Congress Can Force Action To Fix The VBA

Here are my recommendations to congress which, I call the “Veteran Claims Accountability and Improvement Act (VCAIA).”

Veterans must be the focus of VA actions; thus, I am proposing implementing a customer focused disability compensation system.  The VA as an organization is marginally effective at processing and deciding claims for disability compensation.  In other words, they get the job done; however, they trip, fall, and blunder their way through the process leaving frustrated and dead veterans in their wake.  VA will never change on their own initiative, so VA must be forced through legislation to change.  I have a number of suggestions that would set VA on the right track.  All of my suggestions are designed to support a fundamental change to the way VA does business.  VA currently carries out all functions to serve the VA.  Every action is predicated on the premise of how to make things easy on the VA workforce.  There is never a thought about by making things easy on the VA, things are made difficult for their customers: veterans.  It’s time to make a central shift to a customer-focused system which will not only provide fair outcomes for veterans, it will also force VA employees to be accountable for their actions.

A customer-focused system is simply a system where every action is customer centered.  In other words, actions are tailored per an evaluation of the customer’s probable needs.  I also consider efficiency as a key factor.  VA spends hard earned tax payor dollars with wild abandon; thus, cost considerations are a central theme within my recommendations.  Keep this in mind when reviewing my suggestions, each and every one of my recommendations are doable.  There will be legislators who will dismiss my recommendations as nonsense.  I also know VA will vigorously oppose my recommendations as unnecessary or unfeasible.  I have no doubt the naysayers will be many.  My hope is we veterans can find legislators willing to fight for veterans: I do believe this is a nearly impossible task, but not impossible.  We shall see.

I am presenting the VCAIA by identifying problems with general solutions.  The details of how exactly to craft legislation are easily created once “buy in” by those people in power is established.  I could literally make dozens and dozens of recommendations, but I decided to just discuss the issues at the top of my list.  I am presenting my recommendations in no particular order:

• Problem: C-files and contractor C&P exam results are not provided to veterans in a timely manner.
  • Solution: Provide veterans electronic access to their C-file; or
    1. When a C-file is created automatically send a copy to the veteran.
    1. Post contractor C&P exam results the veterans VHA health record or automatically send a copy to the veteran.
    1. At a minimum, there must be a standard timeframe set for requiring VA to provide requested documents.  I’d think providing the requested information within 30 days is reasonable.
    1. The length of time VA takes to provide requested information to veterans must be tracked and reported to congress to ensure compliance.

I am working with a veteran right now that requested his C&P exam results twice: first 10 months ago, then again 3 months ago.  He has only one month remaining within his appeal/review period.  His decision states he is being awarded both a 0% and a 30% rating for the same condition with the same effective date.  He received no backpay so obviously the 0% was what he must have been awarded.  When the veteran told me his situation, I was very skeptical of what he was saying; thus, I asked him to send me a copy of his decision.  Sure enough, the decision awards both a 0% and a 30% rating for the same condition with the same effective date.  Crazy, right.  He told me he informed the examiner of his symptoms that clearly reflect a 30% rating according to the rating schedule.  We can easily settle the rating issue by simply reviewing the C&P exam results.  Sadly, VA is ignoring the veterans repeated requests without explanation.

Currently lawyers and others representing veterans are getting electronic access to their client’s records through the Veterans Benefits Management System (VBMS).  Why not give veterans that same access so they can view their information as needed?  Currently the costs involved in providing tens of thousands of veterans with their information annually is likely staggering:  processing information (FOIA) requests, processing equipment, equipment maintenance, paper, data disks, mailing, toner, and the list goes on; all of these costs can be avoided by giving veterans access to VBMS or by establishing another electronic access capability for veteran use.

If electronic access efforts fail, then automatically supplying veterans with their C-files and contractor C&P exam results will generate substantial savings by minimizing the processing FOIA requests.  The vast majority of veterans involved in the claim process will eventually request their VA held information; streamlining the process and reducing costs makes sense.  The bottom-line here is that veterans need their information to properly file claims and to file claim appeals within mandated time requirements.

• Problem: VA claim denial decision notifications are to general and often leave veterans confused and frustrated.
• Solution: require VA to give specific denial rationale.

A veteran can’t properly contest a denial if they don’t know exactly why their claim was denied.  VA seemingly has an unwritten policy to keep veterans at a state of high anxiety.  I wonder are they trying to get veterans to drop their claims or drive them to suicide?  General denial reasoning is useless in the appeals process and the VA knows this. To refute benefit denials, veterans need to know exactly why their claims were denied.

