VA Disability Claims Processing: Preliminary Observations on Accuracy Rates and Quality Assurance Activities
Published: 2014-07-14T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: With a growing workload of disability claims due, in part, to recent wars, VBA faces difficulties in improving the accuracy and consistency of its claims decisions by VBA staff in 57 regional offices. To help achieve its goal of 98 percent accuracy by fiscal year 2015, VBA recently implemented a new way of measuring accuracy, and changed several quality assurance activities to assess the accuracy and consistency of claims decisions and to provide feedback and training to claims processors.
In this statement, GAO discusses initial observations from its ongoing review of VBA's quality assurance efforts, addressing the extent to which (1) VBA effectively measures and reports the accuracy of its compensation claim decisions; and (2) VBA's other quality assurance activities are complementary and coordinated. For this work, GAO analyzed STAR accuracy and VBA claims data from fiscal year 2013 (the most recent fiscal year for which complete data are available); reviewed relevant federal laws, regulations, guidance and other documents relevant to quality assurance activities; and interviewed VBA staff from headquarters and four VBA regional offices (selected to achieve variety in geography, size of workload and reported accuracy rates), and Veterans Service Organization officials. GAO has no recommendations at this time. GAO plans to issue its final report later in 2014, along with any related recommendations.
section_title: What GAO Found
paragraphs: The Veterans Benefit Administration (VBA) within the Department of Veterans Affairs (VA) now measures and reports the accuracy of its claim decisions in two ways—by claim and by medical issue—but its approach has limitations. When calculating accuracy rates for either measure through its Systematic Technical Accuracy Review (STAR) program, VBA does not always follow generally accepted statistical practices. For example, VBA does not adjust its accuracy estimates to reflect that it samples the same number of claims for review from each regional office despite their varying workloads, and thus, produces imprecise estimates of national and regional accuracy. Further, because VBA does not clearly explain differences in how its two accuracy measures are calculated or their associated limitations, reported information about accuracy performance lacks clarity and may be confusing. Finally, VBA reviews 39 percent (over 5,000) more claims nationwide than necessary to achieve its desired precision in reported accuracy rates, thereby diverting limited resources from other important quality assurance activities, such as targeted reviews of error-prone cases. VBA could achieve its desired precision by reviewing fewer claims for offices with smaller workloads or higher performance levels.
Overall, VBA has made enhancements to its other quality assurance activities, although GAO identified implementation shortcomings that may detract from their effectiveness. To improve local quality, VBA recently created quality review teams (QRTs) comprised of certified staff in each regional office. QRTs review a sample of claims before they are finalized to identify specific error types and help prevent inaccurate decisions. QRTs also assess individual staff performance; however, claims processed during overtime were excluded from such reviews in three of the four offices GAO visited, which may undermine regional quality for a portion of claims. VBA officials told GAO they do not know the extent to which this occurs nationally. Recent VBA data shows that about 10 percent of claims were processed during overtime. Also, to help ensure claims processors make consistent decisions when presented with the same evidence, VBA began using a questionnaire approach to test for consistency. Although these questionnaires allow VBA to reach more staff and require fewer resources to administer, VBA did not pre-test them to ensure the clarity of questions or validity of the expected results. For each enhancement, their effectiveness is unclear because VBA has done little to date to assess their impact on improving accuracy.
VBA has also taken steps to coordinate its quality assurance efforts, but has not maintained centralized guidance and other key supports that might help prevent future errors. VBA coordinates quality assurance efforts by disseminating national accuracy and consistency results, trends and related guidance to regional offices, which use this information to train staff. Further, VBA uses the results of STAR reviews for other quality assurance activities, such as focusing QRT in-process reviews on commonly made errors. However, regional office staff told GAO that there are multiple sources of guidance, that searching these sources is time-consuming and difficult, and that VBA's policy manual and national training are not sufficiently updated to help claims processors avoid future errors. In addition, regional office data systems do not allow managers to readily track error trends, resulting in ad-hoc and inefficient work-arounds.

