The A to Z Guide to VA Disability Benefits
JimStrickland912
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Q: How long will it take for my claim to be finished?
A: There are many variables that will affect the length of time the process will take. Some variables are in your control, most aren't. If you have done your part by submitting the VA Form 21-526 complete as it should be and provided good evidence to support your claim, that will ensure that it will move a bit faster. Otherwise, your claim enters a very long line of some 400,000 other claims that are waiting to be adjudicated and it waits its turn for attention. I advise veterans I work with to plan on at least one year for a single, routine claim. If there is any doubt about how clear the evidence is, plan on 1 1/2 to 2 years and if an appeal is involved, think in terms of 2 to 4 years...or more.
Q: I'm a Vietnam veteran. My friends have told me that I'm eligible for benefits through the VA. To be honest, I could use some help as my health isn't good. I've read so much about how the younger troops need help that they aren't getting and how backed up VA is in processing claims. I've decided I'm not going to file for anything so that one of the OIF/OEF vets can take my place and maybe get what's due to him a little sooner. Am I making the right decision?
A: No. Your intent is noble but the fact is that if every Vietnam veteran did that the response from VA would only be to cut the budget accordingly. The system will only be repaired when we all demand what is rightfully ours. We aren't being given benefits, we earned those benefits many years ago. If you walk away it gives the bean counters more ammunition to tout that the VA doesn't need more funding. You sure don't help the younger vets that way.
Q: I'm 100% P & T. My VA Medical Center is about 2 hours away. There is a hospital nearby but I'm not sure if I could use it in an emergency. Will VA pay for that if I have an emergency like a stroke or heart attack? What will the hospital do when i tell them I don't have insurance and only have VA health care?
A: The VA will pay for a 100% P & T veteran to use a civilian facility in an emergency. However, it rarely works as smoothly as it should. Once the veteran is able to he or she must begin to attempt to be transferred to a VA facility and/or confirm an authorization to stay at the civilian hospital. This will often involve multiple phone calls and speaking to a number of different people. It's very important to make notes of who you've talked to at what number and when the conversation occurred.
Any hospital that accepts Medicare as a form of payment (all hospitals do) is required to accept your VA health care card as the payment in full. The hospital will not be allowed to add on any co-pays or additional charges.
Q: I've been scheduled for a reexamination...a Compensation and Pension (C & P) exam because the VA says that my condition has probably improved. I haven't used any VA doctors for over 5 years, I don't trust them and I don't believe I was being treated properly. I have Medicare so I can use civilian doctors. I have all my records from my civilian doctors and I sent those records in to the Regional Office (RO). I don't believe that I will be given a fair and impartial examination by the contract doctors that the VA uses and it is a waste of my time. Can I refuse the C & P exam since I've provided the other records?
A: No, you can't refuse the exam unless you're willing to accept that your current rating will be lowered automatically. The VA may, at its discretion, accept civilian and other records in lieu of a C & P exam. You may ask them to do so by writing a formal letter to them and stating your concerns. It is their choice though and if they insist that you undergo a C & P exam, you must do so.
Q: I am rated as 100% IU. I received a letter yesterday that says I did not return a form to VA that they mailed to me last month. The letter tells me that they are going to take away my IU and reduce my compensation. I never received any such letter from VA. What should I do?
A: Any veteran who collects Individual Unemployability compensation is required to complete a VBA 21-4140 that will certify that the veteran hasn't worked in the previous year. The form comes about the anniversary of the award of the benefit. If the veteran doesn't receive the form or forgets to complete it and mail it in, VA will propose to reduce the rating and eliminate the IU award. The veteran must then react quickly and respond within 30 days. A form may be downloaded by clicking here and promptly returned via certified mail with return receipt requested. Enclose a cover letter notifying the VARO that the vet didn't receive the form and that should take care of it.
Veterans who receive the IU benefit will be required to complete this form each year. It's smart to keep some copies handy and if one isn't mailed to you, complete one of yours and return it on the date of your award anniversary.
