of these tools include hiring 

staff, fee basis support, the locum tenens program, and additional 

funding. 

The national standard for completing C&P disability exams is 30 

days, or 45 days for IDES. This is measured from the day VBA 

electronically submits an exam request to the day VHA electronically returns the report. For fiscal year 2014 the average time was 

24 days and 32 days for IDES. The total number of disability 

exams and medical opinions completed by VHA and its contractors 

was 1.85 million for fiscal year 2012, 2.17 million in fiscal year 

2013, and 1.58 million in fiscal year 2014 to date. 


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In addition to examinations completed by VHA, VBA contracts 

with three vendors. They provide examinations to 18 regional offices. VBA is able to conduct contract examinations using both 

mandatory and discretionary funds. VA’s authority to use discretionary funds for contract exams expires this December and VA 

supports extension of this authority. VBA’s authority to use mandatory funds for contract exams is limited to ten regional offices. 

The authority to contract disability exams is essential to VBA’s 

goal to eliminate the claims backlog. 

In fiscal year 2013 VBA contractors completed over 225,000 examinations in addition to the 2 million exams conducted by VHA 

and its contractors. In fiscal year 2014 exams conducted using 

mandatory appropriations were completed on an average of 29 days 

and exams conducted using the discretionary funding were completed in an average of 17 days. 

VBA and VHA have worked to expand capacity for disability examinations provided internally and through contract resources. 

This collaboration has helped improve the timeliness and accuracy 

of examinations and ultimately improved the delivery of benefits to 

disabled veterans. 

This concludes my testimony, Mr. Chairman. I would be happy 

to address any questions you or other members of the committee 

may have. 


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The *Chairman.* Thank you very much, Mr. Murphy. Mr. Turek, 

you are recognized for five minutes. 

STATEMENT OF GEORGE C. TUREK 

Mr. TUREK. Thank you, Mr. Chairman, Mr. Ranking Member, 

and the committee members for providing me the opportunity to 

testify today. My name is George Turek. I am a veteran. My wife 

and I and four dogs and five cats, all rescue, live in Houston, 

Texas. 

I have been in the independent medical evaluation business for 

36 years, having established the first fee standing IME facility in 

the U.S. in Detroit, Michigan in 1978. We formed Veterans Evaluation Services in 2007 to provide outsourced medical disability examinations, or MDEs, to the VA. We became involved because we 

are highly committed to our veterans. 

Currently VES has two contracts with the VA for outsourced 

MDEs, one with the VBA and the other with the VHA. Our VBA 

contract is a single source discretionary funded contract and we 

serve in seven and a half regions. Our VHA contract is indefinite 

quantity for overflow cases from VAMCs across the world and we 

compete with compete with four other contractors on this contract. 

We thoroughly enjoy working with both the VBA and the VHA and 

their respective staffs are top notch. 

There are challenges, however, adhering to each agency’s divergent processing and work flow requirements. The differences in 

work flow processes between the VBA and VHA are notable. One, 

VBA outsourced MDE allotments are controlled by senior staff in 

Washington, D.C., while the allotments of MDEs from the VHA are 

determined by each individual VAMC. Number two, although they 

use the same computer system to process MDEs, VBA and VHA 

use totally different scheduling systems. The VBA uses CAATS, 

which is highly automated and efficient, while VHA uses 

DemTRAN, which essentially consists of encrypted emails that 

have to be manually entered into our system each and every referral. And number three, the VBA and VHA have two entirely different work flow processes for the same exact MDE. An MDE referred from the VHA requires over twice as many steps to process 

as the same one referred from the VBA. Number four, monthly billing is a one-step process with the VBA while it is a 12-step process 

with the VHA. With the VBA we simply prepare one bulk bill for 

all the MDEs performed in the past month. But with the VHA each 

MDE is billed separately and sent to each referring VAMC. Based 

on our experience of working with both agencies, it is our opinion 

that the VBA method of outsourcing MDEs is far more time efficient and cost effective. 

Now I would like to comment on two pressing issues. This committee, the Senate Veterans’ Affairs Committee, and the VA have 

been struggling for years with the backlog of veterans disability 

claims. Now in addition you are forced to deal with the backlog of 

veterans seeking timely treatment appointments at VAMCs. I am 

convinced that we have at least a partial solution for both frustrating problems. Our recommendation is that VAMC medical providers perform medical treatment only, no MDEs, allowing them to 


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focus 100 percent of their time on treating veterans. With 80 percent of all MDEs currently conducted by VAMC medical providers, 

this would free up hundreds of thousands of man hours for VAMC 

medical providers and their support staff to treat veterans. Concurrently, the VA should outsource all MDEs to community based 

medical providers. Private contractors have access to trained and 

experienced medical providers as well as the necessary support 

staff to allow them to timely and cost effectively process all MDEs. 

The simple, reallocation of existing assets would go a long way 

to resolve the backlog of both treatment cases and C&P claims. 

This can be done quickly, much more quickly than building new 

hospitals and clinics and then hiring and training staff. This method of handling MDEs is consistent with how independent medical 

examinations, the commercial equivalent of MDEs, are processed in 

all other delivery systems, where they are part of the claims management process, not the healthcare delivery system. This is a crucial point and one which the members of this committee who are 

themselves physicians should well understand. This protocol is 

tried and true and has worked extremely well in the commercial 

world for years. We believe that it would likewise work well for the 

VA. We are simply suggesting that with regard to MDEs, the VA 

should adopt the commercial market method for processing claims. 

The mission of the VHA should be to treat veterans, period. On 

the other hand, the VBA should function as the claims administrator for MDEs by ordering and scheduling them with independent community based medical providers as part of the C&P 

benefits delivery process. 

Lastly, with regard to pending legislation, House Bill 2189 and 

Senate Bill 2091 are commendable but we believe they do not go 

far enough. All VA regional offices should be allowed to outsource 

MDEs under mandatory funded contracts with private contractors. 

This would dramatically increase the resources available to the VA 

to reduce the backlog of C&P claims as well as reduce the treatment backlog at VAMCs. 

Mr. Chairman, that concludes my statement. I would be pleased 

to answer any questions that committee members may have. 


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EXECUTIVE SUMMARY 

The VA and this Committee are confronted today with two significant issues affecting our nation’s veterans: 

1. Veterans are waiting too long to receive medical treatment at 

VAMC’s; and 

2. Veterans are waiting too long to receive C&P benefits because 

of the backlog of MDEs waiting to be performed. 

A simple, straightforward and easily implemented solution would 

be to outsource all C&P MDEs to community-based medical providers, thereby allowing VAMC-employed medical providers to 

focus 100% of their time on providing treatment to our veterans. 

The VA’s mantra should be: all hands on deck for treatment and 

C&P benefits for our veterans. 

Private contractors such as VES already successfully facilitate 

approximately 20% of all MDEs, with quality ratings equal to or 

surpassing those of VAMC-employed medical providers. Private 

contractors have access to trained and experienced communitybased medical providers, as well as the support staff, facilities and 

other resources necessary to process all MDEs. 

Outsourcing MDEs is consistent with the long-standing and proven practice in the commercial insurance claims industry of ordering 

IMEs from independent community-based medical providers. Doing 

so maintains the integrity of the medical opinion by removing any 

internal or institutional bias, and allows for a truly independent 

and objective medical opinion. There is every reason to believe that 

the VA would experience similar results with MDEs if it adopted 

the insurance industry’s approach to IMEs. 

Both the VBA and the VHA currently utilize private contractors 

to perform MDEs, although the process for ordering and conducting 

MDEs is divergent depending on which agency is involved: the ordering process is different, the scheduling systems are different, 

the workflow processes are different and the billing and collection 

processes are different. The VBA’s process, we believe, is more 

time-efficient, cost-effective and less prone to mistakes than that of 

the VHA. 

Another difference in outsourced MDEs is the type of contractual 

funding: discretionary vs. mandatory. Discretionary-funded contracts, with inconsistent monthly referral volume, make it difficult 

for contractors to develop and maintain fully credentialed and readily available medical provider networks, let alone to plan, budget 

and staff accordingly for the work. At least until the backlog is 

eradicated, all outsourced MDE contracts should be mandatoryfunded. 

H.R. 2189 and S. 2091 are commendable, but all VA regional offices should be allowed to outsource MDEs (not just 15) through 

the open RFP and competitive bidding process. This would dramatically increase the resources available to reduce the backlog of 

C&P claims. 

All hands on deck for treatment and C&P benefits for our veterans! 

The *Chairman.* Thank you very much, Mr. Turek. We appreciate all of you being here today. And I am going to start with kind 

of a lengthy set up to a question, but I think it goes right to the 


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heart of some of the problems that this committee is having with 

the Department. 

To the VA witnesses, you have noted that you have a joint analytics team in place that tracks C&P exam performance metrics. I 

am curious as to which one of you oversees the office because in 

preparation for this hearing VA provided three separate documents 

to this committee, each of which contains different numbers listed 

in the column total examinations completed by VHA clinicians for 

fiscal years 2012 and 2013. In June 2014, correspondence between 

OCLA staff and my staff stated that in fiscal year 2012 never mind 

1,789,470 examinations were completed and in 2013 1,996,148 examinations were completed by VHA clinicians. In the answers to 

the pre-hearing questions that were submitted for today’s hearing, 

the table contained in the answer to pre-hearing questions, number 

seven, located on page five of eight in the document states that fiscal year 2012, 1,791,192 were completed by VHA clinicians, and in 

2013 1,998,886 examinations were completed. And finally, in VA’s 

written testimony today, which was provided at the same time and 

in the correspondence as the answers to the pre-hearing question, 

it states that in fiscal year 1,850,386 examinations were completed 

by VHA clinicians and in 2013 2,176,651 examinations were completed. 

As you are all aware VA, and VHA in particular, has been recently exposed for manipulating performance metrics and data. 

How can we take any of the numbers reported here at face value 

when you reported three separate numbers for the same metric including two sets of differing numbers that were reported to the 

committee on the same day? 

Dr. CROSS. Sir, I am happy to respond. The Ph.D. level statisticians that helped prepare this report for the VHA component of the 

numbers are in Florida. I went over with them with the same numbers in preparation for this committee hearing. I said, why are the 

numbers different? In every case, they had a good answer. For instance, when you look at the numbers on total examinations, in one 

chart they included medical opinions and in the other chart they 

did not. Other differences related to the exact point in time when 

the measurement was started and the measurement was ended. 

We can go through these with you. I know my staff will go through 

every one of them with you if you are—— 

The *Chairman.* If you would deliver it for the record. But it 

makes it very difficult when you provide conflicting numbers like 

that to the committee and expect us to be able to decipher how 

those numbers were arrived at. 

Mr. Murphy, why does VBA only award contracts to single, nationwide vendors who can bid on the entire contract, rather than 

soliciting a regional contract provider in particular geographic 

areas? 

Mr. MURPHY. Mr. Chairman, in years past prior to the contracts 

that we have in existence today, that was the practice. However, 

since I have been in the Compensation Service Director position, 

the three contracts that we do, have awarded have been recompeted. The larger contract on the mandatory funds, we broke the 

area of the country down into four areas and then we awarded 

those four areas to the best contractor, the best bid in that process. 


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So in years past in prior contracts it was one which would cover 

the entire nation. We have modified that under the existing contract and we are taking a hard look at that for a recompete which 

is going to be necessary because we are going to be out of option 

years at the end of 2015. 

The *Chairman.* Dr. Cross, do you use a regional method instead of the nationwide? Is that an appropriate way to look at it? 

Dr. CROSS. Our contract is nationwide, Sir, with additional contractors. We have four at the moment. We used to have five. And 

we are happy with that arrangement. 