On a recent claim decision notification forwarded to me I noticed a troubling fact.  It seems VA is continuing a trend that I had hoped would go way under the AMA.  Under the legacy claims program VA had a habit of copying and pasting general denial information.  In other words, hundreds of thousands of veterans had their claims denied with the exact same copy and pasted general denial statement.  Of course, this left all the veterans confused as to why exactly their claim was denied.  On this recent decision it states:

You submitted a medical opinion from your private physician with your claim. The medical opinion we received from the VA Medical Center was more persuasive than your private physician’s opinion because it was based on a thorough review of your relevant military and personal history and contained more convincing rationale.

It dawned on me that I had seen that explanation before, so I searched through other recent decisions, from other veterans, and low and behold I found two other decisions with nearly the exact wording.  VA you have no shame.  VA, as usual, cannot be trusted to provide the veteran with the claim specific information a veteran requires to actually understand the denial.  It appears that every veteran with an overruled private medical opinion is getting the exact same copy and pasted denial rationale.  What the hell VA!

Copy and pasting is only part of the problem.  The denial reasoning gives no specific details.  OK, what exactly did the VA consider in the veteran’s relevant history that the veteran’s private physician did not consider?  How exactly is the VA’s medical rationale more persuasive?  Maybe the actual VA medical opinion gives some important details; however, most opinions are provided by VA contractors and, as noted above, VA may not provide copies of the opinion to veterans within appeal mandated time requirements.  In any event, we wouldn’t need to see the actual medical opinion if the denial decision gave a full and thorough explanation of the denial reasoning.

Adjudicators must be required to spell out their exact reasons for denying claims. They cannot be allowed to issue a denial based on some general, copy and pasted, generic phrase as a substitute for claims specific denial reasoning.  Keep in mind, even though VA claims are a legal process, it is not an adversarial process; thus, VA is required to give full disclosure of claim details to claimants.

• Problem: VA generated claim errors result in unwarranted claim denials.
  • Solution:  require all VBA ROs to publicly list an email contact that will coordinate corrections to errors made by their office.
    • Other than an email to the VBA noting the error, veterans or their representatives will not be required to submit appeal or review forms.
    • Error corrections are made by the person committing the error and that individual’s personnel record must note the error for future reference.  Adjudicators making repeated errors must be subject to retraining or dismissal.
    • To avoid burdening ROs, an error review panel should be established for each RO to screen error complaints: only clearly identified RO errors will be forwarded for correction.
      • This panel will be drawn from veteran volunteers: local VSO personnel would likely be very happy to serve.
      • VSO, accredited agent, and lawyer identified errors bypass the panel requirement.

The vast majority of VA adjudicating power resides with the first level adjudicators working within all RO facilities.  HLR and VLJ staffing is minimal in comparison; thus, overburdening these limited resources must be avoided.  Appeal wait times are long enough without sending claims into the system that should not be in the system.  It is essential that only claims that require the weighting of evidence enter the appeals system.

Clearly identified errors will be easily and quickly corrected.  My TBI claim was wrongly denied when the adjudicator determined there can be no TBI unless service medical records documented a head injury; that determination is an error as there is no such requirement.  Denials based on bad judgement or ignorant adjudicators are extremely common.  In this case, the adjudicator made an uninformed medical judgement that a TBI must involve an actual head injury.  This adjudicator is of course completely ignorant of a blast-induced or a whiplash type TBI event.  In any event, I simply contacted the St. Paul RO with the DOD/VA definition which specifically does not require a head injury and the RO immediately took steps to correct the error.  No waiting or forms to file.

In my case, the official method would be to: (1) fill out VA form 20-0996 to start a HLR and submit the form to the claim intake center, or (2) fill out VA form 10182 to start a NOD and submit that form directly to the BVA.  Once the appeal or review is received by VA, they have to process the paperwork into the system.  In both cases I’d simply need to point to the obvious error and hope the VA adjudicator would read the information on the form; however, there is no guarantee the adjudicator will actually read the form.  I routinely advise veterans where the error identified by the veteran is completely ignored by the higher-level reviewer or VLJ.  In any event, after submitting the required form, the veteran can do nothing but wait for a decision to come in the mail; months certainly will pass, likely more than a few and possibly a year or two.  On my TBI claim VA made additional errors on subsequent decisions; thus, the official method would have played out over several years at a minimum.  Luckily, I was able to work directly with the RO so they could correct their repeated errors in a timely manner without any forms to file. 