Q: I had surgery done at my VA medical center. The surgery was for a carpal tunnel condition in my right hand and wrist. Now my hand and wrist aren't working like they should. I've lost feeling in a lot of fingers and I can't grip a pen to sign my name (I'm right handed). I found out the doctor who did my surgery had never done one of these operations by himself before and that he cut a nerve by accident. A physical therapist told me it may never get better and we're doing things so I can become left-handed. Do I have any options to sue them?
A: (Answer provided by Katrina J. Eagle, Attorney at Law) You didn't say whether the right hand and wrist are service-connected or not. If so, I would pursue an increased-rating claim immediately. If not, the language of "may never get better" is not strong enough to show permanent damage -- yet. In that case, I would wait no more than 12 months post-surgery, and if there is still no improvement, look into having a doctor review the case and see if he/she determines negligence was committed. If so, consult with an experienced FTCA attorney to discuss your options in more detail. Finally, regardless of what you decide to do, seeking regular medical care and treatment is key for documenting the consistent problems you experienced as a result of the "botched" surgery and, or the severity of your current condition as a result thereof.
Also see 38 USC section 1151 & The Federal Torts Claims Act
Q: I want to file to increase the rating in 2 of my 4 rated disability conditions. I'm sure they are worse than they were 3 years ago when I had my C & P exam. A friend told me that if I do that I risk losing all my benefits. What should I do?
A: Any time you ask VA to make any modification to your ratings, you risk a thorough review of your complete file. The VA is always on the lookout for an opportunity to lower your compensation. It isn't uncommon that a veteran asks for an increase to a rating and VA responds with a proposal to reduce the existing rating.
Before you apply for an increase or ask for any other change you should study the applicable rules and regulations carefully to be sure that you are qualified and that you will be able to submit the appropriate evidence. Then you should do a simple risk/benefit analysis in your own mind to determine that it's going to be worth the effort.
If you have a legitimate reason to apply for an increased rating, you should proceed to do so. Should VA respond with a proposal to reduce an existing rating, the appeals process is in place for you to halt that action and you should timely respond with a Notice of Disagreement.
Also see How To File A Claim
Q: I'm a veteran of 2 tours to Iraq. My primary care doctor at the VA clinic has told me I have PTSD. He is making some plans to have me evaluated by a psychiatrist but it seems that is going to take a while as they're very busy. He recommended that I go to a local "Vet Center" and talk to them about joining up and getting involved with that program. I'm not very good around people I don't know so I'm not sure this is a good idea. What could I expect from a vet center if I decided to go?
A: (Answer provided by Paul C. Burton) Thank you for your service! I have good news for you. Vet Centers were founded for veterans like you. What you can expect to find at your local Vet Center is fellow veterans who relate best to others who served in the Armed Forces; men and women just like you. Vet Centers are staffed by counselors who are trained and experienced in assisting veterans. Vet Center counselors can administer testing that is highly informative in assessing Post Traumatic Stress Disorder (PTSD) and other mental health issues related to PTSD. Such test results can be important items in a veteran's PTSD claim. Vet Center counselors are also prepared to assist with VA claims, direct you to community resources for veterans, and to assist with other veteran's problems. I also think that at your local Vet Center you are most likely to find other veterans who will become friends and an integral part of your support network. In my own experience, the local Vet Center is worth it's weight in gold! I encourage you to give it a try! Good luck, and thank you again for your service!
(Find a Vet Center close to you.)
(More about Vet Centers)
Q: I am 100% service connected. If I am injured or have a heart attack or have some other event that might require emergency treatment, will the VA pay for me to use a civilian hospital? The closest VA facility is more than an hour away from my home.
A: Yes, the VA will pay for emergencies for 100% service connected veterans and also in many instances for any veteran with a service connection. The trick is to notify the VA Medical Center nearest you as soon as possible and ask to be transferred there. The veteran or another responsible individual must make good notes of the time the call was made, who received the call at the VAMC and any other details.
