Walz Demands Action After VA Whistleblower Exposes ER Denial Scheme

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Rep. Tim Walz (D-MN) is now calling for an IG investigation into a non-VA emergency care denial scheme after watching KARE 11 coverage.

Reporter AJ Lagoe just ran the above news story exposing a framework forcing improper denials. In the piece, Lagoe interviews one VA whistleblower whose job was to approve or deny non-VA emergency room bills submitted by veterans.

According to that whistleblower, the agency requires top performing employees to process 22 claims per hour to achieve “outstanding” ratings. That comes to less than three minutes on each claim per hour for a GS-6 to interpret emergency room medical records, the law, and then approve or deny the claim.

That whistleblower, referenced only as Joe, not only admits VA is adjudicating the claims improperly, but he also indicates the time restraints preclude fairness and consideration of all evidence resulting in improper denials.

RELATED: Veteran Takes On VA Over ER Bill Denial

Rep. Tim Walz Demands Action

His words and the report from Lagoe resulted in Rep. Walz promising prompt action and an IG investigation into wrongdoing.

“We’re looking into it,” Rep. Walz said. “I think after your report we’re going to ask the IG (Inspector General), as we always do, to look in a little deeper and see if this is systemic, and try and figure out how deep it goes.”

“When you point out a story like you ran, I think it warrants looking at it,” Rep. Walz said. “Let’s figure out if this is a problem either in staffing, or if there is a cultural issue forcing quantity or look good, over actually being good. We should find that out.”

For new readers, this scandal was first brought to light by me last May after February emergency room visit. My daughter’s mom died from burn pit exposure, and I subsequently experienced heart attack-like symptoms and went to the nearest emergency room.

In the following months, I spoke with VA Chief Experience Officer Linda Davis twice. She asked me to forward my emergency room bills to her so her staff could help take care of it.

I took that to mean they would sort it out with Minneapolis VA staff to ensure it was covered or at least fairly adjudicated.

Over a month passed after submitting the records and I heard nothing from Minneapolis VA about payment.

In mid-May, I received a denial stating a “prudent layperson” would not go to the emergency room with my symptoms.

How obscene.

RELATED: Are VA ER Bill Denials Bad Faith Insurance?

Anyone watching public service announcements about heart attack or stroke know seconds count when experiencing chest pains, especially on the heels of the death of a family member. If you experience chest pains, trouble breathing, and light-headedness, you better get to the nearest emergency room.

Taking Charge

Taking matters into my own hands, I contacted my friend AJ Lagoe. His team immediately put together a plan to expose what happened to me because it was likely denials like mine were going on elsewhere.

Four months later, KARE 11 not only cracked open the scope of the scandal – – that 100,000 veterans are being denied over $2.5 billion in emergency room coverage each year – – but their coverage inspired Rep. Walz to demand an investigation.

One whistleblower confirmed what we all expected. VA employees are not reading the full files before denying the claims because they have an incentive to not read the whole file much less grant claims.

The process of even granting claims takes longer than denying claims, much less that truly adjudicating the claim in a legal manner requires reading the documents in the file.

Soup to nuts, for a non-doctor, non-lawyer reviewing the file, it would likely take 30 minutes to read each claim and approve or deny, not less than three minutes.

RELATED: Growing Pattern Of ER Denials Emerges

Next Steps

Because of my story, and those of others coming forward, VA will be investigated and forced to pay millions through education of veterans and VA employees in proper adjudication and processing requirements of these claims.

Veterans seeking non-VA emergency care must be experiencing an emergency and notify VA within 72 hours of the event.

Do not expect coverage for follow-up appointments for the non-VA care you received that was previously an emergency. VA generally will not pay for such services because they will not deem the services to be provided in an emergency.

Seems straightforward, right?

The biggest problems veterans face is contacting VA in an emergency. Most often, during weekend ours, no one is staffing the VA phone when the veteran or her family members call in.

In my mind, Congress should consider expanding the 72-hour notice requirement. This is not reasonable, especially since it can be quite hard contacting VA while you are stuck in a non-VA hospital or in a coma.

