ptsd Unauthorized Medical Services

[evandc]

Little history..100% TDIU P & T PTSD since July 2002 & 100% Cancer (AO) since Oct 2004

Feb 18, 2009 went to local hospital (3 miles from home) for chest pains. One & half hours to my regular VA Hospital. Stayed 4 days & asked to go to VA, set up by my PCP & had prodecure (3 stents) about month later in Augusta, Ga. I normally go to Dorn in Columbia, SC. When I got to local hospital gave them my VA Card before I told them I thought I was having a heart attack. Later they asked about my Medicare & that's who they got the money from ($2000 out of $21,000). I gave all the information to VA in Columbia.

Then today I got the turn down from Augusta, Ga VA Hospital. Only reason I was in Augusta is because Columbia was remodling the Heart Cath Lab.

Reason for not Approving Claim "Medical treatment was for non-service connected codition which was clinically determined not an adjunct to the service connect disability"

Guess they didn't read the second half of rule number one.."OR for any condition of a veteran who has been determined to be totally & permantly disabled as a result of a service-connected disability"

SO what should I do? I don't know if I can appeal without driving myself crazy waiting. I'm so upset I can't remember how to attach the letter or even do a search of this site. We know they are wrong & I guess I had been warned in advance that the VA would do anything not to pay $1000 bill, but I did it by the book & still have a unpaid bill.

Please help me, I'm so confused & upset.

Don

[Chuck75]

What I would do initially -- Get the exact wording of the applicable regulation and cite it as appropriate, mentioning it's identifying reference.

Call the Augusta patient Advocate & if needed, billing. Be polite.

If that does not work

Send a letter (Certified mail) and Fax to Augusta, with a copy to the VAOIG and perhaps your congressional representatives and the VA Secretary.

Put copy's to etc. at the bottom of the letter to Augusta.

It's likely that Augusta billing did not "notice" that you were 100% SC. (OOPS!)

Did the local hospital do anything to "stabilize" your condition before they sent you to the VA hospital? Such as treatment with TCB?

Time is golden, and significant treatment is needed within a fairly short time frame, if long term damage due to a heart attack is to be minimized.

Since you are an A.O. Veteran, presumptive status for ischemic heart disease now exists.

Little history..100% TDIU P & T PTSD since July 2002 & 100% Cancer (AO) since Oct 2004

Feb 18, 2009 went to local hospital (3 miles from home) for chest pains. One & half hours to my regular VA Hospital. Stayed 4 days & asked to go to VA, set up by my PCP & had prodecure (3 stents) about month later in Augusta, Ga. I normally go to Dorn in Columbia, SC. When I got to local hospital gave them my VA Card before I told them I thought I was having a heart attack. Later they asked about my Medicare & that's who they got the money from ($2000 out of $21,000). I gave all the information to VA in Columbia.

Then today I got the turn down from Augusta, Ga VA Hospital. Only reason I was in Augusta is because Columbia was remodeling the Heart Cath Lab.

Reason for not Approving Claim "Medical treatment was for non-service connected condition which was clinically determined not an adjunct to the service connect disability"

Guess they didn't read the second half of rule number one.."OR for any condition of a veteran who has been determined to be totally & permanently disabled as a result of a service-connected disability"

SO what should I do? I don't know if I can appeal without driving myself crazy waiting. I'm so upset I can't remember how to attach the letter or even do a search of this site. We know they are wrong & I guess I had been warned in advance that the VA would do anything not to pay $1000 bill, but I did it by the book & still have a unpaid bill.

Please help me, I'm so confused & upset.

Don

Edited January 26, 2010 by Chuck75

[Pete53]

Remember that you only have 30 days on an Administrative Appeal and if you Appeal it you have to go straight to the BVA,

Although you are upset I suggest that you notify Fee Service in writing that you want a hearing and that you are appealing their decision. If you are able go to Fee Service and talk to someone. If you have a VSO notify them that you are having this problem and would like help.

You should win this one and good luck Don.

[evandc]

Chuck, Pete,

Thanks for replies, try to answer your questions.

Will get Advocate contact at VA Hosp from Vet Group friends, looking up the regs. from the reason they gave listed 3 rules & turned down was "Medical treatment was for non-service connected condition which was clinically determined not an adjunct to the service connect disability"

But second part of the rule one said "OR for any condition of a veteran who has been determined to be totally & permantly disabled as a result of a service-connected disability"

Will work on letter, got to get my head together & calm down, get my facts etc..

OOPS-that could be reason OH you are 100% sorry we didn't know that. They don't seem to be debating I needed the immediate care or that I notified them (which I did). It was weekend & we didn't have much choice after I was stablized & confirmed I would get to my PCP, PDQ. I called her & got to Columbia that week & was some weeks before I had the stents etc.

I had CAD as far back as 2000, but on VA Cath decided not bad enough to do stents or whatever (less than 50% blockage). Filed in 2000 & of course turned down. Waiting for rules before I would file for Ischemic Heart Disease. Also have PN in lower (really bad) & upper extremities, but not diabetic (thank God). Lot of AO related problems for RMEF..Go Figure

VSO-no, since I was 30% I just struck out on my own. I have made many mistakes, but I have no one else to blame or to depend on for help. Tick, Tick does the 30 day clock start from date of letter (1/14/10) or date r'cd (1/25/10)? Eleven days for letter to get 50 miles.

More question or replies please.

Thanks,

Don

[Pete53]

Don:

You will do fine just remember that clock is ticking. Also that VA Hospital appeal is much different. I don't know if I were you if I would not cover your bases by asking for CAD to be rated as secondary to your Service Connection as there is ample proof available that it can be.

About the VA paying for 100% Veteran on emergency basis which I think you fit into. The primary thing they the VA gripe about is that they were not notified so that they could bring you to VA and do the intervention. As it was an emergency you asked but were not able to get to VA and that should be what you focus on.

In the end you will win this my friend so relax and play the game. You did it before you can do it again.

[john999]

While I was waiting for my IU I had some serious dental work done. I paid out of my pocket, of course. After I got IU I filed a claim for unauthorized medical expense with the fee base office. After a bunch of runaround the VA paid about 70% of the cost of the dental work. This was due to the fact that if I had been granted IU without being denied the first time I would have been eligible for VA dental care. I am sure the VA would tell most that you can't get this reimbursement. The VA hides a bunch of facts from vets. If you don't already know your rights they will never volunteer to tell you. A felon gets his rights read to him. Veterans must play hide and seek with the VA. I always believed we were treated with less respect than criminals.

[evandc]

The VA & I go back to 1973. I was 10% back then. Lots of boring history I'll skip, but spent 62 months going to 50% from 30%. Appealed to BVA, Remanded & on & on. I won with back pay.

When I think have a clue about what is going on the VA changes the rules. I love playing a game where the VA makes all the rules, hides the rules, expects you to go by the rules & then does not follow the rules.

I'll know tomorrow after get some contacts from Vet Group. My concern with CAD is-might be approved, low balled 20-30%, cut my Cancer below 30% & end up losing my SMC "S" & $300 a month. Does that or any of this make sense?

Don