All too often the authorization to use the civilian facility isn't as clear as it should be, the transfer to the VAMC may not have happened and days later the veteran will receive a bill. When the veteran calls the VAMC to find out why they aren't paying, they may say there is no record of such a call or that the person who received the call wasn't the one who should have authorized the stay or any of a dozen other reasons they can't pay.
Be aware that VA is never a secondary payer to any other insurance you may have, including Medicare. If you are being admitted to a civilian facility and hand them both your VA health ID card and also your Medicare card, the hospital is most likely to initiate billing with Medicare, not VA. Later you'll receive a bill for the deductibles and learn that VA will not pay those even if your health emergency was due to your service connected condition.
All this should be thought through in advance, just in case you have a true emergency. The letter below is from a reader of "Jim's Mailbag" who had an interesting encounter with VA & Medicare.
Jim;
I have been reading your column for some time and really appreciate the help you are providing veterans in dealing with the cumbersome VA system. I am sure there are many veterans who are in the same situation that I am. I have been receiving SSDI for 24 years which enabled me to be covered by MEDICARE. For 7 years I have been rated as having a service connected disability, currently rated at 70% disabled. I live in a rural area 200 miles from the nearest VAMC.
Under MEDICARE I could see physicians of my choice in the nearest town. Some specialty physicians are available in the nearest town. Virtually all specialties are available within 30 miles. There is a hospital with emergency room in the nearest town and a major hospital center within 30 miles. Under MEDICARE, I had the same Primary Care Physician for 15 years. I was able to receive both primary and specialty care with only a short wait and emergency care as needed within 8 miles.
At some point, in the last several years, the VA was designated as my primary health care provider and MEDICARE as the secondary provider. This has meant that I must receive primary care at a nearby community clinic with long waiting lists and frequently changing physicians and staff. Any specialty care must be referred to the VAMC with many months waiting list for appointments.
I learned that MEDICARE had been changed to my secondary provider when I severely fractured my wrist. I was treated at the local emergency room and then referred to a hand specialist in a nearby town. Eventually he ordered specialized occupational therapy by a hand specialist 3 times a week for 4 months. Customized splints and other appliances were required. As a result of this therapy, surgery was avoided. Unfortunately, MEDICARE declined coverage since they are now designated as secondary provider. The VA declined to cover saying that I should have driven the 200 miles to the VAMC (a physical impossibility) and there was no proof, despite multiple X- rays and exert medical testimony, that the therapy was needed.
When an individual lives a considerable distance from a VAMC and has MEDICARE or other insurance, it is no benefit to be forced into the VA health care system. I understand the need for the VA to monitor my disability and am happy to provide copies of any medical records for any condition. However the burdens of the VA medical system are preventing me from receiving medical care. How can I restore MEDICARE to my primary healthcare provider? Thank you.
Reply;
This was a new one on me. At about the same time I received this, I had another Veteran reader who cautioned me, "Medicare Part A may not be free to Veterans enrolled in the VA medical system. If you have Medicare, It may cost you your Veterans benefit of being treated in a non-VA hospital in case of an emergency...just having Medicare Part A could disqualify a veteran."
The rules that govern Veterans Health Administration (VHA) benefits are complex. If you ask a question of 5 experts at 5 different places, you may well receive 5 different answers. The Medicare benefit is no less complex with its requirements for different plans for hospitals (Part A) that are separate of those for physician providers (Part B) and the need for a supplemental policy and a drug plan. When you mix them all together, you concoct a witches brew full of hazards and pitfalls. Like so many other aspects of our lives with benefits, stepping off on the wrong foot may set in motion a situation that will take a lot of work to remedy.
In the case of the Veteran with a broken wrist we discovered that there is a little known program (at least to the average user) within Medicare known as Medicare Second Payer or MSP. In concept, this is fairly easy to understand. If a Medicare patient has another insurance provider, that other insurance is almost always viewed as the one to bill first. For example, if a patient is working and has private insurance through the employer and also has Medicare, the private insurance should be the first billing target by any health care provider. Then later, Medicare may or may not pick up and pay any charges that the primary payer didn't. If you have private insurance and Medicare, Medicare is clearly seen as the Secondary Payer or...MSP. This also applies to civilian (non-VHA) disability insurance or workman's compensation. Those payers are billed first as the primary insurer and Medicare is second.
