Veterans Affairs TBI Scandal Affected 25,000 Veterans

Veterans Affairs TBI

Veterans Affairs TBI

Benjamin KrauseYesterday, the Department of Veterans Affairs disclosed to KARE 11 News reporter AJ Lagoe that over 25,000 veterans received brain injury exams from unqualified doctors.

A nationwide VA audit called for by Rep. Tim Walz (D-MN) revealed unqualified VA doctors performed the examinations back to 2007. VA Secretary Robert McDonald is expected to announce later this week that affected veterans can apply for “equitable relief”.

RELATED: VA Ignored ‘Important’ TBI Exam Policy


The agency said it will send out letters to all veterans affected. These veterans will be eligible for new examinations by qualified doctors. The extent of the “equitable relief” will hopefully be explained at that point.

According to VA policies, only four types of doctors who are qualified to conduct initial TBI assessments are neurologists, psychiatrists, neurosurgeons and physiatrists. Nationwide, doctors other than these four specialists were conducting the exams.

RELATED: Scope Of VA TBI Scandal Exposed In TV Special

To put this in terms a mechanic could understand, it is like asking a mechanic who works on lawnmowers to take a peek under the hood of your broken Ferrari. This is what I think of when I learn that nurse practitioners or family practice doctors are working on your brain.

Would any sensible Ferrari owner ever think this makes sense? Do you think a nurse should evaluate the impact of your brain injury?


For a little background, on of my clients was “Patient Zero” for this issue. I called out VA for having not one but two unqualified doctors evaluate his TBI residuals that led to a brain tumor.

Previously, I conducted research into VA’s policies on TBI assessments. This revealed training policies and manuals the agency claimed it was following but obviously was not. The case for Patient Zero clearly showed VA was violating its policies in a blatant and knowing manner.

RELATED: Resources To Help Prove Your TBI Benefits Claim

Once I called out the agency, they failed to immediately repent up until I called in KARE 11 News reporter AJ Lagoe to investigate the issue on the broader scale.

By last August, his investigation revealed over 300 veterans in Minnesota alone were seen by unqualified clinicians to assess their TBI residuals. The investigation did not end there, and Lagoe has been hitting VA across the country as audit numbers were disclosed.

And kudos to Congressman Walz. His call for a nationwide audit following Lagoe’s coverage revealed problems at various facilities across the country.

We are still waiting for the House Committee on Veterans Affairs to call for a hearing on the scandal, but one will no doubt be held in the near future to ensure the agency treats veterans as fairly was we deserve.


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  1. I believe the worst thing that happened to the V.A. employees was the bonus granted by President Peanut Butter Jimmy Carter. The temptation and power afforded the employees to make life threatening decisions for us veterans was and is a monster that is consuming the wellness of the fabric of our society.

  2. It all starts at the Regional Office. They order the TBI exam and are advised who is supposed to conduct the exam. If the examiner does not have the proper credentials , then the exam is supposed to be returned to the VAMC or reordered so a contractor who has the proper credentials can do the exam. It is as simple as that. It not about removing anyone’s license at the VAMC. It is about accepting inadequate exams and knowingly doing so without demanding the proper credentialed doctor to examine the veteran. Production demands to reduce the backlog drives this kind of sloppy work.

    1. I have a bridge to sell you, or, some land in Florida to sell if you prefer.

    2. I might agree with you if this has not been happening across the nation and since 2007, if not well before.

      That it has tells me the VA never cared about requiring a properly credentialed examiner providing the exam, like they ignore with many other exams.

      You would think the workload and backlog, if that contributed to this, the numbers would be much lower than 25000 minimum.

  3. Huge kudos to you Ben for doing the hard work necessary for Patient Zero. Clearly it should result in many veterans benefiting from what you have forced them to do.
    I say SHOULD, because it looks like the VA will be choosing who gets those letters. How would they know who should get them if they deny they have TBI? Will they just reopen all claims of TBI? What about those veterans who have TBI but their medical providers did not document the symptoms well enough for a veteran who may not know they should claim TBI?

