WOOD COUNTY, Wis. (WSAW) - While some veterans are getting their benefits through the Department of Veterans Affairs processed quickly, others are frustrated with the wait times. County veteran service officers said more people than ever are filing because they are eligible through the PACT Act.
The PACT Act was signed into law in August of last year, which allowed veterans exposed to toxic environments during their tours to be eligible for benefits and services. About 18 million veterans around the country are now eligible, including roughly 331,000 veterans in Wisconsin. The PACT Act allowed the VA to add staff to help with the expected influx; it now has more than 29,000 employees.
The White House and VA have touted record processing rates of nearly two million claims in the past year, which is 13% more than the previous record. For some filers, though, there is an additional system -- in some cases -- creating a headache.
In December, 2021, before the PACT Act was signed, the VA Benefits Administration slowly began rolling out a pilot program: an automated decision support system (ADS) that would help process veterans’ disability claims. 7 Investigates requested to interview with the VA numerous times, but it would only respond through email and sent its own Q&A about the system.
“Unfortunately, the program’s got some growing pains,” Rock Larson, the veterans service officer for Wood County said.
A VSO’s role is essentially to be an advocate for veterans when they are trying to receive their entitled benefits and help them navigate the VA system. They are not employees of the VA.
“On rare occasions, things get stuck, because it’s so big and then we can nudge it,” he explained. “But we can’t nudge any of these automated support ones.”
He can see the system’s potential, but noted some issues, and reported them to the Milwaukee Regional Office, which went up the chain of command to Washington D.C.
“In the long run, it’s going to make things better for the VA, and the veteran -- and even us that we’re trying to make sure the VA does their job right for the veteran. But right now it’s got growing pains.”
He said for some people, getting a disability approved is their entrance to enroll in VA health care. “So it’s holding up them getting into good overall health care.”
Here is how VA Press Secretary Terrence Hayes explained it in the emailed Q&A:
Hayes stated the technology uses generative artificial intelligence, or AI, natural language processing, machine learning, and robotic process automation to help review hundreds or thousands of documents that can be part of each benefit claim.
“Using this combination of automation tools enables the rapid review of hundreds – sometimes thousands – of documents to identify, surface, and analyze relevant claim information for claims processors,” he stated.
It extracts the relevant data related to the specific claimed disability, summarizes it, and runs the data through an algorithm to determine if the records are sufficient to decide the claim. If it is, the claim goes to a human claims processor for review. If it determines it is not sufficient, it requests a VA examination.
“VBA utilizes a Verify, Validate, Graduate (VVG) plan, a rigorous, detailed approach to provide effective oversight of the ADS process and ensure the accuracy of the summary sheets used by claims processors to make decisions on Veterans’ claims for disability compensation benefits,” he explained.
The pilot started testing at the Boise Regional Office with only a few claims processors and only for service-connected hypertension. The VA found the pilot to be successful and has been expanding it to include more than 90 conditions, focusing on those related to the PACT Act. Over the last year and a half, it also expanded to other regional offices; two more were added this month for a total of 10 sites across the country now using the AI technology.
Hayes explained that each time the system is implemented at a new site, it goes from a prototype to a pilot phase. After care review and evaluation, the condition may be graduated to national deployment. He said the goal is to automate 90% of the claims volume over the next year and a half.
For the 2023 fiscal year, more than 100,000 automated claims were completed; 85% were related to toxic exposure. He stated veterans received an initial decision 20 days faster with automation compared to when claims were processed in the traditional way. The system has ordered more than 20,000 exams, meaning the claims did not have sufficient records to make a decision on the claim using AI.
Claims processors “touch” automated claims 20% less than traditional processing, Hayes said, allowing for more claims to be processed and increasing customer service.
While all of this data looks positive, county VSOs are finding a mix of claims that are speedy and claims that are longer and more problematic.
“It will all go back to the date of the original claim, but right now, it might be 200 days old when the average claim for the VA back in June was 107,” Larson noted.
The current posted processing average nationally is about 103 days for claims, generally. The average PACT Act claim takes about 153 days.
VSOs say they try to make each claim as concise as possible and use a variety of different strategies to avoid delays and appeals.
“I know some are easy and some are harder, I will submit a claim for the easy one, which will get them into the door and the benefits, other benefits. And then the day after I submit that claim, I’d submit what’s called an intent to file which says I’m going to file a different claim. And I’m gathering the evidence to make it a better package for the VA to decide,” Larson explained.
He continued that he is noticing that if a veteran’s claim falls under one of the conditions that are processed in the AI system, any other claims after that are paused. The VA denied that.
“Work in progress, and it happens to your work that’s in progress,” Larson stated, “it’s disconcerting.”
Two of those claims are Jerry Zehrung’s.
“There was snow on the ground when I filed the intent to file. It was springtime when the stuff was filed. And as of now, an AI program has determined that I will be put into limbo,” Zehrung listed as the timeline of his claims. He was not sure of the exact dates, but the intent to file was submitted in January and the full filing happened in April.
He is a Navy Seabee who served during the Gulf War.