VA’s notification and education of veterans regarding non-VA care in an emergency is a complete joke, and they know it’s a joke citing lack of understanding of benefits as a reason why denial numbers are so high.

Confounding matters, the agency refuses to publish its intricate processing policy.

But even if they did, VA is obviously not processing even claims submitted within the timeframe much less claims of veterans filed out of time due to an inability to reach VA while unconscious.

Source: http://www.kare11.com/news/investigations/congressman-calls-for-federal-investigation-of-va-er-denials/478866144

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91Veteran
91Veteran

Two things I notice about this.

1. Congressman Walz is asking the IG to investigate, as other Congressmen have asked the IG to investigate other issues. Where the hell are the House and Senate VA committees and their investigation?

2. Again, if a claims examiner is spending 3 minutes per claim to meet a QUOTA of 22 per hour, how is it that examiner can look at the veterans medical records to determine if the ER care received was for a service connected condition? Hell I have gone to the VA for years and have not been asked by my Primary Care doctor about some service connected conditions. A PRIMARY CARE provider that SHOULD be familiar with my medical history?

If these examiners are only a GS-6, exactly what kind of training do they get to examine claims? Are they given a Tip and Jane book for a simple reading test? I can’t believe a GS-6 in any federal agency has enough power to demand any kind of training other than possibly which icon to click on a computer screen.

Keep up the excellent work Ben and AJ.

Ranger11bv
Ranger11bv

I have gone to non-VA hospitals in the past. Is there a way i can get the records of the VA deny letters??

Frank
Frank

My VAMC delayed diagnosing my cancer for 13 months. They then referred me to a non-VA medical center for surgery & radiation therapy, and added a kicker: payment is on you. I ended up unemployed, bankrupt & homeless. I’m still fighting VA for redress, including initiating inquries from my congressional delegation, calling “Bob,” emailing Dr. Shulkin, personally handing Dr. Shulkin a summary of my case, calling the new White House hotline the day it launched (“we’ll get back to you in 14 days”), calling them again after 3 months of silence (they were fuzzy about my first call, talked to me for over an hour, told me they would get back to me “in 14 *business* days,” emailed me that, unavoidedly, they would take longer, but would get back to me by 9/21). To date, nada, zip, zilch.

Oldmarine
Oldmarine

The IG is a joke just like the rest of the so called Justice System …They will just clear coat that turd and call it all good..I can guarantee they do it on the disability claims also, When you look at your denial letter and it doesn’t make any sense you know the reason……They need a good Audit and not by one of their paid off Auditors ….FOLLOW THE YELLOW BRICK TRAIL..[money]……. And Rep. Walz Go back to sleep because you wont change shit just like the rest of them politicians ….

namnibor
namnibor

Sorry to break the news but…this prudent layperson believes with all my heart & mind the VA OIG are a dried-up spent whore, but she’s still taking orders amongst the sand in the Vaseline as Vets get the abrasive screw.

windguy
windguy

I think you’re doing old whores a terrible disservice.

namnibor
namnibor

“[….Confounding matters, the agency refuses to publish its intricate processing policy….]”
Simply open a medical or veterinarian science book on the digestive system of cows and pigs and there you have VA intricate process detailed. Replace food in digestive tracts with a Veteran’s ER bill or claim for services. Done.

namnibor
namnibor

Note that a cow indeed has 5 stomachs for processing, that’s 2 more than the VA possesses, as it’s one minute per stomach.

namnibor
namnibor

One minute per ER claim for services/one minute per bovine stomach.

Peter Kreutzfeldt
Peter Kreutzfeldt

It’s not just the outright denial of a claim. Many vets are left in limbo not knowing which direction to seek. I my case I’m in chronic pain each day because the CHOICE program decided to sit on things, decided not to communicate with claimants or just not do anything about it. I wonder how many vets decide on their own to bring things to an end because they have no idea which way to turn.

91Veteran
91Veteran

Peter, on the Choice program, there has been a pattern since it began with denials, and I firmly believe it is to maximize profits for the companies running the program.

