10-min interview request: How can physicians advocate for veterans?

[Sarah Greenberg]

Hi Bronvovet,

Thank you again for taking the time to answer my questions and clarify the VA claims process for me. I just listened to one of the Had It podcasts and Dr. Bash also mentioned the "traps" of DBQ's and how to get around them.

For example, Dr. Bash said that a physician needs knowledge of the rating schedule, as there are only 70 DBQ's, but 2,000 rating schedules. 

Is my understanding of the rating schedule correct? I found the rating schedule here. The rating schedule is the document that the VA uses to determine the severity of the disability and the extent to which the disability affects the vet's ability to work, so that the vet receives appropriate compensation. The rating schedule breaks down disabilities into categories based on the part of the body impacted. Each category contains a group of medical issues, which are further broken down into a list of diagnoses that have a specific diagnostic code. Each code specifies symptoms that are required for various ratings of disability. The ratings are percentages and depend on whether the diagnosis is severe, moderately severe, moderate, or mild. For a severe diagnosis and rating, the vet must experience/exhibit the symptoms listed under that rating.

Eyecare physicians would use The Organs of Special Sense section of the rating schedule.

Whew, is that correct?

Where are the symptoms listed in the rating schedule?

Thank you so much!

Sarah

[broncovet]

You have that about right, and Dr. Bash is the expert on writing IMO/IME's that work for Vets.  The physican should not try to "rate" the Veteran, that is, to suggest a disability percentage.    The VA's "rating specialists" think they are the only ones who can do that, and dont like it very well when docs suggest a disability percentage, even tho I think the doc is infinately more qualified.  

Years ago, the "rating board" had medical professionals on staff, and they rendered medical opinions.  That proved too costly for VA, so the "rating board" no longer has "medical professionals" and they must rely on the medical opinions of VA or independent medical opinions.    It is error for the VA to substitute their own unsubstantiated medical opinion for that of a medical professional.  Also, the Veteran is rarely a medical professional and can not give competent testimony regarding his nexus, or diagnosis.    He can, however, give "lay testimony" on simple observable facts such as "I got shot in the left leg" or 

"My wife says I snore every night".  But, his testimony that he has an Anterior Cruciate Ligiment tear caused by a 30 meter vertical  fall in military service probably wont fly absent a Doctor confirmation of the diagnosis.  

[Andyman73]

Sarah,

As you are rapidly learning, the whole VA claims process is a huge web designed to create confusion and delay.  Now, imagine that you are one of us, a Veteran who is trying to live their lives with what health and physical ability they have after serving our great country.  Now, imagine the daunting task of trying to file a claim, how to write it up, what evidence to submit, if you even have your Service Treatment Record(STR). 

Still with me? Let's go deeper into the rabbit hole....we rejoin the Vet as they sit in the exam room for the C&P(compensation and pension) exam for their claim.  Right off the bat the Vet will be on edge, as most examiners have a near adversarial approach to the exam process.  Then the questions start, that try to lead the Vet to say something that can and will be used to discredit their claim.

Sometime later, weeks or months, the Vet gets the award/decision letter, with great anticipation they open it to find that their claim has been denied due to lack of evidence(most often ignored) or no service connecting treatment record.  Or even more insulting, a lowball rating.

Now they are crushed, heartbroken, dejected, or outraged and angered to the point of losing their composure. 

I went 15 years between my initial rating and my next increase.  This was mostly due to lack of knowledge, fear of rocking the boat, and overwhelming sense of hopelessness.  I had no knowledge of what to do, shoot, I didn't even know what I didn't know.  And it drove me to the point of comtemplating suicide.

By the grace of God, I stumbled upon Hadit while researching something else.  This website created by Tbird is probably God's greatest gift to Veterans of all generations and their families.

Semper Fi

Andyman.

[Sarah Greenberg]

Hello everyone!

Thank you all for your help. I am so grateful for your expertise. Here is my article so far. What do you think?

