When To Report This Va Doc To Oig?

[Josephine]

For those of you who have followed my claim, you know that my claim has gone to the AMC and back to the Judge, did get the IME to him in time. My husband says to wait until the Judge makes his decision before reporting her to the OIG?

My question, is when do I turn this Dr. L Lxxxx over to the Office of the Inspector General?

I have now 5 copies of this particular C&P of 2005, to date the records have been altered

The first Copy of the C&P:

COMPENSATION & PENSION EXAMINATION APR. 14, 2005

Filed a comlaint against the C&P to Patient Advocate.

May 16, 2005 Dr. L. Lxxxxx placed this on the C&P

You may not VIEW THIS COMPLETED PRIVACY AMENDMENT NOTE

Addendum Oct. 2006

Does not alter initial conclusion.

Addendum Nov 16, 2007

Priority of exam: Original S.C

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

Examining Provider : Dr. Laxxx Lehmxxxx

Examined on: Nov.16, 2007

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

Examination Results:

Picked up copy of C&P and Addendums to take to Dr. Crowley:

All of this had been removed from the medical records

You may not VIEW THIS COMPLETED PRIVACY AMENDMENT NOTE

Adddendum of Nov. 16. 2007

Addendum Nov 16, 2007

Priority of exam: Original S.C

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

Examining Provider : Dr. Laxxx Lehmxxxx

Examined on: Nov.16, 2007

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

Examination Results:

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

Dr. Crowley was under the impression, I had a Compensation and Pension Examination Nov. 16, 2007, until I showed him the copy I picked up the day before and everything has been removed from the computer. The Privacy Amendment Note and any mention of a C&P Nov. 16, 2007.

I am so confused.

Thanks,

Betty

[ruby]

Yes, I am understanding it better. I will write more tomorrow,its late, you have some issues to address to someone.

Take your time and start writing what happen as clearly as you can step by step. Remember the person reading this knows nothing, while you should try to keep it to the point, don't leave anything out.

Dr. L and Dr. Bxxx were both in the room. She did not do any talking only he did. This would be Dr. Bxxxx.

Dr. Bxxxx only acknowledged the C&P.

Dr B ask all the questions, but Dr L is the one that wrote the exam up and Dr B cosigned the note, your complaint was against Dr L, is this correct?

Did you file the complaint prior to getting a copy and reading it or right after the exam?

30 Days after the compliant was filed she blocked your access to your file or just that note of April 2005?

Trying to figure out if you had read the CE- then made a complaint or filed the complaint and then got a copy of the CE

There was no exam in 2007 just a note saying you were examined.

[Josephine]

So the difference is - they took off the part where it says you were examined - and left the opinion.

Free,

This is exactly correct. It appeared I had an examination Nov. 16, 2007, when it fact, it was a review of the records.

The AMC wrote to my doctor for a correct diagnosis October 15, 2007 and he responsed. Anxiety Disorder with depression.

Next the AMC sent all the records to Dr. L and B and Nov. 2007 and their innocent examination report was the last one.

" The most current credible diagnosis". " Personality Disorder not otherwise specified".

This might seem like a SMALL thing to some people, and I'm sure the VA will try to say it was an innocent error, which was corrected.

I question, if it was an innocent error, who removed it from the computers? I have a copy with it there and a copy with it gone.

However, I think it is important BECAUSE:

1. You do NOT "correct" a medical record by deleting something. You correct it by stating the correction. They could have simply stated - The previous entry is in error. This was not an examination. It was merely a follow up report by ___"

It was merely a report that appeared to be an examination, as I have not had a C&P at any VAMC for almost 3 years.

To DELETE something usually indicates you are trying to cover something up...make an error go away.

This is exactly my thinking also.

That is not to say they INTENDED to cover it up. They may have merely been trying to correct it. Sometimes they don't have a clue. But they need to GET a clue - if they are working with medical records.

2. They told you it affected your case. And then the evidence that it was ever THERE disappeared. Again, they may NOT have done this with the INTENT to harm. But again, that is why rules are in place.

Yes, When Kathy the Claims Examiner at the AMC called me, and I brought this to her attention, she told me it was in my best interest to waiver my 60 day rights for more information and she would walk it back to the BVA. This she did. Now, the paper has been altered and I have a copy of each with and without and so does the Judge and Dr. Crowley.

Who removed it from the computers?