    This reminds me of the letters sent to Gulf War veterans by the Pentagon to veterans they determined were affected by the chemical weapon fallout when the munitions bunker at Khamisiyah was blown up. Those exposures were based on flawed computer modeling by the CIA, and only accounted for units at the company level at the lowest. It did not account for smaller units detached from the main unit, and did not account for anyone in a unit traveling outside their designated camp. People traveling outside their camp to get supplies, fuel, ammo, mail, medical care, etc., were not accounted for, even if they traveled to units that were on the Pentagon list of units affected.
    In my units case, we were across the road from a unit that was considered affected by the fallout…based on a computer model. We were within 5 miles of many other units considered affected. I recall our M8 (if I recall the model correctly. We may have had one of the newer alarms.) alarm going off, but was told it was a false alarm.

    The ultimate result of this was veterans being denied any claims of possible chemical exposure if they did not get that letter.

    I fear the same thing here if the VA gets to choose who might be affected by this TBI issue.

  4. Equitable relief is something the Regional Office personnel do not have a clue how to process. Those types of claims would linger on the vine or get shredded because of ignorance. A better course of action would be a widely publicized action lawsuit against VA.

    1. Right, you definitely wouldn’t want to bet the farm that your RO would know what to do with your ER petition. (Come to think of it, you wouldn’t want to bet the farm that the Central Office would either.) Look it up here: 38 U.S.C. § 503(a)(b)(c ). Anyone want to guess, ballpark, how many ER petitions the Secretary approves each year? 5000? 1000? 100? 50? 25?

      1. The report was just due to congress April 1. I have seen 11 million approved under the secretary’s hand down to $150 for a piss test when the VA claimed drugs and the vet wasn’t even at the VA and had his own done.

  5. My noggin got knocked by incoming 82mm mortars. But that was like 50 years ago. I’ve thought about letting them (VA) know about it now, because back then there was no TBI or PTSD at VA. After reading Ben’s article here, I don’t think it would do any good to tell them anyhow.

    1. @Dennis
      You remember the 122 rockets? They aren’t that accurate, but caused lots of damage and loss of life on small firebases!

  6. I think the neurosurgeons and neurologists are the ultimate source and there are not many of those (the VA is willing to pay for.) The psychiatrists are just certified pill pushers, and could be easily overridden, because they are the desperate sob’s that will hang you in a second breaking all rules of integrity for a VA paycheck.

    It’s easy to beat the VA on comparable experts, so they just make you wait a year every step so you have to keep forking out the dough to experts, whose evidence expires in a year and has to be repeated again and again for wait after wait.

    1. Actually, once the neurosurgeon is done saving the life, it is a physiatrist, or Physical Medicine and Rehabilitation doctor who manages all the physical, occupational and cognitive therapies of a TBI rehabilitation.

      Neurologist are the likely treaters of post traumatic cephalgia, or the headaches that can occur after a head injury.

      1. Yeah, like the VA’s own Dr. Houlihan, aka, Candyman, VA Psychiatrist, and many other VA Shrinks that even if a patient is doing very well with a particular medicine, VA Psych’s have to always knee-jerk them out and try yet something new…it’s throwing big pharma blow darts at the pin cushion that happens to be a Vet.

        Sorry so stern here but you always seem to come on here and blow the rainbows and fairy dust out the VA’s ass whenever anything major is uncovered…it’s a pattern, and ‘damage control’ in an ethical hacking way. Vets are not as dumb as you would love for us to be.
        Your defense of the AFGE blows your credibility out of the water. It comes exactly across as the Nazi’s did in the Nuremberg Trials where they ALL said, “We were just following orders”…so for you to point fingers at “other management” without actually doing the right thing as a VA employee and be a Whistleblower on what you see and name names, etc.??????

        Troll and Pollen is thick in the air.

      2. Merri,
        Actually you are way lost in the woods!
        As of 2011 the BPM&R set new guidelines for Brain Injury Medicine (BIM) to include treatment after.

        Please do us, yourself, and the world a favor…when you get a thought, and I do mean when, research then research more…that way you come to the table with REAL information that is not 5 yrs outdated.
        Have a good evening.

    2. Even a neurologist at a World-Renowned medical center will prostitute their medical license if it would help the VA defeat a cut and dry case of seizures caused by a TBI.