Are you confused yet? Just wait...
Enter the Veteran who has both VHA healthcare and a Medicare card. In this instance, Medicare may or may not be the primary payer for services...it just depends on circumstances. If our broken-wristed Vet had gone to a VHA facility, the VHA would have automatically become the primary payer...to the VHA. This means that VHA would have taken on the total responsibility to fix that fracture or to refer the Veteran to an outside specialist on a fee basis contract. VHA would have been responsible to cover it all except for any copays the Vet may be required to make with a rating of less than 100% disabled. In this case though, our Vet took that fracture to a civilian facility. That's understandable, she was in pain and needed emergency treatment.
So why the problems with billing?
As the Veteran and I thought this through, we determined that as she was being checked in through the civilian facility's emergency department, she probably handed over her VHA Identification card and also her Medicare card. The hospital always wants to ID the patient and assure themselves of future payment.
In formal medical terms, this important, complex procedure is often referred to as The Wallet Biopsy.
Our Veteran, being in serious pain from that fracture, hadn't called or even considered going to the VA facility. She was treated, released and received some ongoing therapy without VA being involved. Then she was notified that VHA wasn't paying the tab for all this and since Medicare was designated as the Secondary Payer, neither were they.
It took us a couple of days before we had our "Ah-Ha!!!" moment. Once the penny dropped, we soon determined that the hospital's insurance and billing department, seeing that VHA card, had billed them first, then Medicare. This was an error of the civilian facility's billing department. Medicare saw that VHA had been billed and assuming that it was an authorized (fee basis by VHA) procedure, declined to deal with it. The VHA declared that they were not notified and had not pre-authorized fee basis so it wasn't their problem.
Our Veteran, armed with all this information, called her local Medicare offices and spoke with the Coordinator of Benefits or CoB. Incredibly, the CoB understood and instantly agreed and said that it would be taken care of and that in about 2 weeks, all the civilian providers should re-submit their bills to Medicare for payment. Records were to be corrected and would show Medicare as the primary payer.
If you are one of the very fortunate Veterans who have both a Medicare benefit and also a VHA benefit, how you receive your care is largely up to you. You may choose to use civilian providers for all or some of your care or you may stick with your VA care all the way. If you have both insurances available to you, you may have the most flexible health care plan available anywhere.
On the cautionary side of all this is that you should plan in advance on exactly what you want to do and what makes the most sense for your health and your finances. Whether you have all these benefits or only one, advance planning is the key to smooth sailing.
A: There are many variables that will affect the length of time the process will take. Some variables are in your control, most aren't. If you have done your part by submitting the VA Form 21-526 complete as it should be and provided good evidence to support your claim, that will ensure that it will move a bit faster. Otherwise, your claim enters a very long line of some 400,000 other claims that are waiting to be adjudicated and it waits its turn for attention. I advise veterans I work with to plan on at least one year for a single, routine claim. If there is any doubt about how clear the evidence is, plan on 1 1/2 to 2 years and if an appeal is involved, think in terms of 2 to 4 years...or more.
Q: I'm a Vietnam veteran. My friends have told me that I'm eligible for benefits through the VA. To be honest, I could use some help as my health isn't good. I've read so much about how the younger troops need help that they aren't getting and how backed up VA is in processing claims. I've decided I'm not going to file for anything so that one of the OIF/OEF vets can take my place and maybe get what's due to him a little sooner. Am I making the right decision?
A: No. Your intent is noble but the fact is that if every Vietnam veteran did that the response from VA would only be to cut the budget accordingly. The system will only be repaired when we all demand what is rightfully ours. We aren't being given benefits, we earned those benefits many years ago. If you walk away it gives the bean counters more ammunition to tout that the VA doesn't need more funding. You sure don't help the younger vets that way.
Q: I'm 100% P & T. My VA Medical Center is about 2 hours away. There is a hospital nearby but I'm not sure if I could use it in an emergency. Will VA pay for that if I have an emergency like a stroke or heart attack? What will the hospital do when i tell them I don't have insurance and only have VA health care?