All of the wasted manhours, claims overburdening the appeals system, and stress on veterans can be avoid by simply forcing the VA to correct their own errors.  There will be veterans who believe VA committed an error when in fact VA did not.  This is why I came up with the idea of impowering a panel to review possible errors submitted by unrepresented veterans.  A panel is really not required, but I think a good idea.  A volunteer panel could not only screen incoming complaints, but act as an oversight mechanism and perhaps report directly to congressional committees.  Firsthand accurate and unbiased information on the error situation would be invaluable.

• Problem: the VA quality program (STAR) is ineffective at tracking or correcting errors that result in unwarranted adverse claim determinations.
  • Solution:  transition to or establish a customer focused quality program that ensures proper claim determinations delivered to veterans.  Congress must mandate the nature of the VA quality program.
    • Narrow the quality program focus to errors that result in unwarranted adverse claim determinations.
    • Quality sampling must focus on high error claim types.
    • Initiate an active quality control (QC) program.
    • quality control over medical exams and opinions.
    • Conduct benchmarking to determine realistic claim processing task times.
    • Track accuracy rate for each adjudicator and medical examiner.  Retrain or terminate personnel with poor accuracy rates.
    • Initiate a quality testing program.
    •  Require adjudicator denial decisions, grant decisions, and time per claim to be tracked.  Adjudicators with a very high denial rate, grant rate, or low time per claim rate should be investigated to determine if their decisions are reasonable.  Retrain or terminate employment.
    • Implement negative opinion ratio claim monitoring.  Require VA C&P examiner opinions negative or positive to be tracked.  An examiner with a very high negative opinion rate should be investigated to determine if their opinions are reasonable.  Retrain or terminate employment.
    • VBA decisions that are overturned or remanded by the BVA, CAVC, or Federal Circuit must be analyzed for RO errors.  Errors identified will be treated the same as all errors within the quality program to include being added to the overall error rate.

Veterans deserve due process in claim adjudication.  The VBA must take steps to ensure claim decisions are sent to veterans that are free of error; to that end, a quality assurance program is key.  Quality programs ensure product quality by reducing deviations within the production process that cause errors; however, a successful quality program not only reduces errors, it is also cost effective and most importantly provides the customer with a quality product.  An effective program operates under a strategy or focus.  As far as I can tell, the VBA operates under an all-encompassing strategy that is focused at reducing any and all errors: which is one reason why it doesn’t work well. The thought at the heart of every quality program must be the customer.  The thought at the heart of the VBA quality program is the VBA.

The object of a quality program should be to minimize errors through purging deviations within the overall process; however, the focus of the program must be to get a quality product to the customer.  VA will never admit to any significant problems with their quality program.  They want to report a low error rate, so they’ve designed a quality program to deliver that result. Reporting high quality and actually having high quality are not the same thing.  The VBA reports an accuracy rate of 90% or so; which even if true, in quality circles, is bad.  I suspect the quality program has been tailored to mainly analyze claim types that are less error prone; thus, allowing VBA to report a high accuracy rate with a straight face.  There are several types of claims: original, new, increase, reopen, and secondary.  Error opportunities are not equal among the claim types.  Sampling is at the heart of any quality system.  If we really want to deliver an error free claim decision to veterans, we must logically employ quality program sampling accordingly.

Original claims for compensation are usually submitted at service separation when all the medical information is current and medical nexus opinions are not required; thus, these claims are very easy to process and there is little chance of an error occurring.  If quality sampling is weighted heavily with original claims, we would find a low error rate simply because there is little chance of error.  Claims filed or reopened many years after service are often problematic.  There may be a long medical history that must be evaluated and/or the course and nature of a disease must be analyzed and compared the medical history.  There are many regulations and often case law that must be considered.  A medical nexus opinion is likely also required.  Simply put, old claims are often very complicated and as such are prone to error.  If quality sampling is weighted heavily with old type claims we would find a high error rate because there is a high chance of errors.

