Veteran Oversight Now is an official podcast of the Department of Veteran Affairs, Office of Inspector General. Each episode features interviews with key stakeholders, discussions on high-impact reports, and highlights of recent oversight work. Listen regularly for the inside story on how the VA OIG investigates crimes and wrongdoings, audits programs that provide benefits and services to veterans, and inspects medical facilities to ensure our nation’s veterans receive safe and timely health ...
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Inside Oversight is an official podcast of the Department of Veteran Affairs, Office of Inspector General. Each episode examines in detail some of our more nuanced oversight reporting. To understand the complexities of the topics, we talk with the report authors to gain insight into how the team conducted its work, what it found, and the impact on veterans and the public. Visit the VA OIG website for recently published reports.
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Unpaid Postage Bill Delays Critical Cancer Screenings—Rebroadcast
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In this latest episode of Veteran Oversight Now, we’re revisiting a highly downloaded episode from February 2024—Unpaid Postage Bill Delays Critical Cancer Screenings. Hear from a VA OIG healthcare inspection hotline director, who discusses delays in the receipt of patients’ colorectal cancer screening tests due to an unpaid postage bill by the Pho…
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Veteran Dies Following Delay in “Code Blue” Alert at Memphis VA Medical Center—Rebroadcast
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In this latest episode of Veteran Oversight Now, we’re revisiting a highly downloaded episode from April 2024—Veteran Dies Following Delay in “Code Blue” Alert at Memphis VA Medical Center. Hear from a VA OIG healthcare inspection hotline director discuss how a telemetry technician’s failure to follow a series of communications within the time fram…
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Poor Paperwork Potentially Puts Patients at Risk: New Mexico VAMC Reuses Medical Devices without Documenting Proper Cleaning
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22:36
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In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses findings at the Raymond G. Murphy VA Medical Center in Albuquerque, New Mexico, where there was no documentation of required reusable medical device reprocessing, which put patients at risk for infection if the reusable medical devices used dur…
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Inadequate Care Coordination at the VA Southern Nevada Healthcare System in Las Vegas
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In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses allegations that facility staff at the VA Southern Nevada Healthcare System in Las Vegas delayed ordering medications following an elderly patient’s discharge from a community hospital. The OIG substantiated that inadequate care coordination le…
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Patients Delayed Care Due to Failure to Follow Behavior Health Consult and Scheduling Process
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In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses allegations that some patients’ behavioral health consults were being discontinued at the Oklahoma City VA Medical Center, which resulted in some significant delays in patients receiving recommended behavioral health services. This podcast edit…
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IG Missal Highlights 91st Semiannual Report to Congress
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In the latest episode of Veteran Oversight Now, VA Inspector General Michael J. Missal discusses the VA OIG’s latest Semiannual Report to Congress that covered our oversight work from October 1, 2023, to March 31, 2024. Specifically, he shares results of our most recent work related to VA’s Electronic Health Record Modernization program. To date, t…
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Veteran Dies Following Delay in “Code Blue” Alert at Memphis VA Medical Center
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In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses a telemetry technician’s failure to follow a series of communications within the time frame established in the facility’s cardiac telemetry monitoring policy delayed initiating a code blue alert, ending with the patient’s death. This edition al…
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Chronic Leadership Failures Plague Cardiology Department at Indiana VAMC
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In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses how multiple OIG reports detail chronic leadership failures at the Indianapolis, Indiana VA medical center. This edition also includes highlights of the VA OIG’s work from February 2024. “It overall affects the care that the patients receive. S…
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Unpaid Postage Bill Delays Critical Cancer Screenings
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30:43
In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses delays in the receipt of patients’ colorectal cancer screening tests due to an unpaid postage bill by the Phoenix VA Health Care System in Arizona. This edition also includes highlights of the VA OIG’s work from January 2024. “The VISN actually…
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IG Missal Reflects on Inspector General 45th Anniversary and Latest Semiannual Report to Congress
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In the latest episode of Veteran Oversight Now, VA Inspector General Michael J. Missal shares his thoughts on changes to federal oversight since the passage of the Inspector General Act in 1978, which established 12 presidentially appointed IGs in federal departments with a mission to provide independent oversight. The VA OIG was one of the origina…