      A documented necrosis of cerebral tissue on an MRI/CT at site of injury and area of brain affecteddoes NOT have EEG leads purposefully, henceforth no epileptogenic activity showing up on the printout.
      Must be bucking for the Chief of Neurology position.
      Must have consulted and been treated by at least 25 neurologists over a 25 year span but this neuro was the only one that kept stating my seizures were hereditary and congenital. My sister watched me grow up from infancy and is a Pediatrician for 36 years, said I never had any kind of seizures and my Mom who was 82 wanted to kick the neuro’s behind for such a blatant misdiagnosis.

  7. “VA Ignored ‘Important’ TBI Exam Policy”?

    Hardly the first time VA’s ignored its own policy, or its “ethical & legal obligation.”

    “VA has an ethical and legal obligation to disclose to patients adverse events they experienced during the course of their care, including when the adverse event event may not be obvious or severe, or where the harm may only manifest in the future.”

    The “policy” tied to the obligation set out above, is this one:

    “It is VA policy to notify our patients of their rights under section 1151 of title 38 United States Code and the Federal Tort Claims Act, including information about procedures available to request compensation as well as where and how to obtain assistance in filing claims.”

    FWIW, here’s how VA defines adverse event: “Definition of Terms … Although ‘adverse event’ is often used interchangeably with other terms such as ‘medical error’ […], there are some important differences. […] ‘medical error’ implies that there was a mistake in the provision of care, whereas ‘adverse event’ implies only that something bad happened, not that anyone did anything wrong.”

    Show of hands on the questions below, okay?

    Injured in the course of VA medical care?

    VA disclose it to you?

    VA notify you of your 1151/FTCA rights?

    1. Yep, just like the ‘old’ “Article 99” which was used by VA.

      “We know you received this debilitating medical condition while serving in the military. Yet, you will not be treated by VHA or compensated for it by VBA!”

      Rememer that movie?

  8. Ben,
    Would you please inform the “powers that be ” that Physiatrist still needs 3 yrs follow on education(Fellowship) plus an additional 1-2 yr residency…
    So for the VA and the mouth breathers in Federal government this comes out to:
    4 years undergrad PLUS 4 years medical school EQUALS a basic Physiatrist… but to be qualified for Brain Injury Medicine (BIM) they still need 3 years Fellowship PLUS 1-2 years of residency in Brain Injury Medicine (BIM) then they are qualified to actually say something about a Brian Injury. In total education, the doctor needs 12-13 years of education NOT 8 yrs as the VA would like the veterans and the rest of the world to believe.
    The “Physiatrist” qualification that the VA states is good enough to perform examines about Brain injuries is a joke. That’s like saying a Boy Scout is qualified to perform Heart Surgery, no disrespect to the BSA.
    The Board of Physical Medicine and Rehabilitation has the edjucational requirements posted for the general public to view.

      1. ??? What do you want to show me? This site is linked to Rosemont il ?
        The AMA is in Chicago il…
        Merri, the math doesn’t change to qualify people.
        No BIM- no Qual for grown ups…sorry but big boy rules…we didnt write them. We sure don’t want a high school nurse making the diagnosis.

  9. Being a Vietnam Vet (BlueWater) and listening to the BS that come from Government I see this as:
    “The Human Life Is Expendable The Dollar Isn’t.” and I have been saying this when I first started working at “The Wall” in DC. Look at Congress, Look at Every Single Federal Agency, now look at each and every State, County, Parish, Municipality all the way down to your local town. This disgusting game must stop not by the Worthy Military (active duty) and Every Single Veteran that has served by putting his//her life on the line so these facilities can do but screw us over time and time again, I can tell you from a Vietnam Veterans point of view and what these idiots have told us an then some 15+ years later say the same damn things, in the same tone of voice, to the Gulf War Vets. They think that we are a bunch of stupid kids that never grew up. Well I will tell you something Mr/Ms SoAndSo, your go to war and seeing what the Truth Is! How do you think BlueWater Vietnam Veterans feel. We do have the presumptive finding. Hello, anybody home?