section_title: Letter
paragraphs: I am pleased to discuss the Department of Veterans’ Affairs (VA) quality  assurance activities for ensuring accurate and consistent decisions on  veterans’ disability benefit claims. Through its disability compensation  program, VA provides cash compensation to veterans for disabling  conditions incurred or aggravated while in military service. In fiscal year  2013, VA paid $53.6 billion in disability compensation to 3.6 million  veterans. For this same time period, VA reported a 96-percent issue- based accuracy rate and a 90-percent claim-based accuracy rate, while  setting a goal of 98 percent for both measures in fiscal year 2015.  However, the Veterans Benefit Administration (VBA) within VA has faced  difficulties in improving the accuracy and consistency of its claims  decisions. Accurate initial claims decisions can help ensure that VA is  paying disability benefits only to those entitled to such benefits, and in the  correct amounts. Meanwhile, consistent decisions help ensure that  veterans’ claims receive comparable treatment, regardless of which VBA  staff member or regional office processes the claim. GAO and VA’s Office  of Inspector General (OIG) have previously reported on shortcomings in  VBA’s quality assurance activities. Concerns also have been raised  about the lack of transparency related to recent changes in the calculation  of VBA’s national accuracy rate for compensation claims—which is based  on its national Systematic Technical Accuracy Review (STAR)—and  whether recent changes reflect reliable measures of accuracy. My  remarks today are based on ongoing work requested by this committee.  Specifically, we examined: (1) the extent to which VBA effectively  measures and reports the accuracy of compensation claim decision- making, and (2) the extent to which VBA’s other quality assurance  activities are complementary and coordinated.
To inform our work, we reviewed STAR guidance, reports, and methods  for sampling and estimating accuracy of claims decisions, and analyzed  STAR and VBA claims data for claims processed in fiscal year 2013, the  most recent year for which complete data are available. We also  assessed VBA’s methods against accepted statistical practices. In  addition, we assessed the reliability of STAR and VBA claims data used  for all our analyses and determined that they were sufficiently reliable for  the purposes of providing information on trends in claims decisions. We  also reviewed relevant VBA reports and practices for reporting accuracy  and compared these against requirements for agency performance  reporting and related GAO work. To determine the extent to which STAR  and other key quality assurance activities are complementary and  coordinated, we reviewed relevant guidance and policy documents,  interviewed cognizant VBA officials, and visited four regional offices to  gain a range of perspectives on how quality assurance activities are  implemented at the regional office level,shared across quality assurance activities. We reviewed VBA’s methods  for designing and implementing its consistency reviews against generally  accepted practices in survey and questionnaire development. We also  compared VBA’s quality assurance practices against its internal guidance  and Standards for Internal Control in the Federal Government (AIMD-00- 21.3.1). We intend to produce a report later this year that will provide our  final results.   as well as how information is  Our work was conducted in accordance with generally accepted  government auditing standards. Those standards require that we plan  and perform the audit to obtain sufficient, appropriate evidence to provide  a reasonable basis for our findings and conclusions based on our audit  objectives. We believe that the evidence obtained provides a reasonable  basis for our findings and conclusions.
subsections: section_title: Background
paragraphs: VA pays monthly disability compensation to veterans with service- connected disabilities (i.e., injuries or diseases incurred or aggravated  while on active military duty) according to the severity of the disability.  VBA staff in 57 regional offices process disability compensation claims.
These claims processors include Veterans Service Representatives who  gather evidence needed to determine entitlement, including VA and  military medical records, and Rating Veterans Service Representatives  who decide entitlement and the rating percentage. Each claim requires a  determination on one or more medical conditions. In fiscal year 2013,  VBA decided more than 1 million compensation claims.
Since fiscal year 1999, VBA has used the STAR program to review the  decisional accuracy of disability compensation claims. Under the STAR  program, VBA reviews a stratified random sample of completed claims,  and certified reviewers use a checklist to assess specific aspects of each  claim. Specifically, for each of the 57 regional offices, completed claims  are randomly sampled each month and the data are used to produce  estimates of the accuracy of all completed claims. VA reports national  estimates of accuracy from its STAR program to Congress and the public  through its annual performance and accountability report and annual  budget submission. VBA also produces regional office accuracy  estimates, which it uses to manage the program. These and its national  accuracy rates are reported in a publicly-available performance database,  the ASPIRE dashboard.
Prior to October 2012, VBA’s estimates of accuracy were claim-based;  that is, claims with zero errors were considered accurate and, conversely,  claims with one or more errors were considered inaccurate. Beginning in  October 2012, VBA also began using STAR data to produce issue-based  estimates of accuracy that measure the accuracy of decisions on the  individual medical conditions within each claim. For example, a veteran  could submit one claim seeking disability compensation for five disabling  medical conditions. If VA made an incorrect decision on one of those  conditions, the claim would be counted as 80 percent accurate under the  issue-based measure. By comparison, under the claim-based measure,  the claim would be counted as 0 percent accurate. In March 2014, VBA  reported a national estimate of issue-based accuracy in its fiscal year  2015 annual budget submission and plans to update this estimate in VA’s  next performance and accountability report. VBA also produces issue- based estimates by regional office, and reports them in the ASPIRE  dashboard. For fiscal year 2013, the regional office claim-based accuracy  rates ranged from 78.4 percent to 96.8 percent, and the issue-based  accuracy rates ranged from 87.0 percent to 98.7 percent.