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Lessons Learned after Patient Death following a Fall in a Las Vegas VA Outpatient Clinic
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In this latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses the lessons learned in the care of a veteran who died after a fall in a VA outpatient clinic, part of the Southern Nevada Healthcare System in Las Vegas. This edition also includes highlights of the VA OIG’s work from August 2023. “Since [the …
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Nurse Consultant Shares Challenges for Veterans with Opioid Use Disorder Transitioning from DoD to VHA
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In this episode of Inside Oversight, Nicole Maxey, a nurse consultant with the Office of Healthcare Inspections, discusses the VA OIG’s evaluation of the transition of clinical care for service members with opioid use disorder from the Department of Defense to the Veterans Health Administration. Nicole describes deficiencies in documenting patients…
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“I don’t want to die.” Veteran Left Alone in VA Emergency Department Dies from Suicide
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In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses deficiencies in the quality of emergency department care for a veteran who died by suicide at the John Cochran Division of the VA St. Louis Healthcare System in Missouri. This edition also includes highlights of the VA OIG’s work from July 2023…
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Health System Specialist Discusses Inadequate Care at the West Palm Beach VA Facility
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In this podcast episode of Inside Oversight, Erica Taylor, a health system specialist with the Office of Healthcare Inspections, discusses a healthcare inspection at the West Palm Beach VA Healthcare System in Florida that assessed allegations related to a patient’s cancer care coordination. “Over the years, the OIG has published many reports detai…
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Veteran Suicide at Outpatient Clinic in South Carolina Highlights Tragic Missteps in Patient Care
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In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses missteps in the care of a veteran who eventually committed suicide on the grounds of the Aiken Community Based Outpatient Clinic, part of the Charlie Norwood VA Medical Center in Augusta, Georgia. This edition also includes highlights of the VA…
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VA OIG Safety Expert Discusses Deficiencies with Patient Safety at the Tuscaloosa VAMC
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In this episode of Inside Oversight, Amanda Newton, an associate director with the Office of Healthcare Inspections, discusses a report on deficiencies with the Patient Safety Program at the Tuscaloosa VA Medical Center in Alabama. She shares how a lack of resources, supervisory engagement, and failure of facility leaders to act impacted the medica…
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Oversight, Employee Participation Critical to Patient Safety Programs Says Healthcare Hotline Director
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In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses how she and her team triage healthcare-related hotline inquiries. She shares how concerns over the management of a patient safety program led to an inspection and subsequent report at the Tuscaloosa VA Medical Center in Alabama. This edition al…
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IG Michael J. Missal Discusses VA OIG's 89th Semiannual Report to Congress
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IG Michael J. Missal discusses the VA OIG's 89th Semiannual Report to Congress covering the reporting period of October 1, 2022, to March 31, 2023. Plus oversight highlights from the VA OIG's work in March and April of 2023. For this six-month period, the VA OIG identified more than $401 million in monetary impact for a return on investment of $4 f…
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Proactive Oversight: Senior Leader Shares How the VA OIG is Changing Some Healthcare Inspections
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In this episode, host Fred Baker talks with Dr. Julie Kroviak, the principal deputy assistant inspector general of the VA OIG’s Office of Healthcare Inspections, about changes to how cyclical healthcare reviews are conducted. Dr. Kroviak explains how her teams are reworking the Comprehensive Healthcare Inspection Program cyclical reports to provide…
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Intimate Partner Violence Assistance Program Implementation Status and Barriers to Compliance
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In this episode, Dr. Amber Singh, an associate director with the VA OIG’s mental health team within the Office of Healthcare Inspections, discusses a published report on VHA’s Intimate Partner Violence Assistance Program. Her team conducted a national review of the program to evaluate implementation status and identify perceived barriers to complia…
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VA OIG Teams Tackle Security Posture Problems at VA Medical Facilities Nationwide
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In this episode of Veteran Oversight Now, host Fred Baker talks with Shawn Steele, the director of the VA OIG’s Office of Audits and Evaluations Healthcare Infrastructure Division. Taking a very unique approach, 150 OIG staff recently mobilized to evaluate the security posture of 70 VA medical facilities over three days. Persistent police staffing …