What you need to know about helping vets who walk through your doors

While many physicians want to help veterans get the medical attention and compensation they need, navigating the Veterans Affairs claims process can be a nightmare. In fact, some vets say that way the VA merely placates the men and women who risked their lives for their country partially explains why the suicide rate among vets is so much higher than the national average.

 

As an eye care physician, you can help advocate for your veteran patients to get the compensation they deserve. We want to equip you with the knowledge and tools to do just that.

What you need to know first:

1.     Veterans need to meet three requirements in order to receive benefits:

a.     The vet has a documented in-service event, or was on active duty-with at least one day within a period of war. This event in service could include a single incident/event (explosion, gun shot, exposure to chemicals). The physician must rely on the vet’s account of the service event, unless the event is in records available for the physician to review.

b.     The vet needs a current diagnosis of a physical/mental condition from an Independent Medical Exam (IME). This is where you come in. As a physician, you are qualified to make this diagnosis.

c.     A “nexus,” or connection between the in-service event and the current diagnosis. The nexus needs to be stated in a formal letter from you, the physician who has conducted the Independent Medical Exam (IME). In the letter, state the symptoms the vet is experiencing, and the extent to which the symptoms affect his/her ability to drive and earn a living. If the vet is homeless or about to become homeless, state that as well.

What you need to do next (paperwork):

1.     In your nexus letter, the VA requires precise language to demonstrate the connection between the vet’s time in service and his/her current medical condition. Use this jargon when stating the nexus:

a.     If there is a 50% chance that the vet’s condition was caused/aggravated by his/her time in service, then write, “This condition was as likely as not caused/aggravated by the vet’s in-service event (state the event).”

b.     If there is a 75% chance, then write, “This condition was more likely than not caused/aggravated by the vet’s in-service event (state the event).”

c.     If there is a 100% chance, then write, “This condition is due to the vet’s in-service event (state the event).”

d.     If you’re not certain of the percentage, but the evidence appears plausible, use the 50% chance jargon.

 

2.     During the Independent Medical Exam (IME, the exam you conduct for the vet), you also need to complete a Disabilities Questionnaire (DBQ). Published by the VA, DBQ’s are medical examination forms specific to the disability of the veteran. The VA uses the DBQ when reviewing your IME and nexus letter to assign the appropriate amount of disability compensation to the vet.

a.     The DBQ’s are categorized by type of condition/disease (i.e. Ophthalmological). Find all DBQ forms here. Find the DBQ for Eye Conditions here.

b.     Attach your nexus letter and diagnosis to the DBQ.

c.     Note: The DBQ does not always ask for a nexus, diagnosis, effective dates, or how the condition has affected the vet’s ability to work; these are crucial elements for the vet to get compensation.

3.     To ensure that the VA reviews all of your paperwork, not just the DBQ, do the following:

a.     On the last page of the DBQ, there’s a space for remarks or comments. Write, “See my attached nexus opinion” so the VA has to find it.

b.     Number every page of the paperwork packet (DBQ, nexus letter, IME paperwork) so that nothing gets lost.

c.     At the top of the DBQ, write, “This is a VA Exam” so that the VA does not discard it (that has happened).

 

What you need to do last:

 

1.     Make a copy of the DBQ, nexus letter, and IME and give the copy to the vet. YOU keep the originals. Keep the vet’s paperwork for 10-20 years. Some disability claims go on for 13+ years.

a.     Vets are responsible for submitting their paperwork to one of these Mailing Addresses for Disabilities Claims.

b.     Some vets should seek legal representation if their claims have been denied several times. Refer them to the Veterans Benefits Manual, the most reliable source of legal information for vets to win their claim. You can also refer vets to the list of lawyers who represent veteran claimants, vetted by the National Organization for Veterans Advocates.

[broncovet]

Sarah:

   I like it.  I will make just a few "clarifying" changes, in red this time.  