Beyond STAR, VBA has programs for conducting regional office quality  reviews and for measuring the consistency of decisions. In March 2012,  VBA implemented a quality review team (QRT) at each regional office,  consisting of staff dedicated to conducting quality reviews. A QRT  conducts individual quality reviews of claims processing staff members’  work, for performance assessment purposes. The QRT also conducts in- process reviews before claims are finalized to help prevent inaccurate  decisions by identifying specific types of common errors. Such reviews  also serve as learning experiences for staff members. Since fiscal year  2008, VBA has also conducted studies to assess the consistency of  disability claims decisions across regional offices. Initially, these studies  have included inter-rater reliability studies that assess the extent to which  a cross section of claims processors from all regional offices agree on an  eligibility determination when reviewing the entire body of evidence from  the same claim. In 2013, VBA moved beyond the inter-rater reliability  studies and introduced consistency questionnaires as its primary means  for assessing consistency. A questionnaire includes a brief scenario on a  specific medical condition for which claims processors must correctly  answer several multiple-choice questions.
section_title: VBA’s Approach to Measuring and Reporting Accuracy of Claim Decisions Has Limitations
paragraphs: When calculating accuracy rates, VBA does not follow generally accepted  statistical practices. For example, VBA does not calculate the margin of  error associated with each estimate that it generates, which prevents a  complete understanding of trends over time and comparisons among  offices. In addition, VBA does not weight the results of its STAR reviews  to reflect its approach to selecting claims by regional office, which can  affect the accuracy of estimates. According to our analysis of VBA data,  weighting would have resulted in a small change to VBA’s nationwide  claim-based accuracy rate for fiscal year 2013: from 89.5 percent to 89.1  percent. However, 29 of the 57 regional offices’ would have experienced  a somewhat greater increase or decrease in their accuracy rates.  According to VBA officials we interviewed, although STAR management  used a statistician initially to help develop the way in which they measure  accuracy, it currently does not use a statistician to, for example, weight  STAR results and calculate margins of error for accuracy estimates.  Further, VBA officials said they did not consult a statistician when  developing the new issue-based accuracy measure, but rather relied on  the same sampling methodology and approach for estimating accuracy as  for the claim-based measure. We have previously reported that to be  useful, performance information must meet users’ needs for  completeness, accuracy, consistency, and validity among other factors.
In addition, VBA’s accuracy reporting lacks methodological details that  would help users understand the distinction between its two accuracy  measures and their associated limitations. While VBA’s new issue-based  measure provides additional perspective on quality of claims decisions, to  date VBA has not fully explained in its public reports how the issue-based  and claim-based measures differ. VBA began reporting the issue-based  measure in its ASPIRE dashboard in 2013. The issue-based measure  tends to be higher than the claim-based measure because the former  allows for claims to be considered partially correct, whereas the claim- based measure does not. According to VBA officials, the issue-based  estimate provides a better measure of quality because veterans’ claims  have increasingly included multiple medical issues. Our analysis of STAR  data confirms that, as the number of issues per claim increases, the  chance of at least one issue being decided incorrectly within a single  claim increases because there are more opportunities for error (see fig.  1). However, VA did not report in its fiscal year 2015 budget request how  these measures are calculated and why the issue-based measure might  be higher than the claim-based measure.
Further, VA has not explained in public reports that its accuracy  measures are estimates which have distinct margins of error and  limitations. These margins of error are necessary for users to make  meaningful comparisons, for example, between the two measures or over  time for the same measure. Further, each accuracy measure has distinct  limitations, but VA does not report this information. For example, the  claim-based measure does not provide a sense of the proportion of  issues that the agency decides correctly because the measure counts an  entire claim as incorrect if any error is found. On the other hand, the  issue-based measure does not provide a sense of the proportion of  claims that the agency decides with no errors. In prior work, we identified  clarity as a key attribute to a successful performance measure, meaning  that the measure is clearly stated and the associated methodology for the  measure is identified. Measures that lack clarity may confuse or mislead  users. We have also reported on best practices in implementing related  federal performance reporting requirements, such as those in the GPRA  Modernization Act of 2010. Specifically, agencies must disclose  information about the accuracy and validity of their performance  information in their performance plans, including the sources for their data  and actions to address any limitations.
