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foleyj
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Posts posted by foleyj
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I have a Non Va Physician that I see for a SCD and this Non Va Physician wants me to get an MRI, can take the order or Rx that he gave me to get this MRI to a VAMC and have it done there?
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Va will not pay for prescriptions at private facilities unless it is a fee basis situation. The VA will not accept prescriptions from non VA doctors.
VA doctors can write prescriptions that can be filled at outside pharmacies.
The VA will pay for emergency medical treatment of 100 percent Vets.
If the Vet has health insurance that pays, Then all bets are off.
J
J,
Saw your post and found this on another forum site and thought you may want to look into it.
§17.96 Medication prescribed by non-VA physicians.
Any prescription, which is not part of authorized Department of Veterans Affairs hospital or outpatient care, for drugs and medicines ordered by a private or non-Department of Veterans Affairs doctor of medicine or doctor of osteopathy duly licensed to practice in the jurisdiction where the prescription is written, shall be filled by a Department of Veterans Affairs pharmacy or a non-VA pharmacy in a state home under contract with VA for filling prescriptions for patients in state homes
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Carlie thanks. I know about the worksheets, but I thought I saw a post that stated something about the VA putting out new guidelines or information to help vets private physicians when they are giving the medical opinion.
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A few months back I read a post that had a link to the VA site that provided information for private physicians to be able to fill out forms for VA and use the right language, does anyone know what I am referring to and have the link?
Thanks
Jason
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This was the original post with the background information;
I am hoping that there is someone here that can help me with this. I am SCD 20% for DDD and had spinal fusion of L4-L5 on 7/8/2009. I was admitted to the hospital on 7/8/2009 and released on 7/12/2009. I was given a letter from the discharging surgeon that I would require 3 months of convalescence. I submitted a claim on 8/7/2009 for a convalescence rating of 100% for the 3 month period that I would be on convalescence. I received my decision on 1/25/2010, here is where it gets confusing. I will first post the decision and then I will point out the things that I think are confusing according the the regulation.
Decision:
An evaluation of 100% has been assigned effective August 7, 2009 based on surgical or other treatment necessitating convalescence. Hospital records indicate that you underwent L4-L5 laminectomy and S1 fusion, on July 8, 2009. The statement from the physician indicated that you would need a three month period of convalescence. The 20 percent is continued form November 1, 2009, first day of the month following your three month period of convalescence. The effective date of the temporary 100 percent evaluation is August 7, 2009, the date we received your claim for benefits. The effective date of reduction back to 20% is November 1, 2009 the first day of the month following your release from the convalescence period.
Points of Confusion:
1. The rating decision assigned the effective date of the convalescence as 8/7/2009 which was the date the claim was received. According the 38CFR 4.30 A total disability rating (100 percent) will be assigned without regard to other provisions of the rating schedule when it is established by report at hospital discharge (regular discharge or release to non-bed care) or outpatient release that entitlement is warranted under paragraph (a)(1), (2), or (3) of this section effective the date of hospital admission or outpatient treatment and continuing for a period of 1, 2, or 3 months from the first day of the month following such hospital discharge or outpatient release.
The effective date should be the date of hospital admission which would have been 7/8/2009, not 8/7/2009 which was the date the claim was received.
2. Even though they assigned the effective date as 8/7/2009 I was only paid for 2 months instead of the 3 months that was given by the order from the doctor. I was only paid for September and October the rating went back to 20% on November 1st.
I am not sure why I was only paid for 2 months even if they had the wrong effective date.
So what I need is, first for someone to look at this and make sure that I am not mistaken in my assumptions that the rating was not assigned correctly. Also if it is correct what is my next course of action? Do I file and NOD? A letter of Reconsideration? Or a CUE claim? Any help would be appreciated.
Thanks
Jason
So I sent in another letter requesting a re-evaluation of the the claim, and again I got another decision letter explaining that I was paid for the convalescence, which again is only 3 months. I sent the last one through my VSO, so is there something, or someone else that I can contact to help me with this? Sending the letters do not seem to help because whoever is reading them is not reading the regulation that I include with it. PLEASE HELP!!!!!!!
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foleyj,
I don't see it as a CUE at this point as there has not been any final adjudication
and the one year mark hasn't gotten here yet to file a NOD.
jmho,
carlie
What would your recommendation be? My understanding about a CUE claim is that it is generally, either the correct facts, as they were known at the time, were not before the Board, or the statuary and regulatory provisions extant at the time were incorrectly applied. In my particular case I would think that the regulatory provisions were not applied correctly. Specifically the assignment of the effective date, and the payment of only 2 months instead of 3 as stated by the physician.
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I am hoping that there is someone here that can help me with this. I am SCD 20% for DDD and had spinal fusion of L4-L5 on 7/8/2009. I was admitted to the hospital on 7/8/2009 and released on 7/12/2009. I was given a letter from the discharging surgeon that I would require 3 months of convalescence. I submitted a claim on 8/7/2009 for a convalescence rating of 100% for the 3 month period that I would be on convalescence. I received my decision on 1/25/2010, here is where it gets confusing. I will first post the decision and then I will point out the things that I think are confusing according the the regulation.