The *Chairman.* And very quickly, and this may take a little 

more than 30 seconds, but in response to pre-hearing question 

number nine, I note that despite providing two full paragraphs in 

response to the question, the answer was not given. So I am going 

to ask it again. Yes or no, does VHA pay for local C&P exam programs by using money from its general purpose fund? 

Dr. CROSS. Funding for the program comes from VERA, which is 

the overall mechanism that we have for distributing funds to the 

VISNs. 

The *Chairman.* So that does or does not come from the general 

purpose fund? 

Dr. CROSS. That is correct, yes. 

The *Chairman.* Okay. Yes or no, is this the same fund from 

which VA pays for its primary care? 

Dr. CROSS. Yes. 

The *Chairman.* Yes or no, VHA is suffering from a dearth of 

providers and long appointment wait times in primary care? 

Dr. CROSS. Yes, sir. 

The *Chairman.* Yes or no, there is no separate line item in the 

budget specifically allocated to the C&P examination process alone? 

Dr. CROSS. Yes, sir. For Fy 15 there is no separate tie one item 

for C&P. And may I go back into your previous question—— 

The *Chairman.* Yes—— 

Dr. CROSS. —in regard to the shortage of personnel, there are 

other factors as well related to—— 

The *Chairman.* Just yes or no. Thank you. 

Dr. CROSS. Yes, Sir. 

The *Chairman.* Given the recent issues at VHA with primary 

care in particular, do you think there should be a separate line 

item? 

Dr. CROSS. Sir, I am not sure on that. I think that is something 

we would have to consider. 

The *Chairman.* Okay. Thank you. Mr. Michaud? 

Mr. MICHAUD. Thank you very much, Mr. Chairman. As I stated 

in my opening statement, your efforts to reduce rating claims, otherwise known as the backlog, has been laudable. However, we are 

starting to see a new backlog of other workloads, such as non-rating workload and appeals. When will the VA adjust their staffing 

to ensure that these areas are adequately addressed for timely outcomes on behalf of our veterans? 

Ms. MCCOY. Sir, I would say yes, we have made substantial 

progress on serving veterans whose claims have been pending the 

longest with our oldest claims initiative. Also those priority veterans, such as homeless, terminally ill, financial hardship. That 


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has been our primary, first focus in reducing the rating claims 

backlog. We have also continued at the same time to process nonrating claims. Last year 2.4 million non-rating claims, this year on 

track to complete 2.8 million non-rating claims. There are dedicated staff in the regional offices for that work, as well as the appeals work. They focus on that work during their day hours. On 

overtime they are helping on the disability rating claims. So we 

have taken steps to continue working on that as well. 

It is of course not going at the pace that any of us are satisfied. 

We have put other measures in place. Some of those include automation. We have a rules based processing system that is processing 

dependency claims received online in as little as one day. We also 

have worked with Compensation Service to put in place a contract 

to more quickly address the dependency rating claim, non-rating 

claims that are pending. We have a number of efforts underway. 

And these have been part of our transformation initiatives from the 

beginning. 

Mr. MICHAUD. But are you seeing an increase in the backlog in 

the appeals process? 

Ms. MCCOY. Part of producing more claims is that there are 

other side claims that come up. So we have completed more than 

a million claims for each of the last four years and we are on track 

to complete 1.3 million claims this year. So some of the secondary 

effects of that are additional non-rating claims and additional appeals. The appeals rate has stayed steady for about the last 20 

years, at about 11 percent. So when we complete more claims, as 

that appeals rate does continue to stay steady, there is a volume 

that comes along with that. Last year we did complete more than 

76,000 appeals. 

Mr. MICHAUD. I see that most of the contractors tend to slightly 

lag VA in terms of examination timeliness. How do the contractors 

compare to the VA in terms of quality metrics? 

Mr. MURPHY. Sir, are we referring specifically to the VBA contractors on this? 

Mr. MICHAUD. Yes. 

Mr. MURPHY. Okay. The VBA contractors have two different performance standards based on what year those contracts were 

awarded. One of the contractors is on a 20-day standard and they 

are currently performing at 17 days. The other contractors are on 

a 38-day standard and they are currently delivering in 39 days. 

And as we recompete these contracts and as we move forward we 

have lessons learned in improvements and efficiency and we are 

leveraging that and reducing those times in contracts. 

Mr. MICHAUD. Thank you. Mr. Turek, in your testimony you 

highlight a large disparity in the number of examinations per 

month and how this is a challenge. Can you explain why there are 

such significant shifts in the number of medical examinations that 

are requested per month? 

Mr. TUREK. Yes, I can. We have two different contracts. We have 

the VHA contract, which is a demand contract, and then we have 

the VBA contract, which is a discretionary contract and we receive 

so much money per year from Mr. Murphy. 

With the VBA contract if we receive X amount of money, we will 

be given so many cases per month based on the amount of money 


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that is allocated for the year. That way we do not use it all up in 

six months and fall on our face, run out of money. With the VHA 

contract it is purely discretionary demand by the VAMCs themselves. So in essence we have 151 customers with the VHA contract. With the VBA contract we have one customer. And we have 

to essentially deal with each VAMC and let them know our services 

are available for overflow and they can choose to use us or not use 

us. So we never know from one month to the next how many cases 

we are going to get from any of those 151. Right now we have 

about 75 that are actively sending us cases around the world. And 

we do, I believe we are the only contractor that does overseas work 

for the VHA as well. 

So it is tough when you have discretionary funds and on top of 

that you have another contract where you do not know what you 

are going to get, you know, from month to month for staffing purposes and dealing with just trying to run a business. It would be 

much better if we had, you know, a contract that was much more 

stable and we had some kind of uniform flow coming in. That way 

we could service the contract better and we could make sure that 

we had the right doctors in the right places. 

Mr. MICHAUD. Okay. Thank you. Thank you, Mr. Chairman. 

The *Chairman.* Thank you very much. Mr. Runyan, you are 

recognized for five minutes. 

Mr. RUNYAN. Thank you, Mr. Chairman. And I want to apologize 

for not being here on Monday but I had the opportunity to have 

Acting Secretary Gibson up in our Philadelphia health facility. And 

to go back to the question you had asked Dr. Cross a second ago, 

it was myself and my colleague, Pat Meehan, an opportunity to sit 

down with him and talk to him about exactly how Dr. Cross answered your question about why the numbers. And we talked about 

15 minutes about standardization, so we can get out in front of 

these problems from a central office level before we end up in these 

crises. So that was brought up in that hearing and I just wanted 

to make you aware of that. 

The *Chairman.* Thank you. 

Mr. RUNYAN. And to all of our witnesses, I know Mr. Murphy, 

you previously expressed support of H.R. 2189, which has the language of my bill, which was H.R. 2423, which was cosponsored by 

my good friend Mr. Walz, and is now sitting over in the Senate. 

It includes provisions that would expand VA’s mandatory funding 

for contract examinations. Your testimony dated July 25, 2013 

states that VA strongly supports this provision to extend VA’s authority to contract for C&P examinations. And further stating that 

this authority is essential to allowing the Veterans Health Administration to focus on providing healthcare to veterans needing it. 

Given VHA’s recent issues providing healthcare to veterans in 

need, can you further explain your support of this legislation? 

Mr. MURPHY. Mr. Runyan, we can state that, WC reinforce the 

position that we do strongly support the expansion from ten to 15 

regional offices, and the additional surge capacity that an expansion brings to us to address the surges as they arise around the 

country. 

Mr. RUNYAN. And I thank you again for that support. Because 

I think it is another piece of the puzzle, how we are eventually 


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going to solve this problem. Dr. Cross, with regard to the substance 

of C&P examinations, what are the most frequently conducted C&P 

exams? 

Dr. CROSS. Probably exams related to musculoskeletal. 

Mr. RUNYAN. Okay. 

Dr. CROSS. There are about I think nine or 11 DBQs related to 

that. 

Mr. RUNYAN. How many exams are deemed inadequate for rating 

for purposes by VBA requiring an additional follow up? 

Dr. CROSS. Let me ask Ms. Murray to answer that. 

Ms. MURRAY. Sure. Thank you, Congressman Runyan, for your 

question. VHA has monitored the sufficiency of exams for an extended period of time. And right now we have a goal of no more 

than two percent of those exams being insufficient and we are 

about around one percent of running insufficient exams. And so we 

are taking extraordinary measures to ensure that those exams are 

corrected very quickly. We have providers in the RO that will provide clarifications and get those exams back to the raters to do immediate rating on. So to answer your question, around one percent. 

Mr. RUNYAN. Okay. Thank you. 

Dr. CROSS. Sir, may I add to that? 

Mr. RUNYAN. Yes. 

Dr. CROSS. Any insufficiency is not a good thing from our point 

of view because that means working again to do what we had already done. Putting the clinicians from VHA at the regional office 

was a huge effort and collaboration between VHA and VBA. It 

serves a vital purpose in this regard. We can make those corrections on the spot, as soon as the VBA staff point out to us what 

that is instead of sending it back through the mail or through other 

means to the VHA. We have cut off many days of processing just 

by doing that. 

Mr. RUNYAN. Thank you. One last question. Have any of you 

seen any improvement in performance since the implementation of 

DBQs? 

Ms. MURRAY. Since the implementation of DBQs I think we have 

seen more standardized medical evidence being returned to VBA in 

a format that is usable and efficient for their use. So we have seen 

some improvements, and particularly for our raters to be able to 

more efficiently look at the medical evidence and be able to clearly 

identify the ratable criteria. So it has organized the information 

very clearly for the raters. And so we are providing them that information in that format and I think it is effective. 

Mr. RUNYAN. All right. I yield back, Chairman. 

The *Chairman.* Thank you, Mr. Runyan. Dr. Cross, I think 

your answer in regards to taking physicians and surging them out 

of the regional offices or into the field is a good step. But I want 

to read to you an email that was sent on June 19th. ‘‘Good afternoon, and our in house physicians are out of work. All employees 

currently reviewing and processing claims should be on the outlook 

for any cases that would be appropriate to refer them to our inhouse physicians for medical opinions, consultations, and any possible ACE examinations, etcetera. We need work for them ASAP.′′ 

How would you respond to that? 


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Dr. CROSS. One of the things that we want in our contract support is the ability to control it so that it is supplemental as opposed 

to primary. And I am not sure if that was the case, or where the 

location was that was from, whether it was a VBA contract or a 

VHA contract? 

The *Chairman.* It is within the VA. It is not a contract. It is 

in a regional office. So it is your physicians. 

Dr. CROSS. I would stick with my comment, sir. We prefer a situation where we go to VHA first for the work that we have to do. 

Ms. MCCOY. Mr. Chairman, if I could add, we constantly encourage our regional office personnel to engage with the doctors, the clinicians in the ROs. They do more than fill out disability questionnaires. They do supplemental opinions, as Dr. Cross alluded to. 

They are also available to answer questions for the raters on medical questions—— 

The *Chairman.* If I could, Ms. McCoy, if I could interrupt you. 

But there is a serious crisis out there today with a backlog of people trying to see physicians. And so you have a physician that is 

just sitting there with nothing to do? 

Ms. MCCOY. Sir, we constantly have our folks looking to take 

best advantage of that resource. 

The *Chairman.* But they are looking to take best advantages 

within VBA and not surging them to VA. Why? 

Ms. MCCOY. I understand your concern. It is our concern as well, 

sir. But having those folks available—— 

The *Chairman.* Do you think this email is a strange email? 

Ms. MCCOY. I do not—— 

The *Chairman.* Do you think it is normal? 

Ms. MCCOY. No, I do not think it is normal, sir. 

The *Chairman.* Okay. Does it bother you at all? 

Ms. MCCOY. Of course it bothers me. 