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“Was I exposed to burn pits? Yes, I was, was I exposed to smoke from oil fires? Yes, I was. Was I exposed to-- potentially this would be controversial, but potential nerve agent situations in the theater that I was deployed in? Yes, I was.”
He has had problems in the past getting the care and benefits he needs.
“For the first couple of decades after Shield Storm, that was all either ignored or denied, of course, until satellite imagery proved otherwise. Then it was understood and they categorized it all under one acronym: the Gulf War Syndrome. So, all these random conditions, they just grouped it all into that. And the problem of that is because there were no real concrete set-in-stone definitions, lots of things were denied or they’d say, there’s no correlation between this and that.”
He is grateful that the PACT Act has lowered the burden of proof needed for certain conditions, especially when he has been told his health records from his service time no longer exist.
“They’re saying it’s presumed if you’re there, you’re exposed. That’s awesome.”
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He is frustrated, though, with the length of time it has taken for his claims to process, and the lack of communication from the VBA about the status of his claims. They are frustrations Larson has heard from other veterans.
“The program wasn’t set up to send a veteran a letter, say, ‘Hey, we got your claim, and we’re working on it,’” Larson said.
While veterans can check their claim’s status online, not all veterans have access to the internet or the skills to navigate the program. Zehrung found it complicated and was not able to figure out how to get in. VSOs, while willing to help veterans learn how to use the online portal, say they have been swamped with veterans filing claims for the PACT Act.
Zehrung received his determinations about two weeks ago, after he had already interviewed with 7 Investigates. It took about eight to nine months for his claim to be processed. One was granted, the other denied.
Other VSOs who spoke with 7 Investigates said their claims take anywhere from four to six months, which fits the VA’s current processing timeline. It depends on the complexity and whether compensation and pension exams are required.
Oneida County’s VSO, Tammy Javenkoski, said she has had to file more appeals to VA decisions now compared to a decade ago, explaining that she has seen more mistakes.
“Back in 2013, I rarely filed appeals,” she said. “In fact, I looked up my numbers, and that year I filed 55 claims but only two appeals. Today, I constantly file appeals. As an example, in September 2023, I filed 12 service-connected disability claims and six appeals. Granted, the appeals weren’t for the 12 claims I filed but it gives you an example of how many claims I file vs appeals I file.”
The VA stated processing times are significantly faster than in 2013, 217 days faster.
The Q&A email only stated positives about the modernized system, but in conversation with an employee who worked on that system, they acknowledged that there have been some challenges. Again, 7 Investigates requested an interview to get more questions answered, but the VA has not agreed to that at this point.
Below is the full Q&A from Press Secretary Hayes:
Is automation delaying Veteran claims under the PACT Act? Is it preventing Veterans’ non-PACT Act claims from being processed?
Whenever a Veteran applies for their earned benefits, our goal at VA is to deliver those benefits as quickly as possible. As a part of this effort, VA has begun to use automation in very limited cases to process claims – but this technology is increasing the claims processing speed for Veterans, not slowing it down. It’s also important to note that a claim being processed with the assistance of automation does not halt other claims for that individual from being processed.
In fact, thanks to recent increases hiring and productivity – including increased use of automation – VA is currently delivering more benefits, more quickly, to more Veterans than ever before in our nation’s history:
· In fiscal year, 2023, VA has processed 1.93 million total Veteran claims — surpassing last year’s all-time record total by 13.3%. This marks the 3rd year in a row that VA has set a record for most claims processed in our nation’s history. To put this increase in speed into context, VA has processed more than 8,000 Veteran claims in a day 104 different times this year. Before this year, VA had only processed more than 8,000 claims in a day only six times in VA’s history.
· In total, VA has awarded more than $151 billion in benefits to Veterans in fiscal year 2023, an increase of 16.5% over last fiscal year and the most in history.
· Veterans have filed more than 1 million claims under the PACT Act. VA has processed more than 551,000 of these claims, granting 77.9% of them and awarding more than $2.2 billion in earned benefits to Veterans and survivors.
· Additionally, VA is now processing claims 217 days faster than in 2013 and 15 days faster than in 2022, meaning that Veterans are receiving their earned benefits more quickly than in past surges.
VA will continue to use every tool at our disposal to deliver Veterans their earned benefits as quickly as possible.
Why is VA using automation to help with benefits claim processing?
Response: These tools enable VBA to make faster and more consistent decisions for Veterans and improve the employee’s work experience.
VBA automation technology, known as Automated Decision Support (ADS), focuses on administrative activities such as searching and compiling pertinent records, which frees up the time of claims processors for more complex and analytical duties. ADS technology is comprised of multiple tools and technology capabilities. We are leveraging natural language processing (NLP), machine learning (ML), robotic process automation (RPA) and generative artificial intelligence (AI). Using this combination of automation tools enables the rapid review of hundreds – sometimes thousands – of documents to identify, surface, and analyze relevant claim information for claims processors. When a claim is received, it is run through the rules engine to determine if it qualifies for automation. If it qualities for automation, ADS using optical character recognition (OCR) and natural language processing, scans all documents contained in the Veteran’s electronic claims folder (eFolder) as well as Veterans Health Administration records. The tool then extracts relevant key data related to the specific claimed disability and summarizes the information in a clear and concise format. At the same time, the data is run through a rules-based algorithm to determine if evidence of record is sufficient to decide the claim.
