Updated Sep 23, 2024
In This Section |
This section contains the following topics: |
1. Purpose
Introduction |
This topic describes the purpose of national quality reviews, including |
Change Date |
August 17, 2021 |
3.B.1.a. Methods to Determine and Improve Quality |
Office of Administrative Review Quality Assurance (OAR QA) provides national quality reviews as effective and positive action to improve quality levels for legacy appeals and higher-level reviews (HLRs) of compensation and pension claims. The following topics vary, and describe methods used to determine quality levels and improve quality on an organized technical basis. The methods may consist of
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3.B.1.b. OAR QA |
OAR QA is the Veterans Benefits Administration’s (VBA) national method for measuring national quality reviews on HLRs completed at decision review operations centers (DROCs) and special mission sites, and on legacy appeals at the Washington, District of Columbia, DROC (DROC D.C.). VBA includes these results in the regional office (RO) Director’s Performance Dashboard. |
3.B.1.c. Quality Review and the DROC |
The quality review system assists managers in monitoring the level of service to claimants. This system requires that OAR QA performs quality observations and reviews on a continuing basis in all areas of DROC operations.
Note: The quality review system does not require that evaluations encompass every work team within the DROC. |
2. Quality Review Sampling
Introduction |
This topic describes the quality review sampling procedures, including |
Change Date |
July 15, 2024 |
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3.B.2.a. Selection Procedures |
Each month, the Office of Performance Analysis and Integrity (PA&I) generates a list of end products (EPs) selected for national quality review for delivery to OAR QA via the Quality Management System (QMS). PA&I randomly samples these EPs from those completed during the previous month, which are identified using the transaction date.
The total monthly sample for each DROC includes both rating and non-rating EPs, allowing assessment of all essential claim adjudication actions. |
3.B.2.b. Annual Sample Sizes |
PA&I uses a statistical formula that considers both historical accuracy and workload values when determining valid rating and non-rating sample sizes at each DROC. |
3.B.2.c. Rating EP Review |
Rating EPs are those associated with original claims, supplemental claims, claims for increased evaluation, HLRs, pension, and appellate issues. They involve issues that are generally more complex and subject to greater scrutiny by stakeholders. Review of a rating EP is not limited to rating actions, but rather assesses the accuracy of all adjudicative actions leading up to the completion of that EP.
Compensation and pension rating EPs subject to national OAR QA review are:
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3.B.2.d. Non-Rating EP Review |
Non-rating EPs are those that require development, review, and administrative decision or award action, but generally not a rating decision. However, rating decisions necessary to complete action on a non-rating EP are also subject to review.
Compensation and pension non-rating EPs subject to national OAR QA review are:
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3. Quality Review Structure
Introduction |
This topic describes the quality review structure, including
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Change Date |
July 6, 2020 |
3.B.3.a. Quality Review Checklists |
The OAR QA process requires a comprehensive review and analysis of all processing elements associated with a specific claim or issue. OAR QA designs quality review checklists to facilitate consistent structured reviews. |
3.B.3.b. General Guidelines for BE Quality Reviews |
Generally, OAR QA will record a benefit entitlement (BE) error when an action taken violates current regulations or other directives and affects outcome or has the potential to affect outcome.
Examples of outcome-related deficiencies include, but are not limited to
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3.B.3.c. Grace Period for National Quality Errors |
OAR QA will provide a 30 calendar day grace period on any new claims adjudication procedural manual changes before officially citing a national quality error. OAR QA counts the 30 calendar day grace period as 30 calendar days from the published date of the corresponding Department of Veterans Affairs (VA) Key Changes document.