The *Chairman.* Okay. Ms. Brownley, you are recognized for 

five minutes. 

Ms. BROWNLEY. Thank you, Mr. Chairman, and I thank the panelists for joining us this morning. Mr. Murphy, I wanted to ask you 

what your reaction is to some of Mr. Turek’s testimony with regard 

to what he pointed out, the differences between VHA and VBA, and 

the scheduling systems, the work flow processes. Clearly from what 

he stated it sounded like one is much more superior than the other 

and if you could comment on that, please? 

Mr. MURPHY. We have done some things recently on the VBA 

side, the introduction of CAATS, for example, the scheduling system, and upgrade our systems, leverage some of the technology 

that we had, and the fact that we are moving files back and forth 

electronically as opposed to the paper that we shipped previously. 

And because we are dealing with a single contractor we have been 

able to leverage that a little bit faster. And it is certainly something that we are discussing actively with VHA to roll into all of 

our facilities. 

Dr. CROSS. May I respond to that as well? 

Ms. BROWNLEY. Yes. 

Dr. CROSS. We really appreciate the work that our contractors do 

and Mr. Turek, of course. There is an issue here. He described in 

great detail the additional complexity related to working with the 


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local customers. And so he identified instead of having one customer, 151. That is exactly why we designed the contract that way. 

We want local folks to be taking responsibility for this and determine how much contract work they want to do, how much they 

want to do internally, how much they want to do for fee basis. In 

my view, from where I sit, that is a success. 

Ms. BROWNLEY. Thank you. And Mr. Murphy, do you track the 

C&P exam wait times across regional offices? 

Mr. MURPHY. We track C&P examination times across regional 

offices, yes. And it is measured, like I said in the testimony, from 

the time that we order, complete a Form 2507, the ordering of the 

examination, until the time that it is returned to us electronically. 

Meaning, I now have that examination in front of me and a rater 

can then take action. Yes, we track that. 

Ms. BROWNLEY. Thank you. So you can provide me with the wait 

times in the Los Angeles Regional Benefit Office? And we also have 

an intake site in Port Hueneme. I am from Ventura County in California. 

Mr. MURPHY. Yes, we would be happy to provide you that information. 

Ms. BROWNLEY. Thank you. And in terms of, we have been talking about standardization, and what is the VBA doing to ensure 

that all of the exams, whether they are conducted at VHA or by 

a contractor, are being performed accurately, and that the physicians performing the exams are using the same metrics and criteria for reporting so that veterans are being treated equitably no 

matter who performs the exam? 

Mr. MURPHY. This requires a two-part answer. I can speak specifically to what VBA is doing with our contractors and then there 

is a whole other side of this that VHA is going to need to discuss. 

But we have timeliness standards in terms of how much time you 

need to spend with the veteran as a standard written into the contract. We also have a quality team that samples, measures, monitors. With all of our contractors, they use electronic systems to 

complete these DBQs and they have built in some quality steps and 

measures that require the blocks that are necessary to be completed to require the signature, license numbers, etcetera, that the 

doctors need to complete and provide an adequate DBQ for rating 

purposes. 

In addition to that in the VBA contract there are financial penalties in place that a contractor must meet certain quality standards. So there is an incentive for the contractor to do the right 

thing, to give an exam that is completed the first time. And I believe VHA would like to expand on that. 

Ms. MURRAY. Yes. Thank you, Tom. So the Office of Disability 

has a quality team that randomly selects exams on a monthly 

basis, which is our VHA exams as well as our contract exams. And 

we apply about ten criteria to that to ensure that the information 

that is being requested on the 2507 and what is being provided by 

the examiners are consistent with what is needed and to ensure 

that the information is ratable and it is sufficient for rating. 

We also conduct inter rater reliability between our two organizations and we do some sampling nationwide, and we have both of 

our teams looking at those. And so we ensure that we are looking 


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at these consistently. And when we identify any outliers we immediately provide education and training. Our benchmark is at 90 

percent and we have been maintaining 90 percent across the nation. Our quality managers go out and do individual education and 

training at our sites. And then we also provide all of our training 

modules that we do for our clinicians, we provide those also for our 

vendors. 

Ms. BROWNLEY. So do you find discrepancies across the country 

in terms of regions performing better than others? 

Ms. MURRAY. They are pretty consistent with ranging about 90 

percent. We do have two measures that we look at that tend to be 

something that we have to make sure that we stay on top of. And 

that is sort of, it is not really consistent across any one location but 

just reminders that we send out to be sure that we pay attention 

to this. So just whenever we find that there is an outlyer for the 

month we will immediately send out some reminders, and conduct 

needed training. 

Ms. BROWNLEY. Thank you. And Mr. Murphy, you talked about 

the VBA contractors, or the contracts that you have, and that you 

have two metrics, one 20 days, one 38 days. It seems like the 38- 

day one is performing less than the other. You also talked about 

lessons learned when you renew these contracts. Can you kind of 

share lessons learned? Am I over? Oh, I apologize. I yield back. 

The *Chairman.* There is a little clock right in front of you. And 

there is a little red light that comes on. Thank you, Ms. Brownley. 

Dr. Benishek, you are recognized. 

Mr. BENISHEK. Thank you, Mr. Chairman. I guess I am not understanding exactly the numbers that I am looking at here. Because from what I can understand there was about 2 million C&P 

exams last year. But they talk about 800,000 veterans. So how is 

it that there is 2 million exams and 800,000 veterans? 

Dr. CROSS. Sir, that is one that is fairly easy for me to answer. 

I appreciate that. The exams are multiple for veteran quite often. 

The reason for instance that the standard for C&P in general is 30 

days and the standard for IDES, which is on active duty military, 

is 45 days is because of the increased complexity of those exams. 

So they require typically even more exams, more—— 

Mr. BENISHEK. But I thought you said earlier that only one percent of the exams were not complete? 

Dr. CROSS. I—— 

Mr. BENISHEK. I mean, did not Ms. Murray—— 

Ms. MURRAY. So—— 

Mr. BENISHEK. —did you not just say that only one percent of 

your exams did not have the complete information? 

Ms. MURRAY. So we were asked about the sufficiency for rating, 

and our target is two percent. 

Mr. BENISHEK. But there is twice as many exams as there are 

patients. 

Ms. MURRAY. And so what I would say, Congressman, is that 

many of our exam requests contain anywhere from one condition 

up to 60 conditions. And so depending on how many issues are 

claimed, we are doing multiple exams on any given—— 

Mr. BENISHEK. But that is not the same, you are talking about 

the same thing. You are telling me there more than two exams per 


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patient. Then you previously told me that only one percent of the 

exams do not comply with all the stuff. 

Dr. CROSS. The percentage—— 

Mr. BENISHEK. That is inconsistent. 

Dr. CROSS. Sir, no, that is quite explainable. The percentage for 

insufficiencies applies across the board, no matter how many 

exams there are. We look at those for quality. We have to survey 

the entire package. What we wanted to convey to you is that the 

complexity of this is multiple DBQs, similar to multiple exams, for 

many of these individual patients that come in. We may have a patient come in and says I have a neurological problem, another one, 

and at the same time an orthopaedic problem, and other things. 

And so they are going to have different exams for those conditions. 

They will have different DBQs. 

Mr. BENISHEK. But they do not, the person that does the exam 

is not the same person, then? 

Dr. CROSS. In many cases it is the generalist. We try and do as 

much as this by primary, general type medical skills as we can. If 

it requires a specialist examination, such as say for audiology, they 

have to go see the audiologist. If we are going to do a new diagnosis for PTSD, we want to go find a specialist who is highly 

skilled in that area to do that assessment. 

Mr. BENISHEK. Well I guess I can understand that. It is just that 

it is kind of disconcerting when there is twice as many exams as 

there are patients. It seems like you would try to get most things 

done and I guess I understand that, you know, I am not going to 

do an audiology study as a surgeon. But what, you are saying that 

the rate of people getting, not getting their rating, a sufficient 

exam is only one percent, and that they go back for the same thing 

twice does not occur, basically? 

Dr. CROSS. No, sir. They do not generally come back for an 

exam—— 

Mr. BENISHEK. All right. Okay. 

Dr. CROSS. We do not correct the exam. 

Mr. BENISHEK. I guess that answers the question. Mr. Murphy, 

I am kind of concerned about this process and Dr. Cross kind of 

touched on it a little bit. But, you know, Mr. Turek seems to think 

that it is much more efficient to, the VBA’s method of contracting 

is easier than the VHA’s method. And Dr. Cross may have touched 

on it a little bit but I still do not quite understand the answer, why 

it takes 12 steps to pay somebody through the VHA process versus 

the VBA process. 

Mr. MURPHY. I cannot answer for the VHA in terms of the steps 

that they have to go through. But one aspect of this is I order the 

exam directly from that contractor, where if it is VHA I go to VHA 

first, and VHA uses that as a surge or overflow to order that examination. So there are some additional steps in there as that examination goes from us, to VHA, to VHA’s contractor. 

Mr. BENISHEK. I mean, it seems like the 12-step makes it a 

longer timeline. 

Mr. MURPHY. Again, sir, I have to defer to Dr. Cross on this one. 

Dr. CROSS. Sir, let me provide some more information. Those 

exams are controlled by the local medical center in terms of the 

volume that we want to use, how much we want to pay. That is 


VACREP180 with DISTILLER
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where we want the control, right there, so that they can maximize 

the use of their internal staff. I do not want them having emails 

like the chairman pointed out, ever. 

Secondly we provide some value added in the course of those 

steps, such as trying to enroll the individual in VA healthcare as 

early as possible, and tying into the famous electronic record that 

we have in the VA so that those things link up. 

But to be fair, it is complex. And while it serves our needs we 

would like to streamline that. So we have a program called DEAP 

that our IT folks are working on which will help replace at least 

a portion of the legacy program, which was called CAPRI. So we 

are working on a solution to add more efficiency. But I want to tell 

you that some of that is built in legitimately. 

Mr. BENISHEK. I am out of time. 

The *Chairman.* Thank you very much. Ms. Kuster, you are recognized for five minutes. 

Ms. KUSTER. Thank you very much, Mr. Chair. And thank you 

to our panel for being with us today. I wanted to focus in on a different area of concern. This is with regard to a June 20th letter 

that 32 members of Congress sent to Acting Secretary Mr. Gibson. 

And it relates to the GAO report on VA’s disability claims process 

for survivors of military sexual trauma. In the report we found, we 

learned, that the current regulation for MST claims discriminates 

against survivors of sexual assault and should be simplified and 

improved. And it appears that it is due to the fact that despite a 

change, and I believe this was a court ordered change, in 2002, the 

VA changed the regulation to allow veterans to submit circumstantial evidence, sometimes referred to as markers, because often 

there is not an official record of the assault, typically because the 

victim was not in a position to report the assault that may have 

been perpetrated by a commanding officer. But it seems there is 

wide variation among the claims in these medical examinations 

and in this process. And this GAO analysis found that granting the 

claims ranged across the various states from 14 to 88 percent in 

terms of whether the claims were granted. And I think you will 

agree that is a pretty broad range. 

What I am wondering is what is the process for training and updating and informing these people that are making these evaluations? And then I would also love to hear a comment on the number of claims that were denied. This comes from a June 25th Huffington Post did a very lengthy article about the GAO report, noting 

that it really was more a function of where the evaluation was conducted rather than whether or not the assault occurred as to 

whether or not the claims would be granted. And so what has happened in terms of those that were denied, how have we reached out 

due to the high rate of failure to identify and grant these claims? 

So if you could address those two points, and perhaps Mr. Murphy 

we will start with you and go from there. 