A: The VA will pay for a 100% P & T veteran to use a civilian facility in an emergency. However, it rarely works as smoothly as it should. Once the veteran is able to he or she must begin to attempt to be transferred to a VA facility and/or confirm an authorization to stay at the civilian hospital. This will often involve multiple phone calls and speaking to a number of different people. It's very important to make notes of who you've talked to at what number and when the conversation occurred.
Any hospital that accepts Medicare as a form of payment (all hospitals do) is required to accept your VA health care card as the payment in full. The hospital will not be allowed to add on any co-pays or additional charges.
Q: I've been scheduled for a reexamination...a Compensation and Pension (C & P) exam because the VA says that my condition has probably improved. I haven't used any VA doctors for over 5 years, I don't trust them and I don't believe I was being treated properly. I have Medicare so I can use civilian doctors. I have all my records from my civilian doctors and I sent those records in to the Regional Office (RO). I don't believe that I will be given a fair and impartial examination by the contract doctors that the VA uses and it is a waste of my time. Can I refuse the C & P exam since I've provided the other records?
A: No, you can't refuse the exam unless you're willing to accept that your current rating will be lowered automatically. The VA may, at its discretion, accept civilian and other records in lieu of a C & P exam. You may ask them to do so by writing a formal letter to them and stating your concerns. It is their choice though and if they insist that you undergo a C & P exam, you must do so.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
The President of the United States takes pride in presenting the
MEDAL OF HONOR
posthumously to
PRIVATE FIRST CLASS RALPH H. JOHNSON
UNITED STATES MARINE CORPS
for service as set forth in the following CITATION:
For conspicuous gallantry and intrepidity at the risk of his life above and beyond the call of duty while serving as a reconnaissance scout with Company A, First Reconnaissance Battalion, First Marine Division in action against the North Vietnamese Army and Viet Cong forces in the Republic of Vietnam. In the early morning hours of March 5, 1968, during OPERATION ROCK, First Class Johnson was a member of a fifteen-man reconnaissance patrol manning an observation post on Hill 146 overlooking the Quan Duc Valley deep in enemy controlled territory. They were attacked by a platoon-size hostile force employing automatic weapons, satchel charges and hand grenades. Suddenly a hand grenade landed in the three- man fighting hole occupied by Private First Class Johnson and two fellow Marines. Realizing the inherent danger to his comrades, he shouted a warning and unhesitatingly hurled himself upon the explosive device. When the grenade exploded, Private First Class Johnson absorbed the tremendous impact of the blast and was killed instantly. His prompt and heroic act saved the life of one Marine at the cost of his own and undoubtedly prevented the enemy from penetrating his sector of the patrol's perimeter. Private First Class Johnson's courage inspiring valor and selfless devotion to duty were in keeping with the highest traditions of the Marine Corps and the United States Naval Service. He gallantly gave his life for his country.
/S/ RICHARD M. NIXON
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
MEDAL OF HONOR
posthumously to
PRIVATE FIRST CLASS RALPH H. JOHNSON
UNITED STATES MARINE CORPS
for service as set forth in the following CITATION:
For conspicuous gallantry and intrepidity at the risk of his life above and beyond the call of duty while serving as a reconnaissance scout with Company A, First Reconnaissance Battalion, First Marine Division in action against the North Vietnamese Army and Viet Cong forces in the Republic of Vietnam. In the early morning hours of March 5, 1968, during OPERATION ROCK, First Class Johnson was a member of a fifteen-man reconnaissance patrol manning an observation post on Hill 146 overlooking the Quan Duc Valley deep in enemy controlled territory. They were attacked by a platoon-size hostile force employing automatic weapons, satchel charges and hand grenades. Suddenly a hand grenade landed in the three- man fighting hole occupied by Private First Class Johnson and two fellow Marines. Realizing the inherent danger to his comrades, he shouted a warning and unhesitatingly hurled himself upon the explosive device. When the grenade exploded, Private First Class Johnson absorbed the tremendous impact of the blast and was killed instantly. His prompt and heroic act saved the life of one Marine at the cost of his own and undoubtedly prevented the enemy from penetrating his sector of the patrol's perimeter. Private First Class Johnson's courage inspiring valor and selfless devotion to duty were in keeping with the highest traditions of the Marine Corps and the United States Naval Service. He gallantly gave his life for his country.