Example: OAR publishes a VA Key Changes document showing new claims adjudication procedural manual guidance on January 20, 2020, so the grace period includes the next 30 calendar days. OAR QA will cite BE errors based on the new guidance with EPs cleared on and after February 19, 2020. |
3.B.3.d. Procedural Deficiencies |
Procedural deficiencies generally do not rise to the level of BE errors. OAR QA usually records these deficiencies as
Note: If OAR QA identifies an error with an issue not related to the EP under review, OAR QA will record that error as a comment. |
3.B.3.e. Deselections |
To ensure a statistically valid sample, OAR QA will make every effort to perform a quality review on all cases identified on the OAR QA call-up list. In rare instances, when a review may not be appropriate, OAR QA will deselect the case if there is no other alternative. |
3.B.3.f. Error Citations When Corrective Action Has Already Been Taken |
OAR QA will not cite any errors in cases of EPs called-up for assessment where DROCs discovered the error(s), made proper correction(s), and cleared the correcting EP before OAR QA selected the case, regardless of whether the claimant received incorrect notification.
However, if the DROCs establish a correcting EP and it is still pending, or if the DROC previously established the correcting EP but cleared it with final corrective action on or after the QMS “Run Date” (the date PA&I pulls the case in QMS for national quality review), OAR QA will cite the error(s) made on the EP under assessment. Please note that OAR QA conducts assessments on any DROC corrective action(s) taken. |
3.B.3.g. Reviewing All Evidence Associated With a Claim |
OAR QA must be thorough in their review of each issue. It is not sufficient to simply review a decision and the letter of notification. OAR QA must review all the evidence associated with a claim to ensure that the DROC properly adjudicated all issues (within the scope of the claim). |
3.B.3.h. Clearly Identifying and Explaining Errors |
OAR QA must provide sufficient narrative to clearly identify and explain the error cited. In most cases, the explanation for the error(s) found should be sufficient to allow a reader to understand the problem area(s) without reviewing the claims folder. If the correct action was something other than the obvious converse of the erroneous action, then OAR QA must make a statement indicating what the correct action would have been. |
3.B.3.i. Appropriate Citations |
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3.B.3.j. Cascade Effect |
Based on the logical progression of the quality review checklists, when OAR QA identifies an error, then generally all subsequent processing related to that issue will also be in error. OAR QA refers to this pattern of derived error as a cascade effect.
Examples:
Issue-based reviews focus on the accuracy of specific diagnostic codes (DCs), so OAR QA modifies the prohibition of cascading errors for issue-based reviews that exists for traditional claim-based reviews. With a claim-based review, an incorrect grant results in a C1 error, with no further consideration or errors concerning the evaluation or effective date of that erroneous grant. For issue-based reviews, OAR QA needs more data regarding the complete decision for each DC. An issue-based review requires that OAR QA determines if a disability was adequately evaluated, even if it was erroneously granted. This modification to the normal procedures generally only applies to incorrect grants, as there will be no evaluation or effective date for an incorrect denial or missed issue, though incorrect evaluations could also have incorrect effective dates. |
4. Recording and Analysis of Review Results
Introduction |
This topic describes procedures for recording and analysis of review results, including |
Change Date |
December 21, 2023 |
3.B.4.a. Availability of Review Results |
VBA maintains results of national reviews in QMS. All accuracy reports within the databases include DROC-specific and national results.
OAR QA publishes
OAR QA updates the national quality reports monthly. OAR QA reports non-rating accuracy on a claim-based level, and rating accuracy on an issue-based level. In accordance with standard statistical practice, VBA reports weighted accuracy results.
Note: VBA generates DROC performance ratings during September using the most current available data. For OAR QA reports, the most current data available in September will generally be the twelve-month cumulative report for the period from September through August. This represents the performance year. |
3.B.4.b. BE Categories |
BE review categories include
Note: The BE accuracy rate is the official measure of claims processing accuracy and is the result used for performance measurement purposes. |
3.B.4.c. Decision Documentation/ Notification Categories |
Decision Documentation/Notification categories include review of the decision and the notification sent to the claimant. |
3.B.4.d. Issue-Based and Claim-Based Rating Reviews |
OAR QA conducts issue-based reviews in conjunction with the traditional compensation and pension rating claim-based reviews.