Mr. MURPHY. Let me start with the GAO report. Over the last 

18 months, year to 18 months, we have spent a significant amount 

of time and effort on MST in particular. As a result of GAO and 

other attention around military sexual trauma we made the decision, and we saw the inconsistencies that you are describing early 

on. So we went back in and said the way we are going to handle 


VACREP180 with DISTILLER
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this is we are going to identify specific individuals, train them to 

the standard of this is how you properly identify markers which 

lead to the conduct of the C&P examination, which allows the rating. So what we did not want to do was improperly deny somebody 

even the benefit of coming in and having the C&P examination to 

determine if there is some compensation due to the individual. 

So we went back in and targeted in each regional office specifically trained individuals and said those people and only those people are the ones that will touch MST cases. And the results of that, 

which are not reflected in the GAO report because the GAO report 

looks at a large set of data that is early on in that 18 months and 

before the process that I described to you. So what I am saying is 

the process that they describe versus the process happening right 

now in the regional offices, we are seeing different results from 

them and it is much better results. The rates that we are seeing 

on grant rate for MST are more in line with all of the other situations around PTSD. 

Ms. KUSTER. And could you ask the Acting Secretary, or in your 

office could you report back to, not just the 32 members of Congress that sent this letter, but to this committee and others that 

may be interested on progress beyond the date of the GAO report? 

Because these are troublesome findings. 

Mr. MURPHY. Yes. 

Ms. KUSTER. And if there is progress being made, we would very 

much like, the American people would love to hear progress being 

made right now at the VA. 

Mr. MURPHY. We would be happy to take that for the record and 

provide updated information to the committee. 

Ms. KUSTER. Thank you so much. My time is up. Thank you. 

The *Chairman.* Thank you, Ms. Kuster. 

Mr. Coffman, you are recognized for five minutes. 

Mr. COFFMAN. Thank you, Mr. Chairman. 

Mr. Turek, in your testimony, you propose outsourcing all medical disability examinations to private contractors so that VA employed medical providers would be free to devote a hundred percent 

of their time to treating veterans. 

However, in a recent conversation with VA staff, staff was informed that such a changeover was not feasible because many C&P 

physicians have not treated veterans in many years and are lacking in the proper certifications or because many of them choose to 

work part time. 

As anyone who works in the private sector knows, if your organization’s needs evolve and certain employees cannot evolve to keep 

up with current needs, those employees are terminated. 

Mr. Turek, what are your thoughts on VA’s response? 

Mr. TUREK. Well, my response would be that if those physicians 

are not credentialed, that they should get credentialed. And if they 

don’t want to get credentialed to treat, that they should go back 

into the community or retire and be replaced with active treaters. 

That is my response. 

Mr. COFFMAN. Okay. To the VA witnesses at the panel testifying 

today, please tell me why your responses are more focused on—it 

seems to be more focused on protecting employees than meeting 

veterans’ healthcare needs. 


VACREP180 with DISTILLER
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Can you respond to that? 

Dr. CROSS. Exactly, sir. As my opening statement was, let’s do 

what is best for our veterans in this issue. So let’s look at some 

of this. 

We looked at the number, preliminary numbers just to get a ballpark figure. And I want to be very careful with this because I 

would like to go through and look at these numbers more closely. 

So we started off with the number of 8,000 individuals. What 

does that mean? That means that these individuals have taken the 

course and passed the certification exam. I am one of them. That 

doesn’t mean I am seeing patients routinely. 

Most of these individuals in that 8,000 I would expect are already seeing patients because they see these C&P exams only on 

occasion when they are referred a case such as an ENT doctor. And 

that explains part of that. 

I think the magnitude of this is that roughly a little bit less than 

a thousand of our docs and nurse practitioners and PAs and so 

forth are full time, a little bit less than a thousand. But, again, 

preliminary numbers that we worked up just this week. 

About 1,100 plus, maybe 1,200, in that ballpark, are part time. 

Six hundred and sixty some of them, roughly again, have some primary care experience somewhere in their past. 

But then there is something that I think we can use right away, 

if we can, is about a hundred of them are currently working in primary care and C&P. So obviously that would be the first place we 

would start as a constructive response to the situation that we are 

facing. 

Mr. COFFMAN. Dr. Cross, you said that is the first place, I think 

if I remember your comment, that we should start. How about will 

start? Tell me what the solution is here to move forward. 

Dr. CROSS. You say will we or we won’t? I say there is no choice. 

We are in a situation that, you know, to me it is heartbreaking in 

that we have worked on this. So many of us have worked so hard 

on the system. 

These are veterans that we are taking care of. We have to do better. We have to do better. And so we are going to have to look at 

each of these options with our leadership and use as many of them 

as we have to. 

Mr. COFFMAN. Thank you, Dr. Cross. Really I appreciate your response. 

I think there are so many times before this committee where it 

seems as if there is a defense of the status quo with no hope to 

those veterans seeking treatment or in this case, seeking some type 

of outcome in terms of a claim. And so I appreciate your response. 

Mr. Chairman, I yield back. 

The *Chairman.* Thank you, Mr. Coffman. 

Mr. O’Rourke, you are recognized for five minutes. 

Mr. *O’Rourke.* Thank you, Mr. Chairman. 

Mr. Chairman, I would like to begin by first of all thanking the 

VA. As our ranking member, Mr. Michaud, said, we are very focused on the access to healthcare crisis right now, but we can’t lose 

sight of other important issues within the VA and our responsibilities to the veterans we serve including those carried out by the 

VBA. 


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The director for the Waco regional office which serves the veterans in El Paso, Mr. John Limpose, is coming out to our veterans’ 

town hall this Saturday. And it is really hard for us to and veterans in El Paso to directly hold VBA accountable at that regional 

office. It is a nine-hour drive from El Paso to Waco one way. 

So, you know, his coming out to El Paso, I think, helps us to hold 

the VBA accountable for him to hear directly from veterans. So I 

just through you want to thank VBA leadership for this level of responsiveness and accountability. 

I would like to ask a question based on a comment Dr. Cross 

made about the Integrated Disability Evaluation System or IDES 

which is a process by which we transition wounded active 

servicemembers out. 

And that process is supposed to take 295 days, but because of 

delays within the VBA, in the examination and the rating process, 

we were adding another 185 days to that wait. So those 

servicemembers at the warrior transition unit in Fort Bliss in El 

Paso were literally languishing an additional 200 plus days in some 

cases before they could transition out. 

Mr. Runyan held a great hearing last month where we learned 

that when it comes to the benefits part of this, we are now—we no 

longer have a delay as of March and that on the rating side of this, 

we are supposed to end the backlog by October of this year. 

So I want to compliment you on achieving those goals, but I want 

to ask you how you did it and how that might apply to the situation that we are discussing today. 

Ms. MCCOY. Thank you for your question, Congressman. 

Part of it was sharing resources between the DRAS sites focusing 

on partnership with VHA in getting the examinations completed. 

One of the lessons learned from our oldest case initiative, twoyear-old cases focus, one-year-old case focus was the goodness from 

more hands across the country touching those oldest cases to serve 

those veterans with the longest pending claims. 

As we move forward toward our national work queue in VBA, 

where 90 percent of our claims are electronic in the Veterans Benefits Management System, that gives us agility that we haven’t had 

before. We will be able to move that work around by priority and 

be able to utilize the full resources across the country to do that 

work and all of our work. 

So we are looking forward beginning of next calendar year to 

having more agility with the national work queue. 

Mr. *O’Rourke.* Yeah. If these numbers hold up under scrutiny, 

that is a remarkable turnaround. I would love to see that same initiative applied to the problems that we are hearing today. 

Dr. Cross, did you have a comment? 

Dr. CROSS. Yes, indeed, in terms of the numbers. IDES is overseen by the Department of Defense, VA, VHA, VBA, many, many 

different eyes looking at this along each step of the way. 

So I think in terms of confidence, this is one of those sets of numbers I have the greatest confidence in and it has been working now 

for many years. 

And I wanted to remind you one part of this that has been successful for some time now is the—it is always on time for the exam 

part. 


VACREP180 with DISTILLER
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Mr. *O’Rourke.* Switching gears, you know, Mr. Turek makes a 

great argument and Mr. Murphy brings up some wonderful points 

about where core competencies should be and how we most effectively and efficiently serve the veterans for whom we have a responsibility. 

And I am wondering, is there to kind of resolve some of the differences that—between the arguments that you brought up, is 

there—has there been some kind of independent analysis or accounting that looks at, you know, timeliness, cost, accuracy, overall 

effectiveness for the veteran either by the GAO, a veteran service 

organization, or some other outside party? 

Mr. Turek, are you aware of any study to do so? 

Mr. TUREK. No, sir. 

Mr. *O’Rourke.* Mr. Murphy, do you know? 

Mr. MURPHY. I am unaware of a GAO or IG report. 

Mr. *O’Rourke.* Yeah. I will yield back to the chairman and just 

ask that we pursue a GAO analysis if it is different so that we 

have the facts to make the best policy decisions going forward. I 

yield back. 

The *Chairman.* There was an IG report from 2010, but it has 

not, to my knowledge, been updated—— 

Mr. *O’Rourke.* Thank you. 

The *Chairman.* —since that time. 

Dr. Wenstrup, you are recognized for five minutes. 

Mr. WENSTRUP. Thank you, Mr. Chairman. 

I am going to ask some questions just to get some clarity for me 

of how the system is operating right now, especially between DoD 

and VA. 

I was stationed at Fort Lewis and Madigan last summer, spent 

some time in IDES, the Integrated Disability Evaluation System. 

So my first question is, you know, within the VA, you have MEB 

and a PEB, correct, Physical Evaluation Board, just in DoD? 

Ms. MURRAY. That is correct, just in DoD. 

Mr. WENSTRUP. Okay. So when you are doing your disability ratings, there are standards of measures that you use and, you know, 

I’ve seen the books to determine disability, you know, how you 

come up with the numbers. 

And so there are standards there and the DoD, the army does 

have their board. And they come up with a disability evaluation as 

well. 

Is that rating that is done while the soldier is in uniform able 

to carry right over to the VA or do they start all over again? 

Dr. CROSS. I will ask my VBA colleagues to add into this, but we 

do one rating and it is based on the claimed conditions and on the 

referred conditions. But the referred conditions are those that were 

found unfitting, those conditions that caused the individual to be 

put into the program in the first place. Why? He would be nondeployable and so forth. 

The claimed conditions are the whole person exam that we do 

looking at everything else. For instance, some high blood pressure 

might not make you unfit for duty, but it is still a condition that 

we can help that veteran with going forward. 

Can I ask my VBA folks if they would like to answer? 


VACREP180 with DISTILLER
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Mr. MURPHY. Dr. Cross is spot on. From the VBA perspective, we 

make a rating decision based on all claimed conditions. The Department of Defense uses a subset of that to the conditions which 

are unfitting to continue your military service. 

And the decision that we make that is used to make that decision by DoD is the one that carries forward after the veteran leaves 

service. 

Mr. WENSTRUP. I guess what I am trying to do is cut out redundancy here. And that is the impression I got when I spent time in 

that department that they were saying as a test model, they were 

bringing the VA into that component. Now, I don’t know if that is 

nationwide or if it is just at Madigan right now. 

So if you could help me out. 

Ms. MURRAY. So if I could add, the IDES is the Integrated Disability Evaluation System, meaning that we have integrated the 

DoD side of the program with the VA side of the program. And so 

VA for the most part is doing all of the exams so the 

servicemember goes through the process one time. 

Mr. WENSTRUP. So we are tearing down that wall. 

Now, I got the impression last year that it was just being done 

sort of as a test at Madigan. Is it throughout the military, throughout the army? 