/S/ RICHARD M. NIXON
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Q: I am rated as 100% IU. I received a letter yesterday that says I did not return a form to VA that they mailed to me last month. The letter tells me that they are going to take away my IU and reduce my compensation. I never received any such letter from VA. What should I do?
A: Any veteran who collects Individual Unemployability compensation is required to complete a VBA 21-4140 that will certify that the veteran hasn't worked in the previous year. The form comes about the anniversary of the award of the benefit. If the veteran doesn't receive the form or forgets to complete it and mail it in, VA will propose to reduce the rating and eliminate the IU award. The veteran must then react quickly and respond within 30 days. A form may be downloaded by clicking here and promptly returned via certified mail with return receipt requested. Enclose a cover letter notifying the VARO that the vet didn't receive the form and that should take care of it.
Veterans who receive the IU benefit will be required to complete this form each year. It's smart to keep some copies handy and if one isn't mailed to you, complete one of yours and return it on the date of your award anniversary.
Q: I had surgery done at my VA medical center. The surgery was for a carpal tunnel condition in my right hand and wrist. Now my hand and wrist aren't working like they should. I've lost feeling in a lot of fingers and I can't grip a pen to sign my name (I'm right handed). I found out the doctor who did my surgery had never done one of these operations by himself before and that he cut a nerve by accident. A physical therapist told me it may never get better and we're doing things so I can become left-handed. Do I have any options to sue them?
A: (Answer provided by Katrina J. Eagle, Attorney at Law) You didn't say whether the right hand and wrist are service-connected or not. If so, I would pursue an increased-rating claim immediately. If not, the language of "may never get better" is not strong enough to show permanent damage -- yet. In that case, I would wait no more than 12 months post-surgery, and if there is still no improvement, look into having a doctor review the case and see if he/she determines negligence was committed. If so, consult with an experienced FTCA attorney to discuss your options in more detail. Finally, regardless of what you decide to do, seeking regular medical care and treatment is key for documenting the consistent problems you experienced as a result of the "botched" surgery and, or the severity of your current condition as a result thereof.
Also see 38 USC section 1151 & The Federal Torts Claims Act
Q: I want to file to increase the rating in 2 of my 4 rated disability conditions. I'm sure they are worse than they were 3 years ago when I had my C & P exam. A friend told me that if I do that I risk losing all my benefits. What should I do?
A: Any time you ask VA to make any modification to your ratings, you risk a thorough review of your complete file. The VA is always on the lookout for an opportunity to lower your compensation. It isn't uncommon that a veteran asks for an increase to a rating and VA responds with a proposal to reduce the existing rating.
Before you apply for an increase or ask for any other change you should study the applicable rules and regulations carefully to be sure that you are qualified and that you will be able to submit the appropriate evidence. Then you should do a simple risk/benefit analysis in your own mind to determine that it's going to be worth the effort.
If you have a legitimate reason to apply for an increased rating, you should proceed to do so. Should VA respond with a proposal to reduce an existing rating, the appeals process is in place for you to halt that action and you should timely respond with a Notice of Disagreement.
Also see How To File A Claim
Q: I'm a veteran of 2 tours to Iraq. My primary care doctor at the VA clinic has told me I have PTSD. He is making some plans to have me evaluated by a psychiatrist but it seems that is going to take a while as they're very busy. He recommended that I go to a local "Vet Center" and talk to them about joining up and getting involved with that program. I'm not very good around people I don't know so I'm not sure this is a good idea. What could I expect from a vet center if I decided to go?