  10. This is a major embarrassment, but not untypical. I recently had a nurse practioner determine that despite objective collateral verification findings of moderate to severe osteoarthritis in the knees and back of a veteran, there were “no functional impairment” to his ability to work.

    Someone with those findings should be limited to sedentary and light work activities with limited climbing, lifting and carrying of objects weighing greater than 25 pounds.

    I fired off a letter to the doc in charge of C&P exams and advised him to educate his examiners in the physical and environmental demands of work as defined by the US Dept of Labor and offered to come present a training session.

    I’ve heard nothing back. Not surprised.

      1. In what world are you living that my comment was a defense of anything? Oh yeah…never mind…

      2. Here you go: “This is a major embarrassment, but not untypical.”

        Your “…but not untypical” comment is fat with a lackadaisical attitude. Defensive stance for VA, simple and dumbed-down enough for you?

  11. I was told be a congressional type (and not in Zeldin’s office) that a full committee or joint committee hearing is in the works.

    The aid and attendance that Zeldin called out Shulkin over? It is SMC T…for SC TBI vets. About 1% of service connected TBI vets get approved and the VA is telling congress they expect that number to go down 40% by 2019. One congressman in charge of the brain injury task force says 375,000 vets have TBI from this war.

    By under determining the severity of TBI or not sc it at all they are saving potentially $8,000 per vet per month. Much too much money taken from bonuses to give the vet.

  12. This TBI revelation from the VA OIG that Benjamin has trying to expose for a while is more than likely only being used by the VA Spin Dr. and Sec. McDonald to use as yet another plea for $$$ for a another bandaid that will require yet another $$$ bandaid and yet more legislation in future ordering the VA to actually do the right thing….just as in the current Whistle Blower Protections that the VA freely farts in it’s direction with complete disdain and as with the Union avoiding that kryptonite called accountability by having all of congress hogtied and list goes on…do we trust the new “experts” the VA will send these vets to?
    Did the VA purposefully use dates ONLY going back to 2007 so the VA can deny anything prior to that date because it was “not in the study”?

    Sorry, but this raises many more questions and concerns because I am certain there’s many more Vets affected by this and going back many more years, even decades.

    I guess you have to be a pro sports player to get real Dr.’s. Serving one’s Country is not quite as glamorous as what new pimple a Kardashian has on it’s ass or which pro sports player beat it’s spouse or kids silly or fill in the blanks.

    Yeah, a bit grumpy today. Now get off my lawn! 🙂

    1. The VA could ask for more money for this screw-up, but I think the more likely affect of this is the VA will be telling vets for years that their claim is delayed because they have to review all these TBI claims. The VA will again try pitting veteran against veteran as they have tried for years.
      They did it with Vietnam and Gulf War vets for years.

      1. And remember, you are dealing with veterans with brain injuries and damage to their executive function, memory etc. How are they supposed to file equitable relief claims?

      2. How about where ever the professional medical misconduct occurred, that entire facility’s staff recives no bonuses and pay increases.
        Now those that actually do proper hard work will want to fix the staffing problems within.
        This idea will keep the asking for more money quiet, and, also increase productivity from the top down(Hopefully).
        Of course the whistle blower protection act also has to work too.

      3. I still think if a few providers started getting their licenses to practice yanked, it would cause every other provider to provide proper and ethical medical care, or lose their job. There are also many states with laws requiring licensed providers to report unethical medical practices, or they too could be held liable.
        Your point about whistleblower protection is a good one. If the AFGE were as caring for veterans and their members as some commenters claim them to be, they would be raising 8 shades of hell to protect those employees who blow the whistle and show their members they will stand behind them…and they have minimal concern for veterans.

        That the AFGE is doing none of this shows what a worthless organization it is.

      4. I agree with that.
        If a Dr. Does not report professional misconduct by other Dr. he too is guilty of malpractice (almost all 50 States).

        “…do no harm…”

        Part of their tenant, just hold them to their own standards…we didn’t write them.
        They studied and then volunteered and swore an oath to it. Can’t back out just because it is now uncomfortable.

  13. Here we go again.
    Google this, from “military dot com” | by Bryant Jordan
    4 May 2016

    “VA Secretary Criticizes House Lawmakers Over Planned Budget Cuts”

    Read it!

