Quality Review Checklists

3. Quality Review Structure

Introduction

This topic describes the quality review structure, including

• quality review checklists
• general guidelines for benefit entitlement (BE) quality reviews
• grace period for national quality errors
• procedural deficiencies
• deselections
• error citations when corrective action has already been taken
• reviewing all evidence associated with a claim
• clearly identifying and explaining errors
• appropriate citations, and
• cascade effect.

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

• errors that result in an overpayment or underpayment to a claimant
• procedural deficiencies that violate the claimant’s due process rights, and
• deficiencies which would result in a remand from the Board of Veterans’ Appeals (Board) if not corrected.

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

• decision documentation
• notification
• administrative (internal controls)
• examination and medical opinion request-related
• expedited favorable decision, and
• non-BE errors when corrective action is needed.

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

OAR QA must provide appropriate citation supporting an error call. In most cases, OAR QA should cite the appropriate statute or regulation, but may also cite

• manual provisions
• VBA letters
• General Counsel (GC) precedent decisions, or
• Court of Appeals for Veterans Claims (CAVC) precedent decisions.

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:

• If the DROC did not address an issue, it is most likely that the DROC did not develop, rate, or send notification on the issue.
• If the DROC properly developed a claim but did not properly rate it, then inherently, the notification is incorrect.

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.