Finally, VBA’s approach to measuring accuracy is inefficient because it  reviews more claims than needed to estimate accuracy. VBA randomly  selects about 21 claims per month from each of its regional offices for  STAR review, regardless of the offices’ varying workloads and historical  accuracy rates. According to VBA, this uniform approach allows the  agency to achieve a desired level of precision of its accuracy estimates  for each regional office. However, this approach leads VBA to select more claims for review than are needed at regional offices where the  number of claims processed has been relatively small or accuracy has  been high. According to our analysis of fiscal year 2013 regional office  workload and accuracy results, VBA could reduce the overall number of  claims it reviewed annually by about 39 percent (over 5,000 claims) and  still achieve its desired precision for its regional office accuracy estimates.
Only for one regional office did we find that VBA would need to increase  the number of claims currently reviewed to achieve its confidence level  goal for that office. More efficient sampling could allow VBA to select  fewer cases for review and free up limited resources for other important  quality assurance activities, such as additional targeted accuracy reviews  on specific types of error-prone or complex claims. Specifically, reviewing  about 5,000 fewer claims could free up about 1,000 staff days because,  according to VBA officials, STAR staff review at least 5 claims per day.
Our review of STAR is ongoing. Specifically, we plan to analyze STAR  data and processes to assess whether any types of claims are  systematically underrepresented in accuracy reviews. In addition, we are  further considering the implications of a more efficient sampling  methodology on developing issue-based accuracy estimates.
section_title: VBA Has Enhanced and Coordinated Its Quality Assurance Activities, Although Gaps in Effectiveness Exist
subsections: section_title: VBA Enhanced Other Quality Assurance Activities, but Shortcomings Exist and Effectiveness is Unclear
paragraphs: In addition to its STAR reviews, VBA’s quality assurance framework  includes other complementary activities, some of which have been  enhanced to help meet its 98-percent goal for fiscal year 2015. For  example, VBA established QRTs in regional offices as a means of  strengthening its focus on quality at regional offices, where claims are  processed. QRT personnel—like STAR reviewers—are required to pass  an annual skills certification test. In addition to conducting individual  quality reviews to determine whether claims processors are achieving  individual accuracy targets, QRT personnel are charged with conducting  in-process reviews of claims not yet finalized, looking for specific types of  errors commonly made. Quality reviewers are also responsible for  providing feedback to claims processors on the results of their quality  reviews, including formal feedback from the results of individual quality  reviews and more informal feedback from the results of in-process  reviews. Typically, feedback on quality reviews is provided as reviews are  completed. In addition, at the four offices we contacted, quality reviewers  are available to answer questions and provide guidance to claims  processors as needed.
During our site visits, however, we identified shortcomings in QRT  practices and implementation that could reduce their effectiveness. With  respect to assessing individual performance, we learned that three of the  four offices we contacted have agreements with their local unions that  prevent QRT personnel from reviewing claims processed during  overtime. As a result, regional offices would be limited in their ability to  address issues with the quality of work performed during overtime. VBA  officials told GAO they do not know how many regional offices include or  exclude claims processed during overtime, or the extent to which  excluding cases worked during overtime occurs nationally. According to  VBA data, claims processed on overtime represented about 10 percent of  rating-related claims completed nationally in fiscal year 2013. In our  ongoing work, we plan to review the extent to which this practice is  followed at other regional offices and how claims processed during  overtime are identified. In addition, regional offices we contacted told us  that they face a challenge in conducting in-process reviews as required  because VBA’s Veterans Benefits Management System lacks the  capability to pause the process and prevent claims from being completed  while a quality review is still underway. In our ongoing work, we will  continue to review the extent to which claims are decided before in- process reviews are finalized and whether this causes rework or other  problems.
