Show Notes
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 for every dollar spent on oversight. These figures do not include the inestimable value of the healthcare oversight work completed to advance patient safety and quality care. During this six-month period, the Office of Investigations opened 222 cases and closed 217 (most of which were opened in prior periods), with efforts leading to 122 arrests. The OIG hotline received and triaged 15,526 contacts to help identify wrongdoing and address concerns with VA activities. Collectively, the work during this period resulted in 595 administrative sanctions and actions.
The Office of Audits and Evaluations (OAE) produced 52 work products, including one VA management advisory memorandum that highlighted concerns requiring VA’s prompt attention, 19 oversight reports, and 32 preaward and postaward contract reviews to help VA obtain fair and reasonable pricing on products and services. OAE reports for the six-month period resulted in 128 recommendations.
The Office of Special Reviews issued two publications, including an administrative investigation that focused on VHA employing four people who had been previously excluded from holding a paid position in a federal healthcare program.
The Office of Healthcare Inspections (OHI) focused on leadership and organizational risks, suicide risk reduction, and care coordination. OHI published 14 healthcare inspection reports; two national healthcare reviews; 11 Comprehensive Healthcare Inspection Program (CHIP) reports, including four CHIP summary reports; two Vet Center Inspection Program reports; and two Care in the Community reports.
Featured Publications: Stronger Controls Help Ensure People Barred from Paid Federal Healthcare Jobs Do Not Work for VHA Veterans Are Still Being Required to Attend Unwarranted Medical Reexaminations for Disability Benefits Deficiencies in Lethal Means Safety Training, Firearms Access Assessment, and Safety Planning for Patients with Suicidal Behaviors by Firearms
Opioid Safety at the VA Northern California Health Care System in Mather
More from Veteran Oversight Now
Each month, the VA Office of Inspector General publishes highlights of our oversight reports, congressional testimony, and investigative work. In August 2025, the VA OIG published 17 reports that included 72 recommendations to VA.
The Honorable Cheryl L. Mason was confirmed by the Senate as the inspector general of the VA on July 31, 2025, and shortly after being sworn in, took up her leadership of the VA OIG on August 4. IG Mason previously served as the chairman of the Board of Veterans’ Appeals at VA. For more information on IG Mason, see her bio.
Each month, the VA Office of Inspector General publishes highlights of our oversight reports, congressional testimony, and investigative work. In June 2025, the VA OIG published nine reports that included 81 recommendations. Report topics varied from an evaluation of VA’s governance of recruitment, relocation, and retention incentives awarded for VHA positions to mental health inspections of the VA Salem Healthcare System in Virginia and the VA Philadelphia Healthcare System in Pennsylvania.
Each month, the VA Office of Inspector General publishes highlights of our oversight reports, congressional testimony, and investigative work. In May 2025, the VA OIG published 11 reports that included 54 recommendations. Report topics varied from an audit of the VHA’s Pain Management, Opioid Safety, and Prescription Drug Monitoring Program to a healthcare inspection to assess allegations of deficiencies in the emergency department care provided to a patient at the Martinsburg VA Medical Center in West Virginia.
This Semiannual Report to Congress summarizes the independent oversight efforts of the VA Office of Inspector General (OIG) from October 1, 2024, through March 31, 2025. Visit the VA OIG's website to read the full report.