Agency Spins Growing Pattern Of Non-VA Emergency Room Bill Denials

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Reporter AJ Lagoe and the KARE 11 News Team is uncovering an alarming trend of improper non-VA emergency room bill denials by VA.

Last Friday, KARE 11 exposed the story of Vietnam veteran Gerry Malwitz. The veteran experienced extreme bladder retention and pain following treatment on his prostate. With the nearest VA being 120 miles away, Malwitz went to the nearest emergency room (ER), which happened to be a non-VA facility.

The veteran reportedly notified the agency within the required 72-hour window of the emergency. Months later, VA denied covering his emergency room bill.

The reason?

Like in my case in May, VA contents a “prudent layperson” would not deem urine retention and pain to be an emergency even though the Department of Health and Human Services considered the condition extremely dangerous and recommends those experiencing symptoms report for emergency care.

Sound familiar?

RELATED: Veteran Takes On VA Over ER Bill Denial

In May, VA denied covering my emergency room bill for symptoms of a heart attack stating a prudent layperson would not seek care if experiencing symptoms of heart attack.

Make sense? Ever see a government public service announcement telling viewers to run to the emergency room whenever experiencing heart attack symptoms?

Well, it does according to a VA whistleblower whose interview will be aired Monday at 10PM CST on KARE 11. That whistleblower plans to dish on why VA is denying veterans without regard to the nature of their emergency.

RELATED: Are VA ER Bill Denials Bad Faith Insurance?

As far as Malwitz’s case is concerned, according to KARE 11:

Department of Veterans Affairs Public Affairs Officer Randall Noller promised to help get answers about the specifics of Gerry’s denial and those of several other veterans that KARE 11 was simultaneously reviewing.

Instead, KARE 11 received a statement from VA Press Secretary Curt Cashour, who works directly for VA Secretary David Shulkin.

The statement which answers none of the specific questions asked by KARE 11 reads:

“Unlike private health insurance, there are several variables to VA emergency room care payment approval, such as whether the treatment is for a service-connected injury or illness, whether or not the veteran has other health insurance, and how long it’s been since the veteran has been seen by the VA.  VA will continue to work with veterans to help them understand their emergency care benefits.”

Remember the VA is trying to stick Gerry with an ER bill specifically claiming his extremely painful and potentially life threatening urinary retention was not even a true emergency.

KARE 11 responded to the VA’s statement with two direct questions about Gerry’s case.  We asked if the VA disagrees with the U.S. Dept. of Health and Human Services about the seriousness of urinary retention and what VA Secretary Shulkin believes a prudent layperson should have done in Mr. Malwitz’s situation?

Once again, the Department of Veterans Affairs failed to respond with direct answers.

Personally, I have a growing dislike for some of the feedback Cashour provides on cases seeking specific feedback. KARE 11 went through the trouble of submitting a properly executed release of information to get answers on this case, but the agency is clearly stonewalling.

At the end of the day, over $2.5 billion ER bills from veterans are denied each year. This scandal makes the TBI scandal we exposed two years ago look like a drop in the bucket.

The KARE 11 team also put together this helpful animation video to help views visualize the problem. What do you think the real issue is?

Source: http://www.kare11.com/news/investigations/kare-11-investigates-a-pattern-of-denial-for-veterans/478022800

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Dave F.
Dave F.

Why hasn’t an attorney sued the VA? Seems to me that a class action would quickly solve this problem.

Donald Avant
Donald Avant

I think you can’t sue the VA unless it allows you to…Tort laws…

Ben ?

WyldeChylde
WyldeChylde

Plain and simple. Death to the VA and all scumbags who hold federal jobs through the agency.

Donald Avant
Donald Avant

Delay, Deny, Stall till you die…The VA takes EVERY opportunity to deny benefits of any kind because it allows them to keep the money in the bank a little longer and draw interest. Typical insurance company dodge…

Lem
Lem

Opening the TBI issue again with my claim. SF-95 TBI. Never had an ER bill refused but then I’ve been over 50% for 30 years. Did have an urgent care bill refused when I recognized the problem was urgent care and didn’t take it to the ER where I could have. Now, with Choice authorization, and knowing how to keep it, I don’t have that problem.