If you had not SAVED a copy of the OLD report - you would have been told that thinking it was an exam affected your case - you would have started complaining about how it said you had and exam when you didn't - and ALL the EVIDENCE would been GONE - and the BVA would have thought you were just being a NUT.

I have 20 copies of each report as they have been altererd. I sent copies to the Judge, as I needed time to get the IME into him.

Strange how fast this claim has gone. I received the letter Jan. 8th from Carrie Johnson of receiving my file and 7 days later, I receive another telephone call from Carol at the BVA that she is taking my claims file to the judge. What is is the all fire rush?

No matter how much you complained - you wouldn't have been able to PROVE it - as they had destroyed the evidence.

I have all the evidence and so does Dr. Crowley and the Judge.

Again, I wouldn't so much say they deleted it in order to destroy the evidence. But reguardless of their intent, it had the same outcome.

I just stated to the Judge, due to the circumstances of altered records, and irregularies, please wait for my IME, as I was advised to waiver my 60 days by Kathy at the AMC.

Luckily, you have a copy of the OLD one.

Yes, I do many copies.

3. This calling opinions exams is NOT unique to your case. It happens to MANY vets The VA is aware of the fact that if something is called an exam - people will think it was one. The VA is constantly seeking both exams and opinions - and though they have a zillion forms - it has not seemed to occur to them to create a different form for a doctor to report an opinion than to report an exam.

Dr. Crowley immediately assumed that I had an examination on that date, he said if it was a review of records it should have said so.

To say EXAM indicates you were EXAMINED. To use the term is totally misleading if it is a medical opinion. I bet if you turned something in to THEM that SAID EXAM, when you had NOT been examined - they would throw it right out.

You are right on this one.

They need to get their stuff straight and stop calling reports and opinions exams - as it is most likely affecting many veterans.

Right again.

Here is an EXCERPT from the letter we sent them about my husband's NON-exam they called an exam:

I consider the examination report of March 2002, by Mxxxx, at XXX VA Center, (Attachment 7-1c in my evidence packet) regarding my lung cancer to be totally inadequate for the following reasons and request that it not be used as a basis in determining my case.

According to the C&P Service Clinician’s Guide § 4.2 “1.11 If an examination report does not contain sufficient details to adequately support the diagnoses (unless the diagnosis is already well established) or sufficient information about the current findings and effects on functioning, the RVSR will return the report as inadequate for rating purposes. (38 CFR 4.2)

1. The examiner did not examine me.

Though the report is labeled as an examination, the examiner never met with me. The examiner indicated in his report that he was requested to offer an opinion after review of the medical records whether there is a relationship between my currently detected lung cancer and exposure to asbestos in the service, or to give an opinion as to any other etiology.

There is nothing in the examiner’s report which indicates he even talked to me, let alone examined me. The VA examiner issued his report / opinion after a review of some of my records. However, issuing such a report as a “Respiratory Diseases, Miscellaneous Exam” is misleading, and could be mistaken for an actual examination under the VA Clinical Guidelines, which it is not.

2. The fact the examiner stated I had no shortness of breath, and did not have any apparent residuals of the lung cancer I was treated for without even examining me raises a legitimate question as to the credibility of his report.

Free,

To me there is no way this doctor could tell anything about your husbands condition without an examination and certainly not by reading papers.

My pulmonary function tests done at the same VA facility on March 19, 2002 (the same day the VA examiner indicated he reviewed my medical records – and five days before he signed the report) noted that I had dyspnea on hills and stairs, frequent wheezing, and decreased FVC (73% predicted) and decreased FEV1 (69% predicted)

According to § 4.97 Schedule of ratings—respiratory system.Restrictive Lung Disease - 6844 Post-surgical residual (lobectomy, pneumonectomy, etc.).

FEV-1 of 56- to 70-percent predicted should be rated at 30%

The examiner did not even mention my pulmonary function tests done that day, yet he declared I did not have any apparent residuals of the lung cancer. Though it is part of my medical record, it is not clear whether the examiner realized that I had a left lung lower lobectomy before he issued his opinion on my residuals, as he failed to mention it in the report.

This is not right.

My DLCO was 51% on my pulmonary tests at xxxx in xxx. These were also part of my medical record. According to § 4.97 Schedule of ratings—respiratory system.Restrictive Lung Disease - 6844 Post-surgical residual (lobectomy, pneumonectomy, etc.).DLCO (SB) of 40- to 55-percent predicted should be rated at 60%.