OAR QA conducts an issue-based review and a claim-based review on every compensation and pension rating claim submitted for national quality review. |
3.B.4.e. Task-Based and Claim Based Non-Rating Reviews |
OAR QA conducts task-based reviews in conjunction with the traditional compensation and pension non-rating claim-based reviews.
OAR QA conducts a task-based review and a claim-based review on every compensation and pension non-rating claim submitted for national quality review. |
3.B.4.f. Claim-Based Accuracy |
Claim-based reviews assess accuracy based on the entirety of the claim. If one BE element of the claim is incorrect, OAR QA marks the claim as incorrect. OAR QA calculates claim-based accuracy as the percentage of cases considered correct out of the total number of cases reviewed. |
3.B.4.g. Issue-Based Accuracy |
OAR QA measures issue-based accuracy by individually evaluated medical conditions within a rating-related compensation claim.
Each issue must go through the same claims process that represents a series of completed tasks, such as development, research, adjudication, and decision, that could result in a specific benefit for a Veteran or survivor. More importantly, issue-based accuracy provides the VA the opportunity to precisely target those medical issues where adjudication is most error-prone and DROCs need additional training. OAR QA provides DROCs with the total number of issues reviewed, and the total number of issues in error, on every issue-based review.
Note: OAR QA calculates issue-based accuracy as the percentage of issues considered correct based on the total number of issues reviewed for any review period. |
3.B.4.h. Task-Based Accuracy |
OAR QA measures task-based accuracy by the individual tasks executed within a non-rating compensation claim.
OAR QA independently assesses each task. Task-based accuracy provides the VA the opportunity to precisely target those adjudicative actions where adjudication is most error-prone and DROCs need additional training.
Note: OAR QA calculates national task-based accuracy as the percentage of tasks considered correct based on the total number of applicable tasks reviewed for any review period. |
3.B.4.i. Strategic Oversight and Analysis Reviews (SOARs) |
DROCs must review and address national errors and all problem quality areas in the next periodic Strategic Oversight and Analysis Review (SOAR) covering the quality of claims actions.
Reference: For more information about SOARs, see M21-5, Chapter 1, Section C. |
5. Reporting the Correction of National Error Citations
Change Date |
December 21, 2023 |
3.B.5.a. Outcome of National Reviews |
DROCs will learn the outcome of an OAR QA assessment that results in an error via QMS.
In QMS, the “notified date” shown on the correction record is the date OAR QA notified the DROC of the error in QMS. |
3.B.5.b. Clearing DROC vs. Correcting DROC |
The clearing DROC is the DROC that cleared the EP identified for national quality review.
The correcting DROC is the DROC that OAR QA identifies as responsible for taking the corrective action(s) documented during national quality review. OAR QA will identify the correcting DROC by its DROC number at the beginning of each error narrative. The correcting DROC is responsible for all corrective actions on a claim, even for those errors caused by a different DROC. |
3.B.5.c. Identified Responsible Employee |
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3.B.5.d. Action to Take Following Notification of a National Error |
QMS will route the error correction record(s) to the clearing DROC in all cases. The national error correction record(s) will populate in the clearing DROC’s QMS Coach Team queue. The clearing DROC’s Quality Review Team (QRT) coach, or their designee, will review the national error cited to determine if a reconsideration request will be submitted.
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3.B.5.e. EP 930 Establishment Requirements |
The DROC must establish and clear the appropriate EP 930 for any claim with a cited error where the DROC previously cleared or cancelled the EP, even those that do not require a rating or award correction. OAR QA has established this requirement to ensure data integrity. OAR QA will monitor completion of error corrections using these EPs.
DROCs must establish EP 930s with the National Quality Error claim label and the National Quality Review special issue indicator.