Realize, that even for Choice, you have to be seen once a year by a primary care at the VA in order to not be dropped from the rolls at your VA if you are using the VA as your primary care. It is a stupid new rule that we weren’t notified about. I only found out about it by writing to my congressman about being dropped from Choice. I refused to see the Primary Care at the VA because she was incompetent, wrote progress notes from the Merck Manual to match her assessment instead of listening to the symptoms I stated and noting them. What I had to do was change VA Primary Care by putting in a form through the patient advocate. I’m now authorized 12 visits for this year to my local Primary Care and 52 visits to my PTSD therapists. Paid Banner Health $75.00 to learn the lesson.

The bill is in appeal. Because of my “brain syndrome” I can’t drive at any particular time and couldn’t have driven to the VA I was assigned to for that urgent care problem in time to keep it from becoming a serious problem.

Ranger11bv
Ranger11bv

Another common practice: its reported, we get angry, NOTHING happens….tic

Crazy elf
Crazy elf

“Shithead Shulkin” needs to be fired and indicted over his allowing his management to murder veterans! HE’S AN ACCESSORY TO MANSLAUGHTER!

________________

This out today from “Military.com/Daily News”
Dated; 24 September 2017
via: “Stars and Stripes | by Nikki Wentling”
Titled;
“Facing High Denial Rates for VA Claims, 3 Gulf Vets Intervene”

From the,article, quote: “VA denies more than 80 percent of veterans’ claims…”
This begs the question, “Just what the HELL does VA do with ALL those BILLIONS of taxpayers monies?” “Who’s pockets is it going into?” “When will we see management at VA’s nationwide be hauled into courts, and be sent to prison, for scamming the American People and veterans?”
“JUST WHAT THE HELL IS THE DOJ WAITING FOR?”
Every day veterans are dying due to the corruption, waste, fraud and abuse by VA!
They ALL need to be held accountable for killing veterans!

Rant out for NOW!

namnibor
namnibor

RAND Corp. defines “Prudent Layperson” as an individual that is able to only eat -1- ‘Lays’ potato chip. Translated to a Vet using the VA: never use the ER or you’ll be charged for each ‘chip’ you eat by a lazy engorged employee.

Dennis
Dennis

I thought a prudent layperson was just the politcally correct term for a whore that used a condom? No?

namnibor
namnibor

The whore would reuse a used condom: THAT is being pragmatically prudent when in a bind for a layperson.

TaB
TaB

VA employees and VSOs are paid for going along with the game of screwing over veterans, not because they have any knowledge, skill, and/or ability to do the job.

I’ve seen ignorant, illiterate and down right stupid people who work for the VA. And, I’m not saying this to be rude.

I can honestly say that when I was at other agencies, I worked with people who had impressive resumes….NOT at the VA.

James Gallegos
James Gallegos

The dav representative who said she was going to help me with an manager who falsely accused me of disruptive behavior.

Did such a good job, the manager who falsely accused me, hired her and are good buddies.

The dav representative gave the manager all of my paperwork given to her that proved my case.
People wonder where the money goes, it goes into the employee pockets and manager’s use it to ensure their employees stay loyal so they can get their yearly bonus.

91Veteran
91Veteran

I am sure that RAND report ended with…more research is needed.

Kat Owen
Kat Owen

I know just how he feels, being denied not only emergency room visits, but also visits to the doctors that were APPROVED by the VA and Choice! Want to see the stack of medical bills I’ve got? All stacked on top of each other I’d say about 4 to 5 inches thick, and all gone to collections! Bills since 2014

91Veteran
91Veteran

Kat, have you tried calling the “Choice champion” at your VA? Every VA is supposed to have one. The VA hired them using money for Choice to help vets with Choice, but the VA does a lousy job of letting vets know of their existence.

Dennis
Dennis

Pretty simple.

Since there is zero accountability that can be brought to this equation, it really comes down to something pretty obvious to me. I have worked at many places that serve people. In short order I begin to hate the whining, bitching, stinking customers that I have to put a smile on for. These VA folks are no different. The difference is in how the system is perpetuated.

In a bar and restaurant business I can FIRMLY attest that the patrons are piggish, rude, and inconsiderate jack-asses when they walk in the door. Feed them and get them drunk and then they get happy and make you a profit. It is not fun at all to feed drunk people. However, if we did not put up with them and did not serve them, the bar would fold. We might view them as pigs, but we treat them like customers that we need to serve if we are to survive.

VA system is not dependent upon law, customer satisfaction, or job performance to perpetuate itself. In a system like that there is simply no downside to treating the customers like pigs. After two or three insults that really sting, our heroes at VA likely high five and knuckle bump for each vet they can sting back. What you see develop in government like this has almost nothing to do with rational thought and almost everything to do with 1) protecting your individual slice of the pie, and 2) paying back the asshole customers for all the unsavory insults paid to them. Unlike customer service and satisfaction, it is these two things that drives corruption as see it.