Ms. MURRAY. It is throughout the entire IDES system including 

all services. 

Mr. WENSTRUP. All branches. Okay. So, in essence, it is a onestop shop then for the servicemember. Now, obviously someone who 

has something develop later such as a result of Agent Orange, then 

that is all through the VA side, correct—— 

Ms. MURRAY. Yes. 

Mr. WENSTRUP. —because it is so much later? Thank you. That 

answers my question. 

I yield back. 

The *Chairman.* Thank you. 

Mr. Walz, you are recognized for five minutes. 

Mr. WALZ. Thank you, Chairman. 

And thank you, each, for coming here today. 

And, Dr. Cross, you are right. I said the heartbreaking nature of 

this and it is so frustrating. I am appreciative, though, that we are 

trying to diagnose and then we are trying to come up with some 

prescriptions on this. 

The thing I would say that may be most frustrating for us, and, 

again, I think the specifics of this are going to be important, but 

I am going to take it back up to that 40,000 foot, this cultural issue 

that we keep coming back to. 

And the reason I say this is is that one of the questions I get 

asked by veterans and folks when I am back home is how could 

what happened in Phoenix and other things, how could it possibly 

happen, how could no one have understood this. And that is unfair 

because I would make the argument that people like Mr. Runyan 

knew it was going to happen. 

And in 2012, I traveled with him when we came up with this 

idea and heard from veterans and heard from providers that there 

was a shortage and the C&P exams were taking people away from 


VACREP180 with DISTILLER
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seeing patients to cover that and that there was opportunity in the 

private sector to make up that difference. 

So what we did was work with people, crafted a bill, and Mr. 

Runyan put a bill together. There is a Senate companion. Senator 

Franken has a bill over there on this very issue. 

And I would come back to this. It seemed to me, though, every 

step of the way when we would try and ask and try and be seen 

as collaborators and partners in this, I got the thing, we got it. It 

is under control, we got it. 

And there was no sense of urgency because I clearly remember 

up in New Jersey a veteran coming and saying I am convinced that 

they are spending all their time on these C&P exams and that is 

why it takes me so long to get an appointment. How prophetic was 

that, of coming up, of saying that? 

So, Mr. Turek, I am going to ask you on this. I have got a gentleman out in my district that, again, over three years ago. His 

name is Don Weber. He has LHI that I think does basically what 

you do. And Don made this very same thing. He told me he has 

2,100 physicians, but he is always meant to feel like there is another hoop, there is another to get to, and that his physicians 

aren’t as prepared. 

This is a subjective question to you. Is that a fair assessment 

that is seems like it is always one more thing or that it is not an 

equal ability here because all I care about for you is to provide the 

best care to veterans just like you do? 

And I think there are folks out there that were willing to do it, 

to take away some of that pressure to make it easy as possible. We 

were convinced and I am convinced here is there was no real desire 

to help us move this bill. There was no real desire to make it easier 

for Mr. Turek. 

And I am trying to get at your take on this. Is that true? 

Mr. TUREK. Could you rephrase it, Congressman? I am not sure 

exactly what you are asking. 

Mr. WALZ. What I am saying is that is there a willingness to 

reach out from the VA to say we need your help, let’s get this done 

as easily as possible, and let’s see these veterans and move on? 

Mr. TUREK. Okay. I think that the VBA and we work real well 

together. There is a business partner relationship. I don’t think 

that we have reached that level with the VHA. I will be real frank 

with you. Although we try desperately to partner, you get that feeling that there is, you know, some push back. Okay? And I am just 

being as honest as I possibly can. 

Mr. WALZ. Oh, I am grateful for that because I am being honest, 

too, as I get the same feeling. And I feel like I am one of the offending partners to try and make this work. And I always feel like I 

get resistance. And I understand there are metrics. I understand 

that there has got to be standards that are kept and all that. 

But these folks we are getting there, and I didn’t come to this 

conclusion because I thought this was something to do. I came to 

the conclusion that I thought what Mr. Runyan was proposing and 

what we talked about would have made it easier. I wanted to see 

you get your folks in there, get these C&P exams, and move the 

process forward. 


VACREP180 with DISTILLER
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Mr. TUREK. Well, there is no doubt that given the opportunity, 

we can spool up very quickly and take on a lot more work. 

I mean, I had another company, a commercial IME company 

which we sold three or four years ago to a New York Stock Exchange company. I on purpose kept Veteran Evaluation Services 

because I didn’t want anyone to touch it other than us. And at that 

time, we were doing a quarter of a million exams a year, fully integrated. 

We have been doing it for 36 years. We really know what we are 

doing. We did it in all 50 states, across the world, different benefit 

delivery systems that had different resources and demands. We 

could spool up very, very quickly. 

Mr. WALZ. Well, for your time. 

And, Dr. Cross, again, I come to this because here is the thing. 

Perceived reality is reality. And at this point in time, the VA gets 

no benefit of the doubt on anything. And I am telling you as someone who has been around this, has worked, has tried to do this is 

I feel the resistance. 

Mr. Turek and others, Mr. Weber and others have felt resistance. 

Use us as a resource to help. Use this committee, use these providers. Just help us change the attitude. 

Dr. CROSS. Could I respond? 

Mr. WALZ. It is the chairman’s time. I am going to have to yield 

back. 

The *Chairman.* Yes, you may. 

Mr. WALZ. Thank you. 

Dr. CROSS. Sir, there was a period of time in the past months 

where what you said was precisely correct in my view. It was all 

hands on deck. We were dealing with our colleagues in VBA on the 

one-year-old claims, very large number of individuals, tremendous 

desire on everyone’s part including, I think, this committee’s to 

lower the backlog and to do everything we could. It was hands on 

deck. 

And to some degree, that impacted on the primary care folks. We 

are past that and we work with our primary care community to say 

do what you can. Some of your veteran patients, your patients 

want your input into their condition, but still you have the option 

of sending them to the C&P clinic and so forth. 

So many things have taken place and so many accomplishments, 

but, yes, I have to admit that there was a period of time where that 

was happening. 

Mr. WALZ. Thank you, Mr. Chairman. 

The *Chairman.* Mr. Bilirakis, you are recognized for five minutes. 

Mr. BILIRAKIS. Thank you, Mr. Chairman. I appreciate it. 

What procedures are in place to hold these C&P examiners accountable? Can you elaborate on that? Can you, please, to followup Mr. Walz? 

Dr. CROSS. Perhaps Ms. Murray can help me on this, but the 

oversight from the quality folks, the oversight in terms of their performance is relayed through the entire system and reviewed repeatedly. We look for outliers and we are very aggressive when we 

find outliers. We want to go hold them accountable, but really what 

that means to me in most situations is they are working very hard. 


VACREP180 with DISTILLER
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They need some help. It may be that it is not their fault, that they 

have fallen behind in some way. 

So we go in, educate them, tell them how to use the fee basis system, how to use the contract system. We sometimes even send people in from my office to actually do exams. We development a 

locum tenens program so that we can air assault individuals directly into that program who are qualified when we lose someone 

who is unexpected. 

Mr. BILIRAKIS. Thank you. 

Mr. Murphy, regarding the number of examinations by the VHA 

clinicians, what are the cancellation and no-show percentages for 

fiscal year 2012 and 2013? 

Mr. MURPHY. I don’t have those numbers in front of me. Perhaps 

Ms. Murray does. 

Ms. MURRAY. Sure. The cancellation rates when our office stood 

up was about 18 percent and have been holding at about 18 percent for many years. Since we have jointly began to look at the flow 

of the work between the VHA and VBA, we have reduced the cancellation rate down to 14 percent. We have revised our policies to 

clarify guidance. 

And any cancellation rate that peaks or is out of the norm, we 

immediately contact the facility, take immediate actions. And if 

anything comes to our attention through anything outside of our 

data, we immediately take actions to assess what the issue is and 

implement corrective actions. 

Mr. BILIRAKIS. Is it common practice to call the veteran to remind the veteran that an appointment will take place? 

Ms. MURRAY. So our—— 

Mr. BILIRAKIS. Is that a common practice within the VA? 

Ms. MURRAY. So for C&P, our process is that when the 2507 

exam request is received at our medical center, there is a requirement to contact the veteran by phone. 

Mr. BILIRAKIS. Okay. If there is a no show or cancellation, is that 

included in the veteran serve category? 

Ms. MURRAY. Can you repeat the question, sir? 

Mr. BILIRAKIS. Well, if there is a no show, let’s say a no show, 

is that included in the veteran serve category? First of all, why 

don’t you answer this question. What does constitute as a veteran 

being served by VHA clinicians, i.e. attempted to contact the veteran, made contact with the veteran, appointment scheduled, appointment completed? What is the definition—— 

Ms. MURRAY. Yes. 

Mr. BILIRAKIS. —of a veteran being served? 

Ms. MURRAY. Sure. That represents the 2507 exam requests that 

has come over from VBA and the exams completed and closed out 

in the CAPRI System and returned back to VBA. That is what that 

number represents, everything that has been completed. 

Mr. BILIRAKIS. Okay. Mr. Murphy, VBA is now tracking the difference between the electronic date stamp from when the request 

is submitted by VBA and when it is returned to VBA as complete. 

Is anyone from VA using this information to track the overall 

number of days from when the veteran submitted the claim? 

Mr. MURPHY. Yes. VBA’s clock never stops from the time I identify there is a need until the rating is done. Our clock on the timeliVerDate Aug 31 2005 06:39 Oct 30, 2014 Jkt 000000 PO 00000 Frm 00051 Fmt 6633 Sfmt 6633 C:\PDF\89376.TXT PAT

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ness for the exam doesn’t stop. We talked about cancellations. If 

there is a cancellation or a delayed appointment or any of the other 

things that happen, I still have a claim that has to be done in less 

than 125 days. 

So in order to drive that process, we sit down with VHA every 

Friday and we dig deep and sometimes the conversations aren’t so 

pleasant, but that is exactly how it needs to be. We, the VA, have 

a mission. We have to deliver on it. And we have candid, frank conversations based on the numbers to drive the performance of the 

whole organization. 

Mr. BILIRAKIS. So you are saying that when the veteran submits 

the claim, there is tracking between when the veteran submits the 

claim and when the claim is completed, not just when it is stamped 

by the VA? 

Mr. MURPHY. Correct. In years past, there were people involved 

in the process. There has been steps put in place now where it is 

done by triggering events in the system. So we have taken the ability away from the individual to date stamp and do things. The system tracks it. 

When the 2507 request for examination is completed and we hit 

the enter button, that gives me the ability without the individual’s 

ability to influence to look at that and tell when exactly that examination started. 

On the other side, VHA completes the examinations required, returns them to me. And when they show up back in my box, there 

is another trigger that is electronic and we can go back and we do 

go back and measure the spread between those two dates. That is 

the 24-day number average that you are hearing. 

Mr. BILIRAKIS. All right. Thank you. 

My time is expired. I yield back. 

The *Chairman.* Dr. Ruiz, you are recognized for five minutes. 

Mr. RUIZ. Thank you, Mr. Chairman. I appreciate that we must 

leave no stone unturned as we identify ways the VA can expedite 

quality care for our veterans. 

My question is, what measurements does the VA have in place 

for a compensation in pension and medical examination that demonstrate the VA is conducting quality exams that further a veteran-centered mission? Specifically, do you have a system in place 

where a veteran can provide feedback on the quality of the medical 

assessment? 

Ms. MURRAY. So, I thank you for your question, Congressman. 

For our military service members that are going through the process, that process is in place. They are surveyed and we get their 

feedback on their experience with our examiners. And on the C&P 

side, it is not quite as formal but we are developing tools to be able 

to put that in place more specifically for our C&P. 

