The Fungus Among Us: Why VA is Using AI to Detect Fraud
Remember those pain “clinics”? There wasn’t much treatment going on there, just a wink and a nod after you saw some doctor’s name on the side of a public transit bus. Pill mills they called ‘em. Well, those dried up and moved on to selling Ozempic (all rights reserved, of course). Another type of mill has popped up in recent years—instead of a pill mill, its a C&P mill.
Who Would’ve Thought?
Never seen this coming, who would’ve thought, who could’ve known? Any variation will do. If you really want to get down to the root cause of the C&P mills (what exactly those are, discussed below), you have to understand a little bit of history. Before the embarrassment at Saigon, the last combat troops to withdrawal from Vietnam was in March 1973. For the sake of the argument, let’s say the youngest American was 18. That makes him born roughly in 1955. So, in 2025, the youngest Vietnam Veteran is 70-years-old. Although, most of you reading this probably know several in their mid-70s.
Let’s use that as a starting point—stay with me.
America trucks along in the 1980s with no major, prolonged, conflicts (we won’t count that whole invasion of Panama). Then we get to the 1990s, and boy did things pick up in true American fashion with the Gulf War (Desert Shield, Desert Storm). Then, in 1993, someone came up with a good plot for that famous movie, Black Hawk Down. Then, of course, we hit up the Balkans for a few years. Just like that, I’ve been to the year 2000, not much has changed. We all know what happened on 09/11. That mere 20-year conflict ended with the an absolute disaster on August 30, 2021. Pure chaos.
Oh, by the way, did you know that in 2022, we passed the largest piece of presumptive legislation in the history of Veterans’ benefits? The PACT Act.
You are probably saying by now “Wes, why the history lesson?” Here’s the kicker. We have an entire generation of Vietnam Veterans turning to the VA for end of life care. They are all 70+. They earned it, no one blames them. That Agent Orange is finally kicking in as the Parkinson’s Disease progresses. Then we have Gulf War Veterans who aren’t quite as old, but equally as disabled due to their version of Agent Orange (oil fields and Gulf War Syndrome). Following that generation, we have 20-years worth of the Global War on Terrorism—which apparently, we somehow didn’t manage to win and are going back in. Oh, don’t forget the PACT Act—that big daddy piece of legislation expanding benefits for tens of thousands of Veterans.
I say all that to say if anyone at the VA ever tells you they are “so shocked” at the amount of claims Veterans are filing, they are a buffoon, pure and simple. Anyone could have seen this coming miles away. Yet, no one at the VA cared to blow the whistle—and that failure spans multiple administrations, not just D or R administrations. Naturally, without any shock whatsoever, the system has become overwhelmed. Not a single person should be shocked about that. Yet, many career VA employees were (and are) in shock at the number of claims we have pending.
The failures of the VA gave rise to what is now a multi-million dollar industry: C&P mills.
The Fungus Among Us
With the VA becoming overwhelmed day-by-day, many Veterans were looking for alternatives. Some had been to umpteen C&P exams, most with a nurse practitioner fresh out of school, who took a 15-minute PowerPoint class on burn pits, but in all those umpteen exams, no one was listening. Most last 5-7 minutes, and the examiner is using 4.5 of those minutes to ask you why they can’t access majority of the records you know are in your file. Who can blame Veterans for wanting an alternative?
Seeking to fill a legitimate void, up popped these “consulting companies” I have previously wrote about. Not only are they engaging in the unauthorized practice of law by preparing claims forms and giving out advice, they have in-house doctors to do the exams the VA has been unwilling or unable to do for you. Again, I can’t blame Veterans for wanting an alternative. So, these companies use a “stem to stern” philosophy. Since their doctors are in-house, it doesn’t cost them extra to fill out a DBQ for everything you have, head to toe, tell you to go file it with the VA. Whatever sticks, they send you a bill (unlawfully, I might add). So, what’s the problem? Well, for these companies, it is a numbers game. The more DBQs they fill out, the higher the chance the VA accepts 1 of them and they get to send you a bill in return. Their fees are often “six times your monthly increase,” meaning they have an incentive to get you the highest rating possible. This has, unfortunately, caused many of these C&P mills to over exaggerate symptoms, use the same boiler-plate language over and over. In other words, you could be the middle man for a fraud scheme unknown to you. This is the first time you have seen someone actually listen to you, the language in the exam looks legit, it reflects what you have going on. You have no reason to doubt it.
AI to the Rescue
I saw this coming when AI first started rolling out. AI may not be good for some things, but it is really damn good at detecting patterns. Frequently reused phrases, how often the same doctor has submitted a DBQ to the VA, how similar those DBQs are, etc. Sort of reminds me of a Medicare scheme one time. This doctor was just billing Medicare for patients he wasn’t actually seeing. Eventually, he started billing so many hours someone did the math. He would have had to have been seeing upwards of 87 patients a day. Greed is the only thing that caught him.
I envision the same thing here. The VA is going to use AI to see “did this doctor complete 87 DBQs in one day” type thing. Or, has this doctor used the exact same language over and over, and it isn’t specific to this Veteran, and therefore unreliable?
I’m From the Government and I’m Here to Help
I have had a few Veterans call me up a little panicked. Not because they are fraudsters, but because the VA is notoriously bad at a press release. Many thought the VA was going to come through every private DBQ, even if it was done by your doctor who has been treating you for 18 years.
Thankfully, that doesn’t appear to be the case. According to the VA, the AI deployment will only be forward looking, and the VA will not use “the tool to revisit previously finalized and processed DBQs. Additionally, this initiative will not change how VA evaluates or decides claims. No Veteran’s claim or benefit will be reduced or denied because of this effort.”
Yesterday, VA clarified in the following e-mail:
Good afternoon VSO Stakeholders,
We understand there has been increased interest from you all on what VA is doing with artificial intelligence as a result of the article published earlier this week in Stars and Stripes. We wanted to provide you all with some more information on that topic.
VA is developing a new safeguard to protect Veterans from predatory companies that submit fraudulent disability benefits questionnaires (DBQs) for Veterans seeking benefits.
This data collection tool, which has not been deployed yet and is still in development, will help Veterans Benefits Administration field staff identify suspected fraud. It relies on manual data entry and analysis to help identify patterns that may help VA identify when organized fraud rings are posing as legitimate medical providers and preying on Veterans (for example, by excessively charging them).
This is not an AI tool – it relies on manual data entry and analysis. This tool is forward-looking only. VA will not use the tool to revisit previously finalized and processed DBQs. Additionally, this initiative will not change how VA evaluates or decides claims. No Veteran’s claim or benefit will be reduced or denied because of this effort.
This new safeguard is being developed in collaboration with VA’s Office of Inspector General, which released a fraud alert in 2023 related to DBQs. For more information on the OIG’s findings.
If the VA sticks to their word, then I honestly would welcome this tool. It would strengthen the integrity of the system, identify the “bad apples,” and help keep public support for Veterans high. Lord knows it is needed as we prepare for another middle east invasion. I would also suggest the VA publicly publish its findings. If the VA has identified a doctor as a “bad apple,” let the public know.
Maximum sunshine.
Godspeed.
