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How We Can Fix the VA Appeals Process


Earlier this year, Secretary of Veterans Affairs Bob McDonald called for a massive overhaul of the veterans’ benefits appeals process, calling it “cumbersome,” “clunky,” “antiquated” and “confusing.” According to its highest official, the VA appeal process is failing our nation’s veterans.

It is difficult to disagree with Secretary McDonald’s assessment. While the VA claims backlog has decreased by more than 80 percent since 2013, the appeals backlog has more than doubled in the past 10 years – currently totaling some 440,000 appeals. Final decisions on appeals can take three to four years to complete. Secretary McDonald has stated that by 2020 he wants appeals decided in less than one year’s time and indicates he needs legislation to make that happen.

A Need for Congressional Action

The potential change to the VA appeals process was acknowledged to a degree in President Obama’s FY 2017 Budget Submission for VA. The funding request proposes several legislative changes, including closure of the evidentiary record, eliminating the de novo review that usually occurs in the Veterans Benefits Administration before jurisdiction over an appeal is turned over to the Board of Veterans Appeals, and eliminating the option for personal hearings. All of the measures aim to facilitate faster appeals decisions.

The VA argues that with this legislation, the infusion of an additional $46.2 million in funding, and 242 new full time employees in 2017, it can begin to reduce the appeals backlog to the extent that by 2022 – with the ability to add even more employee resources – it can reduce the timeframe for adjudicating appeals to approximately 131 days.

Yet even with additional resources, McDonald has stated the appeals program needs more substantial change. He recently convened a group of veterans’ advocates to hammer out a legislative proposal that would overhaul the appeals process, seeking buy-in from those stakeholder groups before submitting a formal plan to Congress.

Other Opportunities for Change

Enacting legislation and instituting specific guidelines that allow for more improvements within the system will be fundamental to mitigating the appeals crisis. Generally, however, most experts agree that insufficient resources are at the heart of the challenge.

One approach that has gained significant support from veterans’ service organizations suggests that Congress legislate a pilot program called Fully Developed Appeals. Under this program a veteran could agree to forego a hearing and have his or her case transferred immediately to the appeals board, eliminating several processing steps at the regional level and expediting the appeal process for all stakeholders. Using the FDA approach would be voluntary, so veterans would retain the ability to opt out of it at any time and revert to the traditional process. But even FDA advocates have noted that the program would not be appropriate for a majority of new appellants, who will likely continue to use the traditional process.

While it is apparent that the VA and those most familiar with the various steps of the appeals process know that there are significant inefficiencies in the system, not all of those inefficiencies are grounded in statute. The appeals process used by the Centers for Medicare and Medicaid Services and its network of external resources may offer some interesting insights on how to address the issue.

Lessons from Medicare

Certainly there are obvious differences between the Medicare system and veterans’ benefits, but there are also similarities. Both systems involve significantly complex health-related decisions, and veterans are impacted by both systems. In terms of magnitude, Medicare covers some 44 million beneficiaries versus the estimated 21.8 million veterans potentially served by the VA. Both systems administer large sums of federal funding, and are expected by the Congress and the American people to do so properly. 

Medicare also has a complex appeals system involving five levels of appeal. And, while it may be argued that the CMS system is also “clunky,” it is worth noting that it typically meets its restrictive timelines. In 2013, the system processing appeals for Medicare Parts A, B, C and D and DME (Durable Medical Equipment) decided more than 54,000 cases per month without accumulating a backlog and was able to process approximately 75 percent of the appeals in three days or less.

There are a few key reasons for this difference. Medicare appeals reviewers are held accountable to definitive decision timelines throughout the process (often 60 days, but no more than 180). Medicare contractors administering the program are required to strictly adhere to the deadlines set by CMS and must be able to adjust workflow management and staffing to accommodate fluctuations in volume. In addition, each level of the Medicare appeals process involves a new independent appeal, which prevents any one part of the system from creating bottlenecks.

Working Together to Improve Outcomes

The need is clear: VA must have efficient, knowledgeable and reliable support to help deliver fast and accurate appeal decisions that meet the needs of both the agency and veterans.

Appeals administrators at CMS and other industry leaders have valuable insight gained from the Medicare appeals process that could be readily transferred to the VA. CMS uses Independent Review Entities (IREs) and Qualified Independent Contractors (QICs) at various appeal levels and for different Medicare program components, and those private sector organizations with hands-on experience administering federal appeals processes can also likely contribute best practices and help achieve better outcomes (e.g., achieving timely and accurate decisions that reduce the number of reconsiderations) while managing the appeals volume in a less costly, more efficient way.

This is the time for the public and private sectors to work together to enact change that will drive systemic improvements and help modernize the VA appeals environment.

Thomas Romeo is president and general manager of MAXIMUS Federal.

Thomas Romeo is president of MAXIMUS Federal Services.

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