Co Va Co-pay

[gdsnide]

OK As the heading says "VA Co-Pay"

What I am wondering about is if a Vetern is 100% T & P & has to go to the nearest Hospital

"A life or Death situation" will the VA pay the co-pay that said Vetern is charged with.

Incidently, said Vetern gets all Health issued resolved at the VA

OK...Thank U for any one who may be able to give me advise on this subject

GARY

[Philip Rogers]

Gary, the hospital was supposed to immediately notify the VA that a veteran was in "their care." The hospital wrongly billed Medicare, because it's easier and faster to get paid by Medicare. The hospital should refund the monies collected from Medicare and now bill the VA. The VA won't pay as long as Medicare has paid. Hospitals routinely bill Medicare, over the VA, because VA pays so slowly. Good luck, you'll need it.

pr

The only problem I have with not paying any thing is that I do have Medicare & that was used in this situation but I will bang on the VA's door & see if I can do any good

Thank U for all the responses

GARY

[carlie]

Gary,

Here's a BVA case to study.

http://www.va.gov/vetapp09/files4/0928702.txt

Citation Nr: 0928702

Decision Date: 07/31/09 Archive Date: 08/04/09

DOCKET NO. 08-23 989 ) DATE

)

)

On appeal from the

Department of Veterans Affairs Medical Center in Tampa,

Florida

THE ISSUE

Entitlement to payment of or reimbursement for unauthorized

medical expenses incurred at Morton Plant North Bay Hospital

on June 12, 2007.

ATTORNEY FOR THE BOARD

Tresa M. Schlecht, Counsel

INTRODUCTION

Please note this appeal has been advanced on the Board's

docket pursuant to 38 C.F.R. § 20.900© (2008). 38 U.S.C.A.

§ 7107(a)(2) (West 2002).

The Veteran had active service from September 1943 to

December 1945. This matter comes before the Board of

Veterans' Appeals (Board) on appeal from a July 2007 decision

of the Tampa, Florida VA Medical Center (VAMC) of the

Department of Veterans Affairs (VA).

FINDINGS OF FACT

1. The Veteran was awarded a total disability evaluation

based on individual unemployability due to service-connected

disabilities (TDIU) in 2001.

2. The VA Telephone Triage Nurse's advice to the Veteran to

request emergency medical transportation to the nearest

hospital emergency department establishes that an attempt to

use the available VA outpatient treatment facility was not

feasible, and that the situation was an emergency.

CONCLUSION OF LAW

The criteria for payment or reimbursement of unauthorized

medical expenses incurred at Morton Plant North Bay Hospital

on June 12, 2007, have been met. 38 U.S.C.A. § 1728 (West

2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 17.120 (2009).

REASONS AND BASES FOR FINDINGS AND CONCLUSION

The Veteran contends that he is entitled to reimbursement for

unauthorized private medical expenses incurred June 12, 2007,

at the Morton Plant North Bay Hospital, when he sought

emergency department treatment.

As an initial matter, the Board notes that the Veterans

Claims Assistance Act of 2000 (VCAA) imposes a duty on VA to

notify and assist claimants in substantiating a claim for VA

benefits when a complete or substantially complete

application for benefits is received. 38 U.S.C.A. §§ 5100,

5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009);

38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2009).

Given the fully favorable outcome set forth below, no further

discussion of the actions undertaken by VA to meet these

duties is required, since no conceivable prejudice to the

Veteran could result from this adjudication. See Bernard v.

Brown, 4 Vet. App. 384, 393 (1993).

Facts and analysis

Under 38 U.S.C.A. § 1728, there is a three-prong test for

meeting the requirements of entitlement to payment or

reimbursement for unauthorized medical expenses. Failure to

satisfy any of the three criteria precludes VA from paying

unauthorized medical expenses incurred at a private facility.

Zimick v. West, 11 Vet. App. 45, 49 (1998); see also Malone

v. Gober, 10 Vet. App. 539, 542 (1997).