I am not saying for certain that my residuals should have necessarily been rated as a 30% or 60% disability, but I am saying that the decreased levels on the PFTs, which were CLEARLY of record, indicate that that a determination should NOT have been made that I did not appear to have ANY residuals without so much as mentioning the PFT levels, let alone articulating medical reasoning to support such a conclusion. This is especially important in light of the fact the examiner did not even provide me with a physical examination prior to issuing his opinion on the lack of residuals from my cancer.

My, oh, My, this is so unfair. That doctor didn't know squat about your husbands present conditon.

The C&P Service Clinician’s Guide 6.1 d) 4. states “If the DLCO test is not included as part of pulmonary function testing, the examiner should determine whether or not it would provide useful information about the severity of pulmonary functioning in a particular case. If it was not done as part of the routine testing, and would not be useful, the examiner should explain why, e.g., by explaining that the DLCO would not be valid in this particular case because of the decreased lung volumes. Unless an explanation for its omission is provided, the DLCO should be done.”

Though my DLCO’s of record were low, no DLCO was done as part of my pulmonary functioning testing. Nor was there any explanation as to why a DLCO was not done prior to his determination that I had no residuals from lung cancer. Again, I question the adequacy of his report.

I don't think the report is valid.

As I also have resected ribs, an 11 inch long depressed scar spanning from my scapula to under my arm, etc. I question the ethical soundness of a physician making a determination that I had no residuals of lung cancer merely from reviewing some of my medical records, without so much as seeing me, and without articulating sound medical reasons for doing so.

Free, I certainly hope that you will continue to fight this bogus report.

Yep. They need to STOP calling NON-exams Exams. I couldn't get over my husband's SOC going on and on about "You TOLD the doctor this and you TOLD the doctor THAT - because they THOUGHT he had SEEN the doctor.

Those innocent little words of having an examination v not having an examination will change the complete meaning.

As you said, without an examination, the doctor had no ideal of your husband's true condition and without the proper testing. The raters have no reason to question that it was not an examination. They trust the doctors to write if it is indeed an examination.

The doctor innocently place this into the records and I do believe they do it intentinally, as someone said, they are being paid also.

Free

Always,

Betty

[Josephine]

Yes, I am understanding it better. I will write more tomorrow,its late, you have some issues to address to someone.

Take your time and start writing what happen as clearly as you can step by step. Remember the person reading this knows nothing, while you should try to keep it to the point, don't leave anything out.

Dr. L and Dr. Bxxx were both in the room.

Yes, they were both in the room.

She did not do any talking only he did.

That is correct, she did not open her mouth one time.

This would be Dr. Bxxxx.

Yes, Dr. Baxx did all the talking.

Dr. Bxxxx only acknowledged the C&P.

That is correct, he only signed as her Superior.

Dr B ask all the questions, but Dr L is the one that wrote the exam up and Dr B cosigned the note, your complaint was against Dr L, is this correct?

My formal complaint was about the way the examination was held, and the contents of the write-up. I didn't single them out.

Did you file the complaint prior to getting a copy and reading it or right after the exam?

My husband picked up a copy for me and I was on the telephone talking to the Patient Advocate within 3 days as the time fell over the weekend.

30 Days after the compliant was filed she blocked your access to your file or just that note of April 2005?

The exam was held April 12, 2005 and the records show she placed on May 16, 2005:

PRIVACY ACT AMENDMENT NOTE.

Trying to figure out if you had read the CE- then made a complaint or filed the complaint and then got a copy of the CE

She placed the " PRIVACY ACT AMENDMENT NOTE " after she read my complaint.

When Martha Q, the nurse who saw me after this C&P typed a statement for me, then I was able to access the C&P and see the PRIVACY ACT AMENDMENT NOTE.

There was no exam in 2007 just a note saying you were examined.

Absolutely no C&P examination in 2007. I have not seen these doctors since April 12, 2005.

Just a note stating:

Examiner: Dr. L. Lxxxx

Examined on: Nov. 16, 2007

Examination Results.

This is the way I see it. You have a veteran the BVA wants to know. " What is the reason for her early discharge" in 1964?

The veteran has 44 years of treatment records for anxiety with medication.

She files in 1978 and denied.

She files in 2001 and denied.

She files again and denied, but is given a NSC Pension at 100% for anxiety with depression and unemployable to 1983, but denied due to husbands excessive income.

In 2004, this veteran locates her long lost, " Psychiatric Records" in the ST. Louis archives, where they have been for 40 years and not once ask for by the VA.