A: (Answer provided by Paul C. Burton) Thank you for your service! I have good news for you. Vet Centers were founded for veterans like you. What you can expect to find at your local Vet Center is fellow veterans who relate best to others who served in the Armed Forces; men and women just like you. Vet Centers are staffed by counselors who are trained and experienced in assisting veterans. Vet Center counselors can administer testing that is highly informative in assessing Post Traumatic Stress Disorder (PTSD) and other mental health issues related to PTSD. Such test results can be important items in a veteran's PTSD claim. Vet Center counselors are also prepared to assist with VA claims, direct you to community resources for veterans, and to assist with other veteran's problems. I also think that at your local Vet Center you are most likely to find other veterans who will become friends and an integral part of your support network. In my own experience, the local Vet Center is worth it's weight in gold! I encourage you to give it a try! Good luck, and thank you again for your service!
(Find a Vet Center close to you.)
(More about Vet Centers)
Q: I am 100% service connected. If I am injured or have a heart attack or have some other event that might require emergency treatment, will the VA pay for me to use a civilian hospital? The closest VA facility is more than an hour away from my home.
A: Yes, the VA will pay for emergencies for 100% service connected veterans and also in many instances for any veteran with a service connection. The trick is to notify the VA Medical Center nearest you as soon as possible and ask to be transferred there. The veteran or another responsible individual must make good notes of the time the call was made, who received the call at the VAMC and any other details.
All too often the authorization to use the civilian facility isn't as clear as it should be, the transfer to the VAMC may not have happened and days later the veteran will receive a bill. When the veteran calls the VAMC to find out why they aren't paying, they may say there is no record of such a call or that the person who received the call wasn't the one who should have authorized the stay or any of a dozen other reasons they can't pay.
Be aware that VA is never a secondary payer to any other insurance you may have, including Medicare. If you are being admitted to a civilian facility and hand them both your VA health ID card and also your Medicare card, the hospital is most likely to initiate billing with Medicare, not VA. Later you'll receive a bill for the deductibles and learn that VA will not pay those even if your health emergency was due to your service connected condition.
All this should be thought through in advance, just in case you have a true emergency. The letter below is from a reader of "Jim's Mailbag" who had an interesting encounter with VA & Medicare.
Jim;
I have been reading your column for some time and really appreciate the help you are providing veterans in dealing with the cumbersome VA system. I am sure there are many veterans who are in the same situation that I am. I have been receiving SSDI for 24 years which enabled me to be covered by MEDICARE. For 7 years I have been rated as having a service connected disability, currently rated at 70% disabled. I live in a rural area 200 miles from the nearest VAMC.
Under MEDICARE I could see physicians of my choice in the nearest town. Some specialty physicians are available in the nearest town. Virtually all specialties are available within 30 miles. There is a hospital with emergency room in the nearest town and a major hospital center within 30 miles. Under MEDICARE, I had the same Primary Care Physician for 15 years. I was able to receive both primary and specialty care with only a short wait and emergency care as needed within 8 miles.
At some point, in the last several years, the VA was designated as my primary health care provider and MEDICARE as the secondary provider. This has meant that I must receive primary care at a nearby community clinic with long waiting lists and frequently changing physicians and staff. Any specialty care must be referred to the VAMC with many months waiting list for appointments.
I learned that MEDICARE had been changed to my secondary provider when I severely fractured my wrist. I was treated at the local emergency room and then referred to a hand specialist in a nearby town. Eventually he ordered specialized occupational therapy by a hand specialist 3 times a week for 4 months. Customized splints and other appliances were required. As a result of this therapy, surgery was avoided. Unfortunately, MEDICARE declined coverage since they are now designated as secondary provider. The VA declined to cover saying that I should have driven the 200 miles to the VAMC (a physical impossibility) and there was no proof, despite multiple X- rays and exert medical testimony, that the therapy was needed.
When an individual lives a considerable distance from a VAMC and has MEDICARE or other insurance, it is no benefit to be forced into the VA health care system. I understand the need for the VA to monitor my disability and am happy to provide copies of any medical records for any condition. However the burdens of the VA medical system are preventing me from receiving medical care. How can I restore MEDICARE to my primary healthcare provider? Thank you.