The VA folks I have overheard have an intense loathing for vets when they think nodoby is listening. Each denial is a little dance for them. A little victory. Make no mistake about it – of all the enemies our veterans have faced the most determined and damaging is the VA. In that very real sense, vets are at war wih the VA and have been for a very long time.

TaB
TaB

Dude, in my short time at the VA? Yes, heard nothing but loathing for veterans who we were supposed to serve. Worst, these VA employees were also veterans!!!

I was respectful, patient, and received many praises from our fellow vets – yet the VA covered it up and threw me out because I was “unprofessional” to my coworkers? Please…my coworkers were rude to me, managers, and the public. They were quick to learn nasty ways from tenured VA employees.

The stories I could tell you in the short time I was there. I saw everything from screaming at vets, calling police on vets who simply brought their kids to an appointment with them. Horrible…

There were times I would be talking to a veteran and he/she would turn away from the VA employee because they literally said that “I” looked like I knew more. No, I was a new hire, but at least people felt comfortable with me because I showed them dignity and respect, rather than contempt and disdain.

I hate the VA so much. Worst of the worst of all agencies.

James Gallegos
James Gallegos

Welcome to my world, as a former VA employee and would not take any Gump from anyone employees knew not to do anything wrong around me.

I would turn them in if I seen it. ! Friend’s I did not need any friend’s.

Once I retired they attacked me as a veteran ! Telling the main VA that I had been disruptive on many occasions and the believed the manager and called the OIG, FBI and my local police department stating I wanted to murder employees at my local clinic.

They punished me for 5 year’s, they did this without requiring the manager to provide any proof.

When I requested any and all proof they used to prove I had ever been disruptive ever!

VA response was, we have no written evidence of you ever being disruptive!

But they did it anyway.

Crazy elf
Crazy elf

For y’all who are pissed off at the NFL “Looney Liberal Left” protesting the American Anthem and Flag; This just out from;
“End Times Prophesy”
“Brother Jim Reporting” – Sept. 25, 2017
Titled:

“Well, well, well. Look What It Says Here in the NFL Rule Book!”

Looks like almost all the players and owners can be kicked out of the NFL for refusing to Honor the American Flag and National Anthem!

namnibor
namnibor

@Crazy elf- I said last night amongst ‘mixed co.’, and they laughed at me: WATCH: NEXT…the NFL will simply eliminate the National Anthem altogether. I could be wrong but again, just wait for it…

namnibor
namnibor

Things were so much simpler with the Romans, coliseum, Christians, and lions…oh my! 🙂

Sad Sapper
Sad Sapper

I had the va deny my ER bill early this year. The surgeon knowingly prescribed a pain med that I’m allergic to and had to go to my local ER within 24 hrs of discharge from surgery because I was having a hard time breathing…my known reaction to hydrocodone is respiratory distress. They said pain was normal after surgery WTF? So, these dirt bags have no reason to deny other then to cover their butts for bonuses. Whoever is in charge of the billing department at every va should be fired and then hung from the town square by their pinkie toe for everyone to shame them. JMO

sepp dietrich
sepp dietrich

did the VA perform the surgery? and give you drugs that you’re allergic to?

James Gallegos
James Gallegos

Veterans white house hot line for complaints

1 855 948 2311

TaB
TaB

Waste of time. Used it once.

91Veteran
91Veteran

I tried that today James. Waited over 40 minutes for the call to be answered. After explaining why I called, I was told the matter would be referred to a higher level at my VA for review by a Subject Matter Expert.

I asked why are they referring the complaint to the same nitwits that cannot review my medical records to see what I am service connected for. I was told she knew nothing, and repeated the same thing about referring it to my VA.

james gallegos
james gallegos

just thought I would throw it out there. you folks just answered my unasked question. is it working.

you seen where the VA is using veterans in adds on tv, how great it is and they have to fight to keep my VA open.

ian hambek
ian hambek

Va did the same thing to me, said it wasn’t an emeegency, it was chest pain but turned put to be a bad panic attack, so the va said post diagnosis, after the fact, it wasnt an emergency. Apparently my beliefs as a pay person dont count even though the law says it does.alao another scam is the hospital farmed out my xray films to an independent doctor to review and the va denied that as well.