Typically sampling resources are limited, so sampling efforts must be focused where they can be most effective.  The types of claims with the least number of errors do not need to be checked as extensively as the types of claims with the majority of errors.  Sampling must be targeted to error prone claim types to get the best bang for the buck; we must also decide on exactly what is an error.  I suspect any deviation from the instructions in the adjudication manual (M21-1) are currently counted as an error.  Meaning many errors are administrative or book keeping in nature.  If a “t” isn’t crossed or an “i” isn’t dotted some people will count them as errors; however, what if any impact is there to the decision received by the veteran?

In the customer focused quality system I envision, errors will be categorized as major or minor.  A major error is an error that results in the delivery of a wrongly decided or paid benefit, while a minor error has no impact on the customer’s benefit.  Minor errors are not a problem and need not be tracked by the quality system over that they occurred.  Major errors are a big problem which the quality team must track, tend watch, and force corrective action.  Minor errors can be tracked; however, tracking errors that do not affect the customer won’t add value to the end product, but will increase costs.  Analyzing minor errors should fall on the erroring workers supervisor who can report the error types into the quality system’s correction loop to improve the overall system: this will also result in the added benefit of making the supervisor keenly aware of a worker’s performance.

Veterans (the customers) are interested in two elements of the delivered product: (1) a correctly decided claim per a grant or denial and (2) a correctly paid benefit.  These two elements must be at the heart of the quality program.  An outcome-based quality system is also the least expensive to operate.  Cost is directly related to the number of elements measured, tracked, and reported.  If a quality program considers any and all types of errors, the program will capture a total and complete picture of the end product.  This would be wonderful from a production managers standpoint; however, maintaining and analyzing all the data from such a system requires enormous resources.  Congress doesn’t even blink when supplying the VA with seemingly never-ending and ever-growing piles of our hard-earned tax dollars.  This must change.  To minimize costs, we must focus nearly completely on getting veterans a correctly decided and paid claim.

Another issue we must address is “when” quality is checked.  The current quality program checks quality only after the fact; meaning, sampling is done only on completed and delivered to the veteran claim decisions; thus, the first person to notice the error is the veteran.  I purpose holding completed denied claims in a queue for a quality control (QC) check before the decision is sent to the veteran.  This will cause a slight delay, but this delay is for good cause.  It is far more important to issue a correct decision, then to quickly send a decision riddled with errors.  The QC can be limited to error types that occur regularly.  I prefer that 100% of denied claims go through QC; at least, until error rates are significantly reduced.  After error rates are lowered a sample QC program can be instituted. 

When reviewing errors, we must keep in mind that at the root of every error is a VA employee.  Currently adjudicators focus on quantity not quality.  The quality program numbers report only the total production effort and do not yield a valid sample of individual adjudicator performance; thus, we only know the group accuracy.  We do not know how many errors each member of the group contributed; thus, no individual accountability.  I have no doubt the 80/20 rule applies.  I’d bet that 80% of errors are coming from only 20% of the workers.  Sampling efforts must include every worker contributing to the production effort so the worth of each person can be gauged.  This includes the medical professionals conducting C&P examinations and offering medical nexus opinions.

I’ve noticed a very disturbing trend with medical opinions: examiners cite negative information while ignoring positive information.  They will also present a fact that is positive as if it is negative or they limit the significance of the positive information.  It appears examiners are, as a group, biased against veterans receiving disability compensation.  We must take steps to ensure medical opinions balance all the facts involved accurately so that fair assessments are presented to adjudicators.  Medical examination results and nexus opinions must be vetted through the quality program.

Individual accountability must be built into the quality system.  We must know who is committing the errors and how often, then hold erroring personnel accountable.  Exactly how we hold personnel accountable will depend on the error.  Simple retraining may be all that is necessary; however, employment termination may be required.  I propose we closely track individual performance data so we can identify expertise levels.  We’d want to know how many claims a person denies and how many they approve.  The same is true for medical opinions, negative opinion vs positive.  I guarantee, statistically, that there is an average that is a norm.  When we find individuals far outside the norm, scrutiny must be brought to bear.  It is likely a person with a very high percentage of denials or approvals is not properly carrying out their duties. 

Production benchmarking must also be performed so we know how long each task should take to complete.  Again, here individuals far outside the norm demand scrutiny.  There is likely a problem with an individual to slow or to fast in completing claim tasks.  I think it may also be a good idea to start a quality testing program utilizing “test claims” to test the integrity of adjudicators and medical examiners.  Claims would be filed with already known and well-defined outcomes; any test claim decided outside of the expected outcome will have identified a less than stellar employee.  I do not believe people within the VA can be trusted to fairly and accurately assess their system; thus, this program must be controlled from outside of the VA.  We can weed out bad actors, marginal performers, and those people not suited to the job: we just have to decide to do it.