Decision:
An evaluation of 100% has been assigned effective August 7, 2009 based on surgical or other treatment necessitating convalescence. Hospital records indicate that you underwent L4-L5 laminectomy and S1 fusion, on July 8, 2009. The statement from the physician indicated that you would need a three month period of convalescence. The 20 percent is continued form November 1, 2009, first day of the month following your three month period of convalescence. The effective date of the temporary 100 percent evaluation is August 7, 2009, the date we received your claim for benefits. The effective date of reduction back to 20% is November 1, 2009 the first day of the month following your release from the convalescence period.
Points of Confusion:
1. The rating decision assigned the effective date of the convalescence as 8/7/2009 which was the date the claim was received. According the 38CFR 4.30 A total disability rating (100 percent) will be assigned without regard to other provisions of the rating schedule when it is established by report at hospital discharge (regular discharge or release to non-bed care) or outpatient release that entitlement is warranted under paragraph (a)(1), (2), or (3) of this section effective the date of hospital admission or outpatient treatment and continuing for a period of 1, 2, or 3 months from the first day of the month following such hospital discharge or outpatient release.
The effective date should be the date of hospital admission which would have been 7/8/2009, not 8/7/2009 which was the date the claim was received.
2. Even though they assigned the effective date as 8/7/2009 I was only paid for 2 months instead of the 3 months that was given by the order from the doctor. I was only paid for September and October the rating went back to 20% on November 1st.
I am not sure why I was only paid for 2 months even if they had the wrong effective date.
So what I need is, first for someone to look at this and make sure that I am not mistaken in my assumptions that the rating was not assigned correctly. Also if it is correct what is my next course of action? Do I file and NOD? A letter of Reconsideration? Or a CUE claim? Any help would be appreciated.
Thanks
Jason
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Good luck to you. What I don't understand in my situation is that the schedule of ratings for heart bypass surgery specifically states:
7017 Coronary bypass surgery:
For three months following hospital admission for surgery.......................................... 100
Seemed like a no-brainer to me, but I guess I was wrong.
Yeah you would think so. I have a feeling that they just automatically just give 2 months and then hope that you just get frustrated and forget about it. I can't seem to find anyone that actually understands the rating schedule. Good luck with yours.
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Foleyj: Any update? I have a similar situation, and I'm wondering if you had any success. I was supposed to get 3 month temp 100% for heart surgery. My surgery was 7/2/09; the VA rec'd my claim on 8/3/09; the effective date of my temp 100% is 1 Sep 09, ending 1 Nov 09. 2 months instead of 3. I understand that they don't prorate - so I'm wondering why it wouldn't be 1 Sep 09 thru 1 Dec 09 for the temp 100%.
Hi,
No I haven't heard anything yet. I contacted the VA office and spoke with the VA rep that is also my POA and she sent an email to someone she said would take care of it. I have emailed her and have not heard back from her. You might want to contact someone about this because I think that the VA is not rating this correctly. If you go back and look at § 4.30 Convalescent ratings you will see that it states A total disability rating (100 percent) will be assigned without regard to other provisions of the rating schedule when it is established by report at hospital discharge (regular discharge or release to non-bed care) or outpatient release that entitlement is warranted under paragraph (a) (1), (2) or (3) of this section effective the date of hospital admission or outpatient treatment and continuing for a period of 1, 2, or 3 months from the first day of the month following such hospital discharge or outpatient release. My surgery was 7/8/09 and I was released on 7/12/09. I sent the claim in and it was received on 8/6/09. So they made 8/6/09 my effective date and then began the 100% rating on Sept 1st. I sent messages to them through IRIS and the response that I got was that the VA only takes the advice of the doctors for the period of convalescence and they can determine what they think is an adequate convalescence. This is crap because if the doctors note says that you get 3 months then that is what you get. I would definitely contact your VSO or the VA office in your state. I will post something when I get an answer.
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The VA doesn't pro-rate so no matter what date the surgery was you get paid from the 1st of the month after the operation. As far as benefits you would be eligable from the date of the operation. Also to have a Dr. Write that you are off for 3 months might not be enough for the VA. They might want proof that you were out of work for 3 months. I was told that VA won't preapprove temp 100% because you haven't been disabled for that time (meaning you 'might') go back to work before the total time that you requested 100% for. i.e. we won't pay until you were already disabled.
This is just my experiance and hopefully others will chime in.
Quint thanks for the info. After more digging it seems that instead of the effective date of the claim being the day I had surgery, which was 7/8/2009, the VA applied the effective date that they received the claim which was 8/6/2009. Now I guess I have to go back and submitted an NOD and explain everything all over again.
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Yes that what I would think that it would start August 1st, but in the award letter it states it is from September 1, 2009 - October 31, 2009 $3,756.00 for temporary 100% with 2 dependents. I am just wondering why it didnt start august first.