Billy
Billy

Even if you call nobody gonna answer

Billy
Billy

And nobody gonna tell you a number and what if you hit head etc how you supposed to know …i know they not only dont care but demorilization is …standard issue…why 72 hours…whats so impotant about 72 hours…just a snake turning not no real clock no need for clocking crap unless u spooking out

Billy
Billy

Maybe in 72 hours half or third of er patients dead..then they really cant try and call nobody..especially since not one e r in country has on hand an oil grown from a simple plant that will greatly stop strokes etc and our government got patent on it 25 years ago called the 507 patent$$$$$

91Veteran
91Veteran

I could stretch and believe the VA made a mistake in denying payment as they suggest in the linked article, but it seems clear from Spokeshack Cashour that they have no intention of paying regardless of the evidence.

What Cashour claims as variables in whether a vets ER bill should be paid is bullshit. There is no emergency in which a veteran would be thinking of those variables. Are those variables listed in Title 38 or any other law governing the VA paying ER bills?

Doncha just get that “veterans are our number one priority” vibe when reading Cashours comments?

91Veteran
91Veteran

On a similar topic, Choice refusal to pay it’s bills…

Some might recall me saying I was referred to Choice last year, and again earlier this year because my VA does not have the specialists on staff for the care I needed.

I went to those appointments. Today I got a bill from the radiology group saying I had 20 days to pay. I called their billing company and found out they had submitted claims for payment 3 times for the 2016 appointment, and twice for the March 2017 appointment. Choice denied payment saying it was unauthorized.

I called the Choice Champion at my VA and was told the VA now has specific people assigned to handle problems with vets being billed because the Choice program is deadbeat. I talked to that lady and was told she would call the billing company. She also said if I received another bill, or the current bill was not paid within 45 days, I should call her back and she would escalate the problem with Choice. I asked her to do that anyway given Choice had ignored these bills for 18 months.

I then called the VA hotline for Choice billing problems and was given a reference number, so it must be happening all over the country.

I then called the White House hotline for veterans and was on hold for over 40 minutes. After explaining what happened, I was told it would be referred to my VA to a Subject Matter Expert. Nothing more was said. Hopefully other vets calling that hotline are getting help.

I dug around some and found Health Net, who had former Congressman George Miller on their Board of Directors, merged with a company called Centene, perhaps as long ago as 2015. Health Net’s historical stock price went from around $30 per share to over $60 per share.

Centene’s stock price went from around $40 per share in 2014 to over $60 per share in 2015, to over $90 per share as of Sept. 18th.

“https://www.centene.com/investors/stock-information/historical-price-lookup.html”

Who is on their Board of Directors? None other than former House Speaker Richard Gephardt and former Wisconsin Governor Tommy Thompson.

“https://www.centene.com/investors/corporate-governance/board-of-directors.html”

It’s no wonder there is no congressional oversight of this disaster. How many other politicians currently in office are invested in Centene? Or other funds containing Centene stocks? Why have embarrassing congressional hearings when the stock price is doing so great?

Crazy elf
Crazy elf

91Veteran,
From what I’ve read, Florida’s hospitals are owed OVER $140 million. I could be off a few million, give or take. Only it’s gotten outta hand all over the place!

91Veteran
91Veteran

Crazy Elf, I get the sense that these politically connected companies are set up to loot the treasury as thoroughly as possible, and as long as other politicians of any stripe are on the gravy train, they don’t care.
This can be done by owning stock in the company, or being in the right mutual fund invested in these companies, or sitting on their board.

Health Net is still Health Net, but after the merger, it is a subsidiary of Centene.

Health Net and Centene are both involved in private insurance, but they are making the real money by being involved in government program insurance such as Choice, military health care, Medicare and Medicaid.

What the hell do any of them care about the program these companies run if they stiff patients or providers as long as money is being made?

Imagine the billions flowing through these companies.

Now, not only politicians make money when invested in this company, but so do VSOs if they get the right stock tip or hear what’s going on in congress. Any retirement plan of theirs invested in mutual funds benefits from the gravy train. Hell even congressional staffers are making unethical stock trades, either buying if congress takes action in favor of a company, or selling if congress takes action against a company.

These swamp rats and dig in like tapeworms.

Crazy elf
Crazy elf

91Veteran,
I read somewhere our Founding Fathers didn’t want attorneys in any elected office. It was supposed to be a “13th Amendment to the Constitution. Basically, NOT allowing them to be “lawmakers”!
Since the American People are saddled with this, look at how they’ve protected themselves, ie:
They get to use “insider trading” to make money, where other average Americans would be prosecuted over!
They get to use other healthcare vs Obamacare, something we Americans are forced to use!
They, more likely than NOT, have multiple off-shore accounts hiding taxable income!
They, more likely than NOT, use illegal activities to insure they are kept in office!
IF someone, in their “Social Group” is exposed in a criminal offense, they will help in a “cover-up”! Unless, that individual is found to be detrimental to their cause!