 

1.     Veterans need to meet three requirements in order to receive benefits:

 

a.     The vet has a documented in-service event, or was on active duty-with at least one day within a period of war. Veterans can be service connected regardless if they served in a war or not.   "Wartime service" applies to Non service connected pension.   This event in service could include a single incident/event (explosion, gun shot, exposure to chemicals).  Yes, these events can lead to Service connection, but there are many more.  As ONE example, seeing a friend die in combat can be a "stressor" for PTSD.   The physician must rely on the vet’s account of the service event, unless the event is in records available for the physician to review.

 

b.     The vet needs a current diagnosis of a physical/mental condition from an Independent Medical Exam (IME). (Some physicians also write "Independent Medical OPINIONS. (IMO).  In an IMO, the physician reviews the medical records, and offers a medical opinion which often includes a nexus.  For an IMO, the physician need not actually examine the patient, but makes a professional opinion based on the records.  I prefer IME's when possible, but there are physicians who do IMO's and those can be a difference maker.  Many times a Vet who goes to the VA has doctors who are not all that Veteran friendly and dont provide the required nexus stament and a good IMO can fill that gap.     This is where you come in. As a physician, you are qualified to make this diagnosis.

 

c.     A “nexus,” or connection between the in-service event and the current diagnosis. The nexus needs to be stated in a formal letter from you, the physician who has conducted the Independent Medical Exam (IME). In the letter, state the symptoms the vet is experiencing, and the extent to which the symptoms affect his/her ability to drive and earn a living. If the vet is homeless or about to become homeless, state that as well, and the date that the records show (or the date the physician opines) the Veterans symptoms first began.

 

What you need to do next (paperwork):

 

1.     In your nexus letter, the VA requires precise language to demonstrate the connection between the vet’s time in service and his/her current medical condition. Use this jargon when stating the nexus:

 

a.     If there is a 50% chance that the vet’s condition was caused/aggravated by his/her time in service, then write, “This condition was as likely as not caused/aggravated by the vet’s in-service event (state the event).”

 

b.     If there is a 75% chance, then write, “This condition was more likely than not caused/aggravated by the vet’s in-service event (state the event).”

 

c.     If there is a 100% chance, then write, “This condition is due to the vet’s in-service event (state the event).”

 

d.     If you’re not certain of the percentage, but the evidence appears plausible, use the 50% chance jargon.

 

 

2.     During the Independent Medical Exam (IME, the exam you conduct for the vet), you also need to complete a Disabilities Questionnaire (DBQ). Published by the VA, DBQ’s are medical examination forms specific to the disability of the veteran. The VA uses the DBQ when reviewing your IME and nexus letter to assign the appropriate amount of disability compensation to the vet.

 

a.     The DBQ’s are categorized by type of condition/disease (i.e. Ophthalmological). Find all DBQ forms here. Find the DBQ for Eye Conditions here.

 

b.     Attach your nexus letter and diagnosis to the DBQ.

 

c.     Note: The DBQ does not always ask for a nexus, diagnosis, effective dates, or how the condition has affected the vet’s ability to work; these are crucial elements for the vet to get compensation.

 

3.     To ensure that the VA reviews all of your paperwork, not just the DBQ, do the following:

 

a.     On the last page of the DBQ, there’s a space for remarks or comments. Write, “See my attached nexus opinion” so the VA has to find it.

 

b.     Number every page of the paperwork packet (DBQ, nexus letter, IME paperwork) so that nothing gets lost.

 

c.     At the top of the DBQ, write, “This is a VA Exam” so that the VA does not discard it (that has happened).

 

 

What you need to do last:

 

 

 

1.     Make a copy of the DBQ, nexus letter, and IME and give the copy to the vet. YOU keep the originals. Keep the vet’s paperwork for 10-20 years. Some disability claims go on for 13+ years.

 

a.     Vets are responsible for submitting their paperwork to one of these Mailing Addresses for Disabilities Claims.  The Veteran should send the reports via certified mail return receipt requested since VA loves to lose documents, and blame the Veteran for not sending them.  