The point I’m trying to make is that there must be an overall quality strategy that results in reliable outcomes for customers, instills accountability within the workforce, identifies error trends for correction, and smartly measures all input sources.  While at the same time being cost effective.  Changing the quality system at the VBA to focus on its customers is doable; however, I’m sure the VA bureaucrats do not have the desire, required skillsets, education, or production experience to envision and implement a customer focused quality system.  Congress must take action to force the VA to implement the system or at a minimum require customer focused type data to be reported to congress.

•  Problem:  medical opinions on how medical conditions develop, progress, are diagnosed, and on what diagnostic tests are required for commonly claimed disabilities differ from examiner to examiner.  This results in ununiform grants and denials of benefits from veteran to veteran based on the exact same set of facts.
  • Solution:  empower a panel of experts to establish medical definitions, standards, and protocols for commonly claimed disabilities for use in cause and aggravation determinations.

Currently published medical information is primarily designed from a treating the patient perspective; thus, there is little information on causal or aggravating factors.  We need SOPs and decision trees developed that specifically address how to analyze medical histories in relationship to the nature and course of a commonly claimed disabilities.  Medical examiners must follow the same logical path of deduction to provide uniform determinations.  Example:

A 60-year-old veteran files a claim for cervical degenerative disk disease (DDD).  The DDD was diagnosed per X-ray at age 39, nearly three years after retiring from 20 years of active duty.  He has not suffered any traumatic events or injuries after service.  The veteran claims the onset of the DDD must have begun in service due to the nature and course of DDD.  He has submitted medical treatise that states DDD normally takes many years to develop in the absence of injury.

The question here is simple, “was the likely onset of DDD during the 20 years of active duty or during and completely in the three years after service?”  How does DDD normally develop?  How long before DDD is detectable on x-ray or other diagnostic tests?  What factors aggravate DDDs development?  Uniformly the medical community does not have answers to these questions; however, VA C&P examiners will have to answer these questions and the veteran wins or loses the claim based on those answers.  These types of questions cannot be left to expertise, whims, or biases of individual examiners.  A team of medical experts must be empowered ensure uniform medical assessments that are rooted within known medical science to the “as likely as not” legal standard.  Cause and aggravation determinations must be based on a predetermined set of medical definitions, standards, and protocols to ensure fair outcomes for veterans.

Problem:  medical opinions on how one medical condition can cause or aggravate a secondary medical condition for commonly claimed disabilities differ from examiner to examiner.  This results in ununiform grants and denials of benefits from veteran to veteran based on the exact same set of facts.

Solution:  empower a panel of experts to predetermine cause and aggravation relationships for commonly claimed secondary disabilities.

Veterans often claim that one of their service-connected conditions is causing or aggravating a secondary condition.  There are many commonly claimed secondary conditions such as flatfeet causing or aggravating knee, ankle, back, or hip conditions.  Mental health conditions causing or aggravating sleep apnea.  Neck or nasal conditions causing or aggravating sleep apnea.  Physical limitations and pain causing or aggravating depression.   A left knee condition causing or aggravating a right knee condition?.  And the list goes on.  What does the science say?

I filed a claim for several knee conditions on a direct basis, which VA denied per a medical opinion that stated that my service-connected flatfeet cannot cause or aggravate knee arthritis (OA).  VA completely ignored the in-service knee problem documentation and for some reason only considered knee OA secondary to my flatfeet.  I’ve learned from experience to view any absolute type medical opinions from VA medical examiners with skepticism.  Mostly, causation or aggravation determinations cannot be made with absolute certainty.  Sure enough, a simple google search did not find any information to back the VA examiner’s opinion; however, I found ample authoritative information noting that flatfeet are strongly associated with knee OA.  I submitted all the information on an appeal and VA reversed the denial and granted the claim.  I also won the claim on a direct basis at a later date.  To me the question is still open, do flatfeet “as likely as not” cause or aggravate knee OA?  I won in my case, but I could easily have lost.  I wonder what a team of medical experts would say?

