Report Summary

Title: Review of Claims Processing Actions at Pension Management Centers
Report Number: 15-04156-352 Download
Issue Date: 11/1/2017
City/State: Philadelphia, PA
St. Louis, MO
Milwaukee, WI
St. Paul, MN
VA Office: Veterans Benefits Administration (VBA)
Report Author: Office of Audits and Evaluations
Report Type: Audit Report
Release Type: Unrestricted

Pension Management Centers (PMCs) provide benefits and services to some of the most vulnerable veterans and survivors. OIG’s review focused on rating decisions that addressed original pension benefits and claims processing actions related to Medicaid-covered nursing homes.

OIG found St. Paul PMC staff failed to order general medical examinations to support veterans’ pension claims—denying 88 percent of those requiring rating decisions in 2015. St. Paul management and staff misinterpreted VBA’s guidance on requesting general medical examinations to support pension claim and VBA lacked oversight for identifying inconsistent rating practices among PMCs. Consequently, claims processed by the St. Paul PMC were denied more frequently when compared to Milwaukee and Philadelphia PMCs.

Claims processors at the PMCs also delayed and inaccurately processed pension benefits reduction cases whenever beneficiaries resided in Medicaid-covered nursing care facilities. Delays and inaccuracies found in 1,900 of 2,800 Medicaid benefits reduction cases completed in 2015 resulted in an estimated $6.9 million in improper benefits payments. If the PMCs continue to delay and inaccurately process these adjustments, VBA will pay approximately $34.5 million in improper benefits from CY 2016 through CY 2020. Generally, VBA did not prioritize this workload, performance measures for Medicaid-covered nursing home care reduction cases were lacking, and PMCs did not provide training specific to Medicaid-covered cases.

OIG recommended that VBA clarify guidance and provide training on ordering general medical examinations to support original pension claims, review denied pension claims to determine whether examinations were required and implement a plan to ensure rating consistency. We also recommended that VBA prioritize benefit reduction actions and develop workload performance measures for benefits reduction cases associated with Medicaid-covered nursing home.