 

b.     Some vets should seek legal representation if their claims have been denied several times. Refer them to the Veterans Benefits Manual, the most reliable source of legal information for vets to win their claim. You can also refer vets to the list of lawyers who represent veteran claimants, vetted by the National Organization for Veterans Advocates.  NOTE:  Many Veteran advocates recommend the use of a Veteran's Service officer, such as the Disabled American Veterans, as the VSO's do not charge for their service.  However, many Veteran's advocates eventually enlist the services of a legal professional especially with complex claims after a denial by the Department of Veterans Affairs.  In many cases, all or a portion of the legal fees to an attorney are paid by EAJA (Equal Access to Justice Act). 

 

 

[Slick]

lots of answers today.

if already stated apologize, but here's a couple additional pieces

Had this in my file- for what it's worth>

Independent Medical Opinions

VA plays a war game called the War of the Words. The proper wording of an IMO is critical to VA's acceptance of it, as probative evidence.

A Valid IMO must contain the following:

The doctor must have all medical records available and refer to them directly in the opinion.

In cases involving an in-service nexus- the doctor needs to read and refer to the SMRs.

Also the doc needs to have all prior SOC decisions from VA ,particularly those referencing any VA medical opinions and a copy of the actual C & P results is even better. The SOC or SSOC could parse or manipulate critical statements in the actual C & P exam.

The IMO doctor should define their medical expertise as to how their background makes their opinion valid.

They should be willing to attach to the IMO their CV (Curriculum Vitae that contains their medical background and any other info pertinent ,such as any symposiums they attended, articles they had published etc etc,if possible, that show their expertise .)

 A psychiatrist cannot really opine on a cardiovascular disease.

An internist cannot really opine on a depression claim.

They need to have expertise in the field of the disability you have claimed to make their IMO valid.

They should rule out any other potential etiology if they can-but for service as causing the disability.

They should briefly quote from and cite any established medical principles or treatises that support their opinion.

They should point out any discrepancies in any VA examiner’s opinion-such as the VA doctor not considering pertinent evidence of record in the veteran’s SMRs or Clinical record.

They should fully provide medical rationale to rebutt anything that is not medically sound nor relevant or appropriate in the VA doctor’s opinion.

They should then refer to specific medical evidence to support their conclusion.

 

They must use these terms: (VA is familiar with these terms)

"Is due to- 100%

 More likely than not- Greater than 50%

 At least as likely as not- 50% (Benefit of doubt goes to Vet)

 Not at least as likely as not- Less than 50%

 Is not due to- 0% from an post by carlie “

 

It helps considerably to identify pertinent documents in your SMRs and medical records with easily seen labels as well as to list and identify these specific documents in a cover letter that requests the medical opinion.

 A good IMO doctor reads everything you send but this makes it a little easier for them to prepare the IMO as to referencing specific records.

Send the VA and your vet rep copies of the signed IMO.

 And make sure your rep sends them a 21-4138 in support of it- you also- can send this form (available at the VA web site) as a cover letter highlighting this evidence

 PS- Mental disabilities- make sure the doctor states that you are competent to handle your own funds- otherwise, if a big retro award is due-the VA might attempt to declare you incompetent and it takes times to find and have the VA approve of a payee. (unfortunately many PTSD claims these days depend on a VA MH professionals diagnosis of PTSD and an IMO diagnosing PTSD will not be accepted by the VA. See our PTSD forum for the 2010 regs on that.

I need to add here that a secondary condition to an established SC condition wold not need the IMO doctor to read all of the SMRs.

 They just have to state with medical rationale why the second claimed disabilty is due to (secondary to) the initial SC disability.

IMO docs must avoid words like 'maybe', 'possibly', 'could ' or 'might' be related to, or any other wording that VA could construe as  speculative and then disregard the IMO for that reason.

On the other hand the IMO doc should look for any  purely speculative statements in the C & P exam report or in the C & P and overcome those statements by stating they are mere speculation and have no medical basis.

 

2d item that I believe needs to be included with an IME is a "credentialing piece."