    1. i didn’t read where any real accountability with VA employee’s would be implemented via Bobo’s speech/pitch. not surprising.

      reading the comments section also didn’t show any positives towards Bobo’s speech. not surprising either as probably most of the commentators are veterans that have made use of VA over the years, filed claims and such. so they know Bobo’s words are empty for the veteran, but hold promise for the fraudsters and tricksters.

      mo’ money for VA director’s? are you kidding us? and why the beef with the House Bobo? no one in Congress has put any real teeth into curbing the VA’s lawlessness, so why are you upset with the House? The Democrats will just toss mo’ money to VA acting like they are helping veterans. then why haven’t they fixed anything at VA over the last few decades? all of us veterans have written them and called these Congress members. as far as “fixing”, I’m talking about the internal corruption, not the building of band-aid show off new hospitals. surely i don’t have to write the list of internal corruptions within VA. after all these years surely everyone knows of them and the veterans have been stung by them.

      these VA thugs (and not are, i know some great ppl there, a few) & Congress members, all seem to have a bit part in the British “house of cards” series. amoral and ruthless for the mo’ money and power all the while being experts at “bait n switch” with their narrative of how all they do is for helping the veteran community.

      really? well start with working honestly for correct medical diagnosis of veterans and fix the corrupt indulgence known as the VA Claims offices. a system that takes decades to resolve claims is corrupt, plain and simple. i think this a upper management problem and central office legal types than say, the VA doctors and nurses.

      i mean who else trained these doctors and nurses to behave the way they do?

      good link @crazyelf

  14. If the VA is acknowledging 25,000 unqualified TBI exams performed across VAMC’s across USA, it tells me that this number is more than likely much higher, especially when one takes into consideration the number of Combat Troops in various locations in Middle East…and this report just went back to 2007….why not go back to 2001 or so, why only 2007 when those first years of this war were some of the most violent as far as roadside IED, et al????
    Does this make sense to ask this? Is the VA somehow claiming that no troops had any TBI Claims from period prior to 2007?
    Will these new ‘exams’ be as swiftly shot down by VA and sent to die in VA Appeals or even that far?
    How about using that thing called ‘presumptive exposure’ and give ALL those Vets their VA Compensation and Medical Benefits?

    1. @namnibor
      Brother, it always comes down to the “GOD ALMIGHTY DOLLAR!”
      Think about this. IF VA were to have to pay out just 50% of the 25,000 vets back-pay for 10 years. Due to their fowl-up. Old Bagdad Bobby, Gimpy Gibson or another Lackey, like Shulkin, will be back in front of the committee begging for more taxpayer’s monies! (I do believe they will be doing that soon, anyway!)
      You watch, this will play out badly for most of these veterans!

      You do have a common sense question. Over why don’t “…they go back…” further? But that’s common sense. Something VA lacks in abundance!
      If they were to go back. What’s stopping veterans of the previous wars; ie: the “First Gulf War”, (1992), or Vietnam or Korea into forcing VA to capitulate on TBI’s?! Can you imagine the BILLIONS of dollars VA would owe out to veterans?!

      1. Yeah, and I was in NO WAY minimizing the previous wars, police actions, peacekeeper and special ops, Vietnam, et al; no, the point is the VA only took a micro-sample of even this current war which actually extends nonstop to 1991-ish, and then there’s that nasty depleted spent uranium munitions, and Gulf War Syndrome/Illness, et al…you are correct, it’s the almighty dollar over the Veterans that went and served to protect the freedoms of said dollars possess and people that use them…makes me sick.
        Now Sec. McDonald is already making his only useful purpose and going before them asking, “More please, $ir”….where the hell is all the $ going?

        Audit, then start flushing.

  15. I am a veteran that would like more specific info on this matter. I underwent consult and evaluation in 2013 in Marion IL for TBI and am suspect of the results.

    1. @Jordan Taylor
      The best suggestion I can give is this.
      Contact Ben directly by email on this site. Or get a free consultation from an attorney near you. Which helps vets.
      Get all your exrays etc together. Plus a copy of this blog. Take it with you. They might be able to find out if the person who evailuated you was, or was not, qualified to evailuate you!

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