There are either valid theories, studies, and other evidence to support secondary relationships to the required standard of proof or there are not.  These types of questions must be predetermined by experts through a complete review of the science involved.  This will speed the decision process, avoid repetition of effort by individual examiners, and challenges to inadequately provided medical opinions by less informed or skilled examiners; all of which, will reduce manhours resulting in substantial cost reductions.

• Problem: firstly, the cost of manually processing claims is enormous.  Secondly, many claims are denied simply because VA doesn’t ask veterans about the specifics of their claims during the initial claim process:  this results in veterans having to add this information in the appeal’s process.
  • Solution:  introduce artificial intelligence (AI) to the adjudication process with supporting upfront input data forms.

Hundreds of thousands of claims for compensation are filed each and every year; thus, the manhours required to process these claims is immense.  AI will significantly reduce processing manhours by totally or partially automating the decision process for many if not most claimed disabilities.  A computer program will easily be able to order or complete all necessary steps within the decision process.  Tinnitus for example, the number one claimed disability, is an uncomplicated factual determination; thus, AI can easily make the required decisions.  The determinations required to approve a tinnitus claim are situational, yet simple and straightforward as follows:

For each medical condition suited for AI determinations an input form will be created.  The form will be required to be filed with the application for benefits and will obtain the required data to enable a decision to be made.  The tinnitus form would define the term “tinnitus,” list the possible symptoms, and get the answers to several questions:

• Were tinnitus symptoms present in service?
• Were tinnitus symptoms continuous after service?
• Do you have current tinnitus symptoms?

The form answers combined with service medical records, post service medical records, and/or C&P exam results will provide all the input data required for AI to make a determination.  I’ve included a credibility check in the above example; if VA wants to conduct background investigations, credit history, or some other method of assessing credibility on applicants.  It’s actually rare where a veteran is deemed uncredible.  Currently, a veteran’s statement of symptom history is accepted as credible unless there is obvious evidence that notes otherwise; thus, I’d recommend forgoing the credibility check.  For you individuals who want an in-depth credibility assessment, keep in mind backgrounds checks on millions of veterans will cost many millions of dollars all to find the rare veteran with a dubious character.  Of course, even when the VA labels a veteran as incredible that determination may be overturned on appeal to the federal courts.

Instituting a pilot AI program should be enacted immediately.  A successful program will lead to far better outcomes for veterans though fast and fair claim approvals or denials with few appeals filed due to lack of information; fewer appeals mean lower costs to tax payors.  A successful program will also lead to a reduction in the VBA workforce with substantial cost savings.  VA leadership and the federal workers unions will undoubtedly be against AI.  Think about it, AI has the potential to significantly reduce the VBA workforce.  Just the thought of shrinking the VBA workforce will send ripples throughout Washington; hence, VA cannot be trusted to competently plan and execute an artificial intelligence program.  An outside the VA team will have to be selected.  In any event, AI has been around since the 1960s; it’s time for the VA to take advantage of modern technologies to ensure better outcomes for veterans.  The future is now VA: wake up!

• Problem:  claims are denied or underrated because often veterans do not file a statement with information about their self-observable symptoms and facts.
  • Solution:  create self-observable symptom and fact checklists to be filed with claim applications.  Supplying accurate symptom information with the claim application will limit supplemental claims entering the adjudication process.

Veterans, adjudicators, and medical examiners all make curtain assumptions in conjunction with claims for disability compensation.  When many veterans file claims they assume it well be obvious to an adjudicator or C&P examiner that pain, physical, and/or mental health limitations started in service, continued after service, and are currently present; thus, they don’t specifically cite these facts on a statement with their claim applications.  In the minds of veterans, they wouldn’t be filing the claims if they didn’t have current problems related to their service; however, from an adjudicators or C&P examiners perspective claims must be supported by evidence.  If a record doesn’t note that pain, physical, and/or mental health limitations started in service, continued after service, and are currently present; then the claim will very likely be denied for no continuity of symptomatology.  The problem here is just simple miscommunication.

When veterans are denied compensation or are underrated due to miscommunication, they just need to file a statement noting the self-reportable facts on a supplemental claim; then VA will take action to re-adjudicate the claim considering the newly reported information.  Reporting all self-reportable facts on a checklist in conjunction with claim filings will avoid readjudication per supplemental claims.  Needless to say, self-reportable fact checklists will smooth the decision process and reduce overall manhours required to complete the claim process resulting in substantial cost savings.  These checklists will also support the AI adjudication process.