Early on, vets were reporting getting bills because an authorization was not provided, the authorization was not correct according to Choice, or the authorization expired. Choice authorizations were only good for 30 days, so when Choice delays setting the appointment, the authorization would expire and Choice would use that as an excuse to deny payment with the veteran holding the bag. Getting out of the bill maximizes their profits.

The other method they use to maximize profits is to claim any related parts of your care was not authorized. Choice would authorize you to see Dr. BigKnuckles, and nothing else. If Dr. BigKnuckles wanted Xrays, MRIs, or other tests, Choice would deny payment because Xrays, MRIs or other tests were not authorized.

All of this is by design. Each VA used Choice money to hire Choice champions who were supposed to help vets, but it was typical VA window dressing. They hired people who knew nothing about Choice and provided no training to them. Problems continued, so the VA created a hotline supposedly to help vets with bills being sent to collections. Problems continued, so VAs assigned specific people at VA hospitals to help vets with billing.

It’s as I predicted long ago. A massive cash cow for some politically connected people, and a jobs program for VA flunkies.

Meanwhile vets and providers are still left with the bills.

Centene, who recently bought out Health Net and runs them as a subsidiary reported over $500 million in revenue in one year. How? By not paying their bills.

Crazy elf
Crazy elf

This issue has been going on for quite some time now! This is one “reason” I’ve tried to NOT use outside emergency healthcare! Even though I’ve had medical problems, in which I should have gone to the ER!

These “non-payments of ER bills” is, in my opinion, also connected to the “non-payments of the Choice Program bills!”
That being said, here’s a new article out today, 27 Sept 2017 from “Military.com/ Daily News” via: the “Associated Press” | by Hope Yen.
Titled:

“VA: Money for Private Health Care May Run Out by Years End!”

____________________________________

I watched a video recently concerning the issue of WHY Congress, both houses, were NOT interested in fixing any problems within many agencies. It’s had to do with “subsidies”, (Stocks and Bonds), these reprobates are receiving from the corporate world.
Think about it. Why would a representative(s) want to stop the “gravy train” he/she is receiving monies from?
They wouldn’t!
They will allow the monies to continue into their coffers! While sitting back reaping the rewards off the backs of the taxpayers!
How many of them have “off shore accounts” growing fatter each day? Just like the many (CORRUPT) VSO’s have grown their coffers over the years!?

Until there’s an investigation, (which will NEVER happen), by a REAL law enforcement agency, things will continue until Americans have had enough!

That’s my thought this fine Wednesday morning!

namnibor
namnibor

I think the VA employees keep dipping into the Veteran Choice Cookie Jar…then when almost empty: “May I have more, please?” Wait for it…

namnibor
namnibor

“MAY” is only utilized when groveling to congress critters for more taxpayer $$$. Otherwise, do not expect such mannerisms by purple teams.

Crazy elf
Crazy elf

namnibor,
That seems to be the VA’s “modus operandi” every year. Sometimes twice a year!
Sure looks like some of our lawmakers are getting wealthier as time goes by!

Seymore Klearly
Seymore Klearly

Of course any additional funding will have to include opening another 26 VA medical research facilities. Just like last time.

Dennis
Dennis

So……..

once again we rely on the ancient and mythological beast called “More Training” (MOTRA) to descend from the swamp in heaven and deliver us from ignorance? Hmmmm. It could work but this brings to mind my days as a flight instructor for gliders and single engine aircraft. We had a story that seems to be a spot on match for an epic analogy.

The most superior flight instructor in the world, it is told, once boasted that he could teach ANYTHING to fly. Of course once spoken the challenge was made – he was presented with a green toad from the airport pond. He was reminded of his boast.

So the man proceeded to instruct the toad in the fine arts of aviation and the flight instructor signed him off as having passed the ground school with a complete knowledge of aviation. Then after a careful preflight, the instructor threw the toad high into the air and after a gentle arc it crashed to the ground, bruising it.

The instructor decided to bring the FAA doctrine of MOTRA into the equation. The toad was given remedial instruction and once again was signed off for solo by the instructor. This time the instructor decided the toad needed more airspeed to recover from the incipient stall/spin disaster of the first flight so he climbed to the top of the tower with the beacon light. The beacon had sufficient altitude for the toad to reach terminal velocity upon which his control surfaces should begin to function was the idea the instructor had. After a thorough preflight the toad was again launched into the air from high atop the airport beacon

… This flight was brief and an aviation fatality report was filed within the time frame specified by Congress. FAA investigated the incident.