The list goes on and on!
In a way, even though I’m speaking of our “lawmakers”, it sure sounds like I could be talking about those who are in management positions at VA’s nationwide!

windguy
windguy

Kudos to Ben, and Kudos to KARE 11. Real investigative journalism is hard to come by these days. Media based shaming is the only thing that will work. Voting has proven to be useless.

Gee – I wonder who this reporter’s deep throat really is? Regardless, I hope he/they keep it up.

Seymore Klearly
Seymore Klearly

KARE 11 just updated the investigation with tonight’s segment which includes a whistle blower interview. Also an interview with Ben and his family.

“http://www.kare11.com/news/investigations/a-pattern-of-denial-va-whistleblower-exposes-improper-claim-rejections/478547254”

TaB
TaB

I saw the interview and I reported the same thing at the Atlanta VA Regional Office and they opted to fire me. I also reported this to Office of Special Counsel (OSC), and, the offices of representatives/congressmen/senator(s) Barry Loudermilk, Claire McCaskill, Chuck Grassley, Johnny Isackson, and Ron Johnson….and nothing has changed.

The VA has this “points” system – where employees are rated on points based on the worke they do on a case. So, employees will rush processing a veterans’ claim for benefits (i.e. disability benefits) so they can make their points and this results in denials and/or veterans not getting the full rating he/she deserves and/or is entitled to. Worst, some employees waste time and do duplicate work on a case (i.e. send out the same letter twice), just so they can make a point and make it seem like they did work on a case.

The next thing is this stupid ‘National Queque’, that the VA has. Instead of assigning the case to one person from start to end and have that person suspend the case while awaiting documents/information/exams/etc, the employee will touch the case, get a point and then put it back into the queque – where the next person who gets it, has to pretty much check up on the last person because you can’t trust that the last person did what they needed to do with the case (i.e. just sending out a duplicate letter to get a “point”). So, you have a waste in efficiency because multiple people having to take extra time to work the same case.

ANutterVet
ANutterVet

@Tab – – – Thanks for your post. I agree wholeheartedly in what you’ve shared. What you’ve described about a certain non-essential work task segment in claims is a joke. It’s one thing in what a Veteran experiences in the front end of VA services, but who really knows what is going on in the back end of the VA? And, what does points have to do with helping to serve Veterans?

You don’t need points if VA workers are doing their job correctly. No offense, but I’ve never used a point system in the managing of back end paper pushing employees.

I always believed, and still do, that there is a lot of cost saving applications or procedures that can save the VA a lot of money. But no, VA leadership wants more, without specifically documenting REAL numbers that justify their requests. Without an Audit, it’s hard for any party to provide REAL numbers, in which the VA lacks (REAL numbers). The damn Agency has never been Audited, nor do they know what hidden and TRUE assets that it has.

I’ve stopped dealing with a VA employee who is a Veteran, and Patient Advocate. This PT has never responded to me, about my dispute of not receiving proper health care from the VA;s PCP. The VA has violated my disability rights, and doesn’t let me participate in their Evidence Based Medicine model of treating me. They could care less about my input.

TaB, it’s going to take a group effort to change the VA. But many believe that it’s more effective to go it alone. There is no torque or leverage in this mindset. Keep posting. – – – Nutter.

TaB
TaB

Thanks for your response and posts Nutter.

I agree with you. I guess they wanna tell the public that this “points” system is to ensure accountability and to keep cases moving….but problem has and continues to be INCOMPETENCE.

Pre VA points system, VA employees were sitting on cases and/or shreddeding cases. IMO, because they are not hiring competent people and giving them the tools they need to do their jobs.

When I worked at immigration, I was surrounded by people who had degrees and experience in reading/interpreting the laws. Not at the VA. My recent coworkers? Not to be insulting, but when I saw their nasty written remarks about me, they lacked basic grammar and punctuation skills (one even put his written statements/e-mails in all caps) – despite them claiming they had degrees. One who claimed she had a PhD? No customer service skills at all. Another who said she worked as an IT project manager? Didn’t know how to change the background on her computer and/or how to access certain drives and/or transfer files between drives.

The VA hires the worst of the worst and IMO it’s intentional. Because if they hired competent people and streamlined the process, they wouldn’t have an excuse to deny and delay.