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VA OIG Healthcare Systems Specialist Discusses New Report on Intensive Community Mental Health Recovery Programs
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In this episode of Inside Oversight, Dr. Wanda Hunt, a healthcare systems specialist with the VA OIG’s Office of Healthcare Inspections, discusses a recently published report on VHA’s Intensive Community Mental Health Recovery Programs. Her team examined the visit frequency for veterans enrolled in these programs between April 2019 and March 2021, …
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VA OIG Psychiatrist Discusses VHA's Lethal Means Safety Training, Firearms Access Assessment, and Safety Planning
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42:53
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In this episode of Veteran Oversight Now, host Fred Baker chats with Dr. Beth Winter, a psychiatrist with the VA OIG’s Office of Healthcare Inspections. They discuss her path from wanting to provide care for exotic animals to choosing to be “a people doctor instead of an animal doctor.” Dr. Winter’s distinguished career eventually led the granddaug…
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Inspector General Interview: 88th Semiannual Report to Congress
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The Semiannual Report to Congress summarizes the VA Office of Inspector General’s (OIG) oversight efforts from April 1 through September 30, 2022. For this six-month period, the VA OIG identified more than $1.4 billion in monetary impact for a return on investment of $16 for every dollar spent on oversight—which brings the fiscal year 2022 totals t…
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VA OIG Senior Investigator Highlights Noble Mission of Protecting Veterans
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Mentioned Investigations: Former VA Hospital Nursing Assistant Sentenced to Seven Consecutive Life Sentences for Murdering Seven Veterans and Assault with Intent to Commit Murder of an Eighth Fayetteville Doctor Sentenced To 20 Years In Federal Prison For Mail Fraud And Involuntary Manslaughter Retail Ready Owner to Forfeit $72M for VA Tuition Frau…
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OIG Healthcare Leaders Talk VHA Staffing Shortages, Stress on the Workforce
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Related Reports: OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages Fiscal Year 2022 Pursuant to the VA Choice and Quality Employment Act of 2017 (VCQEA), the OIG conducted a review to identify clinical and non-clinical occupations experiencing staffing shortages within Veterans Health Administration (VHA). This i…
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Healthcare Inspector Discusses COVID-19 Outbreak at a Community Living Center in Illinois
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Related Report: Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a Community Living Center at VA Illiana Health Care System in Danville, Illinois The VA OIG conducted an inspection at the VA Illiana Health Care System in Danville, Illinois, to determine the validity of allegations, specific to COVID-19 and the Community Living Center (…
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Healthcare Inspectors Discuss Issues Related to a Patient's Quality of Care in Ohio's Chillicothe VAMC
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Related Report: Failure to Follow a Consult Process Resulting in Undocumented Patient Care at the Chillicothe VA Medical Center in Ohio The VA OIG conducted a healthcare inspection for 10 allegations related to the quality and management of patient care and the availability of resources within the Urgent Care Center at the Chillicothe VA Medical Ce…
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Director of Community Care Discusses VISN 23's Healthcare Inspection
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Related Report: Care in the Community Healthcare Inspection of VA Midwest Health Care Network (VISN 23) The OIG Care in the Community healthcare inspection program examines clinical and administrative processes associated with providing quality outpatient healthcare to veterans. This report provides a focused evaluation of Veterans Integrated Servi…
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Deputy Assistant IGs Discuss Two Burn Pit Reports
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Related Reports: Airborne Hazards and Open Burn Pit Registry Exam Process Needs Improvement Since 1990, some 3.5 million veterans have served in areas that potentially exposed them to airborne hazards and open burn pit toxins, which have been associated with health problems. In 2013, Congress ordered VA to establish a registry to research the poten…
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VA OIG Healthcare Inspectors Discuss the Vet Center Inspection Program
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Vet Center Inspection Program: The VA Office of Inspector General Vet Center Inspection Program (VCIP) provides a focused evaluation of aspects of the quality of care delivered at vet centers. Vet centers are community-based clinics that provide a wide range of psychosocial services to clients, including eligible veterans, active duty service membe…
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VA OIG Director Discusses Forensic Auditing
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The Office of Investigations investigates potential crimes and civil violations of law involving VA programs and operations committed by VA employees, contractors, beneficiaries, and other individuals. These investigations focus on a wide range of matters including healthcare, procurement, benefits, construction, and other fraud; cybercrime and ide…