The FAA investigation concluded that the toad was insufficiently trained for solo flight and recomended strict implementation of MOTRA for future toads learning to fly…

How on Earth this seems related to VA to me I’m just not sure…. croak….croak…..croak…..

91Veteran
91Veteran

Dennis, I take comfort in picturing that toad to be Johnny Isakson getting his ass launched off his stairmaster.

Crazy elf
Crazy elf

I need clarification on this issue.
Example: the Choice Program used to have specific requirements for using it. One must have 3 conditions to use it, ie; 40 mile rule “AND” 30 day rule “AND” one more. (Sorry, I can’t remember the 3rd rule!)
Then it was changed to: 40 mile rule “OR” 30 day rule “OR” one more rule.

Can y’all explain, What are the actual “rules wordings” for veterans to use the ER?

I’ve been afraid to use the ER because of this issue for some time now. Even though, as I’ve said, there have been times I believe I should have gone!

91Veteran
91Veteran

Crazy Elf, the two times I have been referred to Choice has been because my VA does not have the specialists in staff that my VA doctor wants me to see.

Crazy elf
Crazy elf

91Veteran,
I’ve never been allowed to use Choice. My PCP was/is refusing. My question concerns veterans using the Emergency Room!

That being said, What are the actual “rules wordings” for a veteran, say: having medical problems, going to the Emergency Room?

91Veteran
91Veteran

Crazy Elf, if your PCP is refusing referral, I would ask the chief of the clinic why, and to put it in writing.

As for a veteran going to a non-VA emergency room, this is the VA policy on it:

“https://www.va.gov/healthbenefits/access/emergency_care.asp”

If you do a search on “veterans affairs Emergency care”, you will get the above web site and another link to VA Fact Sheet 20-02, Emergency Care for veterans.

Generally, the VA claims a veteran must notify the VA of going to the ER within 72 hours.

The first link provided the “prudent layperson” language, but contains some other interesting caveats, including you must have been seen at a VA within the last 24 months.

The list of caveats for non service connected care is so long, I would be shocked if the VA ever paid an ER claim for that.

Crazy elf
Crazy elf

91Veteran,
Basically, the VA has, through “double-speak rules” (?)

Crazy elf
Crazy elf

91Veteran,
Sorry, for some reason my phone is screwing up!
I’ll continue.
Through “Double-Speak Rules” (?) the VA has insured ways of continuing to “deny” claims. Whether it’s through ER visits or through Choice! By making the “rules” so ambiguous, even professionals would have a hard time interpreting them!
Sounds as if VA has figured out how to keep the taxpayers monies flowing into their coffers; ie: off shore bank accounts and other (possible illegal) acts!

91Veteran
91Veteran

Crazy Elf, if it’s an ER claim being denied, VA employee bonuses are bigger.

If it’s a Choice payment being denied, then all kinds of people invested in certain companies get bonuses when the stock price rises.

With the added benefit of the program having funding for a longer period that pays the salaries of some VA employees. Deny the payment and not help a vet and they get to keep their job longer.

91Veteran
91Veteran

Crazy Elf, basically their “rules” have enough wiggle room for a tunabeast engorged Purple Team member to turn around in without touching the sides of the door.

I don’t believe they look at any claim with this policy in mind. I believe they have specific reasons they look for to deny the claim and move on quickly to the next.

If it were me going to an ER, I would make note of the date and time I called the VA, if possible, and record the call if possible, and still be prepared to fight them for the next several months.

namnibor
namnibor

Perhaps if all the NFL players were military vets and decided to kneel out of protest of our VA and U.S. Gov’t. allowing 22+ Veteran Suicides a day, we could get some real traction on this quagmire we still find ourselves in with the VA doing right thing for those that defended our U.S. of A.?
Second thought, if Vets did protest the Nat’l Anthem, the VA would send out the Disruptive Committee Stormtroopers for our collective asses as we have no rights.

windguy
windguy

Go grab a half dozen of your favorite vets, call local media and protest outside the recruiters office… “Don’t Do It Kid, Your Country Doesn’t Keep Its Promises”.

windguy
windguy

Where’s Trumpmeister’s brave beer-magnate insider?