• Problem:  VA actions are trigger events in veteran suicides.
  • Solution:  collect data on possible VA-related suicide triggers and take action to mitigate triggers.
    • Examine each veteran suicide for VA actions.
    • Compile all collected data into a publicly accessible searchable database.
    • Determine mitigation actions.

I suspect that VA actions are at the heart of many, if not most, veteran suicides; however, there is no publicly available information to confirm or alleviate my suspicion.  Cases like Paul Shuping where shortly after being denied disability compensation benefits, he drove to a VA facility and committed suicide; or Cameron Anestis who went to a VA facility to request treatment for his current suicidal thoughts, but the VA facility turned him away.  He returned home frustrated, fought with his wife, then committed suicide; or Justin Miller who directly upon discharge from VA inpatient care for treatment of suicidal thoughts, walked directly to his vehicle in the VA parking lot and committed suicide with gun that was in the vehicle.  Just how many veterans are committing suicide after contact with the VA?

I deal with veterans very single day that are having a problem with VA and I can tell you that there is a very high anxiety level attached to those conversations.  It often takes many months to years to resolve claim issues and VHA treatment issues can drag on for many years.  This prolonged stress definitely takes a toll, but is this VA related stress a factor in veteran suicide?  I say absolutely YES!  Sadly, there is no data publicly available that tracks veteran suicide in relation to their VA experience.  Actually, I doubt any such data exists.  I’m sure VA isn’t real interested in knowing if they a part of the suicide problem or for that matter, they likely haven’t even considered the possibility; however, if they did have data noting that suicides track directly with VA interactions, I’m sure they would suppress that information.

Isn’t investigating a suicide and collecting specific details that led to the suicide just common sense?  We can’t fix the problem if we don’t know what’s causing the problem.  Every single suicide must be investigated: in depth!  We must follow in the veteran’s footsteps in the days, weeks, months, and possibly years before the suicide.  I would specifically want to know details such as:

1. mental health treatment history and results.
2. VA and Non-VA physical health treatment history and results.
3. Did the veteran have untreated or unreported health issues.
4. Employment history.
5. Family history.
6. Adverse legal actions history.
7. Encounters with law enforcement history.
8. VA claims history.
9. Financial history.

The point here is to build a timeline-based history packed with every important detail in the veteran’s life.  Once a database is filled with the details from thousands of suicide victims, tends will become apparent: then mitigation actions can be planned and acted upon.  Information is the key to logically acting to mitigating veteran suicide, so let’s get started.

• Problem:  Private medical professional (doctors, LNP, PA) medical opinions and DBQs supporting veteran disability claims are not medically vetted for likeliness or scientific soundness.
  • Solution:  add private medical professional opinions to the VBA quality program;
    1. Track the number of opinions/DBQs submitted by each medical professional.
    1. Set charge limits.
    1. Permanently bar medical professionals identified as offering dubious medical opinions/DBQs and report them to their medical boards.

Finding medical professionals to provide medical opinions to support a veteran’s disability claim is a nearly an impossible task; thus, veterans turn to the paid medical opinion industry.  It is a virtual a wild west for veterans trying to find a competent medical opinion provider: it is very buyer beware.  Typically, a veteran will be charged from $500 to $10,000 dollars for a single medical opinion with no guarantee of quality or if the opinion will meet VA requirements.  I’ve read Thousands hundreds of these opinions and I have to say I’m surprised at what some doctors will actually say.  They will virtually say anything to make a buck.  We need to weed out the charlatans putting forth dubious medical opinions.

Besides the charlatans, there are those medical professionals who apparently flunked writing and critical thinking courses because their opinions are so badly written and thought-out that there is no way the VA will give their opinion any legal weight to support the veteran’s claim.  Often when the veteran confronts the opinion writer with their moronic opinion, the writer refuses to correct the opinion or refund the veteran’s money.  There is absolutely no controls or oversite over the medical opinion industry in reference to veterans; thus, many veterans fall prey to unscrupulous or inept medical professionals.

Veterans need professional, fair, well thought out medical assessments and opinions based on known medical science so that veterans receive just claim determinations paid at the proper level of compensation.  We must have some sort of control over who can offer medical opinions and how much can be charged.  VA already has control over who can legally represent veterans in claims for compensation and how much attorneys/agents can charge, why not set the same controls over medical professionals. 