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Audit Manager Discusses OIG Report on VHA's Suicide Prevention Coordinators
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Related Report: Suicide Prevention Coordinators Need Improved Training, Guidance, and Oversight Report Summary: As part of the Veterans Health Administration’s (VHA) suicide prevention strategy, suicide prevention coordinators at VA medical facilities are required to reach out to veterans referred from the Veterans Crisis Line. Coordinators provide…
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Senior Benefits Inspector Discusses Risks with VA's Contract Medical Exam Program
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Related report: Contract Medical Exam Program Limitations Put Veterans at Risk for Inaccurate Claims Decisions Report summary: Given the importance of medical exams to disability claims and the high cost of VA’s contracts with exam vendors, the VA Office of Inspector General (OIG) set out to determine whether the Veterans Benefits Administration (V…
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Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient’s Death by Suicide
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Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient’s Death by Suicide at the Harry S Truman Memorial Veterans’ Hospital in Columbia, Missouri The VA OIG conducted a healthcare inspection to determine the validity of an allegation regarding a patient’s mental health care at the Harry S. Truman Memorial Veteran…
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Challenges for Military Sexual Trauma Coordinators and Culture of Safety Considerations
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Challenges for Military Sexual Trauma Coordinators and Culture of Safety Considerations The VA OIG conducted a review of select activities and challenges of Military Sexual Trauma (MST) Coordinators and Veterans Integrated Service Network Points of Contact in response to a request from Congressman Chris Pappas, Chairman of the House Veterans’ Affai…
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VHA’s Virtual Primary Care Response to the COVID-19 Pandemic
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Review of Veterans Health Administration’s Virtual Primary Care Response to the COVID-19 Pandemic The VA Office of Inspector General (OIG) conducted a review to assess Veterans Health Administration’s (VHA) virtual primary care response to the COVID-19 pandemic, as well as the use of virtual care by primary care providers and their perceptions of V…
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VA OIG Auditors Discuss Improper Payments for Community Acupuncture and Chiropractic Services and Risks to Evaluation and Management Services
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Senior Auditors Geoff Ferguson and Gris Soto discuss two related reports on improper payments for community acupuncture and chiropractic services and overall risks to evaluation and management services. In the first report, the VA OIG audited acupuncture and chiropractic care by non‑VA providers after becoming aware of patterns that suggested quest…
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VA OIG Director Discusses VHA’s Methodologies for Calculating and Presenting Wait Times
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In this episode of Inside Oversight, Daniel Morris, a director within the Office of Audits and Evaluations, provides insight into a recent VA OIG management advisory memo that reported on concerns with consistency and transparency in the calculation and disclosure of VHA’s patient wait times. Report Summary: Concerns with Consistency and Transparen…
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Deputy Inspector General Highlights Newest VA Electronic Health Record Reports
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In this episode of Veteran Oversight Now, guest host Deputy Inspector General David Case joins Dr. Joe Etherage, director of national reporting for the Office of Healthcare Inspections, to discuss three recently released reports on VA’s Electronic Health Record Modernization program—a 10-year, multibillion-dollar modernization effort. Since the Oct…
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Senior Healthcare Inspection Leader Discusses New Vet Center Inspection Program
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In this episode of Veteran Oversight Now, Dr. Julie Kroviak, deputy assistant inspector general for healthcare inspections, discusses her journey from medical student to VA doctor to leading teams conducting oversight of VHA. She introduces the new vet center inspection program, detailing how the VA OIG will inspect roughly 300 vet centers over the…
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VA OIG Special Agent in Charge Discusses New Healthcare Fraud Division
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Visit our website to learn more about the work of the VA OIG's Office of Investigations. Report potentially unlawful activity or potential violations of rules or regulations; fraud, waste, and abuse; and gross mismanagement of VA programs and operations to the VA OIG Hotline: Online: https://www.va.gov/oig/hotline/default.asp Phone: 800-488-8244 Mo…
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VA Inspector General Interview: 86th Semiannual Report to Congress
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The Semiannual Report to Congress summarizes the VA Office of Inspector General (OIG) oversight from April 1 through September 30, 2021. For this period, the VA OIG identified over $2.9 billion in monetary impact for a return on investment of $29 for every dollar spent on oversight. This does not include the inestimable value of the healthcare over…
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