Generally, in order to be entitled to payment or

reimbursement of medical expenses incurred at a non-VA

facility, a claimant must satisfy three conditions. There

must be a showing that:

(a) The care and services rendered were either:

(1) for an adjudicated service-connected disability, or

(2) for a non-service-connected disability associated with and held to be

aggravating an adjudicated service- connected disability, or

(3) for any disability of a Veteran who has a total

disability, permanent in nature, resulting from a service-

connected disability, or

(4) for any injury, illness, or

dental condition in the case of a Veteran who is

participating in a rehabilitation program and who is

medically determined to be in need of hospital care or

medical services for reasons set forth in 38 C.F.R. §

17.47(i);

and

(b) The services were rendered in a medical emergency of such

nature that delay would have been hazardous to life or

health; and

© No VA or other Federal facilities were feasibly available

and an attempt to use them beforehand or obtain prior VA

authorization for the services required would not have been

reasonable, sound, wise, or practicable, or treatment had

been or would have been refused.

A Veteran must satisfy each of these enumerated criteria in

order to establish entitlement to reimbursement or payment of

not pre-authorized, private (non-VA) medical expenses.

Zimick v. West, 11 Vet. App. 45, 49 (1998); Cotton v. Brown,

7 Vet. App. 325, 327 (1995) (holding that all three statutory

requirements must be met before reimbursement may be

authorized).

In this case, the Veteran, who is 83, had apparently been

recently hospitalized for a bowel obstruction, and had

returned home following rehabilitation only a few days prior

to June 12, 2007. The Veteran was receiving home health care

services. VA records establish that the Home Health Aide who

was assigned to care for the Veteran on June 12, 2007, noted

that the Veteran's blood pressure was elevated and his pulse

rate was low.

At 9:44 a.m., the Home Health Aide contacted

VA's Telephone Triage service for the Veteran, who is legally

blind. After being told that the Veteran's blood pressure

was 196/106 and that his pulse rate was varying from 46 to 60

beats per minute, the nurse advised the Veteran and his wife

that he should call 911 and request transport to the nearest

emergency room.

The Veteran was transported by emergency services to Morton

Plant North Bay Hospital. The Veteran was treated in the

emergency department and released back to home in the

afternoon after receiving extensive evaluation including

electrocardiogram (EKG) and computed tomography (CT)

examination of the abdomen and pelvis. The emergency

department concluded that the Veteran did not have a

recurrent bowel obstruction and that his constipation could

be managed at home.

The VA medical reviewer how provided August 2007 opinion

concluded that the circumstances did not constitute an

emergency and that a VA facility was available.

The Board has considered each of the criteria for

reimbursement under 38 U.S.C.A. § 1728. The Veteran's claim

must be considered under 38 U.S.C.A. § 1728, as he has been

granted service connection for several disabilities,

including: posttraumatic stress disorder; shrapnel wounds,

muscles groups I, III, and IV, with traumatic arthritis;

pleural cavity injury: status postoperative hemorrhoidectomy

with mild stricture; and, otitis media.

A combined 90 percent evaluation was in effect for the Veteran's service-

connected disabilities at the time of the June 2007 private

medical treatment at issue. The Veteran was awarded TDIU by

a rating decision issued in August 2001. There is no

notation that the award of TDIU was or was not permanent, but

no further re-evaluation of that award has been conducted or

required, so the award is assumed to be for disability

permanent and total.

Because the Veteran is in receipt of

total (100 percent) compensation benefits, he is eligible for

reimbursement of unauthorized medical expenses, if the other

statutory criteria are met. 38 U.S.C.A. § 1728(a)(2)©.

The Board notes that the Veteran's claim cannot be considered

under 38 U.S.C.A. § 1725, because eligibility for payment or

reimbursement of emergency services under that provision is

limited to Veterans who are not eligible for reimbursement

under 38 U.S.C.A. § 1728. Fritz v. Nicholson, 20 Vet. App.

507, 509 (2006).

Reimbursement for unauthorized private medical expenses is

not available under 38 U.S.C.A. § 1728 unless a VA facility

is not feasibly available and an attempt to use VA facilities

beforehand would not have been practical.

The Board finds

that, as the Veteran was advised that he should not come to

the VA outpatient clinical, but was advised to call 911

instead, the VA facility should be considered "not feasibly

available."

In this regard, the Board notes that the VA

outpatient clinic is reasonably close to the Veteran's home,

but the closest VA emergency department, the Tampa VAMC, is

considerably further away.

As noted, the Veteran called the appropriate VA facility

during hours the VA facility was open, and there is no

evidence that the Veteran could not have arranged

transportation to the VA facility if advised that treatment

at that facility, where his assigned primary care provider

was located, was appropriate.