My 2 IME's done by Dr Bash included following. (provided as an example) would suggest optometrist/opthamologist include appropriate verbiage citing their own expertise-

 

Expertise-Special Knowledge:

 

I have special knowledge in the areas of neurological-spine, sleep apnea, epigastritis-GERD/Lung fibrosis, right knee (10%), hypertension (HTN), nephropathy, hearing loss, scars right/left lower legs and cervical spine diseases, as I have radiology sub-subsection training and testing in these organ system areas as of my comprehensive 1990 boards. I have attended the US Naval course on medical effects of Ionizing radiation in 1989, which at that time was a 2-week in-person course on the campus of the National Navy Medical Center (NNMC) in Bethesda Maryland. (Now it is called MEIR and is a shortened 2.5-day course concerning the biomedical consequences of radiation exposure, how the effects can be reduced, and how to medically manage casualties. The training includes nuclear incidents that can occur on or off the battlefield and that go beyond nuclear weapons events. It covers thoroughly all four of the key subjects: health physics, biological effects of radiation, medical/health effects, and psychological effects.)  I am double board certified specialist (national board of medical examiners and American Board of Radiology with an 4 month internship followed by a 4 year residency and a 3 year Neuroradiology Fellowship  (2 years at NIH) for a post graduate total of year-7+ [PGY-7+] level of training, which is similar to the number of PGYs required for Neurosurgical training, am a Senior Member of the American Society of Neuro-Radiology (ASNR), and am an attending level school of medicine Associate Professor.  It is important to note that vast majority physicians in America are trained only at the PGY level of 3.  For example, almost all the primary care physicians in internal medicine, neurology, pediatrics and family practice are all trained at the PGY-3 level. 

 

For the benefit of VA raters it is important to note that by comparison for example orthopedic surgeons are trained at the PGY-4 and most general surgeons have PGY 5 levels of training and other specialty-trained surgeons are trained at the PGY 6 and 7 levels.  I have completed a fellowship in Neuro-Radiology at the NIH (National Institutes of Health) and as such I am one of about 3000 neuro-radiologists in America at the PGY-7 level of training and one of less than a dozen who have completed a 2 year NIH experimental neuro-imaging research fellowship in the laboratory of diagnostic radiology research (please note that there are about 700,000 physicians in the US).

 

I am a 100% disabled veteran and I have a Masters degree in Business Administration (MBA--Golden Gate University 1981) and have been employed as a Medical Director of a large ($1-200 million annual revenue) philanthropic disabled veterans organization and part of my duties involved reviewing medical records for the employment of disabled personnel and perform site visits to review quality of care at VA’s largest tertiary care hospitals and nursing/domiciliary/state homes.  I therefore have both practical and theoretical experience/training in the issues surrounding the employment of disabled workers (TDIU) and needs of patients for long term care. (Please see my attached C.V.) 

 

Additionally, I have performed and/or interpreted plain x-rays, CT scans, ultrasounds, angiograms, arthrograms, barium studies, contrast studies, PET, nuclear medicine scans, and MRI (basic and research/experimental) scans as appropriate on thousands of patients with this patient’s type of primary and secondary disorders, and I have correlated my findings with the clinical record/physical exam.  Please note that this patient’s claim hinges on the imaging findings.

 

 

Competency, credible and professional opinions:

 

I am highly competent and credible to make the professional medical opinion/s herewith because I am an actively licensed physician (Maryland) with extensive specialized training and experience (22 years of IME production) in the areas of interest (as described above). I have performed several hundred VA IMEs and I am familiar with the VA rating schedule as published in the CFRs/U.S. Codes.  In fact, I have worked as a VA accredited Veteran Service Organization (VSO) representative for 8 years with two different VSO groups (PVA and DAV). I have reviewed the medical record and the patient’s lay statements, I have conducted a clinical historical interview, I have referenced current applicable publications (explained how they apply to this patient’s medical data set), I have examined the patient by way of reviewing his pivotal imaging study reports, I have reviewed pertinent positive and negative medical data, and I have reviewed/referenced other physicians professional medical opinions^1.

 

Medical examination:

 

 

In this case a face-to-face hands-on medical examination was done. The crux of this issue involves causation and etiology and this involves time line diagnoses for which I am exquisitely well trained as a Diagnostician.