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I just the regulation for this and this is what I found;
A total disability rating (100 percent) will be assigned without
regard to other provisions of the rating schedule when it is established
by report at hospital discharge (regular discharge or release to non-bed
care) or outpatient release that entitlement is warranted under
paragraph (a) (1), (2) or (3) of this section effective the date of
hospital admission or outpatient treatment and continuing for a period
of 1, 2, or 3 months from the first day of the month following such
hospital discharge or outpatient release.
So I see where it says from the first day of the month, but it also says that the effective date is the date of admission or treatment. So this is confusing. If the effective date is the date of admission, than why isn't paid from this date? This is the date at which you become 100%.
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Thanks for the info it does somewhat clear things up. The only problem with my situation is that the surgery was on 7/8/2009, so if the VA starts the rating on the 1st of the next month shouldn't it have started on the 1st of August? The other problem is that this is not mentioned anywhere in the regulation that explains the rating criteria. So would it help if I went back to my doctor and had him amend the order for my convalescence? I was actually off of work until November, I just read the regulation and told him to make it 3 months and he said if I needed more to just tell him.
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Well I finally got in touch with a very helpful VA rep on the phone. I was actually surprised that this person was so helpful, but anyway here is the response that was sent to me. Now keep in mind that the original claim was for 3 months.
Mr. Foley:
This is in response to your inquiry dated January 29, 2010, regarding retroactive pay.
Based on the notification letter, the VA granted temporary 100% for two months, September 2009 and October 2009. September 1, 2009 - October 31, 2009 $3,756.00 for temporary 100% with 2 dependents.
I am trying to figure out why I was only paid for two months instead of three. The letter that I sent in from the doctor clearly states that the convalescence will be 3 months.
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Thats what I thought. Thanks.
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I submitted a claim for convalescent pay after spine surgery and the doctor put that I would be out for 3 months. I just received that payment, but it is a lower amount then I was told. I am rated at 60% with a spouse and one child. The 100% rate would be 2932.00. If I am doing the math correctly 2932.00-1129.00=1803.00. The difference is 1803.00 and that should be the amount that I should have gotten for the 3 months for a total of 5409.00. The payment that I received was 4335.00. Is this the way the VA calculates this, or is there a different rate table for this type of situation?
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I did keep copies.
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Just wanted to know if anyone has had this happen to them and what were they able to do about it. I have open claims that have been ongoing for a year and when I try and inquire about them through my VSO or calling and emailing I have been informed that they can not find one of the volumes of my records. How does this happen? So basically all the paperwork and doctors statements that I sent in with my claim are now gone.
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No had not done any of those things, but I just did. Thanks for the information.
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I underwent spine surgery on 7/08/2009 for my service-connected disability of Lower Back Injury Annular Tear and Herniation at L4-L5. I was released from the hospital on 7/12/2009 with discharge orders from my doctor stating that the total time for convalescence after surgery would be three months. Through my VSO I submitted the discharge orders and letter from the physician stating the allowed convalescence period for this type of surgery on 7/15/2009. sent in a Request Temporary Disability Rating of 100% under 38 CFR 4.30 for surgery on Service Connected Condition of Lower Back Injury Annular Tear and Herniation L4-L5 necessitating three months of convalescence. Does anyone know how long this will take, or a way to push it through a little quicker? I have some medical bills that need to be paid and I was out of work for a while and I did not have the leave to cover the lost time.
J
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Thanks to everyone that gave a reply. Maybe I didn't explain myself. First to Philip, I am not trying to claim disability and work at the same time. If you are not aware there are certain veterans that have disabilities and are still able to work. I did not apply for my disability because I could not work. I applied for disability for the loss of use and change in the quality of life due to my injuries. My question had to do with individuals that are rated for multiple SCD for example;
Leg 40%
Arm 30%
depression 30%
Pain 30%
Hand 30%
shoulder 40%
loss of appendage 50%
This list of SCD when added using the VA compensation formula would add to 96% which would be rounded to 100%. So my question was if and individual was rated this way, would that individual be unemployable or would they still be able to work. I just ask because I know certain individuals who have multiple SCD.
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I have not been able to find any posts to address my questions, so here it is, are you permitted to work if the addition of multiple ratings for SCD adds up to 100%?
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Thanks for all the advice and information. I went back to the doc and he changed it from possibly related to to related to on the form. I will let you know how it goes with the claim.
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Thanks for all the help. I got the form from this site and it was described as a nexus form. On the form it has 3 possible choices for the doctor to check the first choice states Related to, the second Possibly related and the third is more likely as not to be related. The Dr. checked the second one which I am assuming is better than the last one.
Non Va Physicians Ordering Tests
in VA Disability Claims Research
Posted
Thanks for the reply. The funny thing is when I go to the VAMC for treatment for my SCD they still bill my insurance company and they pay them. The reason I would want to get it done there is because I wouldn't have to pay the copay for my private insurance which is like 300 dollars every time I get an MRI.