Notes:
Requests for Reconsideration:
References: For more information on the requirement to enter a VBMS note and how to enter one, please see |
3.B.5.f. Corrective Actions and Reporting |
The identified correcting DROC must take corrective action on all national quality errors.
DROCs must complete all actions to initiate the correction within 30 days of notification of the error. If OAR QA cites multiple errors on a case, DROCs must execute all actions to initiate the correction of all errors.
When DROCs initiate all corrective actions, OAR QA considers the error correction “complete” for reporting purposes.
If the corrective action needed is development, rating correction, or award promulgation, once executed, DROCs must check the “Error Corrected” box in QMS and remove the DNR special issue indicator. NWQ will recall the EP and redistribute it when the EP is actionable for subsequent claim processing by any DROC based on capacity.
If no further action is needed after the corrective action is taken and reviewed by a supervisor for completion, the DROC should clear the EP 930.
If the only corrective action is to provide training and/or feedback to the responsible employee, once a supervisor has confirmed the training and/or feedback has occurred, the DROC should enter a VBMS note and clear the EP 930. |
3.B.5.g. Time Limit for Corrective Action |
The correcting DROC is required to initiate and report the corrective action taken for each error within 30 days of notification of an error. |
3.B.5.h. Indicating When Re-Adjudication Is Not Appropriate |
In cases which re-adjudication may be inappropriate, the correcting DROC must indicate why re-adjudication is not appropriate and describe other action taken, such as training or feedback provided to the identified responsible employee, when updating the error correction record in QMS. The clearing DROC may also indicate that the DROC requested reconsideration. If OAR QA denies the reconsideration request, the DROC must make and appropriately report the corrective action. |
3.B.5.i. Clearing DROC’s Quality Review Team (QRT) Coach’s Responsibility for Corrective Action |
If the clearing DROC’s QRT coach, or their designee, reviews and determines an error does not warrant a reconsideration request, they must identify the DROC responsible for corrective actions using the DROC number annotated at the beginning of the error narrative(s).
The error will remain in “pending notification” status, and this action also confirms that the clearing DROC has reviewed and accepted the error. |
3.B.5.j. Correcting DROC’s QRT Coach’s Responsibility for Corrective Action |
The table below outlines the correcting DROC’s QRT coach’s responsibility for corrective action to include
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3.B.5.k. Responsible Employee’s Responsibility for Corrective Action |
The table below outlines the responsible employee’s responsibility for corrective action.
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3.B.5.l. Responsible Employee’s Coach’s Responsibility for Corrective Action |
The table below outlines the responsible employee’s coach’s responsibility for corrective action.
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3.B.5.m. Correction of Local Quality Reviews |
The general procedures for correction of local quality reviews are the same as the procedures for correction of national quality reviews. If the EP associated with the claim reviewed for local quality is still pending, then an EP 930 is not necessary. Corrective action to include mentoring and entering a VBMS note should be conducted under the existing EP.
Exceptions:
References: For more information on
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6. Reconsideration Requests
Introduction |
This topic describes reconsideration request procedures, including |
Change Date |
July 15, 2024 |
3.B.6.a. Formally Addressing Disagreements |
OAR QA anticipates that occasionally DROCs may receive a quality review error they disagree with, or believe the explanation offered is unclear or inadequate. OAR QA must formally address any disagreement over the correctness of an error citation. |
3.B.6.b. Requesting Reconsideration |
If a DROC believes an error call is erroneous, the clearing DROC may request a formal reconsideration by OAR QA. To request a formal reconsideration of an error, the clearing DROC must submit the request through QMS. |
3.B.6.c. Time Limit for Reconsideration Requests |
DROCs must submit reconsideration requests within 10 business days of the “created date.” The 10 business days begin the day after the “created date.”
OAR QA will not accept requests for reconsideration that are not received within the established time limit. If not submitted within 10 business days, OAR QA will reject the request and return it to the clearing DROC’s QMS Coach Team Queue for action.