Reply;
This was a new one on me. At about the same time I received this, I had another Veteran reader who cautioned me, "Medicare Part A may not be free to Veterans enrolled in the VA medical system. If you have Medicare, It may cost you your Veterans benefit of being treated in a non-VA hospital in case of an emergency...just having Medicare Part A could disqualify a veteran."
The rules that govern Veterans Health Administration (VHA) benefits are complex. If you ask a question of 5 experts at 5 different places, you may well receive 5 different answers. The Medicare benefit is no less complex with its requirements for different plans for hospitals (Part A) that are separate of those for physician providers (Part B) and the need for a supplemental policy and a drug plan. When you mix them all together, you concoct a witches brew full of hazards and pitfalls. Like so many other aspects of our lives with benefits, stepping off on the wrong foot may set in motion a situation that will take a lot of work to remedy.
In the case of the Veteran with a broken wrist we discovered that there is a little known program (at least to the average user) within Medicare known as Medicare Second Payer or MSP. In concept, this is fairly easy to understand. If a Medicare patient has another insurance provider, that other insurance is almost always viewed as the one to bill first. For example, if a patient is working and has private insurance through the employer and also has Medicare, the private insurance should be the first billing target by any health care provider. Then later, Medicare may or may not pick up and pay any charges that the primary payer didn't. If you have private insurance and Medicare, Medicare is clearly seen as the Secondary Payer or...MSP. This also applies to civilian (non-VHA) disability insurance or workman's compensation. Those payers are billed first as the primary insurer and Medicare is second.
Are you confused yet? Just wait...
Enter the Veteran who has both VHA healthcare and a Medicare card. In this instance, Medicare may or may not be the primary payer for services...it just depends on circumstances. If our broken-wristed Vet had gone to a VHA facility, the VHA would have automatically become the primary payer...to the VHA. This means that VHA would have taken on the total responsibility to fix that fracture or to refer the Veteran to an outside specialist on a fee basis contract. VHA would have been responsible to cover it all except for any copays the Vet may be required to make with a rating of less than 100% disabled. In this case though, our Vet took that fracture to a civilian facility. That's understandable, she was in pain and needed emergency treatment.
So why the problems with billing?
As the Veteran and I thought this through, we determined that as she was being checked in through the civilian facility's emergency department, she probably handed over her VHA Identification card and also her Medicare card. The hospital always wants to ID the patient and assure themselves of future payment.
In formal medical terms, this important, complex procedure is often referred to as The Wallet Biopsy.
Our Veteran, being in serious pain from that fracture, hadn't called or even considered going to the VA facility. She was treated, released and received some ongoing therapy without VA being involved. Then she was notified that VHA wasn't paying the tab for all this and since Medicare was designated as the Secondary Payer, neither were they.
It took us a couple of days before we had our "Ah-Ha!!!" moment. Once the penny dropped, we soon determined that the hospital's insurance and billing department, seeing that VHA card, had billed them first, then Medicare. This was an error of the civilian facility's billing department. Medicare saw that VHA had been billed and assuming that it was an authorized (fee basis by VHA) procedure, declined to deal with it. The VHA declared that they were not notified and had not pre-authorized fee basis so it wasn't their problem.
Our Veteran, armed with all this information, called her local Medicare offices and spoke with the Coordinator of Benefits or CoB. Incredibly, the CoB understood and instantly agreed and said that it would be taken care of and that in about 2 weeks, all the civilian providers should re-submit their bills to Medicare for payment. Records were to be corrected and would show Medicare as the primary payer.
If you are one of the very fortunate Veterans who have both a Medicare benefit and also a VHA benefit, how you receive your care is largely up to you. You may choose to use civilian providers for all or some of your care or you may stick with your VA care all the way. If you have both insurances available to you, you may have the most flexible health care plan available anywhere.
On the cautionary side of all this is that you should plan in advance on exactly what you want to do and what makes the most sense for your health and your finances. Whether you have all these benefits or only one, advance planning is the key to smooth sailing.