I turn in copies of these vital records to R.O.

Anxiety with Depression is denied due to Personality Traits, but is generous and re-opens all claims due to "Both New and Material Evidence" submitted by the Veteran.

The DRO sends the veteran a SOC and a Form - 9 to BVA. She fills out the form -9 and turns in to R. O.

The DRO gives the veteran a C&P for " An acquired Psychaitric Disorder".

First C&P - Anxiety disorder not otherwise specified with depression.

More likely and most likely a result of service.

Five months later - another C&P by the two nuts.

AXIS 1- Anxiety not otherwise specified

AXIs 11 - Personality Disorder not other wise specified with bordeline, histronian and dependent traits.

Denied by R. O - Personality Disorder.

BVA and remanded to AMC. AMC denies " The most current credible diagnosis is that of the two Psychiatrist, " Personality Disorder not otherwise specified with bordeline , historian and dependent traits.

IME

Dr. Brain Crowley - this veteran was discharged with anxiety and absolutely no evidence to support personality disorder.

Doctors of 43 years.

Dr. Smxxx and Taxxx 1965-1979 - Anxiety

Dr. Kixxx - board certified psychiatrist 1975-76 Anxiety

Dr. Paxxxx 1979-2007 - Chronc Anxiety

Dr. Mullxx - Anxiety VAMC more likely than not

Dr. L. L Personaltiy Disorder

Dr. B acknowledges exam

Dr. Crowley - 300.00 Anxiety NOS, Chronic, Severe, Depressive features. Manifested and began and treated for in service as in SMR's.

This is what the Judges is looking at.

Thanks,

Betty

Edited January 22, 2008 by Josephine

[ruby]

Is this correct? She placed the restriction a month before the exam?

The exam was held April 12, 2005 and the records show she placed on March 16, 2005:

If this is true I would think this note preceding an exam, would show some pre-conceived prejudice against the patient. The exam that took place was done in such a way to justify that prejudice.

If they claim error, then there is an issue of competency, more than one note or notes with erroroneous dates, one being an implied exam or fraudulent exam notes from a CE that never took place. Notes made prior to an exam.

While this may be a practice that is kosher for the VA, I don't believe it would be kosher in civilian law. If worded correctly and sent to the right people could cause this psy facility some problems.

While the outcome of any inquiry you do may not be what you might want, it will possibly change the way things are done.

Should you lose this, you may have other options as a result of these actions.

Have you every gotten a copy of your C file to see what they RO ask them to do at the April 2005 exam and what or why there is a notation for exam in 2007.

The RO/DRO (whomever) may have asked for them to review thier records again.

I am aware those notes are now missing---Which is illegal even for the VA.

[Josephine]

Is this correct? She placed the restriction a month before the exam?

Ruby,

She placed the restriction a month after the examination. After she knew I had a copy and had filed the formal complaint.

The exam was held April 12, 2005 and the records show she placed on May 16, 2005:

Ruby, this is correct, she placed the restriction on after the formal complaint with the R. O and the VAMC.

If this is true I would think this note preceding an exam, would show some pre-conceived prejudice against the patient. The exam that took place was done in such a way to justify that prejudice.

If they claim error, then there is an issue of competency, more than one note or notes with erroroneous dates, one being an implied exam or fraudulent exam notes from a CE that never took place. Notes made prior to an exam.

While this may be a practice that is kosher for the VA, I don't believe it would be kosher in civilian law. If worded correctly and sent to the right people could cause this psy facility some problems.

While the outcome of any inquiry you do may not be what you might want, it will possibly change the way things are done.

I do not wish anyone to have to endure what I have with slanderous C&P and etc.

Should you lose this, you may have other options as a result of these actions.

I will see how the Judge views Dr. Crowley's honest opinion of me.

Have you every gotten a copy of your C file to see what they RO ask them to do at the April 2005 exam and what or why there is a notation for exam in 2007.

My file went straight to the BVA and remanded to the AMC and back to the Judge at the BVA with the IME to review.

The RO/DRO (whomever) may have asked for them to review thier records again.

I am aware those notes are now missing---Which is illegal even for the VA.

The Patient Advocate or Privacy Amendment Officer could never locate any notes on this C&P.

I will go after this doctor after I see what the Judge decides.

Thanks,

Betty

Edited January 22, 2008 by Josephine

[ruby]

Josephine,

March comes before April. Is the March date wrong?

Never mind I looked at the first post it says May. In another post you accidentally wrote March and I was confused.