Note: DROCs may request an exception to the 10-day period by contacting OAR QA at vbawasoarqualitytrn@va.gov. |
3.B.6.d. Misclassified Errors |
OAR QA will not remove BE errors on reconsideration merely because OAR QA misclassified the error on the OAR QA Checklist (e.g., B2 vs. C1) when a legitimate BE error exists. Removing known errors on cases included in the nationally mandated sample is contrary to sound quality control principles and provides stakeholders with inaccurate data.
Notes:
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3.B.6.e. Formal Reconsideration Requests |
The formal reconsideration request must include pertinent
DROCs must submit reconsideration requests via QMS. OAR QA will return the reconsideration decision in QMS. When a reconsideration results in a withdrawal or change in the error status, OAR QA will update QMS to reflect the decision. OAR QA will maintain and monitor results of reconsideration requests in QMS to ensure the effectiveness and integrity of the review process. |
3.B.6.f. Secondary Reconsideration Requests |
DROCs have the right to seek additional reconsideration from OAR QA on upheld BE errors.
DROC Managers or Assistant DROC Managers must submit secondary reconsideration requests
Important: OAR reserves the right to alter this timeline at the end of the fiscal year reporting period to ensure timely final quality reports. OAR QA will withdraw the error if the OAR Assistant Director disagrees with the action taken by OAR QA. In such cases, the OAR QA Chief will return the case to OAR QA to amend the decision as directed and will provide feedback to ensure that OAR QA does not cite such errors in the future. |
7. National Compensation/Pension Rating Quality Review Checklist
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Introduction |
This topic includes the |
Change Date |
December 21, 2023 |
3.B.7.a. National Compensation/ Pension Rating Quality Review Checklist |
The following is a sample of the National Compensation/Pension Rating Quality Review Checklist.
FOR EACH “NO” ANSWER RECORDED, PROVIDE A BRIEF NARRATIVE SUMMARY OF THE ERROR AND STATUTORY, REGULATORY, OR MANUAL REFERENCES. |
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3.B.7.b. Instructions and Guidelines for Rating Review |
OAR QA developed these instructions and guidelines to promote consistency and uniformity in the review of cases selected for OAR QA assessment. The checklist will be used for both Compensation and Pension National Quality Reviews. Use these instructions/guidelines in conjunction with the National Compensation/ Pension Rating Quality Review Checklist.
For the purpose of measuring technical accuracy under OAR QA assessment, OAR QA considers a case either “accurate” or “in error,” for the claim-based review. The claim-based review is separate and distinct from the issue-based review, in which OAR QA only considers the specific reviewed issue as either “accurate” or “in error.” For claim-based accuracy, OAR QA will consider a case “accurate” when OAR QA answers questions 1 through 8 of the National Compensation/Pension Rating Quality Review Checklist as either “YES” or “NO” but no payment adjustment is required.
For each case reviewed, OAR QA must complete and answer all questions on the National Compensation/Pension Rating Quality Review Checklist. A “YES” response indicates that the DROC accurately completed the activity associated with the question. A “NO” response indicates that the DROC completed the activity associated with the question “in error.” OAR QA must indicate “N/A” if the question is not applicable to the case under review, or if OAR QA previously recorded a “NO” response for the only issue subject to review. OAR QA is required to provide a narrative summary with statutory, regulatory, judicial, or manual references for any “error” or “NO” answer recorded.
The general guideline is that OAR QA will record an error when an action is taken that violates current regulations or established policies. Examples of outcome-related deficiencies include, but are not limited to, errors that result in an overpayment or underpayment to a claimant and deficiencies that would result in a remand from the Board if not corrected.
