Copies of C&P Exam Results Must Now Be Requested from Your RO?

[lotzaspotz]

This is interesting and unfortunate, if true.  My husband had another C&P exam yesterday. It was at a VA office in town dedicated to these exams, but not at the VAMC.  While it was going on and I was waiting in the lobby, I asked the receptionist for the form to complete to get a copy of it, as I've always done.  She replied, and the examiner later concurred when I asked him the same thing, that the VA nationwide has implemented a new policy.  Copies of exam results must now be requested directly from the RO, and will not be available until after a claim is decided.  VAMC's will no longer provide copies to veterans.  You can guess what's going to happen (or more likely, not happen) if veterans have to jump through this brand new hoop to get medical information that rightfully belongs to them in reference to their claims and appeals.

Has anyone else heard this?  I'm wondering how the HIPAA laws impact this.  Our Congressman is also an M.D., and I'm ready to contact him, but I'd first like to get my facts straight.  I asked about accessing the information on ebenefits, but they told me to expect a change in that, but they didn't know how that was all going to shake out.  

 

Edited April 8, 2016 by lotzaspotz

[Buck52]

 lot this is older stuff maybe beneficial to you?

Department of Veterans Affairs
VHA DIRECTIVE 2010-024
Veterans Health Administration
Washington, DC 20420
June 2, 2010
CHANGES IN COMPENSATION AND PENSION EXAMINATION REPORTS
1. PURPOSE:
This Veterans Health Administration (VHA) Directive provides policy for making changes in Compensation and Pension (C&P) Examination Reports.
2. BACKGROUND
a. The Automated Medical Information Exchange (AMIE) package is the official communication mechanism between VHA and the Veterans Benefits Administration (VBA) for completed VHA C&P examination reports. The Compensation and Pension Record Interchange (CAPRI) application provides a graphical user interface (GUI) as a front-end for the AMIE application to aid in easily finding and viewing C&P examination requests and examination reports in AMIE. Examinations may be documented directly in the CAPRI GUI, or through a Text Integrated Utility (TIU) progress note copied into AMIE. NOTE: While AMIE is used to transmit C&P examination reports to VBA, the official patient record of the examination report resides in TIU.
b. VHA clinical and VHA contracted staff communicate C&P Examination findings to VBA through AMIE and CAPRI. Once released by VHA, VBA retains a copy of the examination report and uses that copy to adjudicate Veterans’ disability claims. The VBA copy of the examination report is contained in the Veterans claim file (whether electronic or paper).
c. VBA has a custodial relationship to the C&P examination reports. Since disability rating decisions may be made based on existing documentation, any changes made to a C&P examination report must be coordinated with the appropriate VA Regional Office for action to ensure consistency (see subpar. 4b).
d. Changes to existing documentation are made in accordance with the Privacy Act and Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule; however, a critical communication gap exists because VBA is not electronically alerted to changes made to examinations in AMIE and CAPRI after the original version of the completed examination is available. NOTE: Communication with VBA is critical since changes to examination reports may significantly affect the outcome of a disability rating decision.
3. POLICY:
It is VHA policy that any changes to C&P examination reports must be transmitted to VBA using the official communication mechanism, AMIE and CAPRI. NOTE: This requirement applies to all C&P examinations whether they reside in TIU or AMIE and CAPRI. If an examination is modified in TIU, it must also be modified in AMIE and CAPRI in order to ensure that the updates are transmitted to VBA.
4. ACTION:
Each VHA Facility Director is responsible for ensuring:
THIS VHA DIRECTIVE EXPIRES JUNE 30, 2015
VHA DIRECTIVE 2010-024
June 2, 2010
2
a. Appropriate Storage. C&P examination reports must be stored within VA’s electronic health record. When these reports are stored in TIU, a copy must additionally be placed in AMIE and CAPRI for transmittal to VBA. If a C&P examination report has been released to VBA through AMIE and CAPRI, any subsequent changes made to the report in TIU must be transmitted to VBA requiring that changes to the examination report need to be made in AMIE and CAPRI. Whether the report resides only in AMIE and CAPRI, or in TIU and AMIE, a copy of any changed examination must be sent to all third party (non-VA) requestors who have previously received the original document prior to amendment.
b. Changes are Appropriately Made. Administrative corrections or updates (e.g., date of birth, etc.) made to C&P examination reports must be processed by the Chief, Health Information Management, Privacy Officer, or qualified designee. These changes must be minor and not affect the results or findings of the clinical examination. Prior to any administrative correction, the Chief, Health Information Management, Privacy Officer, or qualified designee, must ascertain whether this report has been disclosed to the patient or other third-party and if notification to these individuals would be required. Any changes made to a C&P examination report must be coordinated with VBA and the appropriate VA Regional Office for action to ensure consistency.
c. Amendments are Appropriately Completed
(1) A request from a Veteran to amend a C&P examination report must be in writing and submitted to the Privacy Officer at the VHA health care facility that performed the examination. Upon receipt, the VHA Privacy Officer, or designee, notifies the VBA Privacy Officer that an amendment request has been received. Amendment requests are processed by VHA for all C&P examinations in accordance with VHA Handbook 1605.1. VHA uses standard letter templates to notify the Veteran whether the request for amendment has been granted or denied. The VHA Privacy Officer, or designee, forwards a completed amendment packet to the VBA Privacy Officer, or designee. VHA and VBA are both responsible for providing all parties, to whom they have previously released the C&P examination report, a corrected version of the report.
(2) If a request from a Veteran to amend a C&P examination report is received by the Department of Veterans Affairs Regional Office (VARO), the request must be forwarded immediately to the attention of the Privacy Officer at the VHA health care facility that performed the examination. The corresponding Privacy Officer can be located through http://vaww.vhaco.va.gov/privacy/Documents/VHACOPOList.doc. NOTE: This is an internal VA site not accessible to the public. The time frame for processing a request begins once the VHA Privacy Officer has received the request.
c. Addenda are Appropriately Completed. On occasion the original author, or other clinicians, need to addend a completed C&P examination record in TIU that has been released to VBA through AMIE and CAPRI (i.e., a laboratory value may return late or a mistake may be detected in the original report). The addendum must be processed according to local policy, signed, and reported to the Chief, Health Information Management, Privacy Officer, or qualified designee, through a locally-established process. The Chief, Health Information Management,
VHA DIRECTIVE 2010-024
June 2, 2010
3
Privacy Officer, or qualified designee, ensures AMIE and CAPRI is updated with the addendum and VBA is provided with a corrected copy of the report, which includes the new information.
5. REFERENCES
a. VHA Handbook 1605.1.
b. Privacy Act of 1974.
c. HIPAA Privacy Rule, Title 45 Code of Federal Regulations Parts 160 and 164.
d. VHA Handbook 1907.01.
6. FOLLOW-UP RESPONSIBILITY:
The VHA Office of Health Data and Informatics (19F) is responsible for the contents of this Directive. Questions may be directed to (502) 241-2822.
7. RECISSION:
VHA Directive 2004-014 is rescinded. This VHA Directive expires
June 30, 2015.
J
Robert A. Petzel, M.D.
Under Secretary for Health
DISTRIBUTION:
E-mailed to the VHA Publications Distribution List 6/3/2010

