Non VA emergency room care

[Grunt 8152]

The other week I have a temp of 100 and lower abdominal pain that started week prior but was started to get pretty bad. I called the VA to see if I should get same day appointment or use the urgent Care benefit. They put me in touch with a triage nurse and based on my symptoms and the fact that a recent CT showed diverticulosis we agreed it was likely I had diverticulitis. She told me to go straight to the nearest emergency room and that I should not drive over an hour to get to the nearest VA emergency room. I asked if it would be covered and she said she wasn't billing and didn't know. I asked to be seen by my primary who could then send me to ER but she said no and that I should go immediately and may need IV antibiotics and that she would alert the community Care person.

I can't afford a ER bill so I went to urgent Care which I knew would be covered. They said i had lower right abdominal pain and based on my diverticulosis it could be diverticulitis and I should go get a CT same day. He sent me to the nearest ER and said he was transferring my care there. I expressed concern again about being liable for the cost and he said I should be find since he sent me and they (urgent care) are in the VA network. So I went to ER , got an IV of saline and DR initially thought I had mesenteric lymphadenitis because a previous CT should enlarged messentaric lymph node and that it could mimic appendicitis. I got a CT to rule out appendicitis and came back as moderate diverticulitis with some fluid in pelvis coming from the diverticulitis but nothing that needed to be drained and also moderate swelling of intestines and large amount of fat stranding. I was given option of being admitted or going home with antibiotics. I chose antibiotics and to go home. I had to take script to VA who had to have my primary sign off on it before I could get it. 

My question is based on what happened am I likely to be covered or will VA deny my claim? To me I prudent lay person would go when two medical professionals said to go to nearest ER but I'm afraid now that since my care was transferred by urgent care they might deny me somehow.

Does anyone have experience with this that could offer some insight?

Thanks.

 

ETA: I have no other insurance and this is not related to a service related disability and I am enrolled in VA healthcare and see my Dr a few times a year.

Edited August 31, 2019 by Grunt 8152

[GeekySquid]

Good Question.

It would seem on the surface you did everything you should have to get permission.

If the medical professional said don't drive over an hour to a VA ER, and I assume your nearest VA ER is more than an hour away, you did the right thing by going to a Community Care Authorized Location.

If that Community Care sent you for those other tests, it would seem obvious/logical they are working under their VA Authorization to do so.

If that turns out to be different then veterans need to know that ASAP.

The Community Care program is touted as a benefit but if providers don't have that authority or engage in things like "fly-by doctoring" then there is a huge potential problem for veterans in that they could get whopping bills despite using the authorized center.

BTW what is your Percentage of Service Connection?

 

 

[Grunt 8152]

Currently I am 10% service connected and waiting on a judge to rule on some others. 

My closest ER which I ended up going to is 5 minutes from me while the VA ER is like and hour to hour and a half away.

The urgent Care person said he was transferring my care to the hospital close to me and they were the ones that ran the tests that happen to be the same ones the urgent Care person wanted done.

I will definitely update this topic as well when I get approved or denied. 

[Grunt 8152]

Just thought I would update. Actually went to ER again in November for same issue then following day went back and was admitted for same issue. Everything was covered ! They are also covering the surgery I need for that and concurrent gallbladder removal without having to get it all done at VA hospital. So I'm very happy and impressed.

[GBArmy]

Grunt 8152 Sounds encouraging. what I would do is contact the Patient Care Advocate at the VAMC and inform them of what's going on and make sure your in sync. From what I have heard, while at the civilian hospital you are supposed to sign a release form that you are willing to transfer back to the VA hospital after the surgery. It may be a formality, but if you don't sign off you can be denied VA financial coverage.

[Vync]

7 hours ago, Grunt 8152 said:

Just thought I would update. Actually went to ER again in November for same issue then following day went back and was admitted for same issue. Everything was covered ! They are also covering the surgery I need for that and concurrent gallbladder removal without having to get it all done at VA hospital. So I'm very happy and impressed.

This is good news. If they ask you to sign a paper regarding being transferred to the VAMC, always say yes. The VA likes to use denials as a way to get out of paying.