At IRS, you (not a National Queue) worked your case from start to end. If you had to wait on something, you suspend your case until it comes in. Your manager/team leader would review your queue to see if you were moving your cases or sitting on it for too long. Not at the VA. This National Queue just keeps on shuffling cases all over which results in duplication of work and people wasting time on a case to get a “point” and keep shuffling the case around.

ANutterVet
ANutterVet

@Tab – – – I’d imagine with the Points System, and the loopholes, where more employees can actually sign on and off from working on the same case(s), that there’s most likely an increase of actual time spent per each file. That is, whether something is accomplished on the file or not. What say you? – – – Nutter.

FThomas
FThomas

I know the problem all to well! Went through this last year! What a hassle! The VA local office the notification and ER bill was sent to would state one thing and do exactly the oppisite! i.e. You reported the ER visit in a timely manner and the reason for the visit falls within VA guidelines. NEXT: We are not going to pay the ER bill because it was not filed in a timely manner and does not meet the VA guidelines. BOTH IN WRITING! Get ready people – We still cannot trust the VA!

tom
tom

I watched the video. Funny thing: my name is actually Tom!!
On October 29 of last year at 0415, I passed out, my wife called 911. When the medics got here I was in bad shape (extremely low bp and pulse at 31). We live 28 miles from the Dallas VMC, my wife asked the paramedics to take me to the VA, because that’s where I’ve been in the past for the same thing and the VA has all my records. THEY DECLINED, stating that they are bound by city ordinance: in a life threatening case the HAVE to take me to the nearest ER.
On October 31, after I was stabilized, I called the VA and talked to the on duty administrator. She assured me that the VA would handled the billing and that I should stay at Baylor Hospital until they released me. I am rated at 50% for the same condition they took me to the hospital for!!

When I got out of the Hospital, I got deluged with all the bills, Medicare paid 80% and I was stuck with the other 20%. I called all of the providers and told them to send the bills to the VA. They said they couldn’t because Medicare already paid their portion and that they could only bill ONE governmental Agency. The VA told me that they were correct, they should have sent the bills directly to the VA. So I told the providers to rescind the Medicare and send the bill to the VA, per VA instructions. They did.
The result: The VA denied the payment because of the prudent layperson criteria and that the cost was covered by other insurance (Medicare), even though I had a statement from the city stating why they took me to the nearest hospital. The end result: since the providers rescinded the Medicare payment, I am now liable for the entirety of the medical bills. I am now in the process of trying to un-rescind the Medicare payments.

I am now in the ‘appeal’ process, meanwhile I get 2-3 phone calls a week from collection agencies trying to collect money that I don’t have

signed,
Fucked in Texas

91Veteran
91Veteran

Regarding the KARE11 update with the whistle blower. At 22 claims per hour, that equals 176 claims for an 8 hour day. Assume 165 claims if a half hour lunch. Does one VA hospital actual have that many claims per day for non-VA ER treatment? Is it safe to assume there is more than one claims examiner? If so, that would suggest they are reviewing at least 330 claims per day. I can’t believe there are that many vets going to non-VA ER’s from one VA.

Supposedly, a claim could be passed on to a nurse if there is a question about whether it was actually an emergency. Does anyone believe Ben’s or Bob’s claim was reviewed by a nurse before being denied? I have no doubt that may be the written policy, but I doubt it happens in practice.

I’m just curious what else is behind these denials. I believe the whistle blower, but the numbers don’t add up, which makes me wonder…are claims held for a period of time and this examiner only examines batches of them? Do they only spend a couple days per week on these? Is that the reason for the high numbers? Or do these examiners handle a region? Even if that is the case, I can’t believe there are 330 veterans going to non-VA ER’s per day in a region.

I certainly believe him when he says they look for reasons to deny a claim. It would be much easier than looking at variables that might mean the claim is allowed. It would also speed up reviewing claims. If a claim is denied based on it being incomplete, I suspect that may be the primary reason for denial. If certain information is missing and it is easily seen on a claim within one minute, it would be a fast denial and reason to move on to the next claim.

The Spokeshack Cashour claims there is no quota, but in the next sentence describes them as production standards, as the story points out. Besides, if the performance plans actually contained those standards…why would there not be an error rate in favor of the veteran? Why are the errors ALWAYS in favor of the VA?

Here is hoping KARE11 continues to follow this. The performance plan should be obtainable by the reporters. Redacted historical awards paid to examiners should also be obtainable.