VBA’s efforts to assess consistency of claims decisions have also  expanded in recent years. The inter-rater reliability reviews that VBA  largely relied on to assess consistency since 2007 were time consuming  in that claims processors required about 4 hours to review an entire claim,  the process was administered by proctors in the regional offices, and the  results were hand-graded by national VBA staff. Given the resources  involved, IRRs were typically limited to 300-500 (about 25-30 percent)  claims processors, randomly selected from each regional office. Since VA  expanded its consistency program in 2009 to include consistency  questionnaires, it now relies more heavily on this streamlined approach to  assess consistency. The questionnaires require less staff time to  complete because, in addition to a brief scenario on a specific condition,  participants have 10 or fewer multiple choice questions to answer. The  questionnaires are administered electronically through the VA Talent  Management System, which has allowed VBA to increase employee  participation and administer the studies more frequently. For example, a  recent consistency questionnaire was taken by about 3,000 claims  processing employees—representing all employees responsible for rating  claims.
Although VBA has enhanced its approach to measuring consistency, VA  officials told us that consistency questionnaires to date have been  developed and implemented without any prior pre-testing which would  allow VA to examine the clarity of questions or the validity of the expected  questionnaire results. Pre-testing is a generally accepted practice in  sound survey/questionnaire development and would help determine  whether the test questions are appropriate for field staff and are  accurately measuring consistency. A quality assurance official told us that  by July 2014, VBA plans to begin pre-testing consistency questionnaires  with national quality assurance staff that have claims processing  experience. However, VBA has not yet developed a concrete plan or  written policies for pre-testing the questionnaires.
VBA efforts to evaluate the effectiveness of its efforts have been limited,  although VBA told us that they have seen some improvements in  accuracy following certain quality assurance enhancements. Specifically,  VBA officials told us that, although they have not seen an increase in the  national accuracy rate in the current fiscal year, the number of errors  related to claim development—specifically, to ensuring the claim reflected  sufficient / appropriate medical examinations)—has declined, showing  the success of QRT efforts in targeting these errors through in-process  reviews and providing related training. On the other hand, VBA central  office has only begun to receive data from regional office IQR reviews  and expects to begin receiving additional data and identifying accuracy  trends in the summer of 2014. With respect to consistency studies, VBA  has not evaluated and lacks plans to evaluate the efficacy of its new  approach for conducting consistency reviews to determine its relative  effectiveness. Evaluation can help to determine the “value added” of the  expenditure of federal resources or to learn how to improve  performance—or both. It can also play a key role in strategic planning and  in program management, informing both program design and execution.
In our ongoing work, we plan to further review how VBA uses the results  of its consistency studies to improve quality and whether and how VBA  could further leverage its vast amount of claims data to identify error  trends and opportunities for improvement.
section_title: VBA Has Taken Steps to Coordinate Quality Assurance Activities, but Key Supports Have Not Been Updated
paragraphs: VA has taken steps to coordinate its quality assurance efforts, in part, by  systematically disseminating information on national accuracy and  consistency trends to regional office management and QRTs, which in  turn used this information to provide feedback. With respect to STAR,  regional offices receive quarterly reports on their STAR accuracy  performance, and QRT reviewers receive periodic conference call  updates from STAR staff to discuss error trend information. Managers or  QRT members at each of the regional offices we contacted noted that  they also share STAR data with claims processors through periodic  training focused on STAR error trends. With respect to consistency  studies, regional offices receive national results; regional office-specific  results; and, since February 2014, individual staff results. Officials at each  of the four regional offices we visited told us they discuss the results of  consistency studies and inform claims processors of the correct answers  to the questions.
Based on error trends identified through STAR and other quality  assurance activities, QRT personnel are also expected to disseminate  guidance and provide input into, and sometimes conduct, regional office  training. For example, two of the four offices we contacted cited instances  where they have used consistency study results for training purposes. In  general, at each of the four offices, reviewers conduct, or work with  regional office training coordinators to conduct, periodic training forums  for claims processors. Regional offices we contacted also supplement  training with other communications informed by quality review results. For  example, QRTs at three of the four regional offices we contacted produce  periodic newsletters for regional office claims processors, including  guidance based on errors found in all types of reviews.
In addition to sharing STAR results for regional office training purposes,  VA uses STAR to guide other quality assurance efforts. For example,  according to VBA officials, the agency has used STAR data to identify  error trends associated with specific medical issues, which in turn was  used to target efforts to assess consistency of decisionmaking related to  those issues. Recent examples are the August 2013 inter-rater reliability  study, which examined rating percentages and effective dates assigned  for diabetes mellitus (including peripheral neuropathy); and a February  2014 study on obtaining correct disability evaluations on certain  musculoskeletal and respiratory conditions. In addition, according to VBA,  the focus of in-process reviews has been guided by STAR error trend  data. VBA established in-process reviews to help identify and prevent  claim development errors based on medical examination and opinion- related errors, which it described as the most common error type. More  recently, VBA has added two more common error types—incorrect rating  percentages and incorrect effective benefit dates—to its in-process  review efforts. VBA officials stated that they may add other common error  types based on future STAR error analyses.