However, the Veteran was

instructed that he should not come to the VA outpatient

facility. The Board finds that the instructions of the

Telephone Triage Nurse to the Veteran, the Veteran's wife,

and the Home Health Aide who was caring for the Veteran on

June 12, 2007 establishes that an appropriate VA facility was

not feasibly available and that an attempt to use the

available VA outpatient treatment facility beforehand, that

is, before the Veteran's symptoms escalated, was not

possible.

The VA medical reviewer who provided the August 2007 opinion

determined that the disorder diagnosed by the ER when the

Veteran sought care was constipation, and that such a

diagnosis, which had been present for a few days, did not

constitute an emergency. The medical reviewer, however, did

not discuss the Veteran's hospitalization and treatment for

acute bowel obstruction immediately preceding the June 12,

2007 emergency care. The reviewer did not discuss the

Veteran's history of service-connected hemorrhoidectomy with

stricture, and did not opine as to the likelihood that the

Veteran's constipation could be considered service-connected.

The reviewer did not discuss the Veteran's abnormalities of

vital signs noted prior to his transport to the emergency

department.

The Board finds that the August 2007 medical

opinion that the Veteran's June 12, 2007 was not an emergency

is less persuasive than the June 2007 provider opinion that

the Veteran should request emergency transport to the nearest

emergency facility.

The provisions of 38 U.S.C.A. § 1728 do not include a

specific definition of an emergency other than to state that

there must be a "medical emergency of such nature that delay

would have been hazardous to life or health." The

implementing regulation, 38 C.F.R. § 17.120, does not further

define a "medical emergency." In contrast, 38 U.S.C.A.

§ 1725 specifies that a medical emergency is present if " a

prudent layperson" would have reasonably expected that delay

in seeking immediate medical attention would have been

hazardous to life or health. It is clear, however, that a

prudent layperson would have considered the circumstances of

June 12, 2007 and emergency, since the Home Health Aide and

the VA Telephone Triage Nurse advised him that there was an

emergency.

The Board notes that the Court of Appeals for Veterans Claims

has defined a medical "emergency" as "a 'sudden, generally

unexpected occurrence or set of circumstances demanding

immediate action." See Hennessey v. Brown, 7 Vet. App. 143,

147 (1994), (quoting Webster's New World Dictionary 444 (3d

ed., 1988); accord Merriam Webster's New Collegiate

Dictionary 407 (11th ed., 2003) (defining "emergency" as "an

unforeseen combination of circumstances or the resulting

state that calls for immediate action . . . . an urgent need

for assistance of relief"). Under this definition of an

emergency, as compared to the definition provided by the

medical reviewer, the Veteran's June 12, 2007 circumstances

were an emergency, even though the emergency care ruled out

any immediate threat to the Veteran's life or health.

With the findings that the Veteran is eligible for

reimbursement under 38 U.S.C.A. § 1728, and that VA

facilities were not feasibly available and an attempt to use

VA facilities beforehand was not reasonable or practical, and

that there was an emergency, each of the three requirements

for payment for the Veteran's unauthorized private care on

June 12, 2007 is met. Zimick, supra. Payment or

reimbursement is warranted.

ORDER

The appeal for payment of or reimbursement for unauthorized

medical expenses incurred at Morton Plant North Bay Hospital

on June 12, 2007, is granted.

____________________________________________

MARJORIE A. AUER

Veterans Law Judge, Board of Veterans' Appeals

Department of Veterans Affairs

[Chuck75]

I believe the VA still may have an "out" in that I remember reg language to the effect that if any payer other than the veteran pays even part of the "emergency treatment" costs, the VA can refuse to pay anything. When I looked into this, our group insurance (secondary), and Medicare (primary) would allow the VA to refuse to pay anything, including amounts such as "deductible", "out of pocket", "co-pay", and the like that the group insurance and Medicare do not pay.

[Pete53]

It appears to me that if I go to Hospital for emergency treatment that I will not provide Medicare and Hospital Insurance but simply give the VA 800 number and tell them to get authorization from fee service. Seems like that would solve a lot of problems.

[carlie]

That is if it doesn't automatically show it in the system,

then your plan is like bingo - solves the problem before it even starts.

jmho,

carlie