 

 

 

Depth of knowledge:

 

The VA has recently started to extensively use non-credentialed Nurses/Nurse Practitioners (NPs) and Physician Assistants (PAs), so-called “On-Site Providers” (OSP) or VA examiners, to provide medical opinions in complex cases that often involve the review of medical records that extend over decades.  These non-MD’s do not have the depth of knowledge needed to accurately evaluate the veteran-patient’s primary and secondary medical problems nor diagnose subtle or rare diseases; therefore the quality of these important medical exams is diminished by using these non-licensed practitioners (AKA Dumbing Down).  These reviewers provide sub-optimal reviews simply because they do not have extensive training or experience as compared to a physician.  The axiom “...You see what you look for and you look for what you know...” applies to these complex veteran cases, which involve multiple organ systems and which involve pathologic processes that extend over decades.  These sub-optimally trained reviewers do not know because of limited training many subtle aspects of medicine and therefore are unable to see or look for the linkages necessary to create a fair nexus or analysis of any veterans’ medical issues. Thus these supervised only/novice practitioners are not able to consider every possible sound medical etiology/principle as is required by VA mandate for assignment of medical diagnostic codes.  MD expertise is required for these complex cases as is well-recognized by the VA, which has recommend specialists analysis for medical diagnostic code assignments via the VA court decision in Hyder v. Derwinski, 1 Vet. App. 221 (1991).

 

 

My review on the other hand is based on a deep body of knowledge and training acquired over almost 30 years as is illustrated in my C.V. contained in the file and this CV is compared to the C.V.’s of a standard support staff nurse/PA/health technician (HT)/nurse practitioner (NP) below:

 

 

Dr. Bash                                  Support Staff PA/nurse/HT/NP/OSP

 

College/University                               4 years                                                 2-4 years

Masters degree in Business (2 years)   yes                                                       none

Medical school            MD degree                   4 years                                                 none

Licensed Physician                              Yes                                                      no

Nurse school/PA                                  none                                                    2-3 years

Internship/OJT                                     1 year                                                  none-1

Residency                                            4 years                                                 none

Fellowship clinical                               1 year                                                  none

Fellowship-research at NIH                 2 years (PGY7)                                   none

Practice only under supervision                       No                                                            Yes- Required limited skill/training

Medical director                                   3 years                                                 none

Radiology department director             2 years                                                 none

MS/Brain--MRI research                      Yes since 1992                                                none

Associate professor Medical school     yes-10 years                                        none

Peer reviewed articles                          22                                                        none

Paper H-index (14 Oct 2012)               24                                                        none

http://code.google.com/p/citations-gadget/

Most number of times paper cited       230                                                      none

 

The effect of interferon‐β on blood—brain barrier disruptions demonstrated by constrast‐enhanced magnetic resonance imaging in relapsing—remitting multiple …

LA Stone, JA Frank, PS Albert, C Bash… - Annals of …, 2004 - Wiley Online Library

Abstract Magnetic resonance imaging (MRI) has been a valuable tool to understand the
pathophysiology and natural history of multiple sclerosis (MS), and increasing attention is
focusing on the use of MRI findings as outcome measures in treatment trials in MS. The ...

Cited by 230

 

Number of paper citations                   348                                                      none

Spinal Cord MRI research experience  yes                                                       none

NIH Senior Fellow/staff experience     yes-18 years                                        no

Several thousand VA IME’s                yes                                                       no

50+ site visits for VA Quality of Care yes                                                       no

Years experience as MD                      26+                                                      none

Years accredited VA service rep                      8                                                          none

Review of C-File if available               yes                                                       +/-

Review x-ray/CT/MRI if available          yes                                                    no

Number of years doing VA cases        26                                                        ?

Number of VA Patients done               4000+                                                  ?

Number of VA organ system claims     40,000 est.                                          ?

Success rate of cases                           80-90%                                                            ?

 

Total Formal Post-Grad training years     13 years                                           2-3 years