WASHINGTON >> Fake appointments, unofficial logs kept on the sly and appointments made without telling the patient are among tricks used to disguise delays in seeing and treating veterans at Veterans Affairs hospitals and clinics.

They’re not a new phenomenon. VA officials, veteran service organizations and members of Congress have known about them for years.

The "gaming strategies" were used to make it appear veterans were getting appointments within target times set by the department, according to a 2010 department memo to VA facility managers aimed at fighting the practices.

The memo from William Schoenhard, then the VA’s deputy undersecretary for health operations and management, said that when a medical appointment wasn’t available within the 30-day target time then used by VA, some schedulers would:

— Make a fake appointment within the 30-day period but not tell the patient. The appointment would be canceled later and a new appointment would be made to meet a new 30-day target.

— Note on a paper log the actual distant date of an appointment, but not enter it into computer until within 30 days of the date.

— Give the patient an appointment at whatever date was next available, but log it in the computer as the date the veteran had asked for.

Schoenhard’s nine-page memo ordered the practices stopped and instructed managers on how to detect them. Then he added:

"Please be cautioned … additional new or modified gaming strategies may have emerged, so do not consider this list a full description of all current possibilities of … practices that need to be addressed."

Or as Sen. Patty Murray, D-Wash., put it at hearing this month: "As soon as new directives are put out, they’re torn apart to find out how to get around the requirements."

"Cooking the books" at VA hospitals has exploded into public view since allegations arose that up to 40 patients may have died at the Phoenix VA hospital while awaiting care. The department’s inspector general said he’s found no evidence so far that any of those deaths were caused by delays. He’s widened his office’s probe to include 26 VA centers but hasn’t specified just what is being investigated at the newly added locations.

There are some 1,700 VA health facilities nationwide, including hospitals, clinics and residential rehabilitation centers. Investigators are now trying to determine how widespread is the practice of falsifying records. But the fact it is a problem has been detailed in VA inspector general reports and Government Accountability Office reports to Congress going back a decade.

The 2010 Schoenhard memo cited practices identified by a task force monitoring access to care.

"We have worked very hard … to root out these inappropriate uses of the scheduling system and these abuses," VA’s Robert Petzel testified at a Senate hearing this month. "This has been a very important thing to us for at least the last four years."

Petzel was the top VA health care official until he was forced to resign ahead of his retirement previously scheduled for later this year.

"It’s not that people haven’t brought this up before, it’s just the word ‘secret’ lists blew it up in the media," Vietnam Veterans of America’s Richard Weidman said in an interview. "They weren’t secret, they were handwritten" logs kept aside from computerized scheduling. "People should stop the hysteria and say what the root of this problem is."

The problem, according to Weidman and several other veteran service organizations, is there are not enough medical personnel to meet the demand for VA health care. Several of the groups have complained for years that the VA budget — though continually rising — is too small to provide enough doctors, medical centers and services.

The number of veterans relying on VA for health care has jumped 17 percent since 2009. Operating the largest single health care agency in country with 9 million patients and 85 million appointments a year, the agency has struggled to keep its head above water. It has hired more medical workers and opened 55 more community outpatient clinics, bringing to 820 the number of those clinics nationwide.

VA also has added 21 more mobile clinics to serve veterans in rural areas and now has a fleet of 79 of them.

When it comes to how long it takes to get an appointment, VA stands apart from much of the health care industry. VA now has a 14-day target for seeing patients once they seek appointments and the agency is supposed to chart the timeliness of each of them. Some lawmakers have suggested the target is unrealistic and said basing employee bonuses and pay raises on meeting it is outrageous.

In the private sector, some large health provider networks set standards, but there’s little data on how well the standards are followed, making comparisons difficult. Also, the majority of private physicians in the U.S. are not part of a network.

But like the VA, appointment wait times in the private sector vary widely by geography and the attending physician’s specialty.

Independent reports have found that though access is a problem, VA care is equal to or better than that in the private sector.