Seymore Klearly
Seymore Klearly

Passed out on the couch. He had a few to many last night and the night before and the night before that…

Seymore Klearly
Seymore Klearly

I wonder if he has completed his goal of insuring all VFW’s now have Leinenkugels on tap?

91Veteran
91Veteran

He may be still working out the details on that.

The last I heard of that chump he was flying to Montana for some bullshit reason.

windguy
windguy

I think you confused bullshit reason with Bull Elk season….

91Veteran
91Veteran

That certainly would not surprise me Windguy.

Dina Padilla
Dina Padilla

Anyone who reviews a patient medical records SHOULD BE A MEDICAL LICENSED PROFESSIONAL, NOT SOME BUM OFF THE STREET. I say sorry for saying BUM, because those adjusters that deny claims are told not to process claims and aren’t qualified either to make a medical opinion, all to save the agency money and bonuses are to be made for saving the VA & DOD money. It’s a damn insurance (RICO) racket and nothing more.. An audit should be done on the VA & DOD to see the savings & who outright benefits with bonus money and just how much is made off the money saved from year to year. AN AUDIT PLEASE!

Dina Padilla
Dina Padilla

There should never be a time limit on reviewing a medical chart if there is even an access to one, IF, THERE is even access to a medical chart. 3 minutes isn’t enough time to ask all the right questions nor get all of the answers. Take it from one who was on the phone with patients and who get disciplined more times for being on the phone more than a minute and half, after THE minutes was deemed to be the standard. This in of itself should be the basis of deliberately denying medical care.

Seymore Klearly
Seymore Klearly

The VA management has it’s collective heads up their asses basing bonuses on quantity of claims processed.

Instead of using bonuses to achieve quantity of claims processed. They should be firing those employees who are not producing Quality Decisions in the claims they processed.

If they have been hired to do a job properly and are not doing it so they can get bonuses. Fire the Fricken Chit-heads don’t reward them with bonuses. All they are doing is creating poor decisions and much more work to straiten anything out.

As for the VA Chit-heads screwing up other claims fire them two.

Seymore Klearly
Seymore Klearly

Oh and don’t forget to fire the Fricken Moron at the top for running such a truck up system.

It is long past time to fire Shulkin!!!!!!!!!

Oldmarine
Oldmarine

Seymore you might want to check this out……10 Reasons Why Switzerland is Home to the CIA …..”https://docs.google.com/viewer?a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnx0cnV0aGVyc3dpdHplcmxhbmR8Z3g6NzI4ODJlMGNkZjQzYmUy”

Donna
Donna

Shouldn’t the VA’s claims processing procedures be listed in the Federal Register?? It’s a government entity and it should be well documented one would think!

TLC
TLC

This is part of Congressman Walz statement from above “if there is a cultural issue forcing quantity or look good, over actually being good”. This is a problem not only in processing Non-VA Emergency claims, but also Benefits claims and Appeals. This is a problem not only in the VA but in every company. Havard University School of Business did a report on the effects of treating people like machines and its effects on the individual, the company as well as society.

Leatherneck
Leatherneck

As a Concerned Veteran i was told Veteran Affairs Committee if you do believe that a Veteran Medical Center does you wrong call your Senators and Representative remember do as many times you believe that you should definitely don’t Surrender no excusesl like they listen and Spread the word to your Veterans Friends. ..Semper Fi 👍.

COME MERDIA VA.COM
COME MERDIA VA.COM

THE SENATE @ HOUSE COMMITTE ARE LAZY LARD BOTTOMS LARED ASSES MR WALTZE GET OF YOUR ASS YO INVESTIGATE WE VETS DEEMAND A HEARING ASAP ABOUT THIS VA RICO CRIME RACKET TATS ALL ABOUT THE PROFRMANCE BONUSES $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

91Veteran
91Veteran

Hmmmmmmm. AMEN BRO!

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