While regional offices receive a lot of information on accuracy and error  trends, some quality review staff expressed concern that there was too  much information. At the same time, staff in all four offices said that key  supports were not sufficiently updated to help quality review staff and  claims processors efficiently and effectively do their jobs. Staff at these  offices consistently described problems with data systems, central  guidance and training.
Regarding data systems, at the regional office level quality assurance  information is input into three different systems. Staff at all four offices  we contacted said that these systems lack functionality to create  reports on error trends, so they maintain spreadsheets to track  additional information to allow them to assess error trends from their  office’s quality reviews. At the national level, VA central office has  made improvements in reporting capabilities to obtain information on  errors by diagnostic code, but has not made this available to regional  office quality staff.
Regarding guidance, regional office quality review staff also said they  face challenges locating the most current guidance from all of the  information they are provided. Managers or staff at each of the  regional offices we contacted said that VBA’s policy manuals are  outdated. As a result, staff must search numerous sources of  guidance to locate current policy, which is time-consuming and  difficult. VBA officials acknowledged that there are several ways it  provides guidance to regional offices—such as guidance letters;  periodic quality calls (and notes from those calls); various bulletins;  and training materials maintained on VBA’s Intranet site—and that this  could be confusing to staff. VBA officials also noted that they face  challenges in updating the policy manual to ensure it is as current as  possible.
Regarding training, staff in the offices we contacted also said that in  some cases national training has not been updated to reflect the most  current guidance. This makes it difficult to provide claims processors  with the information they need to avoid future errors. For example,  staff from one regional office noted that training modules on one error  prone issue—Individual Unemployability and related effective dates  of benefits— had not been updated to reflect all new guidance, the  sources of which included conference calls, guidance letters, and  Frequently Asked Questions compiled by VBA’s central office. VBA  officials stated that they are continually updating national training to  reflect new guidance, but that it takes time. Further, according to  officials at the regional offices we contacted, VBA restricts regional  offices’ flexibility to tailor course materials to address office-specific  error trends. We will follow up with VBA’s national training office to  discuss challenges to updating training and reasons behind  restrictions on regional offices’ ability to modify training materials.
In conclusion, VBA has made important enhancements to its quality  assurance program, but has missed key opportunities to fully cement its  commitment to quality. Although VBA’s dual approach for measuring  accuracy provides additional information on error trends, which can allow  VBA to better target quality improvement efforts, VBA is producing  imprecise estimates of accuracy that, while not completely reliable, are  being used by program managers to guide improvement efforts. VBA also  missed an opportunity to win the public’s trust when it introduced a new  accuracy measure without full explanation of its meaning and limitations.  At the same time, VBA is expending more resources than needed to  produce its accuracy estimates—resources that could be better used to  achieve more precise estimates or drill down on error trends to guide  improvement efforts. VBA has bolstered regional attention to quality and  national consistency efforts, but several shortcomings—such as excluding  claims worked during overtime from regional office quality reviews, or the  lack of pretesting of consistency questionnaires—may detract from their  overall effectiveness. Moreover, VBA does not systematically track the  impact of these efforts on accuracy rates, again creating a gap in  information that could help focus future quality assurance efforts. Finally,  while VBA has made a concerted effort to leverage and share information  resulting from its national STAR and consistency studies and to  disseminate relevant guidance, VBA has not taken the final step of  centralizing its guidance or promptly updating national training. Claims  decisions are highly complex and subjective, and staff who need to sift  through a patchwork of guidance and training to make those decisions  may be vulnerable to repeating prior errors. As we complete our ongoing  work, we will consider any recommendations needed to address these  issues.
Chairman Miller, Ranking Member Michaud, and Members of the  Committee, this concludes my prepared statement. I will be pleased to  answer any questions that you or other members of the subcommittee  may have.
section_title: GAO Contact and Staff Acknowledgments
paragraphs: For future contact regarding this testimony, please contact Daniel Bertoni  at (202) 512-7215 or bertonid@gao.gov. Key contributors to this  testimony were Michele Grgich (Assistant Director), Carl Barden, David  Chrisinger, Alexander Galuten, Joel Green, Dana Hopings, Vernette  Shaw, Walter Vance, Greg Whitney and Amber Yancey-Carroll.
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