Mr. RUIZ. Okay. So it is not there yet, but you are going to do 

it? 

Ms. MURRAY. That is correct. 

Mr. RUIZ. And you are going to do surveys? 

Ms. MURRAY. We have looked at having some kiosks at the medical centers where when a veteran completes his or her appointment, they can go to a kiosk and give us some feedback on —— 


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Mr. RUIZ. In person, or on-line, or a survey? Because, you know, 

as you know, being a scientist, the methodology is everything. And 

you have to match the methodology with the culture of the veterans and what they have access to. So I just encourage you to 

make sure that it is something that they can respond to in a timely 

manner. 

My next question is, if they disagree with the medical assessment in the ratings, what do they need to do and how long do they 

have for it to be corrected? 

Mr. MURPHY. There is an avenue for a veteran to not agree with 

what is found in the medical examination process and after they 

receive their rating decision they have one year to file an appeal 

and run through the appeals process. 

Mr. RUIZ. Okay. How can you expedite that so that they do not 

have to jump through so many loops and bureaucratic red tapes so 

that at the moment that they receive it, there is a discretion and 

then they can maybe have that second exam with a different examiner. 

Dr. CROSS. Let me add to that, please. Sitting in the room with 

the patient, in the examining room, and you are doing the exam, 

what I have witnessed is the patient becomes part of that process. 

And if you make a mistake as you are typing it in, you are talking 

to the patient and you are talking about what you are entering. 

That is the first chance right there to make a correction or engage 

the patient. 

There is something else that I want to tell you about. There is 

a lot of stress for a veteran coming in to that examining room, and 

I talked to them about this, and we want to try and find ways to 

lower that stress. This is such an important event for them. This 

means so much to them and to their family potentially, and we are 

looking at every way that we can to make that experience as more 

—— 

Mr. RUIZ. That is wonderful and I want to expedite the appeal 

process because they cannot get the care that they need, the resources that they need unless they get conclusion with that. 

The other thing I want to note here is that oftentimes certain 

mental health illnesses or physical disabilities do not present 

themself on their exit interview from the Department of Defense. 

So to clearly delineate that a veteran does not have a certain illness, and that becomes your gold standard. That becomes what 

then in the future you might want to refer back to and say, well, 

but your disability was on this when you left the Army, so clearly 

you did not get this illness—this mental health illness, because 

when you left your exam showed this. 

We do know that Post Traumatic Stress Disorders, other mental 

health illnesses that are derived from very high stress scenarios develop over time, including pulmonary illnesses from exposures to 

certain chemicals. So I think that we have to reevaluate how definitive we make that exam when they leave the Department of Defense and recognize that illnesses change. 

Dr. CROSS. One thing that we have not talked about and I have 

not heard in the Committee is something that we are starting new 

is separation health assessment. This is an agreement that we 


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have now worked out with DoD. Both sides have signed it to do a 

standard examination at the time of departure. 

One of the things we will look at, of course, is hearing and see 

where the baseline was at the time that the individual was leaving 

the military as opposed to what it was at some future point when 

a claim was made. 

Mr. RUIZ. Okay. You know, these questions are once again aimed 

at changing the focus and using a veteran-centered lenses from the 

eyes of our veterans, and not from the eyes of the institution. 

Okay? 

Thank you. I yield back my time. 

The *Chairman.* Thank you. Mr. Huelskamp, you are recognized 

for five minutes. 

Mr. HUELSKAMP. Thank you, Mr. Chairman. I appreciate particularly your opening questions. I want to follow up on a few of those, 

particularly the concern about different data being submitted to the 

Committee about actual number of exams actually conducted. 

But first of all I wanted to hear an explanation a little bit more 

on CAPRI. It is a Legacy system. How old is that system again? 

Who would answer that question? How old is old? Is it a DOS 

based system? 

Dr. CROSS. I do not know precisely how old it is. 

Mr. HUELSKAMP. Anybody have any guess? Is it contained wholly 

within the VISTA system, or is it separate? Can you describe the 

architecture of how these two systems work together, or part of the 

same system? 

Dr. CROSS. Sir, if you are asking me to start describing IT stuff, 

we are in trouble, I think. So I will get you that answer if that is 

what you want. 

Mr. HUELSKAMP. I would like to see that as well, and it is troubling to have obviously three separate sets of data submitted. That 

needs to be answered, I think. You have offered to answer that separately. 

So do you have any staff here that can answer that question, 

how old is this system? Because as you know that is something 

that I think the American people have been most upset about, is 

for years this Committee has been told things are fine and then 

whistle blowers say, well, no, because somebody was gaming the 

system. As of today there are 70 different investigative teams looking into criminal allegations across the country. 

So do you have any staff available? 

Dr. CROSS. There are staff members watching this program on 

TV, and their job is to go find the questions that I cannot answer. 

Mr. HUELSKAMP. Okay. All right. Well, thank you. I will follow 

up with that. Are there any bonuses tied to performance in the 

numbers of the exams conducted and completed? 

Dr. CROSS. Yes. The bonuses in this case are part of a large package of performance measures. Certainly just one small part of that 

overall package of performance that the individual is held accountable for. 

Mr. HUELSKAMP. And that would be for SES employees and/or 

the examiners? 

Ms. MURRAY. We could probably come back to you on that, but 

we would, you know, we do roll down our measures through the orVerDate Aug 31 2005 06:39 Oct 30, 2014 Jkt 000000 PO 00000 Frm 00054 Fmt 6633 Sfmt 6633 C:\PDF\89376.TXT PAT

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ganization. So, you know, those measures are—in my performance 

plan. They are probably at the VISN level and I would venture to 

say that they are being held accountable at the medical center 

level, as well. 

Dr. CROSS. For clarification, none of those are the 14 day issue 

in regard to C&P, which is irrelevant to C&P. We do not measure 

wait time because we do not have wait time, and as such we have 

process time. 

Let me explain. You have 30 days to get this job done. Whether 

we get the person in on the second day of that period or the tenth 

day of that period, we have still got to wrap it up in 30 days. 

Mr. HUELSKAMP. And what happens if you do not? Again, remind 

me what happens, Doctor. 

Dr. CROSS. Then you are out of standard and they will receive 

our personal attention. 

Mr. HUELSKAMP. Okay. Do they lose their bonuses? 

Dr. CROSS. What we try and start with usually is education and 

trying to figure out why they fell out of standard and help them. 

But, yes, ultimately it could have negative consequences. 

Mr. HUELSKAMP. Well, yeah, I appreciate that, Doctor. I would 

like to see from you then how these bonuses are tied to whether 

it is the member exams or the wait time, I would—you have a different term. I would call it the wait time, especially if they are 

waiting as long as some of my constituents have been waiting to 

get through the process. Thirty days would seem fairly miraculous 

to many of them based on their situation, and can you provide that 

back to me, a description of how that would ruin the bonuses? 

Dr. CROSS. Sir, I will do my best on that. I am happy to show 

you mine. 

Mr. HUELSKAMP. Are any of the folks here are SES level? Are 

you, Doctor? 

Dr. CROSS. I am a physician so we fall in a different category, 

but they call it SES equivalent. 

Mr. HUELSKAMP. I though the Administration announced SES 

employee bonuses for VBA had been cancelled for 2012; is that correct or am I missing that? So they still come out. Dr. Cross, you 

did get a bonus then, or not? 

Dr. CROSS. Last year? 

Mr. HUELSKAMP. Yes. 

Dr. CROSS. Yes. 

Mr. HUELSKAMP. Okay. How much was your bonus? 

Dr. CROSS. I have got here the past three years. Would you like 

them all? 

Mr. HUELSKAMP. If you provide them to the Committee, however 

you would like to do that, so. 

Dr. CROSS. Do you want me to provide them separately? 

Mr. HUELSKAMP. Let’s just provide them separately. It would 

have to make it—I am just curious about that and look forward to 

a description of how that is signed together, sir. Just understand 

my concern. I want to make certain that the data is accurate and 

how it might be tied to bonuses, because on the VA health side, 

that has been the excuse, that we had a system that encouraged 

folks to do bad things, which is meet standards and got bonuses 

as a result. 


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So with that, Mr. Chairman, I yield back. 

Dr. CROSS. We understand quite specifically. 

The *Chairman.* Yes, as I understand bonuses for VBA were 

suspended for last year and for VHA this year. And Dr. Cross, you 

are with VHA, correct? 

Dr. CROSS. Yes, sir. 

The *Chairman.* Okay. Thank you. Ms. Titus, you are recognized for five minutes. 

Ms. TITUS. Thank you, Mr. Chairman. Thank you, Mr. Murphy, 

for being here. As you know, as a Ranking Member of the Disability Subcommittee, we pay a lot of attention to this issue. Chairman Runyan and I have heard a lot about this over the last 18 

months, so these issues are not really new to us. 

Maybe you could tell me how many veterans though in Nevada 

have had these C&P exams from contracted positions outside of the 

system. Do you all have numbers like that? 

Mr. MURPHY. I do not have those off the top of my head. I have 

to take that one for the record. 

Ms. TITUS. Okay. Well, thank you if you will get that back to me. 

And speaking of Nevada, I will take this opportunity to raise some 

issues with you that I have done in the past. A claim that is completed today in Reno for Las Vegas, the District I represent where 

most of the veterans in the State are, closes at 300 days. And it 

was the fifth worst in the country. The average was 500 and something days. So you are getting that down, but I would point out 

that half of the cases there were brokerage somewhere else. So if 

you had not brokered them, I do not think you would have been 

making very much progress in the 18 months that I have been 

there. 

Also the VA’s Inspector General released a report that VERA 

was very critical of the leadership of the Reno Office, called in, in 

fact, a leadership vacuum. So I would ask again because I have 

heard from many members of the staff that they have no confidence in the leadership if any of the members of that leadership 

team received any bonuses. 

I hope that you are looking into that and that you will make a 

leadership change at that Reno Office. Now you recently doubled 

VBA staff in Las Vegas and I appreciate that. We certainly needed 

it. But the fact remains that two-thirds of the staff is still in Reno. 

The folks in Las Vegas are being monitored over the phone by this 

leadership vacuum that is in Reno. You obviously can not recruit 

people to Reno, but it is very easy to recruit people to Las Vegas. 

That is what you told me—it was hard to recruit people. 

So I am wondering, isn’t it time to move that office to Las Vegas? 

I mean, you are running out of excuses so let me just make that 

case one more time as I will every time I see you. 

Now I would like to get to my question. I have been very supportive of your efforts to bring down that backlog. We have been 

trying to help. You have been doing a good job. I compliment you 

when you do that. But that 2015 deadline is coming. You are going 

to be under more scrutiny from this Committee, from the public, 

from our veterans, from the media. They are going to be looking 

at those metrics. There is going to be a lot of pressure. 


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I am wondering, do you have any knowledge, any suspicion, any 

concern that the VBA employees like we have been hearing about 

the other employees at the Phoenix Hospital and other places on 

the other side of this equation have falsified the numbers to make 

it look like they are having more success. Is that occurring with 

VBA employees? Tell us something now that we will not hear about 

from some whistle blowers in the next few months. 

Do you have any sense that any of that is happening? 

Mr. MURPHY. I do not believe that any of that is happening. 

There is—and the reason is we are not relying on the actions of individuals to tell us when ratings happen, when notices to veterans 

go out, when appeals happen. All of this is done by triggering 

events in our system. So the numbers reported to you are not done 

by individuals. 

They are not going in and—no individual has the ability to go in 

and change dates, for example. So we are unaware of any manipulation of the system of any kind. 

Now on the other side of that, that is the part that I do not sleep 

at night. I do not want that thing going on, not while I am the 

Compensation Service Director. It is unacceptable at any time for 

that kind of thing to happen. 