OAR QA does not record procedural deficiencies as BE errors. OAR QA records these deficiencies as decision documentation/notification or administrative comments and either the DROC must take corrective action on these deficiencies or submit a timely reconsideration request. OAR QA will not record a judgment or a difference of opinion reflecting a possible better practice or solution as a comment under question 16. If OAR QA identifies an error with an issue not related to the EP under review, then OAR QA also records that error as a comment under question 15. |
3.B.7.c. Rating Review Elements |
The National Quality Rating Review is, generally, focused on EPs associated with original claims, supplemental claims, claims for increased evaluation, HLRs, appellate issues and pension claims. OAR QA will review other issues such as dependency, income, net worth, withholdings/recoupments, incompetency, etc., when applicable to a case selected under National Quality Review, as part of that EP.
The following is a list of explanations of the questions of the National Rating Quality Review Checklist.
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8. National Compensation Non-Rating Quality Review Checklist
Introduction |
This topic includes the |
Change Date |
December 21, 2023 |
3.B.8.a. National Compensation Non-Rating Quality Review Checklist |
The following is a sample of the National Compensation Non-Rating Quality Review Checklist.
FOR EACH “NO” ANSWER RECORDED, PROVIDE A BRIEF NARRATIVE SUMMARY OF THE ERROR AND STATUTORY, REGULATORY, JUDICIAL OR MANUAL REFERENCES. NOTE: DOC ERRORS DO NOT REQUIRE CITATIONS ON THE NATIONAL COMPENSATION NON-RATING QUALITY REVIEW CHECKLIST. |
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3.B.8.b. Instructions and Guidelines for Non-Rating Review |
OAR QA developed these instructions and guidelines to promote consistency and uniformity in the review of cases selected for OAR QA assessment. Use these instructions/guidelines in conjunction with the National Compensation Quality Review Non-Rating Checklist.
For the purpose of measuring technical accuracy under OAR QA assessment, OAR QA considers a case either “accurate” or “in error.” OAR QA will consider a case “accurate” when OAR QA answers all of the questions, with the exception of questions 12 and 13, of the National Compensation Quality Review Non-Rating Checklist as “YES” or “N/A.” OAR QA will consider a case “in error” if the answer to any question is “NO” other than questions 12 and 13.
For each case reviewed, OAR QA must complete and answer all questions on the National Compensation Non-Rating Quality Review Checklist. A “YES” response indicates that the DROC accurately completed the activity associated with the question. A “NO” response indicates that the DROC completed the activity associated with the question “in error.” OAR QA must indicate “N/A” if the question is not applicable to the case under review or if OAR QA previously recorded a “NO” response for the only issue subject to review. OAR QA is required to provide a narrative summary with statutory, regulatory, judicial, or manual references for any “error” or “NO” answer recorded.
The general guideline is that OAR QA will record an error when a DROC action taken violates current regulations or established policies. Examples of outcome-related deficiencies include, but are not limited to, errors that result in an overpayment or underpayment to a claimant.
OAR QA does not record procedural deficiencies as errors. OAR QA records these deficiencies as comments under question 12. However, if the procedural deficiency is severe in nature, OAR QA will record it as an error. OAR QA will record a judgment or a difference of opinion reflecting a possible better practice or solution as a comment rather than an error. If OAR QA identifies an error with an issue not related to the EP under review, then OAR QA also records that error as a comment. |
3.B.8.c. Non-Rating Review Elements |
The following is a list of explanations for the questions on the National Compensation Non-Rating Quality Review Checklist.
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9. National Pension Authorization Quality Review Checklist
Introduction |
This topic includes the |
Change Date |
August 17, 2021 |
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3.B.9.a. National Pension Authorization QualityReview Checklist |
For more information on National Pension Authorization Quality Review Checklist, see M21-4, Chapter 7, Appendix B.a. |
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3.B.9.b. Instructions and Guidelines for Authorization Review |
For more information on Instructions and Guidelines for Authorization Review, see M21-4, Chapter 7, Appendix B.b. |
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3.B.9.c. Authorization Review Elements |
For more information on Authorization Review Elements, see M21-4, Chapter 7, Appendix B.c. |