Received 5103 Notice For Remand - Questions....

[justrluk]

Good afternoon,

Well, I finally received the notice to respond with more support for remanded items from my appeal. I started digging through my copy of my c-file to see if there were any documents the VA asked for that were already in the file. Much to my surprise, I found reports from my STRs that were from the '80s (which the VARO said did not exist in previous decisions, this appeal, etc...) that support my issue that a condition started surfacing while on my initial enlistment. This supports my contention that the issue did NOT pre-exist service, but brings something else to light: if the records are in my hands as part of my c-file, is it a CUE that the VARO never saw/used them?

Also, the latest documents needed by one treating physician are not in my c-file. She is also currently claiming that I owe her $$ from a claim she didn't file timely with TRICARE and was therefore not reimbursed. I assume she will not release the requested treatment records until I pay her the $400.00 she claims I owe. Do I try to get the VA to get the records knowing it will take months, or try to get them myself? I cannot afford to pay her the cash she is demanding (we've been going around and around since 2011), but the remand mentions her by name as having records that will support my claim. HELP!!! I want this over with, but not so much as to sacrifice all the years of work to get to this point only to have things denied because of one doctor's bad billing practices/claims filing.

[TiredCoastie]

Also, the latest documents needed by one treating physician are not in my c-file. She is also currently claiming that I owe her $$ from a claim she didn't file timely with TRICARE and was therefore not reimbursed. I assume she will not release the requested treatment records until I pay her the $400.00 she claims I owe. Do I try to get the VA to get the records knowing it will take months, or try to get them myself? I cannot afford to pay her the cash she is demanding (we've been going around and around since 2011), but the remand mentions her by name as having records that will support my claim. HELP!!! I want this over with, but not so much as to sacrifice all the years of work to get to this point only to have things denied because of one doctor's bad billing practices/claims filing.

This is sounds like a mess. Was the doctor in or out of network with TRICARE when you went to her? If she is or was in-network at the time, she has to accept responsibility for not filing in a timely manner. Out-of-network is more tricky. Most providers want you to sign that you're responsible for any payment if insurance does not pay appropriately, which is negated by TRICARE if the provider is in-network. "Timely" in terms of TRICARE time is a year from the date of service from what I understand. Only thing I can suggest is contact your region's TRICARE main office and ask for assistance.

There are too many doctors out there who don't have good office support. We run into this routinely, and as a result, monitor claim processing very closely.

[justrluk]

TC:

My situation is a bit different: I received a retroactive retirement. In 2012 (Jan) I was awarded a retirment and had to file backdated claims for reimbursment. I sent this doctor a letter with the forms already filled out and a copy of my orders and the SecAF's letter making it all possible. She never filed with TRICARE, so I attempted to do it. TRICARE denied my claim and now she's billing me since then for $450.00. If anything, she sould have reduced her portion but I'll call TRICARE again and see what needs to happen. Still I think she cannot hold my records hostage over a billing issue. If she does, I can see this remand dragging on for years. Her notes and x-rays support my requesting a higher rating while at the BVA Video Telecon. Either way, I have two C&Ps coming up and my appeal was in Jan of this year - can't complain that this took too long. I still don't have a SOC as directed by the BVA, but I don't think I'll get one until my file makes it back to the VARO. I was told that because of the remand, my file was sent to the closest VAMC for the C&P exams. SO: need to get my ducks in a row, capture the info I can and do well at the C&P.

Thanks for helping me with the TRICARE issue. I'll call them today.

[broncovet]

I really dont know if that doctor can withold releasing your records on the bases that you owe money. My guess would be no. Obviously, your medical records would be valuable to the next doctor who is treating you, and, by witholding your records over a money dispute, she compromises your future treatment. At least, it is unethical, or it could even be illegal,(malpractice), if you can document she witheld your records over a money dispute and that witholding of records compromised your treatment, that is, caused you to be unhealthy, then the doctor may be liable for your future care.

A lawyer may love something like this.

[TiredCoastie]

TC:

My situation is a bit different: I received a retroactive retirement. In 2012 (Jan) I was awarded a retirment and had to file backdated claims for reimbursment. I sent this doctor a letter with the forms already filled out and a copy of my orders and the SecAF's letter making it all possible. She never filed with TRICARE, so I attempted to do it. TRICARE denied my claim and now she's billing me since then for $450.00. If anything, she sould have reduced her portion but I'll call TRICARE again and see what needs to happen. Still I think she cannot hold my records hostage over a billing issue. If she does, I can see this remand dragging on for years. Her notes and x-rays support my requesting a higher rating while at the BVA Video Telecon. Either way, I have two C&Ps coming up and my appeal was in Jan of this year - can't complain that this took too long. I still don't have a SOC as directed by the BVA, but I don't think I'll get one until my file makes it back to the VARO. I was told that because of the remand, my file was sent to the closest VAMC for the C&P exams. SO: need to get my ducks in a row, capture the info I can and do well at the C&P.

Thanks for helping me with the TRICARE issue. I'll call them today.

Hope it works out with TRICARE. If she is in-network, or was at the time she treated you, then TRICARE has a process to provide you with relief from the bill.

Broncovet has a very good point, though. Check out HIPAA rules and regs. Under HIPAA, you have access to your records. There is a process through either your state or the federal government to seek relief if she withholds them.

[justrluk]

So I've started preparing for this: I reviewed my daily diaries, tallied the number of real bad flare-ups (3 in the last 12 months), daily neck pain and sleep disturbances. I'll check this against the DBQ and see what this might mean.

[justrluk]

Talked to my VSO earlier today: told me to stop taking meds that will mask the conditions for which I have appealed. I don't know how this will work when the primary med (Humira) has roughly a 6-month half-life in your system before flare-ups start again. He said that even though the documents I sent prove something started in service, they would look primarily at the upcoming C&P results. Why do I feel like I just got set up for failure??