[green]

Freckled one, did you ask to see a copy of the policy?  It could be that no such formal / written policy actually exists but is rather a local opinion which could easily be disputed.

[Berta]

 

It pays to have a witness at C & P exams, even if they make them sit outside of the exam office.

Broncovet has made valid points here:

" Sometimes the examiner either does not have the medical records, or has incomplete records.  The Veteran should have an opportunity to fix these and other potential exam problems prior to a RO decision"

YES! In or around 1988  my husband , a Bath NY VAMC employee, was sent to the Canadaigua VA, for a C & P on his PTSD rated at 30% then.

There was another vet in the waiting room who started going on and on about his 3 tours incountry and how many gooks he killed.

(Since I had been a Vet Center PTSD Rap group member, I wondered why he wasn't 100% P & T yet, therefore why the C & P for him too.)

My husband didn't say a word to him, as he was getting very upset at how this vet seemed to think he won the war all by himself ,and was really a mess at the C & P exam and said he didn't want to even talk to the doctor.

While he was in there, the vet kept yapping away to me, and I began to think he was a wannabee ( real combat vets don't brag about their KIAs to strangers.)

BUT as he yapped on I could hear two nurses outside the room searching all over for my husband';s VA medical records.

Those records had never made it to this other VA.

I called the C & P doctor up (yeah did that with 2 of them over the years....actually more than 2 of them but I do not advise doing that) and told him how the other vet ,scheduled right after my husband, put him into a bad state of mind for the C & P but that I was also witness to the fact that the med recs and C file had still not been found by the time the C & P was over.

My husband got another C & P exam.

For the next one, (I didn't even know of  this C & P being scheduled and it was done at the local VAMC) the doctor noted heart disease as well as the PTSD and this exam only showed up 24 years later during my Nehmer AO IHD review and rendered a favorable 1988 EED for IHD.

They apparently used that one to try to propose a reduction in his 30% due to "substantial employment" ( a part time shit job the director at the VAMC

gave him because they violated his employment rights on another job he was qualified for (full time Fireman OPM qualified statement)  to get a relative into the VA fire department).They didnt want a EEOC case.

and also his one semester of Voc Rehab, per the proposed reduction, had somehow turned him into a rocket scientist.

They dropped the proposed reduction when they read my scathing NOD.

My neighbor took her son to the VA for a C & P and they same thing happened to him.She heard them looking all over for his VA med recs and C file.

She started to snoop around and went into an open doctor's office, no one else was in it, and right on this doctor's desk was his stack of the records they were still trying to find. She told a nurse who got them and brought them back to the C & P examiner.

If a vet can prove the C & P doc never had their records ,they should be able to get a new C & P exam.

 

 

 

 

 

[Buck52]

I don't think there's a regulation that states an examiner can keep your spouse or a witness out of  C&P Exam & to not be with you during an C&P Exam, if there is such regulations have the examiner to present them to you.

Most C&P Examiners I have had Always let my spouse come in.

seems to me if they don't  their trying to hide something or speed through the Exam  and usually when this happens it is usually  Denial.

jmo

..........................Buck

[Buck52]

Just my opinion   but if you have a good examiner and is helpful to you and ask questions and he/she don't mind anyone being with you, from my experience with C&P this is a Veteran friendly C&P Examiner and usually they ask if you have anything they see they need for your S.C. or for increase.

 they will do all they can to help you   its the silent ones that are usually Bad  or they tell you'' ok were done  I just wanted you to know its not me that makes the decision''.

[lotzaspotz]

Freckled one here, lol...

No Green, I thought about asking for a copy of the "policy" but decided against it.  First, because this was a c & p exam, and I didn't want to antagonize the examiner or the keeper of the gate (receptionists have excellent memories and more power than we give them credit for, don't forget that, lol!).  Second, I'm sure there isn't one.  I would be asking for something I know doesn't exist, at least in writing.

I'm going to deal with this another way.