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JIM STRICKLAND'S MAIL BAG: VOLUME #2 FOR 2008 --

Veterans' Advocate Jim Strickland answers

questions from VA Watchdog readers.

Veterans' Advocate Jim Strickland provides regular columns for VA Watchdog dot Org.

If you would like to contact Jim about his columns, you can email him here...

The archive of Jim's articles is here...

-------------------------

by Jim Strickland

Letters in my mailbag are reprinted just as they come to me. Spelling and grammar are left as is and only small corrections are made to improve readability, ensure anonymity or delete expletives that may offend some readers.

Jim;

How come the VA dont submit there evidence when they denial a person . Look like to me they write anything down anythng with out tell you where they found this information.

Reply;

They do tell you. It's all in the award/denial letter. It usually is in a place where it begins, "How we made our decision..." They also list all the evidence that they considered. If you aren't happy with what you see, you should appeal and as you do that, ask for a Statement of the Case. The SOC will be a detailed description of how they arrived at a decision to deny your award.

Jim;

I am a Vietnam veteran and was diagnosed with pc in 9/01 and had a prostatectomy on 11/01. The procedure was successful: "non-detectable" psa and no indication of metastases . After 6 months at 100 percent, I went for my examination and based on urinary frequency was awarded 20 percent. Lately, I have been experiencing "leakage" usually when I cough, laugh, etc. There is also some "residual" after regular urination which I discover after zipping up. My question: do these "conditions" warrant another claim? Is there a "frequency" vs. "leakage" conflict? Can a veteran receiving compensation request a re-evaluation or increase due to the above conditions? Thanks for the service you are performing.

Reply;

You're experiencing very common post prostatectomy issues. Your path with VA is typical. You should now document your current symptoms and file for an increase. How much you ask for will depend on the severity of your symptoms. These symptoms are referred to as "residuals" by VA.

You can find a listing of this by clicking here
http://ecfr.gpoaccess.gov/cgi/t/text/tex
t-idx?c=ecfr&sid=e4baac768962c84de97
c2e8fc2b70914&rgn=div8&view=text&
node=38:1.0.1.1.5.2.102.61&idno=38

Look at Voiding Dysfunction & Urinary Frequency in the table and see where you fit. As you file your claim, be sure to use the verbiage from the regulations as you see it to describe yourself. I hope that helps. Please let me know if I may be of any other service.

Jim;

My husband is currently drawing 20 percent disability for service connected hearing loss. Approximately a month ago we went to the VA hospital to have another hearing test done so that we could request increased compensation for having lost more hearing.

He has another VA appointment tomorrow (Jan.17th), to discuss with a doctor the results of the hearing test.

I have several questions for you so that we can know what we need to ask. First and foremost, I have been told by several friends that should he receive a hearing aide and or surgery to correct the hearing loss, we are at risk for losing what compensation we are currently receiving, is this true? If it is true. What route should we begin to take if the surgery and or hearing aides are our only choices? Should we go ahead and request the increased compensation now with the new information that we know he has had more of a hearing loss since his last hearing test because we are sure that the surgery or hearing aides will take time before either of those options are available.

I realize I am requesting this information on short notice and for this I apologize, but any information that you can provide would be greatly appreciated.

Reply;

The VA won't lower or eliminate the 20% compensation if he accepts hearing aides. Those devices may improve his ability to hear but don't correct the underlying disability.

Your friends are sort of on the right track though. I imagine that they're trying to tell you that if a Veterans condition is measurably improved in some circumstances, the VA is obligated to reexamine the veteran. If the improvement would put the Vet into a different rating percentage, that may happen.

The VA considers that many conditions are temporary and likely to improve. If a Vet is hospitalized for 3 months because of a combat wound, he's rated at 100% during his hospital stay and then 6 to 12 months later, an appropriate level of rating will be assigned.

If your husband had surgery and it corrected his disability, VA may see that as an opportunity to reexamine him and assign a lower rating. I doubt it though. His rating is low...20% isn't a red flag to VA and even if surgery provided some improvement, I think it would be easy to argue that it wasn't perfect and any residual scar would have to be assigned a rating.

Yes, if his hearing exam shows any worsening of his condition, it may be a good time to file for an increase. If you're undecided after you talk to the doc tomorrow, reply to this email and I'll refer you to a friend who is a terrific VSO and has a wealth of knowledge on hearing related issues with VA. He'll give you many better details than I can.

Jim;

If you are tdiupt and SSDI, have a very good close VAMC where you get all medical care plus dental, have no copays or drug costs, do you really need Part B Medicare? I have read some of your past articles on this but wanted an updated opinion. The only justifiable reason I can see to elect to have Part B would be if you moved to a remote location of the US that did not have a VA facility nearby and even then I understand that there is a FEE BASIS program for a situation like that for private care.

What am I missing? Please straighten me out with the facts and or your opinions.

Reply;

I have the same benefit set you do and I kept my part B. I drive about 2 hours to access my VA hospital, my clinic is nearby. My logic is that just in case I ever elect to use the civilian system, it's a small price to pay.

What I haven't done is buy into a Medicare Supplemental policy such as the product AARP hawks constantly. I figure if I have a catastrophic event and I'm taken to a local ER I won't tell them I have Medicare...I'll say I have VA only. That way I'll be transferred to a VA facility and VA will pick up the tab. It's a calculated risk.

A word of caution...as you do have both, if you do choose a civilian provider in the future, you may use either VA or Medicare. If you use VA it must either be a life threatening emergency or you must have pre-approval. If you arrive at a hospital and present both forms of "insurance", you may find that both will decline to pay saying that the other is responsible.

Below this reply I'm reprinting a 2007 letter "Question and Answer" from a Vet who got caught in a Medicare v. VA benefits tangle. It was an interesting situation. This is worth reading again for those who have Medicare and VA health coverage.


Question:

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.

Answer:

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.

-------------------------

posted by Larry Scott
Founder and Editor
VA Watchdog dot Org

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