So we are constantly on the look at for where is the next one 

where we are going to be looked at and under the microscope to 

somebody say, you know, manipulating the data here. And as we 

see opportunities—we automate, we lock down as much as we can. 

We control it so individuals cannot go in and influence their own 

performance numbers to their own gain, to their own benefit at the 

detriment of the veteran and the system in general. 

Ms. TITUS. And I realize that has much improved with the electronic system because that can be electronically dated. But when 

something comes in on paper and you can throw it in the desk and 

wait 30 minutes before you start clocking it, those are the kind of 

concerns I have. 

So you feel like you have some safeguards in place to—— 

Mr. MURPHY. You are absolutely right that something could be 

locked in the desk drawer. The problem is, I still own that from the 

date that it shows up, and when I record it in my system I put it 

at the date that it shows up and I have to come in here and explain 

to you why I have claims that are over a certain age. 

So it is in our best interest and in the veteran’s best interest to 

drive this the way we are driving it and record it back to the date 

of claim. 

Ms. MCCOY. Congresswoman Titus, if I can add, that is one of 

the reasons we have also launched a centralized mail initiative so 

that the mail—it will not be coming to the Regional Offices to be 

opened in their individual mail rooms. It is going to be rerouted by 

the Post Office to the vendor and be scanned more immediately. 

So we are saving time on moving that paper around. We want 

to get it into the system as soon as possible, get it under control 

so that we can see it, and we plan to have that done—that initiative by the end of this fiscal year. 

Ms. TITUS. Okay. Thank you. I yield back. 

The *Chairman.* Mr. Takano, you are recognized for five minutes. 


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Mr. TAKANO. Thank you, Mr. Chairman. Mr. Murphy, am I correct that VHA performed C&P examinations may be entered 

seamlessly into the veteran’s electronic health record? 

Mr. MURPHY. I’m trying to—would you mind repeating that, sir? 

Mr. TAKANO. Yeah. Am I correct in my understanding that VHA 

performed C&P examinations can be entered seamlessly into the 

veteran’s electronic health record? 

Mr. MURPHY. I have got to answer that in two parts, and I will 

talk about it first from the VBA aspect where VBA does directly 

place that into our VBMS system for the rater to have direct access 

to. But there is another part of that where you are asking about 

the electronic health record, and that has implications on the VHA 

side that I need to defer to VHA. Yes, Dr. Cross? 

Dr. CROSS. This is an important question because this is information that although administrative at the moment, serves a purpose 

down the road that is clinical. 

The testing results, the X-rays, all of those kind of things are integrated fully as I understand it into the electronic health record. 

Let me make this distinction. Because it is integrated fully, my understanding is that if there is an abnormality, it gets flagged. If the 

doctor wants to do a graph of all of the blood pressures that they 

have had over the past six months, it becomes part of those graph 

of information. 

But because it is flagged, that information—particularly if it is 

abnormal, is brought right forward to the doctor. It is not a .pdf 

file stuck off in the system somewhere that you have to go looking 

for. 

Mr. TAKANO. Well, Doctor, can you tell me how does the process 

of this record—being able to enter, say the physical examination results into the record, how does that work when they are contracted 

out to non-VA providers? 

Dr. CROSS. I think this applies on the side of our VHA contract 

as probably as well as our VBA contract. They do get information 

back to us, but again, it is in a different fashion than full integration as I understand it. I will ask Tom to comment, or Beth. 

Mr. MURPHY. Are we talking about the exam results from a VBA 

contractor? 

Mr. TAKANO. Yes. 

Mr. MURPHY. Being fed back into our file. Our contractors provide currently into—— 

Mr. TAKANO. Yeah. Into the electronic health record. 

Mr. MURPHY. Okay. Now they are fed into our virtual VA system. 

Mr. TAKANO. Okay. 

Mr. MURPHY. They are not fed into the electronic health record. 

But examinations that are done in-house are. 

Ms. MURRAY. That is correct. 

Mr. TAKANO. Would it be beneficial if there was an ability for our 

contractors who do the health examinations to be able to do that 

directly? 

Mr. MURPHY. Yes. Yes, of course. 

Mr. TAKANO. It would be extremely helpful, right? I mean, it is— 

you lay out an example of why it would be important. Mr. Turek, 

does VES use electronic health records and is your system interoperable with VISTA? 


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Mr. TUREK. I am sorry, Congressman. Could you repeat that? 

Mr. TAKANO. Does your company use electronic health records 

and is your electronic system interoperable with VISTA? 

Mr. TUREK. I wish I had my team IT here. Yes, we do interact 

with the VBA much more electronically than we do with the VHA, 

okay? We would like to see—and I am going to go off course here 

a little bit, but I could see even more beneficial things happening 

down the line to speed up the whole process because what we have 

talked about in the past is taking the data that is gleamed from 

each DBQ and feeding that into—and turning it into XML computable data. 

Mr. TAKANO. But currently you are not completely interoperable 

in the way that VBA is with or VHA is? 

Mr. TUREK. We are not completely. 

Mr. TAKANO. And that is a pretty significant difference, because 

it has huge health implications for the ability of for the integrated 

health system to work. 

And so, in my view, it is a major problem in terms of your argument to contract out the entire examination process. 

Mr. TUREK. Can you talk on that, Tom? Okay, me either. We can 

do anything—we have a full computer staff. We can do anything 

that the VA wants us to do as far as hooking up with the VA. 

Mr. TAKANO. Well, if you could give me an answer to the question whether or not how much it would cost for you to ramp up on 

whether your company can make that kind of investment? 

Mr. TUREK. I cannot do that. 

Mr. TAKANO. Okay. Well, it does not have to be now. You can get 

the answer to me later. 

Mr. TUREK. Yeah. We could. 

Mr. TAKANO. Thank you. 

Mr. TUREK. Sure. 

The *Chairman.* Thank you very much. Ms. Brown, you are recognized for as much time as you need, because of that fine coat you 

have on today. 

Ms. BROWN. Thank you, Mr. Chairman, and before I begin, let 

me just thank you for your leadership and how you conduct the 

Committee. I was not on the Hill Monday night and a news flashing came on about another Committee. And the way that the 

Chairman conducted himself with the witnesses was an embarrassment to the House of Representatives. 

So there are some things that you learn before you come to the 

House of Representatives, and it is how you treat the witnesses, 

and I want to thank you for your leadership in that manner. 

The *Chairman.* Thank you very much. 

Ms. BROWN. Now, after saying that, let me just say that there 

is a lot of doctors on this Committee, and there is a lot of doctors 

on the conference committee. And they talk a great deal about the 

private system. Let us be clear. I am a part of the private system 

and, in fact, I have one of the best. I am a Mayo person. And my 

doctor, Dr. Willis, controls all of the tests that I do, even when I 

have tests here they refer it to them. So it is a real coordinated system. 

And I am not going to sit up here and be on this Committee and 

be involved in dismantling VA or privatizing VA, and you have 


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members, they say, well, we want a certain—I want a system in 

my area and I want all of the doctors to be in my area—all of the 

clinics in my area. 

But the point is we build clinics based on a formula-driven, my 

understanding, by the number of veterans in the area. Can you correct me with that? Is that correct? 

For example, if my clinic is in Las Vegas, which is where I want 

to be, and I live in one of those little outlying areas—based on how 

many veterans in that area is whether or not you have the claims 

there. 

And then I heard other members talking about, well, we do not 

have a hospital in our area. Well, maybe you do not have that 

many veterans in that area. That is why you do not have a clinic 

in that area, and maybe we need to come up with some innovative 

ways to get to those veterans. Clear that up for me. 

Ms. MURRAY. So, ma’am, thank you for your question, and I 

would hopefully be able to provide you more information on that. 

But I think when VHA looks at setting up a clinic in a location 

there are a number of criteria that they look at to do that, and I 

do not know the full details of that. But I would imagine that the 

number of veterans would be one of those criteria, but I can certainly find out more information about that. 

Ms. BROWN. Probably I know a little bit more than you then, because I have been on this Committee for 22 years and my understanding is we come up with clinics and hospitals and cemeteries 

based on the number of veterans in that area. No one has the answer? 

Dr. CROSS. Yes. 

Ms. BROWN. Is that correct? 

Dr. CROSS. To the best of my knowledge, that is correct. 

Ms. BROWN. It is a problem when I am the institutional memory 

in the room. I think VA does an excellent job and the feedback that 

I get is that they are satisfied, but we do have a problem. 

And so, I would like for each one of you—how do you think is 

the best way to address the wait time? And one of the things, like 

in the Gainesville area, I know we have a good hospital there, and 

the information was not put into the system because the computer 

system was outdated. Not that anybody was trying to whatever 

they think that you are doing. They were making sure that the veterans were getting the services. I know about my area. 

Dr. CROSS. Would you like me—— 

Ms. BROWN. Yes, please. I would like a response. 

Dr. CROSS. This is so very important. The confidence is not there, 

as has been pointed out many times. I would judge the wait time 

and so forth by what I experience when I go there. I am a veteran. 

I go to the hospital, at the VA, of course. So I think, you know, 

what you experienced is a starting point to gain that confidence 

back, to make it a reality. 

Ms. BROWN. Well, one of the things that came up in the conference was women veterans, which is the fastest growing group in 

providing services. Well, one of the things that I get when we did 

the clinic in Jacksonville was that we made sure that the doctors— 

and we had the input from the veterans—so that the women say, 

well, we don’t want cat calls when we walk in. How do we control 


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cat calls? The way you control it is the women have a separate entrance. 

And so I think it is very important as we move forward that we 

do not just talk to the veterans, but we talk to the VA physicians 

so that they can make input as to how we can improve the system. 

Dr. CROSS. An excellent idea, and I concur. 

Ms. BROWN. Mr. Chairman, I want to thank you so much for 

your kindness in extending a couple of minutes to me. I yield back 

the balance of my time. 

The *Chairman.* Thank you very much, Ms. Brown. Are there 

any further questions that the members may have? 

I have one, Mr. Murphy. What happens if a claim is just found 

somewhere within the system. Somebody has lost it. Paper file sitting somewhere for two years. Now I am not saying that I have one 

in mind, but I am interested in where the start date begins. Does 

it begin when that claim arrived or does it begin when the claim— 

somebody discovers that the claim was found? 

Mr. MURPHY. It depends on the circumstances surrounding that 

case, but the majority of the time, the overwhelming majority of 

the time, it goes back to the date we received that piece of paper. 

If there is a date stamp on it and we received it four years ago 

and it is sitting in a desk drawer somewhere, it goes into the system as four years old. 

The *Chairman.* What if it is not date stamped? 

Mr. MURPHY. Then we have to figure out how it is that we established the receipt of that. Is the envelope still there and is a postal 

stamp on it? 

And then we have some cases where we can identify that is a 

communication that came in with a certain claim, and we give the 

veteran the most liberal date that we can assign to that case. 

The *Chairman.* So the veteran does get the benefit? 

Mr. MURPHY. Absolutely. The veteran is entitled to the first time 

we see the evidence as an effective date. 

The *Chairman.* Well, the first time you see it, that is the question. I mean, if it came in somewhere and it got misfiled in somebody else’s file and you do not discover it for two years, when does 

that veteran—when does it start? When you find it, you see it, or 

when the veteran says they sent it in? 

Mr. MURPHY. The date of claim on that goes back to the date 

that we can identify that we received that piece of paper. Not 

that—I said a moment ago ‘‘found.’’ It is not found. It is we are obligated—the VA is obligated from the date that the VA receives 

that evidence, and the veteran is entitled to compensation from 

that date. 

Ms. BROWN. Mr. Chairman, on that point. 

The *Chairman.* Yes, ma’am? 