• Problem:  the schedule for rating disabilities has many undefined terms that relate directly to the level of disability compensation; thus, interpretations of these terms differ among adjudicators and among medical examiners resulting in unevenly applied ratings among veterans.
• Solution:  Define terms that relate directly to the level of disability compensation.

VA disability compensation is a really big deal for several reasons with the most important reason being to ensure a basic level of quality of life to disabled veterans.  Jeez Louise, just think of the big government and entrepreneurial machine built around veteran disability claims: state and federal legislative committees, private medical opinion writers, lawyers, claim’s agents, veteran service organization disability departments, state veteran service disability departments, county veteran service disability departments, Court of Appeals for Veteran Claims (CAVC), and a let’s not forget the VBA.

There are thousands of people involved with veteran disability claims in government and business.  That being said, you’d think the VA would put some real deep thought into constructing the schedule for rating disabilities, but as is often the case VA misses the mark.  There are literally thousands of VBA and federal court cases filed every year fighting over the undefined terms that plague the schedule for rating disabilities.  I am just dumbfounded here; I mean really, I am even sort of awe struck at the level of incompetence that the VBA can publicly flaunt.  It’s like VA is screaming “we can be really, really stupid and there isn’t anything anyone can do about it, so kiss our ass you dumbass veterans.”

Disability compensation claims are part of a legal process and the VA has an army of lawyers; thus, you’d think they would have screened the schedule for rating disabilities with a keen eye to limit the possibility of legal challenges.  I mean something as simple as definitions.  I’ve read a fair share of laws and they seem to have one particular section in common, definitions: legislators make a point to define unambiguous terms so everyone reading the law will be on the same sheet of music; a very wise policy.  Sadly, VA lawyers en masse must have skipped that course in law school; thus, now there is one big mess that causes a great deal of stress among veterans.  Let’s look at a few examples.

Here is one the VA does right: “incapacitating episode.”  For an eye condition the schedule notes “an incapacitating episode is an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes.”  A very clear definition. For Intervertebral Disc Syndrome the note states “an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.” Again, a very clear definition; although, I don’t agree with the definition, the definition itself is clear.  Pretty much the VA does a good job explaining incapacitating episodes for various conditions.  Now let’s look at incapacitating exacerbations.  There is no definition anywhere on the schedule for incapacitating exacerbations. 

The law allows the VA to “wing it” when evaluating ambiguous terms; in other words, a VA adjudicator gets to decide the meaning of a medical term.  In most cases, VA decides on an interpterion that leads to no or a minimum benefit for the veteran.  The BVA has determined that incapacitating exacerbations and incapacitating episodes are the same thing.  If that were true, why doesn’t the schedule just use the term incapacitating episodes throughout the schedule?  Of course, here, as is often the case, the BVA has made a very superficial determination.  VA employees including VLGs take the easy way without regard for the veteran’s welfare.  Actually, I have found evidence in the schedule that incapacitating exacerbations have multiple levels of impairment; thus, VA’s determination that incapacitating episodes and incapacitating exacerbations both require doctor ordered bedrest is wrong.

Under multi-joint arthritis (DC 5002) it notes exacerbations are rated at 20%; incapacitating exacerbations are rated at 40%; severely incapacitating exacerbations are rated at 60%; and symptoms that are totally incapacitating are rated at 100%.  It’s clear under 5002 that exacerbations can be mild, incapacitating but less then totally, or can be totally incapacitating.  Clearly the schedule intends to differentiate incapacitating exacerbations from incapacitating episodes.  Here at least, the schedule gives some examples so that we can logically infer a meaning.  Unfortunately, this is not the case with most of the ambiguous terms on the schedule.

The terms severe, moderately severe, moderate, slight, mild, frequent, infrequent, persistent, marked, recurrent, and others are mostly undefined.  Looking at peripheral nerves for example; they are rated as severe, moderate, or mild with absolutely no guiding logic leaving each examiner to make their own determination.  For gastroesophageal reflux disease (GERD) the schedule states “Persistently recurrent epigastric distress:” what exactly does persistently recurrent mean in reference to GERD?   Epigastric distress daily?  Twice a week?  After every meal?  Exactly how often must epigastric distress be present to be persistently recurrent?  Not defining terms obviously leads to differing ratings from one veteran to another even though they have the exact same symptoms.  The solution here is very simple; create a definition for all terms that determine ratings so that fair ratings are issued to all veterans.  This is really a no brainer: wake up VA!