· If the evidence is sufficient, ADS routes the claim to a claims processor for review.
· If the evidence of record is not sufficient, ADS automatically requests a VA examination through the VBMS Exam Management System.
With respect to infrastructure, the current solution developed uses a combination of data center and cloud architecture.
It sounds like you started off with pilot projects. How did you deploy it? Can you describe the implementation process? Is the project complete or is this a continual work-in-progress where you continue to make improvements/add more automation in different areas?
Response: VBA utilizes a Verify, Validate, Graduate (VVG) plan, a rigorous, detailed approach to provide effective oversight of the ADS process and ensure the accuracy of the summary sheets used by claims processors to make decisions on Veterans’ claims for disability compensation benefits.
In December 2021, VBA took the first step of making the ADS concept a reality by initiating proof-of-concept testing at the Boise Regional Office. Proof-of-concept is the initial stage where the feasibility of the technology concept is tested. The goal was to create a working prototype of automation capability that proves the feasibility and advisability of the concept and how it could work in a real-world setting. To ensure the proof-of-concept accurately captured the intended functionality and provided a minimum level of performance in a real-world setting, VBA’s Office of Automated Benefits Delivery established a controlled testing environment at the Boise RO limiting the deployment of ADS to only a select number of claims processors. Additionally, VBA restricted the claim type eligible for automation to only claims for increased evaluation in service-connected hypertension. VBA selected hypertension because the VA Schedule of Rating Disabilities (VASRD) contains clear and objective criteria to evaluate this condition using the Veteran’s diastolic and systolic blood pressure readings as well as the need for continuous medication for control.
The proof-of-concept testing performed in December 2021 was successful, and we expanded functionality to additional conditions, focusing on those related to the PACT Act. Functionality was deployed initially to the Boise RO, then expanded to prototype stations over the course of approximately a year. (VBA currently has eight prototype stations + two additional sites (Roanoke & Lincoln) coming in October for a total of 10 sites)
After ADS functionality is refined during the prototype phase, it moves to the pilot phase. An additional eight ROs are designated as pilot sites and the technology is assessed and validated to ensure it performs as intended. After careful review and validation, an ADS condition may be graduated to national deployment.
Building on the overall success of ADS, VBA is constantly working to improve and expand the role of automation in the claims process. Back in December 2021, automation was limited to only claims for increase in service-connected hypertension. Today, we have expanded ADS automation to over 90 diagnostic codes, additional types of claims (initial service-connection, presumptive service-connection, and pre-discharge claims) with the goal of automating 90% of the claims volume within the next 18 months.
What have the overall benefits been? It sounds like you can process claims much faster. Are there some statistics I can use?
Response: The ADS program has focused on getting decisions to Veterans faster, reducing unnecessary examinations and manual examination ordering, and improving claims processing for employees.
Some key highlights from the ADS program:
· For fiscal year 2023 to date, VBA has completed over 100,000 automated claims. 85% of these claims are related to toxic exposure (PACT Act).
· Veterans receive an initial decision approximately 20 days faster with automation compared to claims processed using the traditional process.
· VBA has automatically ordered over 20,000 exams through ADS’ automated exam ordering process.
· Claims processors “touch” automation claims 20% less than traditional processing. The streamlined process allows VBA to process more claims and enhances customer service for Veterans who receive much needed benefits quicker.
Can you give me a “before” and “after” snapshot? How did you process claims before, and how do you process claims now? I’m asking this because I want to make sure I understand where you improved the technology?
Response: Traditionally, claims processors manually collect evidence by accessing separate databases for a Veteran’s treatment records and service information. To accomplish this, claims process must log into the identified system, identify pertinent records, and manually upload them to the Veteran’s eFolder.
Once all pertinent records are obtained; the claims processor must open each document and review – sometimes thousands of pages – to locate information related to the claimed condition. From there, they make a determination whether sufficient evidence is available to decide the claim, or if an examination is needed.
For ADS claims, automation accesses, gathers, and uploads pertinent evidence from the various repositories and scans the evidence, identifying pertinent data and creates a summary document with the information displayed in a clear and concise format. Technology also assesses the evidence summarized and routes the claim to the expected appropriate next step.
In both scenarios, VBA recognizes that our claims processors are our most valuable asset and they maintain full adjudicative discretion in making claim decisions. ADS equips them with industry-leading tools and solutions to optimize their performance. ADS is not end-to-end automation. Instead, it focuses on the administrative activities leading up to the claim decision that allows claims processors’ to have more time for complex and analytical duties.
VA website Benefit Rates - Compensation (va.gov) (Under the “Learn More about VA Compensation Rates” section) provides a thorough explanation of combined ratings calculation which is codified under title 38. Specifically, Title 38 Chapter 1 Part 4 Subpart A § 4.25.
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