Ms. BROWN. Mr. Chairman, I think we have to encourage our 

veterans to be proactive, also. If my doctor, you know, waits two 

years, I’m not going to wait for any appointment. And so it is important that they also, and the families or the support system, contact the system. I mean, it is going to take a team effort. The Army 

motto is, ‘‘One team, one fight,’’ so we have got to make sure that 

we are not just relying on the VA but the stakeholders involved 


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working with the VA, and the family. It is not just the veteran, it 

is the family, it is the support system. 

Certainly it is the responsibility of the VA, but like you say, two 

years—that is ludicrous. If they had not contacted me in a certain 

amount of time, then I am going to contact them. I am going to go 

to the office, or I am going to the emergency room. And so we have 

got to encourage them to be proactive, also. 

The *Chairman.* Thank you, Ms. Brown, very much. Thank you 

everybody for being here. We thank the witnesses. I would ask 

unanimous consent that all members would have five legislative 

days for which to revise and extend their remarks. 

Without objection, with that, this hearing is adjourned. 

(Whereupon, at 12:01 p.m. the meeting of this subcommittee was 

adjourned) 


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APPENDIX 

STATEMENT FOR THE RECORD 

STATEMENT OF JEFF SCARPIELLO TO

THE HOUSE COMMITTEE ON VETERANS’ AFFAIRS

VBA and VHA Interactions: Ordering and Conducting Medical Examinations 

Chairman Miller, Ranking Member Michaud, and distinguished members of the 

Committee, I appreciate the challenges facing you as you study the important role 

that VBA and VHA have in effectively ordering and conducting medical disability 

examinations (MDE) in support of benefits that America provides in law to care for 

our veterans. 

As background, I am a service-connected disabled veteran who has underwent 

several compensation and pension (C&P) exams, so I understand the process and 

can speak from a recipient’s viewpoint. I have also worked for Disabled American 

Veterans and Paralyzed Veterans of America at the busiest Regional Office (RO) in 

the country in St. Petersburg, FL and am familiar with the disability exam process 

from an advocacy perspective. I have also worked for US Senator Bill Nelson for 

8 years handling veterans and military issues and can speak directly to the impact 

of the backlog and veterans not being able to get timely benefits and healthcare. 

In 2008, I went to work for the Department of Veterans Affairs, Veterans Health 

Administration (VHA) as a Legislative Health Specialist and have investigated complaints regarding the C&P exam process at several locations throughout the country 

and provided written responses with the findings back to members of Congress. In 

2010–2011, I was the Deputy Director of the Disability Examination Management 

Office (DEMO), now known as the Office of Disability and Medical Assessment 

(DMA) led by Dr. Gerald M. Cross who is providing testimony before you today. 

Among my many responsibilities running the DEMO was to help draft, select and 

award the Disability Examination Management contract to vendors and implement 

the contract nationally. I have also drafted all existing policies, directives and guidance currently in effect to govern the current VHA C&P exam process. I am currently the Director of Business Development for Medical Support Los Angeles 

(MSLA), a Medical Company. MSLA has an indefinite delivery, indefinite quantity 

contract with the VHA to conduct medical disability examinations for veterans in 

Region 10 (California, Nevada, Hawaii and Guam) under the Disability Examination 

(DEM) contract. 

I have just a few observations and recommendations to share with you, but first, 

want to explain several reasons why veterans are not getting timely access to health 

care from the Veteran Health Administration that may be a result of the disability 

exam process. As a result of the system-wide delays in processing rating claims Veterans Benefits Administration implemented an initiative to eliminate the 1-year and 

2-year old claims backlog by accelerating the claims rating process. At some locations, VHA primary care providers were asked to augment /assist the C&P exams 

clinics. In addition, VBA’s fully developed claim (FDC) initiative, put additional 

stress on the VHA health care system as veterans began making appointments with 

their primary care/treating providers at the urging of Veterans Service Organization’s (VSO) to have Disability Benefit Questionnaire’s (DBQ) completed in support 

of their disability claims. The Office of Disability and Medical Assessment (DMA) 

attempted to explain that by allowing primary care providers to complete DBQ’s 

could be problematic. However, the VSO’s urged the Secretary and Under Secretary 

of Health to do more to help veterans get their DBQs completed upon request. DMA 

then instituted a ‘‘no-wrong door’’ policy and VHA primary care providers were informed they should do everything they can to complete DBQs when requested by 

the veteran. Subsequently, DMA learned that despite the urging of the Secretary 

and Under Secretary of Health, many primary care providers who were not familiar 

with DBQs continued to refuse to complete them. 

As a result of primary care providers refusing to complete DBQs, VHA DMA implemented DBQ referral clinic (walk-in) guidance instructing primary care providers 

who could not complete DBQs to provide a ‘‘warm-hand off’’ of the veteran to the 

C&P clinic for assistance. Many of the larger C&P clinics are so busy with scheduled appointments that this hand-off typically results in the veteran having to have 

an appointment scheduled to return to the C&P clinic to have the DBQ completed. 

In 1996, when Congress gave VBA the authority to contract MDE’s at 10 locations 

and now with capability that VHA has developed with the DEM contract; the full 


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utilization of these contract vehicles could free up to 7,000–10,000 C&P examiners 

and hundreds of administrative support staff to provide medical care/treatment 

services that would help to resolve the current health care scheduling, access and 

wait time issues plaguing VA. 

It is important to note, as I’m sure Ms. Murray & Dr. Cross will attest to in their 

testimony that VHA’s C&P program is a success. In 2010/11 when I ran the Disability Examination Management Office, C&P exams were averaging over 40 days 

nationally and in some locations 90 days or longer. The implementation of the DEM 

contract has played a critical role in exams now being completed in 22–26 days; 

besting the 30 day or less national requirement/standard for completion of exams. 

However, there is no established national customer service survey that drives performance improvement or to help identify problems from a user/veterans perspective. There is no centralized control of the C&P clinics within VHA, as C&P is not 

recognized as its own separate service line and at each location within VHA, the 

C&P structure varies which makes it difficult for VHA C&P clinics to get on-board 

nationally when new initiatives are rolled-out. Most importantly, C&P facilities do 

not receive separate funding and if they utilize the DEM contract services they must 

pay for it the local level, unlike the centrally funded VBA contracts. 

I have identified several issues with the VBA contract that should be of concern 

to the Committee: 

* VBA does not manage its contract exams as completely as the VHA DEM contract and has been reliant upon VHA to provide them with accurate C&P data. 

* VBA has no governance board and has not allowed any VHA input into the clinical aspects of the exam process. 

* The Compensation Service Director can make unilateral contract decisions that 

involve hundreds of millions of dollars which can give the appearance of impropriety 

if the same vendor continues to receive the contract award. 

* The fact that VBA only awards contracts to single vendors who can bid on the 

entire contract vastly diminishes the ability of other contract providers to participate in providing exam services in geographic areas where they can compete. 

* VBA allows contractors to provide their own quality assurance and has no real 

mechanisms in place like VHA’s quality review specialists to monitor the quality of 

the exams’ 

* Under VBA’s existing contract, exams that are reworked can be double billed 

* No additional authorization is required for additional testing or exams. 

* Payments for exams are more expensive in some cases than VHA DEM contract, 

although they are listed in VBA’s contract as a flat fee. 

Suggestions and Recommendations: 

* Establish a single office that can focus on medical disability examination management. The current oversight is fragmented as currently exists within VBA/VHA. 

The new joint office should include a single SES responsible for the oversight of the 

program and include: contract management staff, clinicians to provide quality assurance of contract exams, administrative support, and VBA adjudicators. 

* Establish one VA national medical disability examination contract that is broken up into multiple geographical regions including overseas exams, where multiple 

contract awards can be given to more than one contract vendor in each region. 

* Allowing multiple contract awards will help drive internal competition among 

contract vendors that will drive performance to provide quality and timely exams 

that will meet or exceed or contract requirements. 

* The DEM contract has a successful contract model in place where the contract 

is divided up into ten geographic regions and multiple vendors are awarded contracts. This would provide fairness and equity so that smaller companies can bid 

in geographic areas where they are best positioned to provide services without having to bid on a single large contract. 

* The efficiencies created by using these contracts will benefit Veterans’ immeasurably by creating more options and accessibility to disability exam services and 

timely access to healthcare that veterans deserve and need. 

* Ensure consistent contract standards, pricing, and timeliness standards within 

existing contracts by VHA / VBA to eliminate confusion. 

* Fast-track any IT system solutions that have been presented that would allow 

this will eliminate current barriers to why VHA facilities are not utilizing the DEM 

contract. 

A lot of work lies before this Committee. All of us who care about the quality of 

medical disability exams and the benefits we have promised veterans and their families are hopeful that your work will lay the foundation for reform and improvement 

of the medical disability exam process that will give truth to the commitment to 

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Thank you for your consideration of my observations, suggestions and recommendations for changes. Taking care of veterans – and doing it well- is the right 

thing to do. 


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George C. Turek 

Supplemental Testimony 

House Committee on Veterans’ Affairs, 

VBA and VHA Interactions: Ordering and Conducting Medical Examinations 

In response to the following question from Congressman Takano, I would like to 

supplement my testimony as follows: 

Mr. Takano: Mr. Turek, does VES use electronic health records and is your electronic system interoperable with VISTA? Currently you are not completely interoperable in the way VBA is with VHA. That is a pretty significant difference because it has huge health implications for the ability for the integrated health system 

to work. In my view it’s a major problem in terms of your argument to contract out 

the entire examination process. Could give me an answer to the question of how 

much would it cost to ramp up and whether your company could make that kind 

of investment? 

Mr. Turek: VES works in an electronic medical records environment. All aspects 

from scheduling to delivery are done electronically. This includes the work performed by VES medical providers who review medical records and complete DBQs 

in the VES Secure Provider Portal. 

With respect to the work VES does for the VBA, we have access to certain limited 

components of VISTA, including CAPRI and CAATS (which recently replaced 

VERIS). We also upload all completed C&P MDE reports and the associated 

diagnostics directly into VBMS, as required by our contract. VES’ captive IT department built this capability at the request of and in cooperation with the VBA. We 

also post the completed reports to our VES Secure Client Portal. 

With respect to the work VES does for the VHA, we do not access VISTA, nor 

do we upload completed reports into VBMS. Although we have offered to do so, the 

VHA has declined this offer. We currently send completed MDE reports to the VHA 

via encrypted e-mail as a secure PDF attachment. We also upload the completed reports to the VES Secure Client Portal. 

With that said, as a private contractor, VES certainly does not have the same 

level of access to or interoperability with VISTA as does the VHA or VBA. Moreover, 

I highly doubt that the VA would allow any private contractor unlimited and unfettered access to a system with such highly confidential and private information. Nevertheless, to the extent the VA was to allow us such access, our company certainly 

has the IT capability and financial resources to make the necessary investment to 

become fully interoperable with VISTA. VES maintains a robust, captive IT department, complete with a team of professional programmers who have previously 

worked together with VA technical experts on a number of IT-related projects. We 

are confident we can accommodate any reasonable IT requirements established by 

the VA going forward. However, absent a more detailed understanding from the VA 

of the parameters of a project to establish full interoperability, we have no basis 

upon which to provide you an estimate of how much that might cost. 

The point is that we do not need the same level of access to or interoperability 

with VISTA in order to provide the VA timely and quality medical disability examination services. Not having the same level of interoperability with VISTA as the 

VHA does not in any way limit or compromise VES’ ability to deliver valuable services to the VA. Moreover, it does not detract from our position that our veterans 

would be better served with the VHA focusing exclusively on treatment, and 

outsourcing all C&P MDEs to private contractors through the VBA. 

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