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Does Anyone Know Why Its Longer For More Complex Claims?

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USCG CWO4

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I recently retired and submitted my BDD claim. There were multiple items claimed and from what I have read it will take longer to get my claim processed. As a matter of fact they estimate late Dec 2012 to April of 2013 and I filed and had my C & P exam in February but my retirement date was 01 May. I understand that it will take longer for my claim because there are more items and its more difficult, but do they take the easier claims and put them on top of the pile? Don't they process claims in the order in which they are received? If so this would mean all claims would take about the same amount of time.

I am a patient man so I understand it will take time, just curious about the process.

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The workers (VA employees) are the ones quoted as saying they denied claims because it was faster, (not me) rather than award them, which takes more time. To quote, they said it this way:

"The workers said those quotas encourage processors to take shortcuts that often lead to mistakes, or to focus on easier cases over complex ones. And when in doubt, processors tend to deny claims, the workers said, because denials are generally faster."

I think I can assume the VA employees who said this, knew about the VA claims process, much better than I do, as I have never worked for the VA. Further, I will go so far as to assume these workers are correct, as the statistics bear out what they say. Only about 15 percent of claims are awarded at the RO level, without an appeal. However, at the BVA, better than 50 percent of these denials are either remanded or awarded upon appeal. This suggests employees are denying claims, because it is faster and they can get more done, even if half of these denials are overtuned at the BVA level.

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Yeah, whatever. One tends to believe or assign credence to whatever evidence that supports what they already want to believe.

The workers (VA employees) are the ones quoted as saying they denied claims because it was faster, (not me) rather than award them, which takes more time. To quote, they said it this way:

"The workers said those quotas encourage processors to take shortcuts that often lead to mistakes, or to focus on easier cases over complex ones. And when in doubt, processors tend to deny claims, the workers said, because denials are generally faster."

I think I can assume the VA employees who said this, knew about the VA claims process, much better than I do, as I have never worked for the VA. Further, I will go so far as to assume these workers are correct, as the statistics bear out what they say. Only about 15 percent of claims are awarded at the RO level, without an appeal. However, at the BVA, better than 50 percent of these denials are either remanded or awarded upon appeal. This suggests employees are denying claims, because it is faster and they can get more done, even if half of these denials are overtuned at the BVA level.

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  • HadIt.com Elder

Everyone is going to offer different opinions. Fortunately this is healthy discussion and it involves some very knowledgeable people.

There will always be a disassociation between an employee or someone who either works or has worked at the VA or a Veterans Service officer and the Veteran.

They are looking at this from their own point of view that was hammered into them from their training.

The Veteran looks at it in a different light. They only know what they have either been told or have learned through research.

Don't let this issue bother you too much as I will tell you from a Quality Assurance point of view exactly why complex claims take longer.

The greater the number of issues a Veteran has as well as the information provided to Prove service connection can be consistent on many factors. This information must be gathered. Then it has to be processed and organized in the claims folder before it even goes to the rater.

This takes time. The Rater also has a time limit he or she can work on an individual claim as the system pays on productivity. (Bonus)

The bottom line is the more issue you have the more adjudication is needed and that takes time.

Basser

Oh and one additional thing. Lets keep this professional. We need this discussion so we can kearn from one another.

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My 2 cents,

Besides the obvious answer to the question, If I was on Blue Collar Comedy, I think I would say "here's your sign"!

As Basser was mentioning that juniour VSR gather the evidence, submit requests exct. before the file goes to the RVSR. VA switched to that model to improve efficiency, its latest incarnation is the CPI model, although the newest workflow process model has just been implemented in 16 VARO's and is a drastice departure from current methods.

Part of the problem how they do things right now is this, if you have multiple issues, you may need multiple C&P's. Since the VA can't walk and chew gum at the same time, they are unable to effectively schedule multiple C&P's. In my records it clearly shows they wanted 2 C&P's I received notices that I would be scheduled for 2 C&P's at two different VAMC's, one of them happened the other did not. Since my file was at one C&P office the second exam didn't happen, file went back - sat in common area(4-6 months) until picked up to rate, rater says where is my exam on X, send it out for the exam. C&P service argues that exam not needed, due to a previous exam, they settle on medical opinion/addendum, comes back sits for anohter 4-6 months, goes to rater, rater indicates both C&P's not sufficient/clear asking for additional medical opinion. When that is done, it will most likely sit 4-6 months until picked up again. Since the people typing up the exam/records requests are not the people making the decision, and they really arn't talking to each other (RVSR scribbles note on file for C&P exam or problem with C&P) The person actually setting up the request for the C&P is most likely doing it 30-60 days after the RVSR looked at the file. If the VSR doesn't understand the note from the RVSR and has to ask a question about it, The RVSR will not recall the specific case at all because they have looked at hundreds of other files. So the request may or may not be correct, but we won't know until 4-6 months after when a RVSR picks up the file to finish it.

Sprinkle in a little apathy, because the VA employee feels they are not appreciated by the population they serve, add a union to prevent any meaningful discipline for poor work performance. What you have left is a system that values quantity over quality, individual situations no longer really matter as long as you can make the numbers look good (gotta love statisticians).

That is part of the reason why complex claims take so long.

Best regards,

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